Hello welcome back to our integrative Women’s Health course. For today’s topic we are going to be focusing on polycystic ovarian syndrome. Polycystic ovarian syndrome.
Clinical Case Study: PCOS A typical case for example from Dr. Xiao, Cheng Cong, one of my masters that I learned from at Beijing University of traditional Chinese medicine. A 28 year old female patient. First visit is May 11th 2009. She has been complaining that she has delayed menstruation for 4 years. Due to her moving 4 years ago, her periods became delayed afterwards. She’s averaging 3 to 5 day flow, 30 to 60 days in between cycles. And her period tends to be scanty dark flow with no clots. There’s no particular dysmenorrhea and her last period is March 9th 2009. And she used traditional Chinese medicine patent formulas and they really didn’t seem to help much. Currently she still has delayed menstruation she has lower back soreness and she has weakness, tired, poor appetite. She does sleep well her bowel movements are pretty good. She’s overweight, obese, 155cm is her height and she weighs about 67.5 kg. Her tongue is pink, the coating is thin white greasy and her pulse is deep and slippery. Deep and slippery. So for example in this case, also her menarche was at age 12 and she had regular menstruation cycles before her move at 30 day cycle she’s always had 30-day cycles.
Upon the examination pelvic exam her external genitalia hair seems to be quite thick pelvic exam is negative everything seems to be pretty normal. The blood test in a blood test her LH level is about 11.07, and FSH is about 3.7 and Estrogen is about 60 and the Progesterone is about .034. And the testosterone is about 4.7 and Prolactin is about 13.26 So and looking at transvaginal ultrasound, her uterus is about 4 x 2.9 by 3.5 cm. Endometrial thickness is about 6 mm. The left ovary appears to be a full .1 – 2.5 cm and right ovary is about 3.9 x. by 2.4 CM. So there is, it seems to be there is about a 10 + polycystic structure in this non echoed area. And so she does appear as having PCO polycystic ovary situation.
What Is PCOS?
So what is it? Well PCOS polycystic ovarian syndrome is probably one of the most common endocrine disorder in women. And yet it remains very difficult to explain and there is a lot we don’t know about it. Despite its very high prevalence in the population, controversy still remains today. Especially regarding its diagnosis that’s why we call it syndrome instead of disease, its etiology and the most appropriate treatment strategy for this condition. Women with PCOS may have enlarged ovary that contain small collections of fluid. We call these follicles located in each ovary are seen during an ultrasound exam.
And we could also see hirsutism and acne. People with PCOS tend to have infrequent or prolonged menstrual cycle menstrual period. They can have excessive hair growth especially in the chin and the side of the jaw here. And an acne situation all around here the forehead here and obesity can all occur in women with PCOS. In adolescence we can see infrequent or absent menstruation and that may raise a suspicion in that time for this particular condition.
The exact cause of PCOS is still unknown. Early diagnosis and treatment along with weight loss may reduce the risk of long-term complication. So weight loss and dietary change and lifestyle modification is still kind of like the first treatment principle. This can also help to reduce the possibility of getting type 2 diabetes and heart disease in the future.
Epidemiology of PCOS? So let’s take a look at the epidemiology of this condition. In prevalence in the United States PCOS is one of the most common endocrine disorders of reproductive age woman with a prevalence rate of approximately 4 to 12%. Up to 10% of these women are diagnosed with PCOS during gynecological visits. Now in some European studies the prevalence of PCOS has to be reported to be 6.5 to 8%. That seems to be a little bit less than in United States. There is a great deal of ethnic variability in hirsutism that can be observed. For example in Asians, East and Southeast Asian women actually have less hirsutism than white woman given the same Sarin Androgen values. In a study that assessed hirsutism in Southern Chinese woman for example, investigators found a prevalence rate of about 10.5%. And in the hirsute women there was a significant increase in the incidence of acne, menstrual irregularity, polycystic ovaries and acanthosis nigricans.
Acanthosis Nigricans and PCOS So acanthosis nigricans it’s a skin condition characterized by an area usually around the neck area of dark velvety discoloration. The body folds increase and this affects the neck area the armpit area and groin area. This seems to be area that you can see. In the slide if you able to look at the slide it’s there in the slide I am showing a picture of it. The skin changes typically occur in people who are obese or having diabetes. Children who develop this condition are at higher risk of developing type 2 diabetes. Rarely though this condition can be a warning sign of a cancerous tumor in an internal organ such as the stomach or liver.
Affected Ages Now PCOS affects premenopausal women. And the age of onset is mostly frequently perimenarchal so just around the age before a woman reaches 16 years old. However clinical recognition of the syndrome may be delayed by the failure of the patients to become concerned by irregular menses. Or a lot of time they aren’t necessarily going to see the doctor right away. They might not be as concerned with their hirsutism or other symptoms or by the overlaps of PCOS findings. Sometimes you can see a normal physiological maturation especially during two years after menarche. Now in lean women the women who are lean, with them they can still get PCOS if they have a genetic predisposition. The syndrome may be unmasked when they subsequently gain weight so sometimes when with weight gain that’s when the symptoms start to show up. So the ages affected can be from adolescence all the way to menopause situation.
Prognosis of PCOS So let’s take a look at the prognosis of PCOS. PCOS does have a lot of different things, a lot of different clinical features, that surrounds this syndrome. The first is cardiovascular disease risk. There is absolutely evidence that suggests that a woman with PCOS may be at an increased risk for cardiovascular and cerebrovascular diseases. Women with hyperandrogenism have elevated sarin lipoprotein levels cholesterol for example similar to those of men. There is also associated risk with insulin resistance or type 2 diabetes. Approximately 40% of women with PCOS have insulin resistance that is independent of body weight. These women are at increased risk of type 2 diabetes and consequently cardiovascular complications. So the American Association of Clinical Endocrinologists and the American College of Endocrinology both recommend screening for Diabetes by age 30 years old in all patients with PCOS. Including it doesn’t matter if its obese or non obese women. Now in patients who have a particularly elevated risk, testing before 30 years old may be an indicated. Patients who initially test negative for diabetes should still periodically be re-assessed throughout their lifetime, that is still important.
These patients with PCOS can also have the social risks of having endometrial hyperplasia. There’s an increased risk of this condition and carcinoma. Because of the chronic anovulation in PCOS, what happens is that it leads to constant endometrial stimulation. With increased estrogen and without progesterone protection this increases the risk of endometrial hyperplasia and carcinoma. The Royal College of Obstetricians and Gynecologists, RCOG, recommends induction withdrawal bleeding with progesterone at a minimum of every three to four cycles every 3 to 4 months.
It is very important for us as clinicians to educate our patients. To discuss with our patient’s the symptoms of PCOS as well as the increased risk for all the associated situation such as cardiovascular and cerebrovascular diseases is warranted. We need to educate our patients with this condition, in women with this condition we get into lifestyle modification such as weight reduction, such as increased exercise and dietary modification.
Now, breast and ovarian cancer with PCOS there’s really no known association with breast or ovarian cancer that have been found. Thus, no additional surveillance is needed for these two type of cancer.
Practice Key Points So let’s move move forward to practice key points, look at sound to practice key points. First of all, women with PCOS have abnormalities in the metabolism of androgen and estrogen, and the control of Androgen production. Therefore PCOS can result from abnormal function of the HPO hypothalamic pituitary ovarian axis. And when a woman is diagnosed with PCOS I’m sorry when a woman is diagnosed with polycystic ovaries that is usually how we diagnosis that, if she has 12 or more follicles in at least one of the ovaries, that would be PCO.
Endocrine Society Guidelines Now that’s take a look at the Endocrine Society guidelines for diagnosis and management of PCOS. In October 2013 the Endocrine Society released practice guidelines for the diagnosis and treatment of PCOS and the following is among their conclusions. Basically using the Rotterdam criteria for diagnosing PCOS, which is the presence of two of the following. Either you have androgen excess, ovulatory dysfunction or PCO. Either two of these will give you the diagnosis of PCOS.
Rotterdam Consensus of 2003 So if we look at the Rotterdam consensus of 2003 in 2003 the Rotterdam European Society for human reproduction, as well as the American Society for Reproductive Medicine sponsored a PCOS consensus workshop group. Which proposed that the diagnosis again includes two out of three of the following criteria. One, oligo- and/or anovulation. Two, clinical and/or biochemical hyperandrogenism. Number three, polycystic ovaries on ultrasound. And as long as other etiologies must and have been excluded.
So there are some differences, some differences between different Societies in National Institute of Health. But basically they all adhere to this diagnostic. In adolescents with PCOS hyperandrogenism is central to the presentation. So in that situation in a conventional sense hormone contraception and Metformin are the treatment options in this population, especially are trying avoid pregnancy at this time. Now postmenopausal women do not have consistent PCOS phenotypes a lot of the time you don’t necessary treat the reproductive cycle and menstrual cycle situation. Now we do need to exclude alternate androgen-excess disorders and risk factors for cardiovascular disease, diabetes , endometrial cancer, mood disorder and obstructive sleep apnea.
Continuing onward with the Endocrine Society guidelines, for infertility clomiphene is the first line of treatment. For metabolic glycemic abnormalities and for improving menstrual irregularity metformin can be an option and can be beneficial. Metformin is of course of limited or no benefit all in managing hirsutism acne or infertility. Obviously more investigations are needed to determine the roles of weight loss and statins for example in PCOS.
Thiazolidinediones So there’s a drug called glitazones. This is a class of medication that’s used in treatment of Diabetes Type 2 they were introducing in the late 1990s. And that can also be used but is really pretty much of an unfavorable risk-benefit ratio and that’s why it’s been discontinued by a lot of endocrinologists.
Signs and Symptoms of PCOS Now in the signs and symptom the major features of PCOS include menstrual dysfunction, anovulation, and signs of hyperandrogenism. Other signs and symptoms of PCOS mainly include the following: hirsutism, infertility, obesity, and metabolic syndrome, diabetes and obstructive sleep apnea.
Family History So let’s take a look at the medical history of PCOS. We want to take a good thorough history for example in family history we want to take a look the menstrual history, the adrenal enzyme deficiency, and if there’s any history of hirsutism in the family. History of infertility and obesity and metabolic syndrome in the family.
Menstrual Abnormalities Now patients with PCOS have abnormal menstruation pattern attributed to chronic anovulation. And the patient usually by herself has a history of menstrual disturbance and it might be dating back to menarche. Some women have oligomenorrhea. Basically this is a situation where the menstrual bleeding occurs at an interval of 35 days to about 6 months with less than 9 menstrual periods per year. Or a secondary amenorrhea, where there is an absence of menstruation for 6 months Now dysfunctional uterine bleeding and infertility are the other consequences of anovulatory menstrual cycles. So the menstrual irregularity in PCOS usually present around the time of menarche.
Hyperandrogenism The hyperandrogenism clinically manifests as excessive terminal body hair in a male distribution pattern. Harir is commonly seen in upper lip, in the chin, around the nipple, along the line the linea alba of the lower abdomen. And some patients have acne and even to the point of male pattern hair loss what we call androgenic alopecia. Other signs can include clitoromegaly, can include increased muscle mass, and voice deepening. These are characteristics of an extreme situation of PCOS and things such as also hyperthecosis.These signs and symptoms could also be consistent with an androgen producing tumor so we need to exclude that diagnosis. As well as exogenous androgen administration or other possible congenital adrenal hyperplasia.
Hyperthecosis Hyperthecosis is a hyperplasia of the theca interna of the ovary. It Is when an area of luteinization occurs along with stromal hyperplasia. The luteinized cell produces androgens which may lead to hirsutism and masculinization.
Premature adrenarche is a common occurrence. And in some cases it may present as a precursor to PCOS. So women sometimes a girl sometimes could already start having excessive hair, could already start having obesity, even before they present having menstruation. So the American College of Obstetricians and Gynecologists ACOG recommends screening with 17 hydroxyprogesterone levels in women suspected of having PCOS who are at increased risk for non-classical congenital adrenal hyperplasia.
PCOS and Infertility Now a subset of women with PCOS is infertile but not every PCOS patient is infertile. But there is a subset of women who are infertile especially when these women do not ovulate properly or ovulate intermittently. Conception may take longer than in other women, women with PCOS may also have fewer children than they had planned. In addition the rate of miscarriage is also higher in affected women.
Obesity and Metabolic Syndrome In obesity and metabolic syndrome, nearly half of all women with PCOS are clinically obese. A study comparing the body mass index in American and Italian women with PCOS showed that American women had a BMI higher than that of their Italian counterparts. Women with PCOS should be assessed for their cardiovascular risk by evaluating their BMI, fasting lipid and lipoprotein levels and risk factors for metabolic syndrome. Many patients with PCOS have characteristics of metabolic syndrome. In fact one study showed a 43% of prevalence of metabolic syndrome in women with PCOS just to give you some idea of that not every PCOS patient is going to have metabolic syndrome but it is quite high up in prevalence. In women metabolic syndrome is characterized by abdominal obesity where the waist circumference is greater than 35 inches. There might be dyslipidemia where the triglyceride level is greater than 150 milligrams per deciliter. High-density lipoprotein cholesterol level can be less than 50 mg. Elevated blood pressure you can see also, and you can have a poor inflammatory state characterized by an elevated C-reactive protein level. The prothrombotic state characterized by elevated plasminogen activator inhibitor-1 and fibrinogen levels. Women with PCOS have an increased prevalence of coronary artery calcification and thickened carotid intima media. Which may be responsible for subclinical atherosclerosis. Prospective long-term cardiovascular outcome studies in PCOS are needed to assess whether the increased cardiovascular risk in PCOS results in higher cardiovascular event rates.
IR and T2DM ACOG does recommend screening for type 2 diabetes and impaired glucose tolerance in women with PCOS by obtaining a fasting glucose level. Then a 2-hour glucose level after a 75-gram glucose low or glucose challenge. Approximately 10% of women with PCOS have type 2 diabetes. And 30 to 40% of women with PCOS have impaired glucose tolerance by 40 years old.
Sleep Apnea and PCOS Sleep apnea can also be an issue. Many women with PCOS have obstructive sleep apnea syndrome which is an independent risk factor for cardiovascular disease. Ask these patients and/or their partners about excessive daytime somnolence. Individuals with obstructive sleep apnea tend to experience a lot of snoring or sometimes apnea episodes during their sleep where they literally stopped breathing. For women with PCOS with suspected sleep apnea syndrome there should be a low threshold for referral for Sleep Assessment. Patients may also be screened in a clinical setting using tools such as the what we call the Epworth Sleepiness Score. Now the Epworth sleepiness score or scale is widely used in the field of sleep medicine as a subjective measure of patient’s sleepiness. The test is a list of 8 situations in which you rate your tendency to become sleepy on a scale of 0 which is no chance of dozing to 3 which is a high chance of dozing. When you finish the test you add up the value of your responses and your total score is based on the scale of 0 to 24. And the scale estimates weather you experiencing excessive sleepiness that possibly requires medical attention. So they are broken down into situations such as when you’re watching TV and when you’re sitting, those kind of situation and the will create a score.
PCOS Physical Exam Hirsutism and virilizing signs Now the next thing we should look at is the physical exam for PCOS. Obviously the patient can exhibit many signs, for example of hirsutism or masculinization signs. You could have excessive body hair in the male distribution pattern as well as acne and some patients have masculinizing signs such as male pattern baldness, alopecia, you could have increased muscle mass, deepening voice, or clitoromegaly. These findings should prompt a search for other causes. Make sure that you have excluded other causes of hyperandrogenism. There is also the modified Ferriman Gallwey score, which grades 11 body areas from 0 – no hair, to 4 – frankly masculinized. This includes the upper lip, the chin, the chest, upper and lower abdomen, thighs, upper and lower back arms, forearms and buttocks. A total score of 8 or more is considered abnormal for an adult white woman. A score 44 is the most severe. In the slide I’ve shown you an image of the modified Ferriman Gallwey score system for you to look at.
Approximately 50% of women with PCOS have abnormal abdominal obesity, characterized by a waist circumference, so sometimes so sometimes we call this centripetal weight gain. A waist circumference greater than 35 inches is considered to be abdominal obesity.
And don’t forget acanthosis nigricans is again a diffuse velvety thickening situation of the skin full in the neck area, in the armpit area, as well as in the groin area. This is thought to be a result of insulin resistance although syndromic and familial variance are described. The situation can also be a cutaneous marker for possible malignancy, so we need to be careful when you see this. There are actually different grades of this, there’s a zero grade which is absence to as high as a severe 5. It is what we call the circumferential rating.
Blood Pressure Moving forward to blood pressure. Patients with signs and symptoms of metabolic syndrome may have elevated blood pressure. Whether a systolic blood pressure of 130 or higher or a diastolic blood pressure of about 85 or higher. So you do want to take a look at the blood pressure situation.
Enlarged Ovaries And obviously you might and most likely you will see enlarged ovaries, not everybody, but the evaluation for the enlarged ovaries is usually done through ultrasound. So we want to be able to do some differential diagnosis because they are conditions that do mimic PCOS and we should rule them out before a diagnosis of PCOS is confirmed. So we need to take a look at some of these conditions. For example you need to rule out primary ovarian hyperthecosis, congenital adrenal hyperplasia, drugs. The use of danazol, use of androgenic progestins, can also create a mimicry of this condition. Hypothyroidism, a patient with menstrual disturbance and signs of hyperandrogenism. Idiopathic hirsutism. Familial hirsutism. Masculinization tumors of the adrenal glands or ovaries. Cushing syndrome. Hyperprolactinemia. Exogenous anabolic steroid use. Stromal hyperthecosis. Okay so these are things you want to try to rule out.
Differential Diagnosis Now although obesity itself is not considered part of the differential diagnosis. Obesity as we said before is highly associated with insulin resistance or any condition that is associated with severe insulin resistance, which may clinically manifest in the same way as PCOS. Obesity therefore may unmask features PCOS in women who are genetically predisposed to this syndrome.
And there are other things you need to rule for example acromegaly, amenorrhea, gigantism, hyperprolactinemia, hyperthyroidism, hypothyroidism. Iatrogenic Cushing syndrome. Ovarian tumors. So these are some things that you do want to rule out.
PCOS Treatment And if we look at PCOS treatment in Western Medicine basically you know really the very first thing we tell patients is to make some change. The number one approach should be lifestyle modification: diet, exercise, weight control, contraception, skincare, emotional care. Should be probably your first line of treatment. And if that doesn’t work out you can try Metformin 1500 to 2000 mg a day. Or you can do oral contraceptives. Or you can do Flutamide. Spironolactone. Or if you’re trying to get pregnant, you want to use Clomiphene citrate or Letrozole. Or gonadotropins or even ovarian drilling. And in the worst situation IVF.
Zang Fu Dysfunction So let’s go to traditional Chinese medicine. The TCM perspective is that this is a Zang Fu dysfunction. And also there are direct causes to this condition. Zang Fu dysfunction basically is the kidney deficiency, spleen deficiency, as well as the liver stasis. And the direct causes are basically phlegm damp, as well as stagnant blood. These are the direct causes.
PCOS Pathology In etiology there is non-endogenous and there’s non-exogenous. And there’s also endogenous. Endogenous causes are basically coming from the inside. These have to do was the faculty organs. So a lot of times, the dysfunction of spleen, liver, and kidney. In the invasion of phlegm damp, this can come the inside and this can come from the outside. So it can be both ways. So phlegm damp invasion is one big one. In pathology in endogenous, you know a lot of time this is due to kidney Yang deficiency unable to warm up and transform water dampness. Or spleen yang deficiency when it is unable to transport and transform water dampness. This water dampness retention can clear phlegm and that the phlegm can create a turbidity to block the Bao Gong. So that’s the endogenous pathology. You might also see it in, for example, kidney yin deficiency with fire rising or liver stasis causing fire. These two situations can all cause parching of the body fluid. And when you keep on boiling, keep on overheating the body fluid guess what happens? That water is going to become stickier, its going to become phlegm. So it transfer to the phlegm, and that in turn causes phlegm turbidity blockage in the Bao Gong.
Then there’s the non-exogenous and non-endogenous type of pathology. You could have a cold invasion, the cause of kidney yang. Confined, unable to warm. You could have a damp invasion, the cause a spleen yang. Confined, unable to transport. Both of these cause water damp retention to create phlegm. Again at the end of the day it’s always the phlegm turbidity blocking the Baa Gong. That is the pathology.
So in TCM it’s management and treatment are in the categories of: treating amenorrhea, infertility, abnormal uterine bleeding, and Zhen Jia conditions.
PCOS Kidney Yang Deficiency with Stagnancy Therefore the main syndrome we have is kidney yin deficiency with stagnancy. We have kidney yin deficiency with stagnancy. We have qi deficiency with phlegm. We have liver qi stasis.
Let’s look at the kidney yang deficiency with stagnancy. This is when we see irregular delayed menstruation. We see infertility history, obesity, hirsutism. There’s oligo and/or hypo-menorrhea, amenorrhea, and under development of the breasts. Aversion to cold, cold and sore back, decrease libido. Decreased vaginal discharge or lubrication. Tongue is pale, coating is thin white, and pulse is deep thready.
PCOS Kidney Yin Deficiency with Stagnancy In kidney yin deficiency with stagnancy we can see irregular delayed menstruation, delayed menarche, infertility history, and hirsutism. So we can see oligo and/or hypo-menorrhea, bright red flow, irregular vaginal bleeding, amenorrhea, under-development of breasts, sore back, decreased libido, decreased vaginal discharge or lubrication, dry mouth. Tongue is usually red, coating is usually lacking or decreasing. And the pulse is usually thready and rapid.
PCOS Qi Deficiency with Phlegm If we look at qi deficiency with phlegm, you’ll see: obese patient, hirsute patient, oligo and/or hypomenorrhea, but the flow is going to be a pinker flow, irregular vaginal bleeding, spotting, amenorrhea, nausea, reflux, you can have epigastric extension, lethargic sleep, fatigue, sore back, there should be decreased libido, excessive vaginal white discharge, diarrhea, and poor appetite. So the tongue here can appear to be pale, swollen with teeth marks, coating is white and greasy, and pulse is thin slippery or deep thin.
PCOS Liver Qi Stasis And the fourth syndrome is liver qi stasis. This is where a lot of time we see a history of severe emotional trauma. This patient can have hirsutism. Oligo and/or hypomenorrhea, amenorrhea, deep red flow with clots, she might have acne, breast tenderness, irritability, restlessness, constipated, bitter and/or dry mouth, tongue is frequently dark red. Coating is usually thin yellow and pulse is wiry slippery and rapid.
PCOS Herbal Treatment Overview So in these four situations we have a very strong herbal strategy for this. In the kidney yang deficiency with stagnancy we use modified Gui Shen Wan, modified Gui Shen Wan. As well as Gui Shen Ci Zhao Tang, Gui Shen Ci Zhao Tang.
In the kidney yin deficiency with stagnancy we use Liu Wei Di Huang Wan combined with Shi Xiao San. Or we can use Professor Lou Yuan Kai’s Experiential Formula for this. Then the third where you have qi deficiency with phlegm we can use modified Cang Zhu Dao Tan Wan. Or, second we can use Shi Jin Yi’s Experiential Formula which we will talk about in a moment.
In the liver qi stasis situation we can use Dan Zhi Xiao Yao San and Qing Qi Hua Tan Wan combination. So that’s the herbal strategy for this condition.
In a kidney yang deficiency if we only have kidney yang deficiency then we can always use You Gui Wan and Jin Kui Shen Qi Wan. But if we have kidney yang deficiency with a lot of phlegm damp, this is where Gui Shen Ci Zao Tong is helpful. And basically using Gui Shen Wan plus Ban Xia, Cang Zhu and Dan Nan Xing can also be used.
So let’s take a look at Gui Shen Wan plus-minus. Now in this situation what we want to do is use a combination of Tu Si Zi, Du Zhong, Guo Qi Zi, Dang Gui, Shu Di, Shan Yao, Fu Ling and this is where we can add Ban Xia, Cang Zhu and Dan Nan Xin into to the mix. We can add Huang Qi, Dang Shen, Bai Zhu if fatigue, poor appetite, and diarrhea is present. We can add Shan Zha. Chuan Xiong, Chuan Niu Xi if dysmenorrhea with dark red clots. We can also use Gui Shen Ci Zhao Tang which is a combination of Tu Si Zi, Du Zhong, Zi Shi Ying, Xian Ling Pi, Ba Ji Tian, Shan Yao, Shu Di, Dang Gui, Shan Ci Gu, Zao Jiao Ci, Xia Ku Cao, and Xiang Bei Mu.
In kidney yin deficiency with stagnancy we can use a combination of Liu Wei Di Huang Wan + Shi Xiao San. Liu Wei Di Huang Wan is obviously Shu Di, Shan Zhu Yu, Shan Yao, and Dan Pi. And you can add in Pu Huang and Wu Ling Zhi. You can also add Zhi Mu, Huang Bo for deficient fire You can also add Da Huang, Mang Xiao, Zhi Shi for constipation. You can also add Bo Zi Ren for insomnia.
Kidney yin deficiency and stagnancy we can also select Dr. Lou Yuan Kai’s Experiential Formula. Professor Lou Yuan Kai is a very famous obstetrician OBGYN in the southern part of China in Guangzhou City. The formula he has devised is Sheng Di 15g, Gou Qi Zi 15g, Nu Zhen Zi 15g, Shan Yao 20g, Zhen Zhu Mu 20g, Shan Zhu Yu 12g, Xian Ling Pi 9g, Ji Xue Teng 20g, He Shou Wu 20g. In this situation we can also add Yu Jin, Bai Shao, He Huang Pi 15g each for liver stasis, if there is any. We can also add Yi Mu Cao 20g, Dan Shen 20g, Tao Ren 12g, Hong Hua 12g for blood stagnation.
Let’s move onto Qi deficiency with phlegm. This is where we can use modified Cang Zhu Dao Tan Wan. Cang Zhu Dao Tan Wan is a combination of Fu Ling, Ban Xia, Chen Pi, Gan Cao, Cang Zhu, Xiang Fu, Dan Nang Xin, Zhi Ke, Sheng Jiang, and Shen Qu. In that situation can add Huang Qi, and Dang Shen into the mix. We can add Dang Gui, Chuan Xiong, Ji Xue Teng for hypomenorrhea. We can Pu Huang, Wu Ling Zhi, Yi Mu Cao for blood stagnation especially if you have a lot of pain.
Another formula to treat qi deficiency with phlegm is doctor, professor Shi Jin Yi Experiential Formula. This is a combination of Chuan Shan Jia, which we don’t use anymore Zao Jiao Ci 12g, Kun Bu 9g, Dan Shen 12g, E Zhu 9g, Bai Jie Zi 9g, Ting Li Zi 9g This is a Formula that’s used for this kind of condition.
Let’s continue on if we have liver qi stasis. We can use a combination of Dan Zhi Xiao Yao San + Qing Qi Hua Tan Wan. So we have Dan Pi, Zhi Zi, Dang Gui, Bai Shao, Chai Hu, Bai Zhu, Fu Ling, Sheng Jiang, Bo He, Zhi Gan Cao. And we can add the Gua Lou Ren, Huang Qin, Fu Ling, Zhi Shi, Xing Ren, Chen Pi, Dan Nang Xin, Ban Xia into the mix.
PCOS Acupuncture Therapy Acupuncture therapy can be very helpful Professor Zhu Xiu Du uses from day 1 – 14 uses acupuncture conception vessel point number 3 to 4. And that’s one pair and you can do Zi Gong to stomach 36 that’s bilateral. 3-day consecutive and one more treatment after one week. And the professor Lin uses alternating of three groups combining with herbal therapies. The first group is spleen 6, CV4, spleen 8 and stomach 28. The second group uses stomach 29, kidney 12, CV2, and spleen 10. The third group uses stomach 28, CV3, stomach 29, and spleen 6. Professor Zhu Xiu Du also suggests deep needling of the Zi Gong point of the enlarged ovary. Deep needling of CV4 to the uterus. If you are not very skilled you may want to do this because you create and possibly might have some damage to the internal organ when you do so.
And there are miscellaneous herbal therapies that are useful. For example Dr. Yu Jin’s Experiential Formula. It’s a combination of shu di, shan yao, bu gu zhi, xian ling pi, huang jing, tao ren, zao jiao ci, shan ci gu. This formula tonify kidney, dissolve phlegm, activate blood, and regulate menstruation.
Review Clinical Case Study So coming back to our original case of dr. Xiao Cheng Cong. A 28 year old female. First visit is May 11th 2009. Delayed menstruation for 4 years due to moving. Periods became delayed afterwards. Period flow 3 to 5 days. Cycle is 30 – 60 days. Scanty dark flow with no clots. There’s no painful periods. The last menstrual cycle is March 9th 2009. And has used TCM patent with no help. And currently there’s delayed menstruation. Lower back soreness, weakness, poor appetite, sleep well, bowel movement is good. Obese, she is about 155 CM weighs about 67.5 kg. Tongue is pink coating is white greasy and the pulse is deep slippery. And again menarche about age 12 had a regular menstrual cycle before the move at 30 day cycle that’s what she had. In an examination the external genitalia hair seems to be quite thick but pelvic exam is negative. Again blood test LH is at 11, FSH is at 3, E2 is at 60. Progesterone is at .34. Testosterone is at 4.7, prolactin at 13.26. Transvaginal ultrasound shows uterus at 4 x 2.9 x 3.5. Endo is at 6 mm, left ovary, size of left ovary is 4.1 by 2.5. Right ovary is about 3.9 by 2.4. And there is 10 + polycystic cysts that show none echoed area.
So the TCM diagnosis in this situation is delay menstruation infertility. Western medicine diagnosis of PCOS primary infertility. And the TCM syndrome diagnosis is kideny spleen deficiency, inflamed stagnation. So the treatment principle is to tonify kidney, strengthen the spleen. Okay this is your organ strengthening. Then you want to disperse phlegm and relieve stagnancy. So the formula she has selected is Xu Duan 15, Du Zhong 15, Sang Ji Sheng 15, Ba Ji Tian 15, Tu Si Zi 15, Bai Zhu 15, Fu Ling 15, Che Pi 12, Dan Nan Xing 6, Gan Cao 6, Ban Xia 10, Zhi Shi 15, Yin Chen 15, Ze Lan 15, Chuan Niu Xi 15, Xiang Fu 12. It’s a pretty big formula. This patient had 4 visits within two months with some mild modifications.
8-23-2009 visit: LH 5.23, FSH 4.02, E2 100, P 0.33, T 2.5, PRL 12.57, lost 6.5 Kg. Patient continued herbs for another six months, menstrual cycles normalized and conceived.
And on August 23rd 2009 visit LH 5.23, FSH 4.02, E2 100, P 0.33, Testosterone level has gone down to 2.5, Prolactin 12.57, and she has lost 6.5 Kg, that’s quite a bit.
Patient continued herbs for another six months and her menstruation finally normalized and she actually conceived.
So in this chart I’ll show you the LH. If you look at the LH, it’s supposed to rise around ovulation for other times LH level is extremely low and usually below 10. But for some patients especially PCO patients for whatever reason their LH seems to be a little bit elevated. And prolactin level, usually can be elevated during the time of when you are pregnant and also when you’re breastfeeding. n the PCOS situation prolactin level can play a little havoc can be a little bit elevated and that sometimes, or it can be normal you know a lot of time it can be normal. LH usually as I say again can be a little elevated with the people who have PCOS. And estrogen level, a lot of times a lot of this follicular cyst produces extra estrogen so the estrogen level sometimes can be elevated. If you look at chart over here you’ll see the estrogen level gradually climb up to the time when you’re ovulating. So a lot of times a lot of PCO patients, even at a very beginning of their cycle there estrogens are already rising much earlier than in other people. And testosterone levels are also very interesting. You’ll see in PCOS patients the testosterone level is a little bit higher than their cohort, than their peers. And there are other test that you may want to consider especially if you’re treating a patient for a metabolic condition So for example you may want to do a fasting glucose, triglyceride, LDL cholesterol, HDL cholesterol. Beside your standard FSH, LH, and testosterone test you can also do the yeah you can do DHEA, hydroxyprogesterone you can also do insulin and also, insulin resistance testing.
So this concludes this topic on PCOS. I hope this is helpful to you and I look forward to seeing you next time. Thank you so much for your participation and your listening.