Professor Zhang Yu-zhen’s Experiences in the Treatment of Premature Ovarian Failure

abstracted & translated by

Bob Flaws, L.Ac., FNAAOM (USA), FRCHM (UK)

Keywords: Chinese medicine, Chinese herbal medicine, gynecology, premature ovarian failure

Recently there have been some frustrations voiced on the Chinese Herb Academy forum (www.chineseherbacademy.org) over the discrepancy between beginner’s textbooks and the mature practice of Chinese medicine. As stated by Eric Karchmer, medical anthropologist and professional practitioner of Chinese medicine, there is wide gap between the simplistic, pro forma treatments given in such textbooks and the real-life clinical practice of Chinese medicine by an intelligent, well educated, and highly experienced practitioner. Unfortunately for Western practitioners, few examples of this more real and enlightened practice of Chinese medicine ever get translated into English. Thus the majority of Western practitioners have little access to the kinds of literature which would help them bridge this gap in their own practice. On the other hand, for those who do read modern medical Chinese, articles on this or that old Chinese doctor’s insights into the treatment of this or that disease are one of the common genres of articles in Chinese medical journals published in the People’s Republic of China. For instance, on pages 13-14 of issue #12, 2006 of Xin Zhong Yi (New Chinese Medicine), Pang Zhen-miao et al., from the First Affiliated Hospital of the Guangzhou University of Chinese Medicine, published an article titled, “An Introduction to the Experiences of Professor Zhang Yu-zhen’s Treatment of Premature Ovarian Failure.”  According to Drs. Pang et al., Prof. Zhang has 30 years clinical experience in the practice of Chinese medicine and scientific research. In addition, she (?) is also one of the authors of Zhong Yi Fu Ke Xue (A Study of Chinese Medical Gynecology) which is used as a standard textbook in every college and university of Chinese medicine in China. Since Prof. Zhang is both an experienced clinician and a textbook author, a summary of this article is presented below.

Disease causes & mechanisms:

After defining the Western medical disease category of premature ovarian failure, they then go on to explain that there is no such disease category of premature ovarian failure in Chinese medicine. However, the clinical symptoms of this condition are blocked menstruation (bi jing), blood withering (xue ku), and infertility (bu yun), each of which is a disease category in Chinese medicine. They next go on to quote the Su Wen (Simple Questions) regarding the mechanisms of menarche and menopause:

[At] seven years in females, the kidney qi is exuberant... [At] two [times] seven, the tian gui arrives, the ren mai is freely flowing, the tai chong mai is exuberant, [and] the menstrual matter therefore descends periodically. Thus [women can] get with child... [At] seven [times] seven, the ren is vacuous, the tai chong mai is debilitated and scanty, the tian gui is exhausted, [and] the passageways of the earth are no [longer] freely flowing. Therefore, the form [or body] has gone bad and [women can] no [longer have] children.  

This is famous passage is then followed by several other statements from Fu Qing Zhu Nu Ke (Fu Qing-zhu’s Gynecology):

The menstrual water exits from the kidneys.

[If] the menstrual water is prematurely cut off, this seemingly [is due to] kidney water debility and drying up.

[If] the kidney qi root is vacuous, how can there be exuberance and fullness and the transformation of the menstrual water [and] its exiting externally?

In explaining the implications of these various quotes, the Chinese authors (most likely Prof. Zhang’s personal disciples) say that the production of the menstruate is dependent on the exuberance of the kidney qi. The tian gui (what is normally glossed as kidney water) arrives. Thus the ren mai is freely flowing, the chong mai become exuberant, and menarche occurs. Conversely, at 49 years of age, the ren mai is vacuous, the tai chong mai is debilitated and scanty, the tian gui is exhausted, and the manifestation of this is the cessation of menstruation. Since premature ovarian failure also results in cessation of menstruation, Prof. Zhang believes that the occurrence of this condition is closely associated with kidney vacuity and chong and ren debility and scantiness. Clinically, this condition is mostly seen in those with natural endowment insufficiency, malnutrition, taxation fatigue, fright and fear, many births, or ending disease. It may also be due to ovarectomy, radiation and chemotherapy, pelvic infection, and contact with environmental toxins resulting kidney vacuity. According to Prof. Zhang, the main disease mechanisms of this condition are kidney-spleen depletion and vacuity, liver depression, and blood stasis.  Either due to 1) kidney essence depletion and detriment, spleen vacuity resulting in a loss of the source of the engenderment and transformation of the qi and blood, and chong and ren qi and blood insufficiency or 2) liver depression qi stagnation resulting in uneasy movement of the blood with blood stasis obstructing and stagnating, the sea of blood is not able to fill and then spill over. Hence the menstruate is stopped and blocked resulting in this disease.

In addition, kidney yin vacuity may not be able to ascend to aid heart yin. This may lead to heart fire becoming hyperactive all by itself. If heart fire hyperactivity is not able to descend and interact with the kidneys, then one sees the signs and symptoms of the heart and kidneys not interacting condition, such as laughing and crying with no constancy, tidal redness of the face, heart palpitations, insomnia, heat in the hearts of the hands and feet, and other such symptoms of decreased hormonal secretion. On the other hand, if kidney yang is insufficient, there will be such signs and symptoms of decreased sexual desire, low back and knee soreness and limpness, etc. Spleen vacuity leads to devitalized eating and drinking and loose stools. Spleen vacuity not engendering the essence and boosting the kidneys can lead to spleen-kidney dual vacuity. Spleen vacuity and liver wood attacking the spleen lead to liver-spleen disharmony. If the liver qi becomes depressed and bound, coursing and discharge loss their normalcy, resulting in vexation and agitation, easy anger, and emotional instability or lability. Liver depression can also result in blood stasis, and, in women, it is blood which makes for function. Vacuity, repletion, cold, heat, and enduring disease as well as kidney vacuity can all also result in blood stasis. Therefore, based on Prof. Zhang’s experience and understanding of this condition and its disease mechanisms, treatment of this disease must involve supplementation of the kidneys, fortification of the spleen, regulation of the liver, and quickening of the blood.

Treatment experiences:

The next section sums up Prof. Zhang’s principles and specific techniques for treating this condition based on her study and clinical experience. Prof. Zhang bases her treatment on a combination of both pattern and disease discrimination. As stated above, her method in general is to supplement the kidneys, fortify the spleen, regulate the liver, and quicken the blood. Thus she commonly uses modified Gui Shen Wan (Return or Restore the Kidneys Pills). This formula is composed of the following:

Sheng Di (uncooked Radix Rehmanniae)

Shu Di (cooked Radix Rehmanniae)

Shan Zhu Yu (Fructus Corni)

Gou Qi Zi (Fructus Lycii)

Shan Yao (Radix Dioscoreae)

Fu Ling (Poria)

Dang Gui (Radix Angelicae Sinensis)

Du Zhong (Cortex Eucommiae)

Tu Si Zi (Semen Cuscutae)

Niu Xi (Radix Achyranthis Bidentatae)

Yin Yang Huo (Herba Epimedii)

stir-fried Zhi Mu (Rhizoma Anemarrhenae)

stir-fried Huang Lian (Rhizoma Coptidis)

Zi He Che (Placenta Hominis)

Chai Hu (Radix Bupleuri)

Dan Shen (Radix Salviae Miltiorrhizae)

Then Prof. Zhang modifies this basic prescription with additions and subtractions depending on the signs and symptoms. Prof. Zhang administers one packet of these medicinals per day as a water-based decoction, with three continuous months of treatment equaling one course.

Within this formula, Sheng Di, Shu Di, Shan Zhu Yu, Gou Qi Zi, Du Zhong, Tu Si Zi, Niu Xi, Yin Yang Huo, and Zi He Che supplement the kidneys and regulate the liver. Shan Yao and Fu Ling fortify the spleen. Dang Gui nourishes the blood. Stir-fried Zhi Mu and Huang Lian enrich yin and downbear fire, thus promoting the communication and interaction of the heart and kidneys. In addition, Prof. Zhang says that there are several special points to this prescription. 1) It combines supplementation of the kidneys and nourishment of the blood at the same time. Within this formula, Dang Gui and Sheng Di nourish the blood. 2) It supplements the kidneys at the same time as it downbears fire. For this purpose, Prof. Zhang combines Zhi Mu and Huang Lian. 3) It searches for yang within yin and integrates stirring and stillness (natured medicinals). This is exemplified by the combination of Shu Di with Dan Shen. 4) It uses bloody, meaty natured ingredients such as Zi He Che to supplement the kidneys. 5) It combines all this with ingredients which course the liver and rectify the qi. For instance, Chai Hu courses the liver and rectifies the qi. Taken as a whole, this formula enriches and nourishes yin and blood, boosts the qi and supplements the kidneys. This then promotes the recuperation of the qi and blood which leads to the filling and exuberance of the sea of blood which leads to the menstruation automatically coming like a tide.

Representative case history:

The third and last part to this article is a representative case of premature ovarian failure treated by Prof. Zhang. The patient was a 29 year-old, married female who was first seen by Prof. Zhang on June 24, 2005. The patient’s menses had been coming 2-3 months behind schedule for the last two years. Her last menses had occurred on June 8^th. Their amount had been scanty and they had contained relatively a lot of blood clots. The patient’s menstrual period had been accompanied by low back soreness, a dry mouth, vexation and agitation, easy anger, chest and rib-side distention and fullness, a somewhat redder than normal tongue with thin, yellow fur, and a fine, bowstring pulse. In terms of reproductive history, the patient had been pregnant once and give birth once. After the onset of this condition, the woman had gone to many doctors but without effect. When examined, the patient’s follicle-stimulating hormone (FSH) serum level was 47.71IU/L, her serum luteinizing hormone (LH) level was 33.36IU/L, her serum prolactin (PRL) level was 11.61µg/L, her serum estradiol (E2) was 920pmol/L, her progesterone (P) was 1.14nmol/L, and her testosterone (T) was 2.70nmol/L. A pelvic examination revealed no obvious uterine abnormalities. However, the left ovary was shrunken, while the right ovary was approximately normal in size. Therefore, the Western medical diagnosis was premature ovarian failure, the Chinese medical diagnosis was delayed or sparse menstruations, and the Chinese medical pattern was categorized as kidney vacuity with liver depression.

Based on the foregoing, the treatment principles were to supplement the kidneys and nourish the blood, quicken the blood and free the flow of the channels (or menses). Therefore, Prof. Zhang prescribed the following modification of Gui Shen Wan:

Tu Si Zi (Semen Cuscutae)
Niu Xi (Radix Achyranthis Bidentatae), 29g each
Gou Qi Zi (Fructus Lycii)
Du Zhong (Cortex Eucommiae)
Bai Shao (Radix Alba Paeoniae)
Yin Yang Huo (Herba Epimedii)
Dan Shen (Radix Salviae Miltiorrhizae), 15g each
mix-fried Gan Cao (Radix Glycyrrhizae)
Chai Hu (Radix Bupleuri)
Xiang Fu (Rhizoma Cyperi), 10g each
Dang Shen (Radix Codonopsis)
Wu Zhao Long (Radix Iopmoeae Caricae), 30g each

The patient was prescribed seven packets of these medicinals, one packet to be decocted in water and drunk per day. At the second examination, there was lower abdominal distention, scanty vaginal discharge, dry mouth, and low back soreness. However, all the other symptoms had slightly improved. Therefore, the patient was now prescribed the following:

Dang Gui (Radix Angelicae Sinensis)
Xian Mao (Rhizoma Curculiginis)
mix-fried Gan Cao (Radix Glycyrrhizae)
Chai Hu (Radix Bupleuri)
Chuan Xiong (Rhizoma Chuanxiong), 10g each
Bai Shao (Radix Alba Paeoniae)
Sheng Di (uncooked Radix Rehmanniae)
Dan Shen (Radix Salviae Miltiorrhizae)
Nu Zhen Zi (Fructus Ligustri Lucidi)
Yin Yang Huo (Herba Epimedii)
Du Zhong (Cortex Eucommiae)
Gou Qi Zi (Fructus Lycii), 15g each

Again, seven packets were prescribed, one packet to be taken per day as before. At the third examination, all the patient’s symptoms had markedly improved, and her vaginal discharge had increased. However, there was still constant low abdominal distention. The patient was prescribed 10 more packets of the last formula. After taking these medicinals, her menses came like a tide. Prof. Zhang had the patient continue with the same formula for one more month. After that, her menses came on time. When her reproductive hormones were tested again, her FSH was 5.76IU/L, LH was 4.05IU/L, and her E2 was 787.3pmol/L.

Discussion:

There are a number of things in this article I would like to comment on. First, Prof. Zhang is the author of a famous beginner’s gynecology textbook. In that book, there are several discreet patterns listed under delayed menstruation, each with their own signs and symptoms, treatment principles, and formula. However, in this article, Prof. Zhang says that most women with premature ovarian failure manifest with a multi-pattern presentation. This is a spleen-kidney vacuity with liver depression and blood stasis. In addition, the kidney vacuity can be either yin vacuity, yang vacuity, or both and, even in the case of yang vacuity, there may be heat evils. Therefore, Prof. Zhang’s commonly used base prescription includes medicinals to supplement and drain and which are hot and cold all at the same time. In my experience as both a clinician and student of the Chinese medical literature, the use of such complex formulas is the hallmark of the really mature practice of Chinese herbal medicine.

Secondly, Prof. Zhang bases her treatment on a combination of 1) the Western medical disease diagnosis, 2) the corresponding Chinese medical disease diagnosis/es, and 3) the patient’s personally presenting Chinese medical patterns. She does not just base on the Western disease nor does she ignore the Western disease. For instance, knowing that the Western disease is premature ovarian failure, Prof. Zhang has chosen to use such kidney supplements as Yin Yang Huo and Xian Mao which are empirically know to promote proper ovarian function. She also uses the Chinese medical disease diagnosis to more quickly focus in on and identify the patient’s presenting patterns.

Third, although Prof. Zhang says that she commonly uses a particular formula, in real life, she may vary considerably from that formula in its particular ingredients as long as she remains true to the idea of the formula, its underlying logic. As a corollary of this, the Chinese authors of this article and ultimately Prof. Zhang expect their readers to know their Chinese medicinals cold so that she/they do not have to explain every reason for using this medicinal instead of that in a given situation.

Fourth, like many old Chinese doctors, Prof. Zhang has developed her own repertoire of medicinals as well as some tricks of the trade. In the representative case history, she uses an unusual medicinal, Wu Zhao Long (Radix Ipomoeae Cairicae, a.k.a. Cairo morning glory). According to the Zhong Yao Da Ci Dian (Great Dictionary of Chinese Medicinals), this medicinal is sweet, cold, and nontoxic and enters the liver, lungs, kidney, and bladder channels. Its function are to clear heat, disinhibit water, and resolve toxins. It is indicated for the treatment of lung heat cough, inhibited urination, strangury conditions, hematuria, welling and flat abscesses, and swollen toxins. Nowhere in the Zhong Yao Da Ci Dian does it mention anything about this medicinal being used for menstrual diseases. So it would seem that Prof. Zhang knows something about this medicinal she is only telling her disciples.

Finally, I hope some readers of this article will be encouraged to begin the study of Chinese. My guess is that most Western readers will find the information in this article useful in their understanding and practice of Chinese medicine. However, it is but a single example of the vast, similarly useful literature that is available in Chinese.

Copyright © Blue Poppy Press. 2007. All rights reserved.