by Eric Brand

PCOS is an interesting condition because it illustrates the integrative nature of modern Chinese medicine. PCOS was not traditionally recognized as a disease category in ancient times, though of course many patients with PCOS would have been treated under the TCM disease headings of irregular menstruation, amenorrhea, and/or infertility.

Our modern understanding of PCOS is intricately connected to an understanding of ovulation, which is a concept that did not, strictly speaking, exist in Chinese medicine prior to the arrival of biomedicine. While it was clearly known that conception happened at a specific time, the exact mechanism of hormonal cycles, ovulation, and menstrual physiology was not elaborated until the modern era.

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For example, consider the following quote from the gynecology section of the Qing dynasty text Yi Zong Jin Jian (Golden Mirror of Orthodox Medicine), which was a comprehensive traditional compilation written just prior to the arrival of biomedicine: “…a woman menstruates one time in one month, and following that time there must be one day that occasions an enshrouding moment: the woman is hot, has steaming qi4, is as if drunk and infatuated, and has an unbearable desire for intercourse. This natural occasion is a true opportunity to conceive a baby and create a life.”

While this quote illustrates that it was known that specific timing was involved in conception, the traditional knowledge of menstruation did not break the cycle down into the stages that we use in modern medicine today. Now that detailed knowledge about menstrual physiology is available, a new avenue of research and treatment has opened up in Chinese medicine wherein medicinals and acupuncture are prescribed based on different phases of the menstrual cycle. Such treatments have become extremely popular within the field of infertility because they create a parallel between TCM theory and modern physiology.

In the past, I taught TCM gynecology at the Pacific College of Oriental Medicine, and I noticed that students were very enthusiastic to learn about treatments designed around phases of the menstrual cycle. Amusingly, many students that eschew what they call “cookbook acupuncture” are quick to follow protocols when it comes to herbal medicine, maybe this relates to a lack of confidence in their budding skills at pattern-based formula modification, or maybe it simply reflects the universal student desire to write down as many “inside tricks” as possible. While I invariably prefer customized, pattern-based treatments for conditions like PCOS and infertility over “cookbook” approaches pegged to menstrual physiology, I must say that I find the study of herbal medicine in relationship to phases of the menstrual cycle very intriguing. Certainly it represents a new direction of integrative thought and research, so I’d like to include some material from Chinese sources that discusses this phased approach in detail.

In terms of disease categories for finding information on treatments that are linked to phases of the menstrual cycle, the best places to look are in discussions of infertility and/or PCOS. Below is a translated excerpt from one of China’s key TCM gynecology texts, taken from the chapter on PCOS.

POLYCYSTIC OVARY SYNDROME

Definition

Polycystic ovary syndrome is a benign disorder that often causes irregular menstruation, hirsutism, mild obesity, and, in some cases, amenorrhea and infertility. The condition is named after the many 2–6 mm sized cysts typically seen in the ovaries, though the cysts may achieve much larger sizes as well. The condition is also known as hyperandrogenic chronic anovulation, which reflects the fact that it is a state typically characterized by excessive androgen production and lack of ovulation. It tends to arise around puberty and often worsens over time.

Treatment Based On Disease Identification

In integrative treatment of PCOS, a number of options exist. One proposed strategy emphasizes a four-phased treatment based on the menstrual cycle, while others use standard base formulas.

It is common for integrative formulas for PCOS to contain elements of kidney supplementation and blood-quickening methods. For example, the empirical formula below was reported to have a success rate of 53% in achieving pregnancy in PCOS patients over the course of 3–6 months of therapy:

Tu Si Zi (菟丝子 cuscuta, Cuscutae Semen) 20 g
Fu Pen Zi (覆盆子 rubus, Rubi Fructus) 20 g
Yin Yang Huo (淫羊藿 epimedium, Epimedii Herba) 20 g
Dang Gui (当归 Chinese angelica, Angelicae Sinensis Radix) 10 g
Ze Xie (泽泻 alisma, Alismatis Rhizoma) 10 g
Chen Pi (陈皮 tangerine peel, Citri Reticulatae Pericarpium) 10 g
Tao Ren (桃仁 peach kernel, Persicae Semen) 10 g
Zi He Che (紫河车 placenta, Hominis Placenta) 100 g

The ingredients above are dried, powdered, and taken in gelcaps. 4–5 pills are taken BID, commencing after menstruation ends each month. This is supplemented with 1 gram of Da Huang (Rhei Radix et Rhizoma) powder, which is also taken in gelcaps.

By another method, the cycle can be divided into four phases, with one base formula for each phase. In this method, the phases generally correspond to supplementing the kidney, quickening the blood and transforming stasis, again supplementing the kidney, and then quickening the blood and regulating menstruation. A basic differentiation is made between patterns of kidney yang debility with vacuity cold of the chong and ren, or insufficiency of kidney yin with depressed heat in the chong and ren.

The following formulas are taken based on the menstrual cycle, starting with 4–6 packs of the follicular formula after menstruation ends. Take four packs of the ovulation formula prior to the estimated day of ovulation, and take 6–9 packs during the estimated luteal phase. Take 3–5 packs of the menses-regulating formula prior to the estimated time of menstruation.

Kidney Yang Debility with Vacuity Cold of the Chong and Ren

Phase One: Follicular Formula
Xian Mao (仙茅 curculigo, Curculiginis Rhizoma) 10 g
Yin Yang Huo (淫羊藿 epimedium, Epimedii Herba) 10 g
Dang Gui (当归 Chinese angelica, Angelicae Sinensis Radix) 10 g
Shan Yao (山药 dioscorea, Dioscoreae Rhizoma) 10 g
Tu Si Zi (菟丝子 cuscuta, Cuscutae Semen) 10 g
Ba Ji Tian (巴戟天 morinda, Morindae Officinalis Radix) 10 g
Rou Cong Rong (肉苁蓉 cistanche, Cistanches Herba) 10 g
Shu Di Huang (熟地黄 cooked rehmannia, Rehmanniae Radix Praeparata) 10 g

Phase Two: Ovulation Formula
Dang Gui (当归 Chinese angelica, Angelicae Sinensis Radix) 10 g
Dan Shen (丹参 salvia, Salviae Miltiorrhizae Radix) 10 g
Chong Wei Zi (茺蔚子 leonurus fruit, Leonuri Fructus) 10 g
Tao Ren (桃仁 peach kernel, Persicae Semen) 10 g
Hong Hua (红花 carthamus, Carthami Flos) 10 g
Ji Xue Teng (鸡血藤 spatholobus, Spatholobi Caulis) 10 g
Xu Duan (续断 dipsacus, Dipsaci Radix) 10 g
Xiang Fu (香附 cyperus, Cyperi Rhizoma) 6 g
Gui Zhi (桂枝 cinnamon twig, Cinnamomi Ramulus) 3 g

Phase Three: Luteal Formula
E Jiao (阿胶 ass hide glue, Asini Corii Colla) 10 g
Gui Ban Jiao (龟版胶 tortoise plastron glue, Testudinis Carapacis Gelatinum) 10 g
Dang Gui (当归 Chinese angelica, Angelicae Sinensis Radix) 10 g
Shu Di Huang (熟地黄 cooked rehmannia, Rehmanniae Radix Praeparata) 10 g
Tu Si Zi (菟丝子 cuscuta, Cuscutae Semen) 10 g
He Shou Wu (何首乌 flowery knotweed, Polygoni Multiflori Radix) 10 g
Xu Duan (续断 dipsacus, Dipsaci Radix) 10 g
Shan Yao (山药 dioscorea, Dioscoreae Rhizoma) 15 g

Phase Four: Quickening Blood and Regulating Menstruation
Dang Gui (当归 Chinese angelica, Angelicae Sinensis Radix) 10 g
Dan Shen (丹参 salvia, Salviae Miltiorrhizae Radix) 10 g
Chi Shao Yao (赤芍药 red peony, Paeoniae Radix Rubra) 10 g
Ze Lan (泽兰 lycopus, Lycopi Herba) 10 g
Chuan Xiong (川芎 chuanxiong, Chuanxiong Rhizoma) 4 g
Xiang Fu (香附 cyperus, Cyperi Rhizoma) 6 g
Chong Wei Zi (茺蔚子 leonurus fruit, Leonuri Fructus) 15 g

Insufficiency of Kidney Yin with Depressed Heat in the Chong and Ren

Phase One: Follicular Formula
Nu Zhen Zi (女贞子 ligustrum, Ligustri Lucidi Fructus) 10 g
Mo Han Lian (墨旱莲 eclipta, Ecliptae Herba) 10 g
Dan Shen (丹参 salvia, Salviae Miltiorrhizae Radix) 10 g
Shan Yao (山药 dioscorea, Dioscoreae Rhizoma) 10 g
Tu Si Zi (菟丝子 cuscuta, Cuscutae Semen) 10 g
Rou Cong Rong (肉苁蓉 cistanche, Cistanches Herba) 10 g
He Shou Wu (何首乌 flowery knotweed, Polygoni Multiflori Radix) 10 g
Shu Di Huang (熟地黄 cooked rehmannia, Rehmanniae Radix Praeparata) 10 g

Phase Two: Ovulation Formula
Dan Shen (丹参 salvia, Salviae Miltiorrhizae Radix) 10 g
Chi Shao Yao (赤芍药 red peony, Paeoniae Radix Rubra) 10 g
Ze Lan (泽兰 lycopus, Lycopi Herba) 10 g
Shu Di Huang (熟地黄 cooked rehmannia, Rehmanniae Radix Praeparata) 10 g
Gou Qi Zi (枸杞子 lycium, Lycii Fructus) 10 g
Tao Ren (桃仁 peach kernel, Persicae Semen) 4 g
Hong Hua (红花 carthamus, Carthami Flos) 4 g
Yi Yi Ren (薏苡仁 coix, Coicis Semen) 5 g
Xiang Fu (香附 cyperus, Cyperi Rhizoma) 6 g

Phase Three: Luteal Formula
Dan Shen (丹参 salvia, Salviae Miltiorrhizae Radix) 10 g
Gui Ban (龟版 tortoise shell, Testudinis Carapax et Plastrum) 10 g
Gou Qi Zi (枸杞子 lycium, Lycii Fructus) 10 g
Nu Zhen Zi (女贞子 ligustrum, Ligustri Lucidi Fructus) 10 g
Mo Han Lian (墨旱莲 eclipta, Ecliptae Herba) 10 g
Shu Di Huang (熟地黄 cooked rehmannia, Rehmanniae Radix Praeparata) 10 g
Tu Si Zi (菟丝子 cuscuta, Cuscutae Semen) 10 g
He Shou Wu (何首乌 flowery knotweed, Polygoni Multiflori Radix) 10 g
Rou Cong Rong (肉苁蓉 cistanche, Cistanches Herba) 10 g

Phase Four: Quickening Blood and Regulating Menstruation
Dang Gui (当归 Chinese angelica, Angelicae Sinensis Radix) 10 g
Dan Shen (丹参 salvia, Salviae Miltiorrhizae Radix) 10 g
Chi Shao Yao (赤芍药 red peony, Paeoniae Radix Rubra) 10 g
Ze Lan (泽兰 lycopus, Lycopi Herba) 10 g
Chuan Xiong (川芎 chuanxiong, Chuanxiong Rhizoma) 4 g
Xiang Fu (香附 cyperus, Cyperi Rhizoma) 6 g
Chong Wei Zi (茺蔚子 leonurus fruit, Leonuri Fructus) 15 g

Treatment Based On Pattern Identification

PCOS primarily involves the liver, spleen, and kidney, as well as phlegm-damp evil. Treatments often utilize methods of supplementing the kidney and transforming stasis, supplementing the kidney and transforming phlegm, nourishing yin and clearing heat, and fortifying the spleen and drying dampness.

Kidney Yang Vacuity Complicated by Stasis

Treatment Method: Warm and supplement kidney yang, dry dampness and transform phlegm.
Medicinal Therapy: Use the formula Gui Shen Wan (归肾丸Restore the Kidney Pill) from the Jing Yue Quan Shu (“Jing-Yue's Complete Compendium”).

Gui Shen Wan (归肾丸Restore the Kidney Pill)
Tu Si Zi (菟丝子 cuscuta, Cuscutae Semen)
Du Zhong (杜仲 eucommia, Eucommiae Cortex)
Gou Qi Zi (枸杞子 lycium, Lycii Fructus)
Shan Zhu Yu (山茱萸 cornus, Corni Fructus)
Dang Gui (当归 Chinese angelica, Angelicae Sinensis Radix)
Shu Di Huang (熟地黄 cooked rehmannia, Rehmanniae Radix Praeparata)
Shan Yao (山药 dioscorea, Dioscoreae Rhizoma)
Fu Ling (茯苓 poria, Poria)
Plus:
Ban Xia (半夏 pinellia, Pinelliae Rhizoma)
Dan Xing (胆星 bile arisaema, Arisaema cum Bile)
Cang Zhu (苍朮 atractylodes, Atractylodis Rhizoma)

This formula can be modified for fatigue, low food intake, and sloppy stool by adding Huang Qi (Astragali Radix), Dang Shen (Codonopsis Radix), and Bai Zhu (Atractylodis Macrocephalae Rhizoma). If there is menstrual pain and dark red blood with clots, add Shan Zha (Crataegi Fructus), Dan Shen (Salviae Miltiorrhizae Radix), and Chuan Niu Xi (川牛膝Cyathulae Radix, cyathula).

Kidney Yin Vacuity Complicated by Stasis

Treatment Method: Nourish yin and clear heat, assisted by transforming stasis.

Medicinal Therapy: One possible base formula is the combination of Liu Wei Di Huang Wan (六味地黄丸 Six-Ingredient Rehmannia Pill) with Shi Xiao San (失笑散 Sudden Smile Powder). If vacuity heat signs are present, Zhi Mu (Anemarrhenae Rhizoma) and Huang Bai (Phellodendri Cortex) are added. Da Huang (Rhei Radix et Rhizoma), Mang Xiao (Natrii Sulfas), and Zhi Shi (Aurantii Fructus Immaturus) can be added if constipation is present.

Alternatively, the empirical formula below may also be used:

Empirical Formula

Sheng Di Huang (生地黄rehmannia, Rehmanniae Radix) 15 g
Shan Zhu Yu (山茱萸 cornus, Corni Fructus) 12 g
Gou Qi Zi (枸杞子 lycium, Lycii Fructus) 15 g
Nu Zhen Zi (女贞子 ligustrum, Ligustri Lucidi Fructus) 15 g
Shan Yao (山药 dioscorea, Dioscoreae Rhizoma) 20 g
Zhen Zhu Mu (珍珠母 mother-of-pearl, Concha Margaritifera) 20 g
Yin Yang Huo (淫羊藿 epimedium, Epimedii Herba) 9 g
Ji Xue Teng (鸡血藤 spatholobus, Spatholobi Caulis) 20 g
He Shou Wu (何首乌 flowery knotweed, Polygoni Multiflori Radix) 20 g

This formula can be modified for liver depression by adding Yu Jin (Curcumae Radix), Bai Shao (Paeoniae Radix Alba), and He Huan Pi (Albizziae Cortex), at a dose of 15 grams each. For blood stasis, add 20 g Yi Mu Cao (Leonuri Herba), 20 g Dan Shen (Salviae Miltiorrhizae Radix), 12 g Tao Ren (Persicae Semen), and 12 g Hong Hua (Carthami Flos).

Qi Vacuity Complicated by Stasis

Treatment Method: Treatment should fortify the spleen, transform phlegm, and dry dampness.

Medicinal Therapy: Use the formula Cang Fu Dao Tan Wan (苍附导痰丸 Atractylodes and Cyperus Phlegm-Abducting Pill), with the addition of Huang Qi (Astragali Radix) and Dang Shen (Codonopsis Radix).

Cang Fu Dao Tan Wan (苍附导痰丸 Atractylodes and Cyperus Phlegm-Abducting Pill)
Fu Ling (茯苓 poria, Poria)
Ban Xia (半夏 pinellia, Pinelliae Rhizoma)
Chen Pi (陈皮 tangerine peel, Citri Reticulatae Pericarpium)
Gan Cao (甘草 licorice, Glycyrrhizae Radix)
Cang Zhu (苍朮 atractylodes, Atractylodis Rhizoma)
Xiang Fu (香附 cyperus, Cyperi Rhizoma)
Dan Xing (胆星 bile arisaema, Arisaema cum Bile)
Zhi Ke (Qiao) (枳壳bitter orange, Aurantii Fructus)
Sheng Jiang (生姜 fresh ginger, Zingiberis Rhizoma Recens)
Shen Qu (神曲 medicated leaven, Massa Medicata Fermentata)
Huang Qi (黄芪 astragalus, Astragali Radix)
Dang Shen (党参 codonopsis, Codonopsis Radix)

This formula can be modified for scanty menstruation by adding Ji Xue Teng (Spatholobi Caulis), Dang Gui (Angelicae Sinensis Radix), and Chuan Xiong (Chuanxiong Rhizoma). For blood stasis, add Pu Huang (Typhae Pollen), Wu Ling Zhi (Trogopteri Faeces), and Yi Mu Cao (Leonuri Herba).

Binding Depression of Liver Qi

Treatment Method: Treatment should course the liver and clear heat if necessary, while simultaneously moving qi and transforming phlegm.

Medicinal Therapy: Use a combination of the formulas Dan Zhi Xiao Yao San (丹栀逍遥散 Moutan and Gardenia Free Wanderer Powder) and Qing Qi Hua Tan Wan (清气化痰丸 Qi4-Clearing Phlegm-Transforming Pill).

Dan Zhi Xiao Yao San (丹栀逍遥散 Moutan and Gardenia Free Wanderer Powder)

Fu Ling (茯苓 poria, Poria)
Mu Dan Pi (牡丹皮 moutan, Moutan Cortex)
Shan Zhi Zi (山栀子 gardenia, Gardeniae Fructus)
Chai Hu (柴胡 bupleurum, Bupleuri Radix)
Bo He (薄荷 mint, Menthae Herba)
Dang Gui (当归 Chinese angelica, Angelicae Sinensis Radix)
Bai Shao Yao (白芍药 white peony, Paeoniae Radix Alba)
Bai Zhu (白朮 white atractylodes, Atractylodis Macrocephalae Rhizoma)
Zhi Gan Cao (炙甘草 mix-fried licorice, Glycyrrhizae Radix cum Liquido Fricta)

Qing Qi Hua Tan Wan (清气化痰丸 Qi-Clearing Phlegm-Transforming Pill)

Fu Ling (茯苓 poria, Poria)
Ban Xia (半夏 pinellia, Pinelliae Rhizoma)
Chen Pi (陈皮 tangerine peel, Citri Reticulatae Pericarpium)
Xing Ren (杏仁 apricot kernel, Armeniacae Semen)
Gua Lou Ren (瓜蒌仁 trichosanthes seed, Trichosanthis Semen)
Huang Qin (黄芩 scutellaria, Scutellariae Radix)
Zhi Shi (枳实 unripe bitter orange, Aurantii Fructus Immaturus)
Dan Xing (胆星 bile arisaema, Arisaema cum Bile)

Acupuncture Treatment

Acupuncture has a marked effect in cases of PCOS. Starting fourteen days after menstruation, begin giving acupuncture daily for three days, wait a week, and repeat the three days of treatment. Apply acupuncture with e-stim to the points CV 4 (Guan Yuan), CV 3 (Zhong Ji), Zi Gong Xue, and SP 6 (San Yin Jiao). In one trial conducted on 59 patients using this method, ovulation was achieved in 20 patients after three months.

Another method is the following set of point selections from Dr. Lin Lan-Jun, based on successful clinical results in his trials:

Point Prescription #1
SP 6 (San Yin Jiao)
CV 4 (Guan Yuan)
SP 8 (Di Ji)
ST 28 (Shui Dao)

Point Prescription #2
ST 29 (Gui Lai)
KI 12 (Da He)
CV 2 (Qu Gu)
SP 10 (Xue Hai)

Point Prescription #3
ST 28 (Shui Dao)
CV 3 (Zhong Ji)
ST 29 (Gui Lai)
SP 6 (San Yin Jiao)