In my last column, I delved into the topic of polycystic ovarian syndrome (PCOS). I noted thin type PCOS women often present less frequent or no ovulation/periods. Ultrasounds on these women show ovaries full of immature follicles, and FSH - LH ratios of 3/5: 1 instead of the normal 1:1. What set these women apart was they often present normal vital signs. Their insulin/glucose levels are normal. They are not hairy and usually are on the thin side. These women are hard to treat because beside the anovulation, they are usually healthy and don't have any glaring things wrong with them. As I mentioned before, this is not the case with the heavier type PCOS women who are relatively easy to treat successfully.
I tend to have success with thin PCOS women, but it often takes eight months to a year or even a year-and-a-half to get them pregnant. I was frustrated with the glacially slow rate of treatment success. Often with my female gynecology patients I would use Jane Lyttleton's four-phases of the menstrual cycle base formula as a guide with great success. However, because of the irregularity of the cycles of these women it is difficult to manage the formula intake, so I switched to what I call a constitutional formula for daily intake and a formula like Toa Hong Si Wu Tang to be taken during menstruation.
I had slightly better results with this, but not as quick as I was hoping for.
The other reason for the switch to the one constitutional formula was that the follicular phase formula is based on Liu Wei Di Huang Wan + Dang Gui and Bai Shao Yao. Even with modifications I wasn't comfortable giving these yin building herbs to these women who seemed to have too much yin clogging up their ovaries already.
Then lady luck smiled upon me and I took Dr. Huang Huang's course on 10-formula families. I cannot rave enough about this course. It was illuminating and extremely useful to hear about herb formula families used to treat different body types. I am sure you have all had patients that you feel you have diagnosed correctly and that their treatment is correct but have gotten slow/plateaued or no results. This course was like the last piece of the puzzle clicking into space. Dr. Huang explained how even with the same presentation and TCM diagnosis you would use different formulas as a base depending on your patient's body type.
The formula family that made it click for the PCOS women (both thin and heavy) was Da Huang. Da Huang is a strong purgative and lower jiao blood mover. Most of us in the west are a little afraid to use it, and have learned to use it only for food stagnation. Dr. Huang said that he polled 120 or so of his Chinese colleagues and asked them which herb was the most useful. Their answer: Da Huang. This is another topic, but I feel that deficiency is over diagnosed here in the west, principally because tiredness is a chief complaint for so many. However we are also mostly over nourished and stressed, thereby making the tiredness a result of liver qi stagnation and dampness. I digress. The point is that we are afraid of damaging qi/yin/blood so much that we do not use strong herbs like Da Huang.
Again lady luck smiled on me because the day after I did the Da Huang part of the course, I had a PCOS patient. She was an athlete, thin, but strongly built. I decided to take the leap and try out my newfound knowledge. I was surprisingly scared, but added Da Huang to her formula. I also added Rou Gui (warm moving lower jiao herb) to her formula because Dr. Huang said this helps to open up the lower jiao even more and soften the harsher cold bowel stimulating effects of Da Huang. Low and behold, she got her next cycle at day 30 and has been regular since then. When she took the formula for the first time she said she felt lighter and clearer than she ever had, it was like a veil was lifted from her.
Previously her tongue was bright red with cracks, she had cystic type acne on her face - she was obviously excess heat and dampness. She had heavily dream disturbed sleep that cleared up as well.
Needless to say, I am now a Da Huang and Rou Gui junkie. Anytime I see excess and/or blockage in the lower jiao, I use that combo to clear it out. It works great for blood stasis, damp/phlegm, cold, you name it.
Going back to the patterns you see with PCOS women in general, they often have phlegm/damp blockage in the lower jiao, often complicated with blood stasis and either heat or cold.
One interesting thing you will see is that their tongues are what I call "old heat spots" (I think I got the concept and/or the term from a Brandon Horn/ Wendy Yu course I attended). These are spots on the tongue that are not raised, often large (pea-sized) and maybe not red or only slightly red. Brandon/Wendy described this as an old infection that was lodged in the body. Through this course and working with HIV-positive patients, I revisited the concept of latent heat and the relationship between heat and dampness.
We all learned in school that heat can create dampness in the body and vice versa. Well these "old heat spots" on the tongue are example of the body trying to protect itself from heat by encapsulating it in dampness. Clinically, you will find women with these spots often have fibrocystic breasts, uterine fibroids and/or polyps and sometimes PCOS. There is usually a history of some unresolved infection (e.g. sexually transmitted diseases) and/or external heat pathogen not properly expelled. Here the body is isolating the pathogen's dangerous effects from the body by encapsulating it in dampness. This knowledge radically changes a treatment strategy. The problem is not the dampness, the dampness is the body's solution to the heat. So if you just clear damp, then you leave the damaging heat in the body. You have to clear heat as well. I'm the last person who should be commenting on the classics, but I believe that Zhu Dan Xi was a big fan of clearing heat.
As Dr. Huang emphasized in his course, clearing heat (any excess as well) works better if you give it a place to go. How does the body naturally clear heat? The most comfortable and usually convenient way is through urination or bowel movements. Hence the use of Da Huang to break up stasis in the lower jiao and clear out the stasis through the bowel movements that Da Huang stimulates. You can also clear out heat/stasis/dampness through urination. This might explained the wide use and effectiveness of Yi Mu Cao that not only clears out stasis in the lower jiao, but it is also cool and promotes urination by clearing out all the waste metabolites that likely accumulate in and around stasis/dampness.
As for acupuncture, I have not had the same "aha" moment as I have with the herbs. With that said, I have great success with PCOS patients and treat them all with both acupuncture and herbs. I use the Dai Mai and the San Jiao/gall bladder/ liver channels to clear the encapsulated heat. I think of this as a Shao Yang unresolved exterior heat stuck inside sort of thing. If I regulate the Dai and "open" up the Shao Yang with the aid of the herbs, the old heat just pours out in the patients stool. Now that the heat is gone the body no longer needs the damp/phlegm and it resolves itself. I open up the Dai Mai with the combo SJ 5/GB 41.
This also doubles with helping out the Shao Yang character of the problem. Locally I like to use (Siman) Kidney 14 to move blood in the lower jiao (the location of the clogged ovaries). Siman is 0.5 cun out from the front Mu of the San Jiao channel (shimen) Ren 5. Shimen means "stone gate" and depending on the source, either causes infertility or opens the gate to clear infertility. So, just to be sure, I don't use Ren 5 and use Kd 14 instead to harness the Yuan qi to move and open the lower jiao that the Front Mu of the San Jiao provides without the possible negative infertile side effects. Using the same theory of giving the heat and blocked material a place to go, I also like to use Ren 3 (Front Mu of the UB) to help clear heat out from the urination.
Hopefully this helps you understand and even better more successfully treat your PCOS patients.
To read Montgomery's last column on PCOS, visit www.acupuncturetoday.com.
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