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During menstruation, if the menstrual flow is sluggish and scanty, sometimes only spotting, or the duration of menstruation is shortened, it is called "hypomenorrhea." This condition is frequently documented in various Chinese medicine classics. Jingui Yaolue refers to it as "unfavorable menstrual flow"; Zhubing Yuanhou Lun calls it "unfavorable monthly cycle"; Danxi Xinfa and Zhengzhi Zhunsheng both term it "hypomenorrhea"; Furen Liangfang and Gynaecology Jinglun also describe it as "unfavorable menstruation." Women with normal menstruation who experience a single episode of reduced menstrual flow should not be diagnosed with "hypomenorrhea." For menopausal women, a gradual decrease in menstrual flow is a sign of menopause and should not be considered "hypomenorrhea." This condition is often a precursor to "amenorrhea" and can lead to infertility.

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1. Blood Deficiency︰Scanty menstrual flow, or even just a few drops, with pale red and thin blood, or as light as yellowish water; delayed menstrual period; lingering lower abdominal pain after menstruation that is relieved by pressing; pale complexion; dizziness and blurred vision; palpitation or severe palpitation; forgetfulness and insomnia; pale lips and nails; dry skin; pale tongue texture; deep, thin, and weak pulse. If internal deficiency-heat arises, symptoms may also include flushed cheeks, tidal fever, night sweats, vexing heat in the chest, palms, and soles; red tongue; and thin, rapid pulse. This condition is often caused by chronic blood loss, excessive childbearing, or inherent spleen and stomach weakness, which prevents the transformation of nutrients into blood, leading to an insufficient Sea of Blood in the Chong and Ren vessels, resulting in scanty or even absent menstrual flow. The clinical manifestations reflect signs of blood deficiency failing to nourish, such as pale complexion, dizziness, palpitation, pale lips, tongue, and nails, and light yellowish, thin menstrual blood. If deficiency-heat disturbs internally, symptoms like vexation, tidal fever, flushed cheeks, and night sweats may appear. Treatment focuses on nourishing blood, and Siwu Decoction with Sunflower Stem Pith can be used. For blood deficiency with internal heat, Lycium Root Bark Decoction can be employed to nourish blood and clear heat.
2. Spleen-stomach Weakness︰Scanty menstruation or dripping discharge, pale red and thin menstrual blood, delayed menstrual period, complexion shallow yellow, shortness of breath spontaneous sweating, weak voice, bland taste in mouth, poor appetite loose stool, or slight edema, leukorrhea clear and profuse, pale lips and tongue, soggy and weak pulse. The spleen and stomach are the foundation of the acquired constitution and the source of qi and blood generation and transformation. Nyuke Jinglun says: "Women's menstrual blood is transformed from the essential qi of the five flavors of food and water." If due to improper diet, or excessive mental overstrain, injury to the spleen and stomach; or if middle qi is damaged by mistakenly taking purgative medications, all can lead to insufficient qi and blood generation and transformation, and the Blood Sea cannot be filled, just like water without a source, hence the scanty or even dripping menstruation. The lackluster complexion, pale lips and tongue, fatigue shortage of qi, pale red and thin menstrual blood, etc., are all signs of qi and blood deficiency; if spleen qi is not robust, then bland taste in mouth, poor appetite loose stool, and thin white leukorrhea occur. For spleen-stomach weakness with scanty menstruation, the treatment focuses on tonifying qi invigorating spleen and harmonizing stomach, using the formula Ginseng, Poria and White Atractylodes Powder supplemented with Chinese Angelica and Sichuan Lovage Rhizome.
3. Blood Stasis︰The menstrual flow is scanty and unsmooth, with purplish dark color, sticky texture, and clots. There is stabbing pain in the lower abdomen that refuses pressure, delayed menstrual periods, dull complexion, scaly skin, breast distending pain before menstruation, purplish dark tongue texture, or ecchymosis, and deep hesitant pulse. One cause is emotional distress, liver qi depression, disturbance of qi movement, blood stagnation due to qi stagnation, leading to obstruction of the thoroughfare and conception vessels. Another cause is residual blood not being completely discharged during menstruation or postpartum, exposure to external cold, or internal damage from raw and cold foods, causing blood to congeal due to cold; or mistakenly taking cold and astringent remedies, leading to retained residual blood, congestion and stagnation in the uterine vessels, and obstruction of the thoroughfare and conception vessels. The main clinical features are: distension and pain in the lower abdomen before menstruation with a sensation of wanting to flow but not being able to, slight relief of pain after menstruation begins, but scanty and dribbling flow with many purplish-black clots, lower abdominal pain that refuses pressure, dull complexion, purplish dark tongue texture or ecchymosis, and deep hesitant pulse. The treatment should focus on invigorating blood and resolving stasis, regulating qi to regulate menstruation, Achyranthes Root powder.
4. Kidney Deficiency︰Scanty menstruation with light red or dull red color, thin texture, lower abdominal pain after menstruation, irregular cycles, dull complexion, vertigo tinnitus, soreness and weakness in the lower back and limbs, frequent urination, or nocturia, or low libido, pale red tongue texture, deep and thin weak pulse. The occurrence of scanty menstruation due to kidney deficiency is caused by congenital insufficiency, multiple pregnancies or deliveries, or excessive sexual activity, leading to depletion of essence and blood, resulting in the failure of the "Sea of Blood" to fill adequately. Insufficient kidney water leads to scanty menstrual blood, while insufficient kidney fire results in light-colored and thin menstrual flow. Symptoms such as vertigo tinnitus, soreness and weakness in the lower back and knees, frequent urination, and low libido may also be present. Since essence and blood mutually nourish each other, kidney deficiency and blood deficiency can also be mutually causative. Kidney deficiency failing to transform essence leads to even less blood, while blood deficiency failing to nourish kidney essence worsens kidney deficiency. Therefore, in treatment, benefiting the kidneys should also involve nourishing blood. The approach should focus on tonifying the kidneys, nourishing blood, and regulating menstruation. The formula Chinese Angelica Rehmannia Drink can be used with modifications.
5. Cold Invading the Uterus︰Scanty menstruation, or cessation immediately after onset, with light red or dark black color, thin and watery consistency, or accompanied by blood clots, lower abdominal cold pain relieved by warmth, delayed menstrual cycle, cold limbs, clear and profuse leukorrhea, pale and dark tongue texture, white coating, and deep and tight pulse. This condition is caused by excessive consumption of raw or cold foods, bathing in cold water, exposure to rain or wading through water, or overuse of bitter and cold medications, leading to cold invasion of the uterus and appendages, congealing blood and obstructing the uterine vessels, resulting in a pattern of pathogenic cold coagulation. Its characteristics include lower abdominal cold pain relieved by warmth, small blood clots mixed with thin menstrual blood, and a dull and dark tongue texture. Additionally, the patient usually prefers warmth and fears cold, has clear and profuse leukorrhea, and a deep and tight pulse, which can help differentiate it from scanty menstruation due to blood stasis. Treatment should focus on warming the meridians and dissipating cold, invigorating blood to regulate menstruation, with modifications of the Meridian-Warming Decoction recommended.
6. Damp Phlegm︰During the late stage [third stage] of menstruation, the flow is scanty, pale in color, thick and sticky, or mixed with mucus-like strands. The body is obese, with dizziness and heaviness in the head, soreness and fatigue in the limbs, chest tightness, gastric stuffiness, occasional nausea, a bland and greasy taste in the mouth, poor appetite, loose and thin stools, and thick, turbid leucorrhea with a foul, fishy odor. The tongue coating is white and greasy, and the pulse is wiry and slippery. This condition is related to obstruction by phlegm-dampness and the spleen-stomach. Spleen qi deficiency leads to impaired transportation and transformation, causing dampness to accumulate and form phlegm. Phlegm-dampness then descends to the Chong and Ren meridians, congesting the uterus and its appendages and obstructing the Jingmai, resulting in scanty menstruation. This syndrome is commonly seen in obese women with a tendency toward phlegm-turbidity accumulation. The clinical features include late-stage [third-stage] menstruation that is pale in color and thick, often mixed with mucus-like strands, as well as profuse, thick, and turbid leucorrhea. This differs markedly from the scanty menstruation with pale, clear flow and thin leucorrhea seen in spleen-stomach weakness. Accompanying symptoms prominently include dizziness and heaviness in the head, chest tightness, nausea, a bland and greasy taste in the mouth, and a white, greasy tongue coating. Treatment should focus on invigorating the spleen, resolving dampness, and dispelling phlegm. Prescriptions such as Cangfu Daotan Wan or Xiong Gui Er Chen Tang (Chuanxiong and Angelica Two Old Ingredients Decoction) with modifications are recommended.

The occurrence of hypomenorrhea is attributed to two aspects: deficiency and excess. In cases of deficiency, the source is insufficient, the Sea of Blood is empty, and there is nothing left to discharge. In cases of excess, the uterine vessels are obstructed, the Sea of Blood is blocked, and menstrual flow is impeded. Therefore, the primary approach to treating this condition is to differentiate between deficiency and excess. "Excess should be purged," and "deficiency should be treated with tonification." It is crucial not to mistakenly categorize all cases as excess pattern and indiscriminately use blood-stasis-breaking remedies, thereby violating the principle of not depleting what is already deficient.

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1. Jiyin Gangmu．Menstrual Regulation Section: "Maijing says: A woman came for diagnosis, saying her menstrual flow was less than before, why is that? The master said: She had diarrhea, if she sweats and urinates smoothly, it is acceptable. Why is that? The master said: She lost her body fluids, so her menstrual flow is less."
2. Nyuke Jinglun．Menstruation Section: "Maijing says: If the chi pulse is slippery, the blood and qi are strong, the woman's Jingmai is not smooth; if the chi pulse comes and then stops, menstruation is not smooth; if the cun and guan pulses are normal but the chi pulse does not reach, menstruation is not smooth, and there will be slight abdominal pain; if the liver pulse is deep, menstruation is not smooth, and there will be lower back and abdominal pain."