Hgardner: September 28, 2020, 3:19pm
Hi, I am new here, this is my first post. I think I followed the rules but I apologize if this isn’t in the right place. I
am new to Sa’am and could really use some help sorting out this case. Thank you!
35 year old woman
Chief complaint : Searing, sharp abdominal pain starting last day of menstrual period and lasting for 7-10 days.
Painful menstrual cramping.
Post-period pain is the worst of the two, 10/10 pain. Getting worse in last 6 months gradually but occasionally
has a light month where it is only 7/10 pain. Unable to discern a pattern.
History of mild endometriosis and small ovarian cysts that come and go.
Uterine area menstrual pain is about the same it has always been, first two days are very painful, takes
ibuprophen, has huge dark clots and tissue.
Mild premenstrual symptoms, mainly irritability and breast tenderness that go away as soon as she starts
bleeding
Has been on a modification of Dang Gui Si Ni Jia Wu Zhu Yu Sheng Jiang Tang or Dang Gui Shao Yao San +
Gui Zhi Fu Ling combo consistently for about a year.
When pain is severe can refer to rectal and vaginal pain
Had appendectomy 2016, laproscopic ovarian cyst removal 2011
Second complaint: struggling with infertility (is ready to give up on this and just wants the pain to stop at this
point), loose stool, anxiety
·naturally conceived daughter 4 years ago, healthy pregnancy, healthy vaginal delivery, no complications
Stool is more loose with anxiety, but is never really solid. Does not cause much discomfort, if any, no
undigested food
Has been trying to get pregnant again for 2 years with no success, but she cares less now about pregnancy and
more about stopping the lower abdominal pain.
Her anxiety was far more severe a year ago, she is able to sleep fairly easily and is not having panic attacks
anymore, just an underlying tendency to anxiety, worse with pain.
Appearance and demeanor : Good facial symmetry +10, attractive, neatly dressed, almost always in nice athletic
clothes, dusky facial color +8, dark eyes and dark shadows under eyes +8, bubbly personality+7, presents as
optimistic and happy but describes herself as having “closet anxiety”, always taking care of others first +10, go go
go always unless in pain +10. Talks fast. Fit. I see her often feeling anxious and smiling to hide it, she is very
gracious and polite, but not timid, abdomen is firm, slightly bright eyes +5?
Lifestyle: Exercises regularly for mental health/stress relief, homestead farmer, works part-time as medical lab
tech, married (supportive relationship), 4 year old daughter, very self-critical, very involved with extended family
needs/health,
Body morphology and flesh quality: Average to slim frame, strong muscle tone, fit/athletic19/01/2024, 11:15Case Study abdominal and pelvic pain – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-abdominal-and-pelvic-pain/1306/print2/6
Skin Quality: good/average. Not too dry, just dusky facial appearance.
Body Temp: cold hands and feet, tends to run cool
GI: gas, loose stool, tends to want iced drinks (we are working on this), can forget to eat
Respiratory: seasonal allergies are often happening, post-nasal drip and headache
Sleep: when circumstances are peaceful and anxiety is low, sleeps well, if anxiety is up has a terrible time sleeping
(if worried about family)
Emotions: positive attitude that feels a bit forced +10; tends to neglect her own needs so that others can be cared
for +7 (getting better);
Urination: tends to be frequent/wake up through night, this has gotten better in last 6 months, otherwise
unremarkable
Other Body:
Tongue: do not have this information at the moment
Excess Presentations:
Heart: warm friendly +7
UB: anxiety _8
GB:
P:
Liver:
SJ: bright eyes +5, polite +8, focused on details +4
Lung:
Stomach: loose stool
LI: never bored or lazy,
Spleen:
SI:puts others needs before her own+8, diminished fertility, talks about ‘giving up on her self’and resolving pain as
‘hopeless’
K: dusky facial color, masses in lower abdomen, symmetrical, attractive, fatigued
The Grossest Thing(s) in the Room: symmetry, dusky facial color/dark around eyes, masked anxiety, abdominal
pain
Main treatment ideas: Alternating tonify Kidney and Small Intestine19/01/2024, 11:15Case Study abdominal and pelvic pain – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-abdominal-and-pelvic-pain/1306/print3/6
Other treatment ideas: Tonify liver (too cold?)
Treatment 1 &2 tonify Kidney bilateral:
Extreme pain with period the next week, less clots, and smaller, but had to take Percocet & ibuprophen
(unusual), had more breast pain than usual before period, very thirsty, unquenchable
After period, energy a little better
Anxiety a little better
Treatment 3& 4 tonify SI bilateral
Had been having referred vaginal and rectal pain along with abdominal pain, has not had this pain since.
Menstruation was more clotted, lots of tissue and large, dark clots passed. Still extremely painful, was stuck in
bed with heating pad, lots of ibuprophen, did not take Percocet.
Loose stool: no change
Treatment 5: tonify liver on Right, SI on Left
This treatment was done during her post-menstrual pelvic pain time, right at the beginning.
Have not seen patient since this treatment, but she reported via email that post-menstrual pelvic pain continued
to get worse over the next 5 days (as it normally does) and noticed no major change in quality. Had to take
medication.
KristinWisgirda: September 28, 2020, 8:21pm
Welcome to the forum @Hgardner! Thank you so much for the case. I appreciate all the time it takes to write up a
case.
Menstrual related cramping typical responds really well to Saam treatments so I am sure that you can help your
patient using Saam. However, I see some problems with your treatments and am not surprised that she didn’t
respond well to them.
I am so glad that you reached out because your case shows that you are misunderstanding the basic Saam method.
Saam requires quite a big shift in thinking from other styles of acupuncture, so it can take time and careful practice
to understand how to work with it properly.
Toby strongly recommends that ALL new practitioners use one sided treatments ONLY for the first year. I’m not
sure where you got the idea to only use bilateral treatment. We just had an advanced class discussing how to use
bilateral treatments because it is an advanced skill. This is because single sided treatments are the safest. Saam is
such a powerful system that improper single sided treatments have sent patients to the hospital. Needling the
second side doubles the possible danger of sending a patient off the deep end. As well, a treatment that might have
worked wonderfully single sided can push the patient too far if needled bilaterally. So it is not only the wrong
channel that is unsafe, the wrong dose of the right channel can be unsafe too.
After practicing for 20 years, Toby uses single sided supplementing treatments 50% of the time because they give
him valuable information about patient response and very often they are enough to make significant changes in
patients’ symptoms. Clarity is key to practicing Saam.19/01/2024, 11:15Case Study abdominal and pelvic pain – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-abdominal-and-pelvic-pain/1306/print4/6
Back to your case:
Hgardner:
The Grossest Thing(s) in the Room: symmetry, dusky facial color/dark around eyes, masked anxiety,
abdominal pain
The following signs are for sure Kidney excess: symmetry (10+!!) , dark facial complexion
The menstrual pain with tissue is also Kidney excess, though other channels could be contributing too.
Your first 2 treatments are supplementing Kidney which is exactly what your patient didn’t need. This has
happened with many new Saam practitioners. We have all made mistakes! Unfortunately you gave her a quadruple
whammy by twice bilaterally consolidating an overconsolidated patient. No wonder she needed to double up on the
meds. The proper treatment would have been to one side supplement SI, the counterbalancer of Kidney, to bring
dynamic movement to the overconsolidated patient.
Treatments 3+4 thankfully counteracted the first 2 improper treatments but really only brought her back to square
1.
For treatment 5 you won’t really know how well the patient responded to SI+ or LIv+ because you did them
together. A mistake with one can dilute or distory any benefit the other one might have had. Again you and the
patient missed out on clarity. I suspect that SI+ would have benefited her but I am not so sure about the Liver+.
You wrote
Hgardner:
strong muscle tone
This sounds like dense flesh which is a Liver excess sign. Her SJ excess signs- you wrote slightly bright eyes and
then gave them a 5± aren’t convincing me that she is clearly more SJ excess than Liver excess.
There are some other aspects of your symptom analysis that aren’t quite right. For instance:
Hgardner:
UB: anxiety _8
Anxiety can be from any of the 12 channel excesses. When it is UB excess it is more fear manifesting as frozen
hypofunctioning. That doesn’t sound like her.
Moving forward with Saam:
When we make mistakes, it is best to sit down and take a close look at our resources to see where our
understanding went astray. Before treating another patient with Saam, you have to review your Saam intro notes
especially the Powerpoint. If you still have access to the recording of your intro class, watch it again. There are lots
of complimentary talks on Saam here that can help reinforce the learning of the method:
https://www.saambenevolentsociety.org/online-classes/19/01/2024, 11:15Case Study abdominal and pelvic pain – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-abdominal-and-pelvic-pain/1306/print5/6
Read lots of cases on the forum and make sure you understand why they worked or didn’t work. Feel free to ask
plenty of questions!
I am willing to help you with this case if you review the above resources and submit another symptom analysis on
this patient. You can also try with another case, if you need a fresh start.
I also recommend taking the intro course again. There is an on demand intro course on the page I linked above.
Many of us on the forum have taken the intro course 2-5 times!
Hgardner: September 28, 2020, 8:28pm
Hi Kristin,
Thank you so much for going over this with me. I see where I made my mistakes, I got hung up on a different
classical way of diagnosing and couldn’t set aside the kidney yang deficiency I’ve been looking at and wasn’t sure
how to tease out what mattered here and what didn’t. I won’t do that again.
I have been reviewing my notes, I just don’t think I understood clearly how to prioritize. I’ll keep at it and I do plan
to take the class again. My thinking for using bilateral treatment was that it is a very severe problem and bilateral in
nature, but I hear you. I won’t do that again. I didn’t hear it said that menstrual pain with tissue is a Kidney excess
symptom, that would have steered me away from this, I’ll make note, thanks for that piece, it does make sense.
I’ll hit the notes and power point again and wrap my head around this. It sounds like moving forward with this
patient you recommend I stick with tonifying SI. Do I just go with the Right side then, because she is female, or are
there other considerations that I am missing?
Thanks again for sharing your expertise and time.
KristinWisgirda: September 28, 2020, 9:12pm
Practicing Saam, you do best to diagnose and treat only on Saam terms. It is not easy to suspend your vast
knowledge and habits of practice and take on a new system like this.
Hgardner:
menstrual pain with tissue is a Kidney excess symptom,
There is an association of blood stasis with Kidney excess in Saam but Toby presents it a bit obliquely in the
Powerpoint by saying that SI excess has a lack of blood stasis signs. (The reasons for this presentation are his wish
to adhere to the way he was taught).
Menstrual pain is stasis in the uterus. While Kidney excess can be considered for any kind of menstrual pain, SI+
isn’t always the way to go. Blood stasis is always a branch so knowing the cause will help you treat it effectively.
The presence of tissue means that there is more substantial denser stasis of blood and is therefore a stronger
indication that blood needs to be moved. The other strong K excess signs of you patient also support the use of SI+.19/01/2024, 11:15Case Study abdominal and pelvic pain – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-abdominal-and-pelvic-pain/1306/print6/6
michaelmax: September 29, 2020, 4:52am
Hgardner:
Thank you so much for going over this with me. I see where I made my mistakes, I got hung up on a different
classical way of diagnosing and couldn’t set aside the kidney yang deficiency I’ve been looking at and wasn’t
sure how to tease out what mattered here and what didn’t. I won’t do that again.
Hello @Hgardner, thanks for joining us in these discussions and this forum is a great resource for learning.
Sound like you now have first hand experience at the power of the system. And why it is a very good idea to only
do one side in the beginning.
A couple of points that might be helpful as you continue with learning Saam
1. One channel can be plenty, and more importantly it keeps your patient safe, and you can better learn the
system because you can reverse an incorrect treatment.
2. It is important NOT to mix your TCM in with Saam. They have different ways of looking at things and it is
very confusing to make a TCM diagnosis and then attempt to treat with Saam. I was working that way in the
beginning and I found I would usually be wrong. When starting out if I was unsure I’d NOT use Saam but I
would attempt to think about it in Saam terms as a way to begin to get the mental framework down.
3. Start slow. Only use Saam if you are sure about your DX.
4. If you’re unsure, come and ask here. We are happy to help you. We want your patients to get well too!
5. Listen to the podcasts on Saam as they can be helpful as well.
6. One last thing. It’s easy in the beginning to think someone has a “kidney” issue and so you tonify Kidney. In
TCM there is usually the idea that the Kidney can be deficient but not excess. In Saam, the KD can most
assuredly be excess. So watch out for that!
Again, one side is plenty if you dialed in the diagnosis. And if you haven’t then one channel can be too much.
So much for that idea that acupuncture is harmonizing and can’t hurt people. People that practice Saam know
better.
Hang in there and ping us here so you can clarify your thinking.
M.