Treatment of Infertility with Chinese Medicine

Polycystic Ovarian Syndrome

Polycystic ovarian syndrome is one of the most common disorders of ovulation that we see in our clinics today. It is a multifaceted disorder affecting endocrine, nervous and cardiovascular systems and has many metabolic repercussions and clinical manifestations. Our understanding of the primary etiology for this disorder is incomplete, however its clinical manifestations and signs are well described. We shall spend some time examining the clinical presentations of PCOS, and what we currently know about its endocrinologic and metabolic basis, so that we can begin to construct a TCM analysis that will give us a framework from which we can design appropriate treatment.

On the one hand, we can approach the treatment of PCOS with the sole aim of trying to increase ovulation frequency (and thus increase opportunities for conception) and on the other hand, with a more thorough analysis, we can attempt a broader approach to treatment that takes into account all the ramifications of this syndrome, including ovary dysfunction. This latter approach may also have a more far reaching impact on the function of the ovaries and the quality of the eggs therein, other than just increasing frequency of ovulation.

Defining PCOS: Clinical Presentation and Diagnosis

Polycystic ovary syndrome (PCOS) is the name given to the syndrome in which the ovaries appear to be covered with many small cysts on ultrasound (and likened poetically to a string of pearls), the menstrual cycles are long or irregular with infrequent ovulations and there are signs, such as more than usual body hair or acne, of excess circulating androgens. The syndrome is also linked with an increased incidence of diabetes and other metabolic disorders and pregnancy complications such as pre-eclampsia. Not all women with polycystic ovary syndrome will present the same way or have the same symptoms or laboratory findings.

This syndrome is the commonest endocrinopathy and the most common cause of anovulatory female infertility in Australia and other developed nations with a prevalence of approximately 9% of Australian women and 21% of Australian indigenous women of reproductive age.³¹ Some 9–15% of women in living in Europe have PCOS and an estimated 6–7 million women living in America have PCOS. As these figures attest, PCOS is a common disorder, and the frequency with which it is turning up in fertility clinics appears to be increasing.

Until the etiology of PCOS is clarified, diagnosis is made according to clinical manifestations. To receive a diagnosis of PCOS a woman must have two of the following symptoms or signs (according to the Rotterdam consensus 2003 criteria):

• Polycystic ovary morphology on ultrasound (defined as more than 12 follicles, size 2–9 mm on each or one ovary and/or swollen ovaries measuring more than 9 mL in volume

• Infrequent, irregular or no ovulation – cycles longer than 35 days or fewer than nine periods a year

• Hirsutism (unwanted hair growth), acne, male pattern hair loss, or evidence of elevated androgens on blood test.

Blood tests may reveal elevated levels of insulin, testosterone, dehydroepiandrosterone sulfate (DHEAS), estrogen, luteinizing hormone (LH), inhibin, anti-Mullerian hormone (AMH), fibrinogen and adipokines and reduced levels of sex hormone binding globulin (SHBG) and adiponectin.

The phenotype (expression of the disease) varies from mild to severe. For example, menstrual patterns can vary depending on the severity of the hormone disturbance, from no ovulations at all (amenorrhea or erratic anovulatory bleeding) to slightly irregular ovulations (long cycles or oligomenorrhea).

Some women show polycystic ovaries (PCO) or polycystic appearing ovaries (PAO) on ultrasound but do not manifest the full-blown syndrome described above. Up to 60% of teenage girls have polycystic ovaries on ultrasound and many of their early menstrual cycles are anovulatory. As many as 20–25% of women of reproductive age will have polycystic ovaries on ultrasound, but no symptoms other than slightly irregular menstrual cycles. These women usually have no problem conceiving, although it may take a little longer than usual.

For women having no or very infrequent ovulations however, fertility is seriously diminished and most of our discussion in this chapter will focus on these women diagnosed with the full syndrome.

Etiology

• Genetics, epigenetics and uterine factors

• Androgens and folliculogenesis

• Insulin resistance and obesity

• Stress.

Although we know that PCOS is associated with morbid metabolic, endocrine and cardiovascular features, we do not yet fully understand its etiology. The two most consistent endocrine findings are elevated androgens and insulin. We shall discuss these and inherited and lifestyle factors below.

Genetics, Epigenetics, Uterine and Early Life Factors

The heterogeneity of clinical and biochemical features in PCOS is likely explained by the interaction of a small number of (as yet unknown) genes with certain environmental factors. Likely candidates include genes that regulate ovarian hormone production or influence body mass index, adiposity or insulin sensitivity.

We see that PCOS tends to run in families and is possibly passed on by the father’s genes. It is more likely to occur if there is a family history of type 2 diabetes or if there is early baldness (hyperandrogenism) in the men in the family.³² In addition to the influence of inherited genes, there may also be predisposing factors operating in the womb during pregnancy (i.e., an epigenetic influence).

Diet during pregnancy may have a profound influence on future health of the adult and this is an area being researched extensively. We know little about dietary triggers in utero for the development of PCOS although some researchers have observed that Vit D deficiency in utero can predispose to the development of PCOS.³³

In animal studies, offspring of sheep and monkeys exposed to testosterone have more PCOS characteristics and this observation is supported by data from human studies.

This has led some investigators to propose that genetically determined hypersecretion of androgens by the fetal ovary may result in many of the observed clinical and pathologic features of PCOS, and may program the pituitary to favor excess luteinizing hormone (LH) secretion, encouraging the abdominal adiposity that predisposes to insulin resistance.^34,35 Other researchers and clinicians feel that the primary genetic predisposition is to insulin resistance rather than androgen overproduction.³⁶

Many women with PCOS were small babies. Such intrauterine growth retardation is in some cases associated with premature puberty in girls with PCOS³⁷ and may be linked with inherited defects in the theca cells of the ovary, which predisposes them to overproduce androgens.³⁸ Another factor which increases prenatal androgen levels and premature puberty is exposure in utero to commonly used pesticides.³⁹ This risk is unfortunately an escalating one in modern and developing nations, and is discussed further in Chapter 9.

Early life exposure to phytoestrogens in the form of soy-based infant formulas, has also been examined as a possible endocrine disruptor acting on ovaries at a very sensitive stage of development. Animal studies would indicate that avoidance of soy formulas and drinks is to be recommended, however human studies are limited and results are as yet not clear cut.⁴⁰

Androgens and Folliculogenesis

Little is known about the regulation of pre-antral folliculogenesis in the normal ovary, let alone in the polycystic ovary, however there is emerging evidence of an intrinsic abnormality of folliculogenesis in the ovaries of women with PCOS that affects the very earliest, gonadotrophin independent, stages of follicle development.⁴¹

The result is lots of immature follicles (primary and early pre-antral follicles); a result of accelerated progression of primordial to primary and early antral follicles and/or a reduced rate of atresia of early antral follicles. Excess androgens are the probable cause of both these phenomena.³⁵

Insulin Resistance

As discussed above, there appears to be genetically determined increased levels of androgens which exert their influence in utero (or prepuberty) and predispose to PCOS and possibly also a genetically determined predisposition to decreased insulin sensitivity. But genetics alone rarely dictates the course of a disease. Environment and lifestyle can also contribute to the development of this syndrome, as we will see when we discuss obesity below. In particular the development of insulin resistance has a major impact.

Humans are still genetically ‘wired’ to thrive on the habits of our ancestors, who consumed nutrient-rich foods, a diet low in carbohydrates and who sustained greater levels of movement and exercise than we do today. In many ways, our environment and lifestyles have evolved too rapidly for our bodies to keep pace. Unhealthy lifestyles and diet and genetic predisposition can cause the pancreas to overproduce insulin in an attempt to maintain normal blood glucose levels. The muscle cells (and others) are overwhelmed by this excess insulin and protect themselves by reducing the number of insulin receptor sites on their surface. The average healthy person has some 20 000 receptor sites per cell, while the average overweight woman with PCOS can have as few as 6000 on the cells of many of their tissues (Fig. 5.6).

Figure 5.6 Insulin resistance prevents glucose entering the cells.

Women with PCOS are thought to possess a selective resistance to insulin (within the liver or muscle tissue), whereas other organs, such as the ovaries, maintain normal sensitivity to insulin. The high levels of insulin in the blood stimulate the theca cells that surround the follicles in the ovary to enlarge and produce more than the usual amount of testosterone which interferes with ovary function and the menstrual cycle. Some researchers believe that hyperinsulinemia and abnormal carbohydrate metabolism not only contributes to ovarian dysfunction but also contributes to poor oocyte quality in those PCOS patients who do ovulate.

As long ago as 1996, the oral contraceptive pill was observed to contribute to deterioration in glucose tolerance and recent studies have confirmed an increased risk of developing insulin resistance in women with or without PCOS after taking the OCP.

For this reason and because of concerns over the metabolic effects of PCOS, it is recommended by many specialists that use of contraceptive pills be limited or avoided if possible. Transdermal and vaginal contraceptives have the same effect and Depo-Provera has a negative effect on weight, often causing up to 10 kg weight gain, which brings its own problems for fertility as discussed below.^42,43

Insulin resistance and weight gain – apples and pears: The severity of the expression of PCOS can be affected by the percentage of body fat. Specialists in Australia report that at least half of their patients with PCOS are obese. (Obesity in women is defined as a waist measurement of 80 cm.) In Europe, 40–60% of PCOS patients are reported to be obese. In Asia, this percentage is lower and in the USA, the percentage is higher.

There is no doubt that obesity worsens the presentation of PCOS but it is also thought that PCOS itself confers a predisposition to obesity. However, it does not have to be extreme weight or obesity that causes a problem in women predisposed to PCOS. Sometimes it is the weight gain itself (even just 10% of body weight) can be enough to affect the ovaries. Excess weight around the abdomen is the pattern typical of PCOS patients and is the pattern associated with insulin resistance and other metabolic disorders. Waist-to-hip ratios are consistently higher (indicating increased abdominal fat mass) in both over weight or normal weight PCOS patients compared with women without this condition. Overweight women without PCOS tend rather to be heavier in the thighs and buttocks than the abdomen,⁴⁴ hence, the apple and pear analogy. Central obesity is an android pattern and likened to an apple shape, while the lower body weight gain is a gynoid fat distribution and likened to a pear shape. So we might ask why should a big stomach be more worrying than a big bottom? Many researchers think the culprit is visceral fat, i.e., deposits of fat around the abdominal organs, as opposed to subcutaneous fat, under the skin. Visceral fat is more metabolically active than subcutaneous fat. Visceral fat has been measured by computed tomography X-ray (CT) scans or by dual energy X-ray absorptiometry (DEXA) scans, and shown to be linked to insulin resistance in both overweight and lean women with PCOS in most (but not all) studies.^45–47

Whether there is abdominal obesity or not, we do know that the fat cells in PCOS patients are significantly larger than in women without PCOS. Also that adipose tissue behaves differently in PCOS, i.e., adiponectin, which is a circulating protein produced by adipocytes is reduced. This appears to be the case in both overweight and lean PCOS patients. These swollen adipocytes are more insulin resistant than regular sized ones, demonstrating how lean women with PCOS are at risk of developing the metabolic effects of the disorder.⁴⁸ Losing weight (which we will discuss further below) is a strategy that can bring great benefit to PCOS sufferers.

Finally, it is worth noting that the effects of insulin resistance can be felt well before puberty. In young girls suffering childhood obesity with deposits of visceral abdominal fat, production of excess insulin affects the development of the ovaries. Again this is likely due to raised androgen levels. There is some evidence to show that if this can be prevented early enough (with insulin lowering treatment between 8 and 12 years), then PCOS is less likely to develop compared with other girls with the same risk factors (i.e., obesity and low birth weight), who are not treated before puberty.⁴⁹

In terms of fertility, obesity in PCOS women not only exacerbates ovarian dysfunction but may also negatively affect implantation of an embryo, should a conception occur – these women show significantly altered proteins in the endometrium that are not seen in lean women who do not have PCOS.⁵⁰ Additionally we know that obesity markedly changes the follicular environment in a way that is detrimental to the development of the eggs, likely reducing conception rates.⁵¹

Stress

Clinicians have observed that stress is a contributing factor in the development of PCOS in some of their patients, notably those who worked 9–14 h a day in professions such as law or finance.³⁶ And animal studies (both in vivo, and with tissue culture laboratory studies) show that increased stress and sympathetic nervous system activity causes development of PCOS like characteristics and infertility.⁵²

In conclusion we can say that there is likely a genetic predisposition in those girls or women who develop PCOS, probably involving genes related to the production of androgens, and possibly those predisposing to insulin resistance. On top of this, events in the womb (including epigenetic changes) and lifestyle factors, during early and middle life can influence the development of the disease. The consequences – including deposits of abdominal or visceral fat – can have deleterious effects on ovary function, follicular environment and the integrity of the endometrium.

PCOS, Fertility and Aging

While lack of regular and predictable release of eggs makes it harder to fall pregnant, the good news is that women with PCOS seem to retain their fertile potential for longer than other women. It appears that the process of ovarian aging may be delayed in women with PCOS and the typical ultrasound features of PCOS appear to diminish with increasing age.

Anti-Mullerian hormone (AMH) is secreted by the primary and preantral follicles and is an indicator of ovarian reserve. It is generally higher and declines more slowly in women with PCOS and it may be the case that their biological clock is not ticking as fast as that of other women. Thus, a greater ovarian reserve is retained in women in their 40s with PCOS and it is possible that they may actually be endowed with a larger ovarian reserve at birth. However, none of this is helpful if the ovaries are not prepared to ripen and release the reserved eggs!

Metabolic Effects of PCOS

So far we have spoken mostly about the effects of PCOS on the ovaries but there are more systemic effects too. Women with polycystic ovary syndrome have a high prevalence of hyperlipidemia, hypertension and progression to type 2 diabetes mellitus. This is similar to the features of the so-called ‘metabolic syndrome’ or ‘syndrome X’. By the age of 40 years, up to 40% of women with PCOS will have type 2 diabetes or impaired glucose tolerance.

The insulin resistance and hyperinsulinemia typical of PCOS stimulates lipid storage, altered lipoprotein and cholesterol metabolism and (possibly) altered steroid hormone metabolism. Women with the syndrome have at least seven times the risk of myocardial infarction and ischemic heart disease of other women.

Risks During Pregnancy

Women with PCOS may suffer increased risks during pregnancy, including higher miscarriage rates, abnormal fetal size for gestational age, pre-term deliveries, gestational diabetes, hypertension and pre-eclampsia.

It is thought that excess androgens, and the related impaired insulin sensitivity, could alter the initial processes of trophoblastic invasion and placentation, leading to some of the above mentioned risks.

However, a high BMI and different PCOS phenotypes may account for some of these obstetric complications, and not all studies have found that PCOS patients have a higher risk of miscarriage.^53,54

PCOS and Emotions

Women with polycystic ovary syndrome (PCOS) have poorer health-related quality of life (especially psychological) than women in the general population and than patients with other medical conditions such as asthma, epilepsy, diabetes, back pain, arthritis and coronary heart disease. Depression in this group of women is often related to obesity and infertility.⁵⁵

The effects of PCOS at different stages of life is summarized in Table 5.20.⁵⁶

Table 5.20

The effect of inherited predisposition to PCOS from uterus to middle age

Treatment Strategies (Western Medicine)

The type of treatment offered for patients with PCOS depends on the symptoms and the specific needs at different stages of life.

In young women, this may be reduction of acne, unwanted body hair growth or a desire for regular menstrual cycles. Or management of the health risks associated with PCOS. However, in this text we shall place most emphasis on discussion of treatments that promote fertility.

Losing Weight

There is ample evidence that weight loss is beneficial in PCOS. There is also good evidence that weight loss improves fertility in all women whether they have PCOS or not, both in terms of spontaneous conception and IVF pregnancies.⁵⁷ Not only does reducing obesity increase ovulation frequency but it improves the very follicular environment in which the eggs themselves mature.^51,58

However, for women with PCOS, weight loss is not such an easy thing to achieve despite the best of intentions. These women may have an increased susceptibility to weight gain and/or find it harder to lose weight than women who don’t have PCOS. High levels of insulin encourage the body to increase fat storage. In a cruel vicious cycle this creates more insulin resistance, which increases blood insulin more and thus there will be even more weight gain.

There is also some evidence that the appetite signals in women with PCOS are disordered – these women produce too much ghrelin which increases appetite and leptin resistance in the brain so that the brain doesn’t get the appetite suppression messages. This means there is a higher satiety level and PCOS patients need to eat more to feel satisfied. Elevated androgen levels are linked with increased cravings for carbohydrates.

The good news is that it is a relatively small weight loss and body fat redistribution that is needed to start the ovaries working again. Just 5–10% of initial body weight (or even just 5 kg), enough to change the waist-to-height ratio, will improve metabolic, reproductive and psychological features of PCOS, including hyperandrogenism, insulin resistance, dyslipidemia, glucose tolerance, menstrual function, ovulation, pregnancy, and quality of life. It is the loss of a small volume of critical intra-abdominal fat, which may be only a small percentage of the total body fat, which confers these benefits.

Which diet should be recommended for weight loss in PCOS? This is a large and fascinating topic but we do not have room for detailed discussions of different diets here. Suffice it to say that there is insufficient evidence to date to confidently recommend one specific diet to all women with PCOS. Although some diet types may be more beneficial for metabolic status, individual constitutions and preferences are important so that the diet will be effective and will be maintained. It is important that changes in diet and exercise routine be amenable to the person involved, as a lifetime commitment to these changes will reap the most benefit. Chapter 9 discusses diet in more detail.

In general, high protein, low glycemic index meals are recommended because they are relatively low calorie, they do not raise blood sugar and do not produce as much insulin, and they manage hunger well. The high leucine content of protein contributes to regulation of protein synthesis and insulin signaling pathways. But a variety of approaches, including calorie counting and meal replacements, can be successful for achieving and sustaining a reduced weight.

The inclusion of dietary fiber at each meal (e.g., from whole grains including oats and barley or pulses) or supplemental fiber such as psyllium, also appears to be helpful in controlling insulin levels. The fiber is fermented by microbes in the large intestine creating short chain fatty acids which reduce insulin resistance by mechanisms acting in adipose, liver, and muscle tissue.

Although there is no clear clinical data from human studies, women and girls with PCOS are often advised to avoid soy products so that an extra load of phytoestrogens does not further disrupt the hormonal milieu.

As important as the diet itself, is the ongoing support given as part of a weight loss program. Goal setting, weight monitoring and individualization of the program, follow-up and monitoring by a healthcare practitioner and support from family or friends are crucial in the ongoing success of weight loss programs. Additionally, stress, patterns of eating (including emotional triggers), and self-esteem need to be addressed.

Exercise does not on its own help significantly with weight loss but it is an important part of a program for PCOS patients because it can improve insulin resistance (even without loss of weight). Exercise increases skeletal muscle insulin sensitivity, so that there is less insulin present in the blood, hence less glucose is converted to fat. High intensity interval training has been shown to reduce insulin resistance effectively with a very small time commitment.⁵⁹

Additionally, exercise has been seen to specifically help shrink abdominal fat cells. And another reason that exercise may be important is the associated reduction in the stress hormone cortisol. This hormone specifically promotes visceral fat deposits.

Pharmaceutical

The Oral Contraceptive Pill: Teenagers and young women with PCOS usually present first to their doctors with acne, which often disturbs them more than the fact that their periods are irregular. Or they may be bothered by increasing hairiness (hirsutism). Western specialists usually respond by prescribing the oral contraceptive pill (OCP) to these young women, thus masking the disease for many years. Missing the diagnosis at this point means an opportunity is lost whereby young women could be advised that lifestyle and weight management is crucial. It is only when a woman stops the OCP when she wants to conceive that the problem is uncovered and properly diagnosed. Even young women who have not been diagnosed with PCOS, who take the OCP for some years, are showing signs of this disorder when they stop the pill. It is an increasingly common observation that these women’s periods do not return regularly and the investigations that follow then reveal signs of PCOS.

As we saw above, administration of combined contraceptives appear to increase insulin resistance, increase triglyceride levels and promote inflammation and hence, it is advisable for young women with a predisposition to PCOS to avoid this form of contraception.

Clomifene Citrate (Clomid, Serophene): For PCOS sufferers with irregular cycles who wish to conceive, the first step is usually a prescription for drugs that induce ovulation. Clomifene citrate is given as 50 mg dose for 5–7 days just after a menstrual period (the period may first need to be induced with progesterone in a woman who is not having any cycles). The dose can be increased up to 200 mg if necessary. However, as we saw above, this drug has a negative effect on the cervical mucus and the lining of the endometrium, and is usually not continued past 3 cycles or attempts.

Women with PCOS do not respond to clomifene citrate with the same success as other patients with different ovulation disorders. Such failure to respond is correlated with BMI and androgen index. This has been called clomifene resistance and often calls for the addition of insulin lowering medications.

Metformin (Glucophage, Diaformin): Metformin is an insulin lowering drug which reduces blood sugar levels, may help weight loss and may increase ovulation frequency. It is prescribed at doses between 1000 and 2500 mg/day and is also used in type 2 diabetes. Common side-effects are diarrhea, nausea, vomiting, abdomen bloating, and flatulence but many of these side-effects diminish with time. Metformin is classed as a Category C drug; it can cause neonatal hypoglycemia at term but is not teratogenic (i.e., it does not cause birth defects). It is usually stopped once pregnancy is confirmed. Other insulin lowering drugs, such as the Glitazones have also been shown to induce ovulation. There is greater concern about the effects on the fetus of these drugs compared with metformin, and they should not be used by women actively trying to become pregnant.

PCOS patients who are reluctant to take pharmaceutical drugs like these can take heart from studies which have shown that exercise and diet can be equally effective in terms of weight loss, increased ovulation and pregnancy rate – and that adding metformin to such a regimen is not necessary since it confers no advantage in terms of pregnancy rates.⁶⁰

Gonadotrophins: If ovulation cannot be induced by clomifene and/or metformin, then gonadotrophins may be given in small doses. This may be within the context of an artificial insemination (AI) cycle, or an IVF cycle.

Women with polycystic ovary syndrome (PCOS) usually respond to these injectable fertility medications with a degree of success. However, these women are more prone to the problems associated with the use of gonadotropins such as ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy (discussed in Ch. 9).

Statins: The use of statins, especially in PCOS patients with high cholesterol, is sometimes recommended. This therapy has been shown to reduce testosterone levels. However, women who are attempting pregnancy are not advised to take statins, since they may cause deformities in the baby.

Surgical

Ovulation problems in women with PCOS can also be treated by destroying or removing portions of the ovaries. Ovulation often resumes more regularly after this, possibly due to the reduced number of theca cells producing testosterone, and reduced number of resting follicles producing AMH and inhibin.

There have been several surgical methods described for doing this including:

• Wedge resection

• Ovarian drilling or cystectomy

• Ovarian diathermy.

The benefits of surgery include the avoidance of drug side-effects, and these procedures are sometimes offered to those for whom clomifene citrate has not been successful. Skillful drilling with laser or diathermy appears to be as effective in inducing ovulations as clomifene citrate or gonadotrophins. The risks are those associated with any surgery and include damage to ovaries and the formation of adhesions.⁶¹

PCOS and TCM

Etiology

To understand the origins of ovarian dysfunction in PCOS, the Chinese medicine practitioner needs to consider the effects of both congenital Jing and acquired Jing (also known as Pre-heaven or prenatal Qi and Post-heaven or postnatal Qi).

In terms of congenital Jing, we recognize that there is a genetic or inherited component in PCOS. Other factors (not inherited) operating in the womb can also exert critical influence. This tells us that a deficiency of the prenatal Qi or congenital Jing may set the stage for the development of PCOS long before the function of ovaries is tested in the 2nd 7-year cycle when the Chong and the Ren vessels become active at puberty. The primary influence here is the Kidney Qi or Kidney Jing and reinforcing the Kidney Jing is often the way we address conditions that have their origins in the Pre-heaven Qi. However, PCOS is a complex disorder and the interactions of factors operating postnatally have a large impact and warrant our close attention. This Post-heaven Qi (acquired Jing) is the realm of influence of the Spleen and the Stomach.

Any treatment strategies we devise for the PCOS patient thus needs to take into consideration both Pre- and Post-heaven Qi.

At puberty, the Chong and Ren vessels and the ovaries become active. In some young women, PCOS will manifest at this point, with erratic lengthy menstrual cycles, which do not ever become regular or sometimes may cease altogether. During the process of folliculogenesis in the ovary, whereby egg cells are systematically and repeatedly ripened, there is a spanner in the works; as discussed above, it appears there is an intrinsic fault in folliculogenesis itself. In an ideal world, we would already have identified these at-risk girls and begun treatment before puberty – as we noted above, if some of the manifestations of PCOS like high insulin are addressed early on (from age 8) then the ovaries and folliculogenesis are less likely to be compromised, i.e., the Kidneys, Chong and Ren vessels will be more likely to function normally once puberty arrives.

It is at puberty that part of the Kidney Jing transforms into Tian Gui, which is responsible for initiating and maintaining reproductive function.

Initial recruitment from the pool of resting follicles (the primordial follicles which can be dormant for up to 50 years) to become primary follicles occurs normally in the ovaries of PCOS patients. The function of the Tian Gui, awakening of the follicles, is normal at this stage but then there is a hold up at the next stage of development when primary follicles should develop into secondary follicles and beyond. Hence, large numbers of primary follicles stockpile. This arrest of follicle development, at its root, can be seen as a failure of Kidney Jing, and specifically the Tian Gui, to drive or maintain all the essential steps of folliculogenesis. There may also be some obstruction of the Qi in the Chong and Ren vessels that contributes to this stalling in follicle development. Both these vessels have their roots in the Kidneys.

In many women diagnosed with PCOS, the symptoms do not manifest until some years after puberty (and sometimes after some years on the oral contraceptive pill or other forms of hormonal contraception). In such cases, some other factors have, perhaps in concert with a predisposing Kidney Jing deficiency, caused interruptions in the Chong and Ren vessels. We shall discuss these in detail below.

TCM Analysis and Diagnosis: Analyzing Symptoms and Signs

Irregular Periods

A consistent clinical symptom in women with PCOS is the irregular or infrequent nature of their ovulation. This may be mild, i.e., a tendency for menstrual cycles to be 5 weeks or more, or more severe with long periods of amenorrhea. Either way, the Chong and Ren vessels are not functioning optimally.

If amenorrhea (or severe oligomenorrhea) dates from puberty, then we would usually consider this a Kidney Jing deficiency or failure of some aspect of Tian Gui. In the case of more regular but slightly long or irregular cycles, we would look at the relationship between the Liver Qi and the Chong and Ren channels.

Weight Gain or a High Waist-to-hip Ratio

There is a clear case to be made for a diagnosis of Phlegm-Damp accumulation in the PCOS patients who present with obesity or a recent weight gain that has affected the menstrual cycle. Even a modest weight gain of 5 kg or so can influence ovarian activity, even though overall physical appearance may be fairly normal. As described above, the sort of weight gain typical of PCOS patients is that around the waist. Dai vessel dysfunction may allow a build-up of Damp and eventually Phlegm-Damp, in this area.

Loss of weight has been seen to improve ovulation frequency. Thus it appears that mobilization of Phlegm-Damp may be all that is required to unblock or to improve the function of the Chong and Ren channels.

The insulin resistance that we discussed above is especially common in PCOS patients who have poor diets and do little exercise. Junk food or rich diets and lack of exercise are associated with sluggish movement of Qi (especially Spleen Qi) and accumulation of Damp. Additionally, those women who are having very infrequent periods are missing the opportunity to expel turbid Damp from the lower Jiao with their menstrual flow and thus it accumulates. As mentioned above, it has been observed that obese women have an altered uterine environment, which is disadvantageous to embryo implantation.⁵⁰

This may be one manifestation of the accumulation of this turbid Damp in the lower Jiao.

Acne, Hair Loss, Hirsutism, Cardiovascular Disease

Some of the typical androgenic signs and symptoms of PCOS can be interpreted as Damp or Blood stagnation. For example, acne of the type seen in PCOS will usually be diagnosed as Damp-Heat manifesting in the skin. Both hair loss on the head and hirsutism on the body are deemed to be a sign of Phlegm-Damp in modern Chinese medicine texts.⁶² Many aspects of cardiovascular disease are diagnosed as Blood stagnation.

Precocious Puberty, Small Birth Size (or Large)

Precocious puberty usually occurs when a young girl is overweight, i.e., there is an excess of Phlegm-Damp. Large size at birth predisposes to excess weight during childhood and beyond. However, a small birth size (also linked to premature puberty and PCOS) is more likely to make us think of Kidney Jing deficiency.

Surgery, Scans, and Blood Tests

TCM diagnosis relies on analysis of clinical symptoms and some signs that are easily evaluated such as pulse and tongue. In some cases, laboratory and surgical investigations can broaden or enhance our diagnostic repertoire. For example, laparoscopic investigations on women with PCOS usually reveal swollen ovaries; the polycystic ovaries themselves look shiny and swollen when viewed during laparoscopy, i.e., they look Damp (Fig. 5.7).

Figure 5.7 Polycystic ovaries appear shiny and swollen.

Scans (CT and DEXA) may reveal fat deposits around the central internal organs of women with PCOS even where there is no obesity or weight gain. Similarly, enlarged adipocytes (fat cells) are found in women with PCOS whether they are overweight or not. We would relate these findings to abnormal accumulations of Phlegm-Damp. The pattern of fat deposits or Damp accumulation follows the Dai vessel pathway. The swollen cystic ovaries also lie in the path of the Dai vessel. Even in women where there is no obvious truncal obesity or weight gain, the swelling of the ovaries could indicate smaller localized accumulations in the Dai channel or the Liver channel.

Blood tests that show high levels of clotting factor (fibrinogen) in PCOS patients confirm the increased risk of Blood stagnation in these patients.⁶³ See Table 5.21 for a summary of this analysis of PCOS signs and symptoms.

Table 5.21

Summary of TCM analysis of PCOS symptom and signs

Symptoms, signs and etiologic factors	TCM analysis
Irregular periods	Chong and Ren channel dysfunction
Swollen shiny ovaries	Phlegm-Damp accumulation
Weight gain around the middle	Phlegm-Damp accumulation
	Dai Channel dysfunction
Visceral fat deposits, enlarged fat cells	Phlegm-Damp accumulation
Losing weight improves ovarian activity	Mobilizing Damp unblocks Chong and Ren channels
Acne	Damp-Heat
Hairiness	Damp?
Prone to cardiovascular disease	Blood stagnation
Increased coagulation factors	Blood stagnation
Precocious puberty	Phlegm-Damp accumulation
Genetic and intrauterine factors	Kidney Jing deficiency
Small birth size	Kidney Jing deficiency

Making a Diagnosis

Having looked at the PCOS patient’s history and analyzed the ways in which she presents in the clinic (and other associated findings), we can now formulate our diagnosis. Irregular or absent periods is the feature that infertile PCOS patients most commonly share. In TCM terms, these women suffer a disturbance of the Chong and Ren vessels.

We know that the foundation of the Chong and Ren vessels is the Kidneys and that the Chong and Ren vessels require nourishment by Qi and Blood and can be obstructed by Phlegm-Damp and stagnation of Qi and Blood (Fig. 5.8).

Figure 5.8 Chong and Ren vessels – normal physiology. The Chong and the Ren vessels originate in the Kidneys and are governed by them. The Spleen supplies the Blood and nourishment for them, and clears Fluids and Damp. The Liver moves the Qi and the Heart moves the Blood and houses the Shen.

If we now put the dysfunction of the Chong and Ren vessels at the center of our analysis of women with PCOS who are not ovulating regularly, we come up with this diagrammatic analysis (Fig. 5.9).

Figure 5.9 Chong and Ren vessels – abnormal physiology in PCOS. When Kidney Jing, Yin or Yang is deficient, the Chong and Ren vessels lose their foundation, are malnourished and no longer properly managed. When Spleen Qi is deficient, Damp and Phlegm-Damp can collect and obstruct the channels, and lack of Qi and Blood can results in a lack of nourishment. If the Liver Qi is stagnant, Qi in the Chong and Ren vessels can become obstructed.

Heart Qi stagnation (and Shen disturbance) may be a reflection or manifestation of long-term Chong and Ren disturbance, but it is less likely to be a causative factor in PCOS. On the face of it, PCOS being an ovulation disorder, we might assume involvement of the Heart and the Bao vessel, as we did in our earlier discussion of amenorrhea, but here the problem lies with the ovary and not with the hypothalamus or pituitary gland, as it did in other instances of ovulation disorder.

While the Chong and Ren vessels are at the center of the problem causing failure to ovulate regularly in PCOS, another extra channel, the Dai vessel is also of interest because of its function of controlling circulation of fluids in the lower Jiao. The Dai vessel is situated around and through the abdomen from the level of the 2nd lumbar vertebrae and extending downwards. Not only is this the precise area where the waist expands in PCOS patients with abdominal weight gain but also includes the part of the body containing fat deposits around the central organs and the swollen ovaries typical of PCOS. Any accumulation in this area is likely to obstruct Dai vessel function. Conversely, Dai vessel dysfunction will allow a build up of Damp and eventually Phlegm-Damp in this area.

The Dai vessel also intersects Ming men and passes through the Kidneys, hence malfunction of the Dai vessel may well be a contributing factor to impaired folliculogenesis and ovary function at a very fundamental stage. Its other important role is to bind the channels running perpendicularly on the abdomen. This includes not only the primary meridians but also the Chong and the Ren, thus Dai vessel disturbances may be reflected here too. Spleen and Liver channels may also be affected.

In addition to the Chong, Ren and Dai vessels, we should mention the Bao vessel and Bao channel (see Ch. 2), which are important in transporting Jing and Tian Gui from the Kidneys, and Blood from the Heart to the Uterus. There are no points on the Bao mai that we use directly, however Heart and Kidney points can indirectly influence its activity.

Our working model for diagnosing PCOS is summarized in Tables 5.22 and 5.23.

Table 5.22

Diagnosis of PCOS (weight gain)

Organs	Kidneys, Spleen
Pathogen	Phlegm-Damp accumulation
Channels	Chong Ren obstruction
	Dai vessel accumulations

Table 5.23

Diagnosis of PCOS (no obvious weight gain)

Organs	Kidneys, Liver
Pathogen	Qi and Blood stasis (± Phlegm-Damp accumulation)
Channels	Chong Ren obstruction

A genetic predisposition to PCOS implicating the Kidneys plus a Spleen Qi weakness contributing to weight and blood sugar problems together become the ‘Ben’ of our diagnosis, combined with an accumulation of Phlegm-Damp, the ‘Biao’ causing obstruction in the Chong and Ren vessels (Fig. 5.10).

Figure 5.10 This PCOS patient had amenorrhea and weighed 87 kilos – most of her weight was around her stomach.

Where weight gain is not a factor, we attribute the obstruction in the Chong and Ren vessels to Qi, Blood, and possible local Phlegm-Damp stasis. The Ben of our diagnosis is the Kidneys (a predisposing factor) but the Biao is the Liver Qi stagnation leading to stagnation of Qi and Blood. Accumulation of Damp is not always apparent, except for the presence of cysts on the ovaries and sometimes deposits of fat around the abdominal organs. Liver Qi stasis can create Phlegm-Damp by disrupting Gall Bladder function. When bile is not produced properly, then fat metabolism is affected, provoking the formation of Phlegm-Damp which may manifest as fat deposits in the abdomen but no apparent weight gain (Fig. 5.11).

Figure 5.11 This PCOS patient weighed 45 kg, and suffered amenorrhea.

Figure 5.12 summarizes some of the ways that different pathologic states can lead to ovulation disorders of the type seen in PCOS. There is a third pattern, Qi and Blood deficiency, which can also affect the Chong and Ren leading to dysfunction due to lack of nourishment; however this is more often a different sort of amenorrhea pattern (not PCOS) and was discussed in an earlier section. This chart also does not include the Blood stasis that sometimes complicates PCOS, particularly long-term disease. It is at its later stages that Blood stasis signs such as cardiovascular disease develop, and the amenorrhea of PCOS is not usually related to Blood stasis alone.

Figure 5.12 Summary chart of PCOS pathomechanism.

Clinical Progression

Let us now examine how different aspects of the PCOS pathomechanism play out at different times. Specifically, we are interested in how the predisposing Kidney factors interact with Spleen deficiency and Liver Qi stagnation to create the pathology and clinical picture typical of PCOS.

Kidney deficiency meets Spleen Qi deficiency or Liver Qi stagnation

• at time of conception

• at time of puberty

• in reproductive years

• in later years.

At Time of Conception: When there is both Kidney Jing deficiency and compromised Spleen function in the mother (e.g., poor nourishment or inappropriate food) at the time of conception of a baby girl, then that baby may be predisposed to PCOS or blood sugar disturbances. Also intrauterine growth retardation will predispose to PCOS.

At Time of Puberty: At time of puberty, interaction of Kidneys and Spleen are important to establish the function of the Chong and the Ren cycle. At puberty, or in the second of the 7-year cycles, not only must the Tian Gui flourish but there must also be adequate nourishment and Blood – or the menstrual cycle cannot become well established. Anorexia and bulimia can have very dire consequences at this stage of a girl’s development. On the other hand, when nourishment is overdone, and the girl becomes overweight, the 7-year cycle may be advanced and the periods come prematurely, but not regularly. Liver Qi plays a part at this stage too – there are many stresses on young teenage girls, not only academic stresses but social stresses. Early sexual activity can disrupt the Chong vessel activity, as can the use of hormonal contraceptives and the ‘morning after’ pill.

In Reproductive Years: The interaction of the Kidney and Spleen later in reproductive years, e.g. 20s and 30s can also lead to disruptions in the Chong and the Ren vessels leading to PCOS. If Spleen function is poor, or the diet is bad and body weight increases, then in susceptible women, Chong and Ren vessels are obstructed and what was a regular cycle may become long or eventually stop. Use of the oral contraceptive pill or other hormonal contraceptives may impair Spleen function, affecting blood sugar metabolism. Hormonal contraception also interrupts the Liver in its function of overseeing cycles in the body and the resulting stagnation can disrupt Chong and Ren function. If stress impacts the Liver Qi sufficiently, this can contribute also to disruption of the Chong and Ren vessels.

In Later Years: As often happens with long-term disease of any nature, Blood stagnation develops. In the PCOS sufferer this may manifest in cardiovascular disease. Long-term Kidney and Spleen imbalance can lead to diabetes and other manifestations of metabolic syndrome such as hypertension. These are serious disorders which require correct treatment, however in this text we shall keep our focus on the aspects of PCOS which affect fertility.

Treatment with TCM

TCM analyzes pathologic conditions according to how they present in the clinic and as such, we can approach the treatment of PCOS-related infertility as we have been doing all along, gathering information about the menstrual cycle, etc. – however, as we saw with endometriosis, there is a special pathology we need to address in these diseases – in this case, it is the factor inhibiting the growth of the follicles in the ovary and preventing a regular menstrual cycle.

Practically speaking, treatment of PCOS can take two different approaches: one with a single focus on facilitating the release of eggs and conception, and one more complex addressing all the issues inherent in this disease, both Ben and Biao. However, these two approaches are not mutually exclusive.

The PCOS patient who is trying to conceive will generally be more interested in what you can do to help her ovulate regularly than in how you can help her lose weight or prevent heart disease or diabetes in the future. Focussing on ovarian activity and ripening and release of eggs, we use treatments that are aimed primarily at re-establishing function of the Chong and the Ren vessels, with secondary focus on the function of the organs. Acupuncture is particularly useful in this regard but while it may stimulate some ovulations, restoration of a regular menstrual cycle will only be achieved with attention to the underlying organ dysfunction. For a simplified approach to induce ovulation, see the Research section below, where standardized (or largely standardized) point prescriptions were used on PCOS patients in trial settings. The information we have gleaned from these trials has been incorporated into the acupuncture protocols suggested below for treatment of different types of PCOS.

When it comes to treating this condition in the larger context (looking further than ovulation induction), we need to consider several layers of treatment: Kidney or Spleen Qi deficiency or Liver Qi stagnation, with the consequent Phlegm-Damp accumulation or Qi or blood stagnation blocking the Chong and Ren channels. Chinese herbal medicine and acupuncture have a lot to offer in this regard. Lifestyle modification is an important component of any type of treatment a PCOS patient chooses to use.

PCOS with Weight Gain

Resolving Phlegm-Damp to regulate/unblock Chong and Ren Channels

For PCOS patients with weight gain, and Phlegm-Damp accumulation, we can take either of two clinical approaches. First, we can focus on primarily mobilizing the Phlegm-Damp and second, we can focus on supporting Kidneys (or focus on primarily supporting Kidneys and secondarily clearing Damp and Phlegm).

Mobilizing Damp and Phlegm primarily

This approach might be chosen for large PCOS patients with stubborn weight gain and who are having few, if any, menstrual cycles per year. The Chong and Ren vessels in this case are seriously obstructed.

Herbal Formula: The combination of a well known formula such as Cang Fu Dao Tan Tang with a more modern formula Bu Shen Hua Tan Tang meets our requirements for these patients. By promoting Spleen function to resolve Damp, expelling Phlegm-Damp accumulation and benefiting Kidneys, we aim to clear Chong Ren obstruction and re-establish ovarian function.

Cang Fu Dao Tan Tang (Atractylodes and Cyperus Guide out Phlegm decoction) with Bu Shen Hua Tan Tang (Decoction for Restoring the Kidney and Removing Phlegm) modified

Cang Zhu	12 g	Rhizoma Atractylodis
Fu Ling	15 g	Sclerotium Poriae Cocos
Ban Xia	9 g	Rhizoma Pinelliae
Sha Ren	6 g	Fructus seu Semen Amomi
Fo Shou	3 g	Fructus Citri Sarcodactylis
Chen Pi	9 g	Pericarpium Citri Reticulate
Dan Nan Xing	6 g	Rhizoma Arisaematis
Zhe Bei Mu	6 g	Fritillariae thunbergii Bulbus
Zao Jiao Ci	9 g	Spina Gleditsiae Sinensis
Shan Yao	9 g	Radix Dioscorea Oppositae
Shu Di	6 g	Radix Rehmanniae Glutinosae Conquitae
Bu Gu Zhi	9 g	Fructus Psoraleae
Yin Yang Huo	9 g	Herba Epimedii
Ji Xue Teng	12 g	Radix et Caulis Jixueteng
Zhi Zi	3 g	Fructus Gardeniae Jasminoidis

Cang Zhu, Fu Ling, Chen Pi and Sha Ren are the main herbs used to clear Damp in this formula. Cang Zhu and Fu Ling strengthen the Spleen to clear dampness. Sha ren augments their action by warming the Middle Jiao, and with Chen Pi and Fo Shou moves the Qi to facilitate the movement of Damp.

Stronger phlegm mobilizing herbs in the form of Fa Ban Xia, Zhe Bei Mu, Zao Jiao Ci and Dan Nan Xing are needed to break up the accumulation of Phlegm – in other words, the shiny swollen theca cells of the ovary and the multiple cysts therein.

To promote ovarian function, we next add Kidney herbs. Shu Di enriches the Kidney Yin and Jing to provide the essential basis for the growth and development of mature eggs in the follicles. It is supported by Shan Yao, which reinforces the Yin of the Spleen and the Kidneys.

Bu Gu Zhi strengthens Spleen and Kidney function and also supports the previous group of herbs by drying Damp. Yin Yang Huo we add to promote maturation of ovarian follicles by boosting Kidney yang function and stoking the fire of Ming Men.

It is hoped that by antagonizing androgens with the action of these herbs, it may be possible to reduce the follicular atresia. Ji Xue Teng is added to promote movement of Blood in the Chong vessel.

Zhi Zi clears Heat arising from accumulated Phlegm-Damp. In some women, this dose will need to be increased. And in the case that Heat has damaged Yin, another herb such as Di Gu Pi would be substituted.

This formula is quite drying, which means we need to carefully monitor the Yin during treatment.

Acupuncture Points: We know that certain acupuncture protocols can help to stimulate ovary function in PCOS patients (see Research section, below), and using these plus points chosen according to our TCM diagnosis, provides the basis for treatments applied in the clinic. In the case of the patient with significant Phlegm-Damp, we use Spleen and Stomach points to strengthen the Spleen, Spleen and Dai vessel points to promote clearing Damp and Kidney points to support ovary function.

Acupuncture points (Table 5.24) for the treatment of PCOS with weight gain – Phlegm-Damp accumulation predominant are as follows:

Table 5.24

Acupuncture points^a used in the treatment of PCOS with weight gain – Phlegm-Damp accumulation predominant

Treatment goal	Acupuncture points
To invigorate Kidney Yin and Yang	Ren-6, KI-3, SP-6 and BL-23
To promote Spleen function in clearing Damp	SP-5, SP-9, BL-20, ST-40, SP-3, SP-15
To activate the Chong vessel	Ren-3, KI-13 and SP-4
To encourage removal of Damp via the Bladder	BL-28
To encourage removal of Phlegm-Damp obstructing the Dai vessel	GB-26, GB-27/28, GB-41, TH-5
To activate local Qi circulation (around the ovaries)	Abdomen Zigong, K-14, ST-28
To regulate metabolism of fluids in the San jiao	TH-6, TH-9
To clear Heat arising from Phlegm-Damp blockage	CO-11

^aReinforcing or reducing technique is used; electro acupuncture can be used on the abdomen or back points and connected to Spleen points on the leg at 10 Hertz 3–5 Amps for 20 min.

Ren-3	Zhongji
Ren-6	Qihai
SP-6	Sanyinjiao
Sp-9	Yinlingquan
SP-4	Gongsun
SP-5	Shangqiu
KI-13	Qixue
Abdomen Zigong
BL-23	Shenshu
BL-20	Pishu
BL-28	Pangguanshu
GB-26	Daimai
GB-27	Wushu
GB-28	Weidao
GB-41	Zu Linqi
TH-5	Waiguan
SP-15	Daheng
ST-28	Shuidao
ST-40	Fenglong
SP-3	Taibai
TH-6	Zhigou
TH-9	Tianjing
Co-11	Quchi

Supporting Kidneys Primarily

This approach is more likely to be chosen for a PCOS patient with infertility who is not too overweight and who is having some cycles, albeit irregularly indicating that the Chong and Ren, while not functioning well are not as obstructed as in the previous case. Her history of menstrual irregularity may go back as far as puberty.

Herbal Formula: To achieve this, we go back to our primary infertility formula Gui Shao Di Huang Tang that supports Kidneys and the Blood, modifying it with Kidney Yang herbs and Damp clearing herbs.

Gui Shao Di Huang Tang (Angelica Peonia Rehmannia decoction) modified

Dang Gui	9 g	Radix Angelicae Sinensis
Bai Shao	9 g	Radix Paeoniae Lactiflorae
Shu Di	9 g	Radix Rehmanniae Glutinosae Conquitae
Shan Zhu Yu	9 g	Fructus Corni Officinalis
Shan Yao	9 g	Radix Dioscorea Oppositae
Fu Ling	15 g	Sclerotium Poriae Cocos
Mu Dan Pi	9 g	Cortex Moutan Radicis
Ze Xie	15 g	Rhizoma Alismatis
Tu Si Zi	9 g	Semen Cuscatae
Du Zhong	6 g	Cortex Eucommiae Ulmoidis
Sha Ren	9 g	Fructus seu Semen Amomi
Zhe Bei Mu	6 g	Fritillariae thunbergii Bulbus
Zao Jiao Ci	6 g	Gleditsiae Spina

Gui Shao Di Huang Tang, which reinforces Kidney Yin and Blood (described in Ch. 4) is modified here to include herbs (Tu Si Zi and Du Zhong) which supplement Kidney Yang. Sha Ren is added to help the Spleen Qi mobilize Damp. The doses of Fu Ling and Ze Xie are increased to further mobilize Damp.

Alternatively, Gui Shao di Huang tang can be combined with pills to strengthen Spleen Qi and clear the Phlegm-Damp using one of the patent medicines described below.

When the patient starts to notice some stretchy cervical secretions (as distinct from other forms of vaginal discharge which may be present due to the Damp), which indicate the Yin base is being established, then more Kidney Yang tonics can be added to the above formula or to Gui Shao Di Huang Tang:

Ba Ji Tian	6 g	Radix Morindae Officinalis
Bu Gu Zhi	6 g	Fructus Psoraleae
Yin Yang Huo	6 g	Herba Epimedii

These Kidney Yang tonics also provide some support for Spleen Yang and will aid in drying some Damp.

If BBT readings taken at this point indicate that ovulation has been successfully induced, then herbs for the post-ovulatory phase can be given according to the principles outlined in Chapter 4. If ovulation does not occur but secretions from the cervix continue, the doses of the Yang tonics above will be increased: namely,

Ba Ji Tian	9 g	Radix Morindae Officinalis
Bu Gu Zhi	9 g	Fructus Psoraleae
Yin Yang Huo	9 g	Herba Epimedii

Acupuncture Points: Points (Table 5.25) are chosen from:

Table 5.25

Acupuncture points^a used in the treatment of PCOS with weight gain – Kidney deficiency predominant

Treatment goal	Acupuncture points
To invigorate Kidney Yin and Yang and Jing	Ren-4, Ren-6, KI-3, SP-6, KI-6, and BL-23
To promote Spleen function in clearing Damp	SP-5 and BL-20
To activate the Chong vessel/to regulate the Chong and Ren vessels	KI-13 and SP-4 Ren-3, Ren-7, KI-14, K-6, LU-7, PC-6 and KI-5
To regulate Qi in the Dai vessel	GB-27
To activate local Qi circulation (around the ovaries)	Abdomen Zigong and LIV-5

^aReinforcing technique is used; moxa is useful on Ren-4. In the case of insulin resistance or elevated testosterone, etc. use electro-acupuncture connecting abdomen points to inner leg points on the same side 10 Hertz, 3–5 Amps, 20 min.

K-6	Zhaohai
Lu-7	Lieque
SP-4	Gongsun
PC-6	Neiguan
K-13	Qixue
K-14	Simen
Ren-3	Zhongji
Ren-7	Yinjiao
Ren-4	Guanyuan
SP-6	Sanyinjiao
K-5	Shuiquan
BL-23	Shenshu
BL-20	Pishu
GB-27	Wushu
LIV-5	Ligou

To promote weight loss, reduce insulin resistance and encourage ovulation with acupuncture, treatments need to be frequent and regular – preferably 3 times a week. Monitoring of possible ovulation is recommended (with BBT, or in the case of women with reasonably predictable cycles, a urinary LH predictor kit). Once an ovulation has occurred and if the patient has attempted to conceive, the use of electroacupuncture on abdomen and Spleen points should be discontinued for the remainder of that menstrual cycle.

Patent Medicines

Patent medicines, which can be used concurrently to strengthen Spleen Qi and clear the Damp are:

Yue Ju Er Chen Wan (Gardenia Ligusticum pill)

Cang Zhu	Rhizoma Atractylodes
Shen Qu	Massa Fermenta
Chen Pi	Pericarpium Citri Reticulate
Fu Ling	Sclerotium Poriae Cocos
Ban Xia	Rhizoma Pinelliae
Xiang Fu	Rhizoma Cyperi Rotundi
Zhi Zi	Fructus Gardeniae Jasminoidis
Chuan Xiong	Radix Ligustici Wallichii

This well-known formula eliminates all types of stagnation, including Phlegm-Damp (Cang Zhu, Ban Xia, Chen Pi, Fu Ling), food (Shen Qu), Qi (Xiang Fu) and Blood (Chuan Xiong) and is especially indicated if there is Heat associated with the stagnation (Zhi Zi).

Cang Fu Dao Tan Wan (Atractylodes Cyperus Phlegm pill)

Cang Zhu	Rhizoma Atractylodes
Xiang Fu	Rhizoma Cyperi Rotundi
Ban Xia	Rhizoma Pinelliae
Fu Ling	Sclerotium Poriae Cocos
Chen Pi	Pericarpium Citri Reticulate
Dan Nan Xing	Rhizoma Arisaematis
Zhi Ke	Fructus Citri seu Ponciri
Gan Cao	Radix Glycyrrhizae Uralensis
Sheng Jiang	Rhizoma Zingiberis Officinalis Recens
Shen Qu	Massa Fermenta

This formula (also described above) includes many of the herbs and actions of Yue Ju Er Chen Wan but also includes Dan Nan Xing, which eliminates obstructions caused by Phlegm-Heat. In addition to addressing Phlegm-Damp accumulation in PCOS, this formula can be useful for treating fallopian tubes blocked by Phlegm-Damp.

A third option is:

Xiong Gui Ping Wei San (Ligusticum Angelica Balancing the Stomach powder)

Cang Zhu	Rhizoma Atractylodes
Chen Pi	Pericarpium Citri Reticulate
Hou Po	Cortex Magnoliae Officinalis
Zhi Gan Cao	Radix Glycyrrhizae Uralensis
Sheng Jiang	Rhizoma Zingiberis Officinalis Recens
Da Zao	Fructus Zizyphi Jujuba
Dang Gui	Radix Angelicae Sinensis
Chuan Xiong	Radix Ligustici Wallichii

This formula attempts to clear Damp by combining herbs that support Stomach and Spleen function with Damp-clearing herbs and Blood tonic herbs. It is more appropriate for women who have a weak constitution.

Treatment of PCOS in women who are overweight must always include some evaluation of diet and lifestyle. Anything we can do to encourage weight loss in these women will enhance ovarian function and fertility. We discussed weight loss and some strategies to achieve this in the previous section.

From a Chinese medicine perspective, one size does not fit all when it comes to diet. (We discuss this in more detail in Ch. 12). When it comes to weight loss most of us look at strategies to boost the action of Spleen Qi in clearing Damp and optimizing metabolism. The typical overweight Damp and Spleen Qi deficient woman is the pear shape we discussed above, i.e., large thighs and bottom, or a low waist-to-height ratio (WHR). While no-one claims to have an easy fix for losing weight, this TCM pattern is at least straight forward to diagnose and treat. And if compliance is good, weight loss will be steady. However, the pattern of obesity that we see in PCOS is a different type, it is more like a male pattern obesity – the large abdomen, or truncal obesity. There may also be fatty deposits around the viscera. The WHR is high. In this case, Damp arising from dietary or lifestyle factors or a genetic propensity is congealed into Phlegm-Damp in particular sites or regions, i.e., the ovaries and the abdominal area. This pattern of obesity can be associated with Heat (e.g., high blood pressure and florid face) and the treatment we apply must take all of this into account not just relying on reinforcing Spleen function.

As mentioned above, it is the first 5–10% of body weight that needs to come off and it is this mobilizing of Damp that appears to make the difference to reproductive function. It is not necessary that a certain number of kilos are lost or that a certain BMI is attained before ovarian function starts to improve. Patients will be heartened to hear that they just have to start the process of mobilization of Phlegm-Damp accumulation. Programs that support PCOS sufferers to lose weight have found that exercise in a group context adds an important psychological component to recovery. Since Damp is an internal environment which can cause sluggishness, low motivation and depression, this sort of encouragement is important.

Exercise, touched on above and also discussed in Chapter 12, is an essential component of a weight loss program, especially where there is insulin resistance. Interestingly, exercise helps weight loss specifically around the abdomen (and reduces visceral fat), whereas calorie restricting diets without exercise tend to encourage more weight loss around the thighs. This tells us that the fat or Damp accumulation around the waist is more stagnant, i.e., more like Phlegm-Damp than just Damp, and targeting this with exercise is particularly important for overweight women with PCOS.

CASE HISTORY – BARBARA

Barbara (39 years) had a long history (all her reproductive years) of oligomenorrhea and amenorrhea, which had only recently been diagnosed as PCOS. She had a weight problem and she wanted to conceive.

Her digestion was sluggish and she tended to bloating and constipation. She suffered constant fatigue, blocked sinuses and was always clearing mucus from her throat. Her tongue was pale and puffy and coated, and her pulse very thready.

The diagnosis of her amenorrhea was a clear-cut case of obstruction by Phlegm-Damp due to Spleen Qi deficiency. To treat this and help her conceive, we needed to strengthen her Spleen and Kidney Yang to clear the Phlegm-Damp.

Taking some of the Damp clearing and Kidney supporting elements of Cang Fu Dao Tan tang and Bu Shen Hua Tan tang, and combining these with Spleen supporting herbs from Si Jun Zi Tang, we made a formula that helped Barbara to mobilize some of the accumulated Damp. Xiong Gui Ping Wei San augmented this action.

Bai Zhu	9 g	Rhizoma Atractylodis Macrocephalae
Dang Shen	9 g	Radix Codonopsis Pilulosae
Shan Yao	9 g	Radix Dioscorea Oppositae
Fu Ling	16 g	Sclerotium Poriae Cocos
Dang Gui	9 g	Radix Angelicae Sinensis
Shu Di	6 g	Radix Rehmanniae Glutinosae Conquitae
Shan Zhu Yu	6 g	Fructus Corni Officinalis
Lu Jiao Pian	9 g	Cornu Cervi Parvum
Tu Si Zi	12 g	Semen Cuscatae
Bu Gu Zhi	9 g	Fructus Psoraleae
Yin Yang Huo	9 g	Herba Epimedii
Zhe Bei Mu	6 g	Bulbus Fritillariae Thunbergii

In addition, she took a patent formula called Xiong Gui Ping Wei San.

Acupuncture points: Ren-4, Ren-6, SP-6, SP-9, ST-25, ST-28, ST-36, ST-40, LU-7

Taking the above herbs and variations on this theme, Barbara’s periods returned much more regularly than before (though not faithfully, every 28 days) and her weight dropped somewhat. After 3 periods (and 4 months) she conceived. Her pregnancy was dogged by ghastly nausea and vomiting, thanks to her Spleen deficiency and Damp. The thought of swallowing Chinese herbs was more than she could face, but acupuncture and ginger helped a little.

PCOS without Weight Gain

Regulating Liver Qi to Regulate Chong and Ren Vessel Activity

You will find that there are two main approaches we can take in the clinic for this type of PCOS as well – and I should hasten to say these are very likely not the last word either. As our understanding of this disease grows and clarifies so will the treatment we offer be expanded and finessed.

Liver Qi Stagnation Leading to Localized Damp Accumulation

This is a relatively severe clinical picture where ovarian activity is significantly compromised and there are few if any periods. Localized accumulation of Phlegm-Damp manifests as cysts in the ovary and visceral fat deposits.

Where there is significant blockage caused by Liver Qi stagnation, a strong approach incorporating purgatives may be required to eradicate the Phlegm-Damp and any Heat built up with the obstruction. After a short course of our guiding formula (Fang Feng Tong Sheng San), another formula more geared toward maintaining good movement of the Liver Qi can be used.

Herbal Formula:

Fang Feng Tong Sheng San (Ledebouriella pills with Magical Effect)

Fang Feng	9 g	Radix Ledebouriellae Sesloidis
Jing Jie	9 g	Herba seu Flos Shizonepetae Tenuifolia
Ma Huang	6 g	Herba Ephedra
Jie Geng	9 g	Radix Platycodi Grandiflori
Bo He	6 g	Herba Menthae
Lian Qiao	9 g	Fructus Forsythiae Suspensae
Huang Qin	6 g	Radix Scutellariae Baicalensis
Zhi Zi	6 g	Fructus Gardeniae Jasminoidis
(Jiu) Da Huang	6 g	Rhizoma Rhei (wine fried)
Shi Gao	9 g	Gypsum
Mang Xiao	6 g	Mirabilitum
Hua Shi	9 g	Talcum
Dang Gui	9 g	Radix Angelicae Sinensis
Chuan Xiong	6 g	Radix Ligustici Wallichii
Bai Zhu	9 g	Rhizoma Atractylodis Macrocephalae
Bai Shao	9 g	Radix Paeoniae Lactiflorae
Gan Cao	6 g	Radix Glycyrrhizae Uralensis
Sheng Jiang	6 g	Rhizoma Zingiberis Officinalis Recens

This formula is not a commonly encountered one in gynecology but it serves our purpose here in clearing Heat and Phlegm-Damp (Lian Qiao, Shi Gao, Huang Qin, Jie Geng) via the bowels (Da Huang and Mang Xiao) and urine (Zhi Zi, Hua Shi). The mild dispersing action (Ma Huang, Fang Feng, Jing Jie, Bo He) it has on the exterior disperses Liver Qi stagnation. Fang Feng has the special attribute of removing Damp blockages by transforming Damp into Yang Qi and lifting the Yang. To protect the Spleen Qi are added Bai Zhu, Gan Cao and Sheng Jiang. To harmonize the Blood are added Dang Gui, Bai Shao and Chuan Xiong.

This formula represents a fairly drastic approach to kick-starting the ovaries again by purging Heat and stagnation. We saw a similar approach when Heat from Liver and Heart Qi stagnation had damaged the Yin, causing amenorrhea, and purgatives were used cautiously to drain Heat and thus recover the Yin. In this case we are dealing with an excess pattern, however, not a deficiency pattern, and can use stronger herbs for longer. Nevertheless, the patient must always be watched carefully to see the response and the formula is used for a limited period of time. Follow-up treatments include formulas such as that mentioned below, which circulate Liver Qi but also reinforce Kidney function.

Acupuncture Points: Points for Liver Qi stagnation leading to localized Phlegm-Damp accumulation (Table 5.26) are chosen from:

LIV-3	Taichong
LIV-5	Ligou
LIV-8	Ququan
LIV-13	Zhangmen
LIV-11	Yinlian
Ren-1	Huiyin
Ren-3	Zhongji
GB-41	Zulinqi
TH-5	Waiguan
GB-26	Daimai
ST-29	Guilai
ST-28	Shuidao
GB-27	Wushu
GB-28	Weidao
BL-18	Ganshu
BL-19	Danshu
SP-6	Sanyinqiao
SP-9	Yinlingquan
PC-5	Jianshi

Liver Qi Stagnation causing Obstruction to Qi and Blood Flow in the Chong and the Ren Vessels

Where less drastic measures are called for, or after a course of the above formula, we shall use a formula that promotes movement of Qi and Blood in the Chong and the Ren, at the same time as resolving any local deposits of Phlegm-Damp and reinforcing the Kidneys.

Table 5.26

Acupuncture points^a used in the treatment of PCOS from Liver Qi stagnation leading to localized Phlegm-Damp accumulation

Treatment goal	Acupuncture points
To regulate the Liver Qi	LIV-3, LIV-5, LIV-8, LIV-11, LIV-13, BL-18, BL-19
To clear Damp and promote menstruation	SP-6, SP-9, Ren-1, Ren-3,
To open and regulate the Dai vessel which is a conduit for Damp in the lower body	GB-41 and TH-5. GB-27/28, GB-26.
To promote Qi and Blood movement around the ovaries	ST-29, ST-28
To facilitate unblocking the Bao Mai and regulate menstruation	PC-5

^aUse even or reducing technique. Electroacupuncture can be used, connecting abdomen and Inner leg points 10 Hertz, 3–5 Amps, 20 min.

Herbal Formula: Using Xiao Yao San in combination with Bu Shen Hua Tang tang will achieve our aims.

Xiao Yao San (Free and Easy powder) with Bu Shen Hua Tan Tang (decoction for restoring the Kidney and removing phlegm) modified

Dang Gui	9 g	Radix Angelicae Sinensis
Bai Shao	12 g	Radix Paeoniae Lactiflorae
Chuan Xiong	6 g	Radix Ligustici Wallichii
Chuan Niu Xi	9 g	Radix Cyathula
Gou Qi Zi	9 g	Fructus Lycii Chinensis
Chai Hu	9 g	Radix Bupleuri
Xiang Fu	12 g	Rhizoma Cyperi Rotundi
Li Zhi He	9 g	Semen Litchi
Xia Ku Cao	9 g	Spica Prunellae Vulgaris
He Huan Pi	9 g	Cortex Albizziae Julibrissin
Tu Si Zi	12 g	Semen Cuscatae
Yin Yang Huo	9 g	Herba Epimedii
Shu Di	9 g	Radix Rehmanniae Glutinosae Conquitae
Shan Zhu Yu	9 g	Fructus Corni Officinalis

A variation of Xiao Yao San (the well known Free and Easy powder), combined with elements of the formula Bu Shen Hua Tan tang will move Qi and Blood in the Chong and Ren vessels and aim to restore menstrual regularity.

This formula contains herbs (Bai Shao, Dang Gui, Chuan Xiong, Gou Qi Zi and Chuan Niu Xi) to build the Blood and encourage its movement in the Chong vessel.

These are supported by herbs such as Chai hu, Xiang Fu, Xia Ku Cao and Li Zhe He which move and unblock the Qi in the Liver channel. He Huan Pi is an important addition to relieve constraint in the Liver channel and address emotional stress.

Finally, we add herbs such as Shu Di, Yin Yang Huo, Shan Zhu Yu and Tu Si Zi to tonify Kidneys to encourage normal ovary function.

Acupuncture Points: Points (Table 5.27) are chosen from:

Table 5.27

Acupuncture points^a used in the treatment of PCOS from Liver Qi stagnation causing obstruction to Qi and Blood flow in the Chong and the Ren channels

Treatment goal	Acupuncture points
To regulate the Liver Qi	LIV-3, LIV-5, LIV-8, LIV-11, BL-18, BL-17
To support Spleen	SP-6, SP-10
To build Liver Blood	SP-10, LIV-8
To promote Qi and Blood movement around the ovaries	ST-29, Abdomen Zigong
To pacify mind, relieve stress	LIV-3, LI-4, PC-6 PC-7, Yin Tang.

^aUse even or reducing technique. Electroacupuncture can be applied connecting abdomen and inner leg points 10 Hertz, 3–5 Amps, 20 min.

LIV-3	Taichong
CO-4	Hegu
LIV-5	Ligou
Yin Tang
PC-6	Neiguan
PC-7	Daling
Abdomen Zigong
ST-29	Guilai
SP-10	Xuehai
SP-4	Gongsun
LIV-8	Ququan
K-13	Qixue
K-14	Siman

CASE HISTORY – EFFIE

Effie was an elegant, young 29-year-old woman who had lost her periods and wanted them back. She wasn’t planning on becoming pregnant just yet but was anxious to keep this option open. Plus, she didn’t feel right without her periods.

She had started taking the oral contraceptive pill shortly after puberty and continued taking it for 15 years without a break. She stopped the pill and her first natural period came about 6 weeks later, the next was 9 weeks after that and the next was 12 weeks later; then nothing.

At this point, her doctor ordered some tests. An ultrasound revealed polycystic ovaries and her serum testosterone and DHEA levels were slightly elevated. No insulin resistance was evident either on blood tests or with a glucose tolerance test. Her diagnosis was PCOS. Her older sister had also received this diagnosis so an inherited component is likely in this case. Her doctor offered her no treatment since she didn’t need Metformin for insulin resistance and didn’t want to take clomifene at the time. She decided to look for alternatives and came to my clinic.

Effie appeared to be a slim woman, but she didn’t have much of a waist – her waist-to-height ratio was slightly higher than normal. She was not hirsute and despite the occasional breakout, had good skin. She exercised regularly and had a good relatively low carbohydrate diet.

Her job was stressful and involved irregular hours and she described herself as irritable and moody. But she slept well and felt well and energetic.

Her pulse was tight and her tongue slightly coated. Her diagnosis was Liver Qi stagnation, leading to obstruction of Chong and Ren vessels.

Treatment with acupuncture aimed to regulate Liver Qi and regulate Qi, Blood and Phlegm-Damp in the Chong, Ren and Dai vessel, and promote ovulation.

Herbs were prescribed to support Spleen and Kidney function, regulate Qi and Blood.

Acupuncture points: ST-28 and SP-6 with electroacupuncture, GB-27, Ren-3, Ren-7, LIV-5 Co-4

Variations at different times included: SP-4, PC-6, LIV-8, ST-40, ST-36, GB-41, TH-5, SP-9

If we were sure an ovulation had occurred (there were usually clear ovulation signs and Effie’s breasts became swollen and sore premenstrually), then we would change to points which moved the Liver Qi and Blood.

For example, LIV-14, LIV-8, SP-10, SP-6, PC-5, ST-29, K-14

Herbal ,formula

Dang Gui	9 g	Radix Angelicae Sinensis
Bai Shao	12 g	Radix Paeoniae Lactiflorae
Chai Hu	9 g	Radix Bupleuri
Bai Zhu	9 g	Rhizoma Atractylodis Macrocephalae
Fu Ling	9 g	Sclerotium Poriae Cocos
Chuan Xiong	6 g	Radix Ligustici Wallichii
Dan Nan Xing	3 g	Rhizoma Arisaematis
Zao Jiao Ci	6 g	Spina Gleditsiae Sinensis
Xiang Fu	12 g	Rhizoma Cyperi Rotundi
He Huan Pi	9 g	Cortex Albizziae Julibrissin
Bu Gu Zhi	9 g	Fructus Psoraleae
Yin Yang Huo	9 g	Herba Epimedii
Shu Di	6 g	Radix Rehmanniae Glutinosae Conquitae
Shan Yao	9 g	Radix Dioscorea Oppositae

Variations at different times included Tao Ren, Hong Hua, Dan Shen, Chi Shao, Cang Zhu, Sha Ren, Zi Shi Ying.

It was 14 acupuncture treatments (over 3 months) and several formulas later that she got her next period – after 7 months of amenorrhea. I had suggested an intense program of acupuncture would be the best way to get things moving, however her job which entailed a lot of travel did not allow this. Possibly with more intense treatment, the ovarian environment might have changed more rapidly than it did, and she might have ovulated sooner.

Nevertheless, once things got started there was no looking back. Once the Liver Qi was moving (Effie’s mood was the first improvement we saw) and obstructions in the Chong, Ren or Dai vessel were cleared, then the ovaries started to function again.

Her next cycle was 7 weeks compared with the previous 7 months, and the next 4 periods followed at precise 6-week intervals, with clearly discernible ovulations signs around Day 28. She continued to have acupuncture weekly or fortnightly throughout this time.

If this continues, and it certainly appears to be a trend, this means Effie will have 8 or 9 cycles per year, which means it may take slightly longer to conceive when she and her partner decide to have a baby, but with the clear predictability of her ovulations hopefully not too long.

Furthermore, the regularity of her cycles now indicate that the Chong and Ren vessels are working although the delayed switch from Kidney yin to Kidney yang in the menstrual cycle indicates there is still some underlying deficiency. This is the inherited component of Effie’s condition and may not be able to be changed. She is recommended to continue with herbs and acupuncture from time to time, and certainly if she plans to conceive.

Research in PCOS and TCM

Researchers in various parts of the world have demonstrated that acupuncture can improve ovary function and increase ovulation frequency. Some of these studies have found that levels of LH and testosterone and insulin in PCOS patients were found to be beneficially reduced by course of acupuncture.^64–70 Other studies have specifically looked at the effect of acupuncture in increasing insulin sensitivity.⁷¹

And several studies have examined the effect of acupuncture on rats with PCOS demonstrating increased ovulations and reduced insulin resistance.^72–75

These studies used standardized treatments using abdomen and limb points according to segmental innervation of the ovaries in some studies and TCM principles in others. Primary points were chosen from the Ren, Stomach, Spleen, Kidney, Bladder, and Liver channels. Points chosen that relate to sympathetic nervous system segmental innervation of the ovaries (the level of vertebrae T9–L2) were abdomen points Ren-4 and 6, Stomach and Kidney channel points on the abdomen and Bladder channel points on the lumbar region. Points relating to parasympathetic nervous system segmental innervation of the ovaries (the level of vertebrae S2–S4) were sacral points such as BL-27, 28 and medial leg points such as SP-6, SP-9, LIV-3, K-3. Points unrelated to segmental innervation included points such as PC-5, PC-6, TH-6, Co-4, Du-20, etc. Points chosen for their TCM properties include Ren-3, Abdomen Zigong, SP-6, LIV-3, ST-36, ST-40, ST-29 and SP-20. These are summarized in Table 5.28.

Table 5.28

Acupuncture points used in PCOS trials

Abdomen points were needled deeply and where electroacupuncture was used it was applied with mild to moderate intensity (3–5 mAmps) at low frequency (2–10 Hz) for 20–30 min. Leads were attached from abdomen to leg points on the same side.

The frequency of application of the treatments appears to be important. Some investigators have found that 2–5 treatments per week for 4 months is necessary to return ovary function and regular ovulation. Practically, this is challenging for patients in terms of time and cost, however some clinics have set up programs whereby frequent short treatments at low cost have been provided to great benefit. The mechanism of action of the acupuncture is not yet elucidated although some researchers believe that it is mediated via the sympathetic nervous system.

While a lot of the research emphasis has been on acupuncture for PCOS patients, there have been fewer studies on the effect of Chinese herbs, and most of the trials have been small or not well controlled.⁷⁶

Some trials have compared Chinese herbal preparations with Metformin favorably, e.g., those patients who took the herbs over a 3 months period reported a higher ovulation frequency, greater reduction in testosterone levels and BMI compared with those who took Metformin.⁷⁷ We shall discuss the evidence for adding Chinese herbal remedies to a regimen of clomifene below.

Combining TCM and Western medicine

It is likely that many of your PCOS patients will be seeing reproductive specialists or endocrinologists who will have prescribed medications. As we discussed above, the usual pharmaceutical treatment for PCOS patients wishing to fall pregnant includes Metformin (Diaformin) to help reduce insulin and regulate blood sugar levels and clomifene (Serophene) to help induce ovulation.

Looking at these drugs from a TCM point of view we are aware that Metformin can often compromise Spleen Qi (loose stools and nausea) and that Clomid can compromise the Kidney Yin (reduced endometrial thickness and number of endometrial glands and drying of cervical mucus). When our patient is attempting to conceive healthy Kidney Yin and Yang and Spleen Qi are vital, so combining a TCM approach to support Spleen and Kidneys with these drugs is an important consideration.

A large number of trials in China have examined the combined effect of Chinese herbs and Clomid on women who were not ovulating. When they assessed parameters like endometrium thickness, cervical discharge and ovulation and pregnancy rates, typically they show improvement on all counts when they compare with control groups given Clomid alone.^78,79 One trial which compared the ovulation rate induced by acupuncture and herbs compared with that induced by clomifene found they were equally effective, but that a significantly larger number of women conceived using the acupuncture and Chinese herbs.⁸⁰ Studies that looked specifically at anovulatory PCOS patients found the same thing, i.e., significantly improved ovulation and pregnancy rates compared to controls.⁸¹ When patients with PCOS proved to be resistant to the effects of clomifene, pre-treatment with Chinese herbs for 2 months overcame this resistance and ovulation could be induced.⁸²

A recent review also reports that PCOS patients who take Chinese herbs with Clomid can significantly increase the odds of pregnancy.⁸³ Studies in PCOS rats have shown that Chinese herbs can improve ovarian function and reduce testosterone levels.⁸⁴ Typically the herbs used in the clinical trials are standardized formulas that boost Kidney Yin and Yang, promote Blood and Qi circulation and clear Damp and Phlegm.

Similarly, acupuncture can support the action of Metformin and Clomid in promoting ovulation, while at the same time attempting to ameliorate the undesirable side-effects. If your PCOS patient is not ovulating and is prescribed clomifene (which is appropriate unless they are Yin deficient and dry), then suggesting concurrent treatment with herbs and/or acupuncture has good clinical evidence basis.

In conclusion, we can say that PCOS is one of the most complex and challenging endocrinologic and reproductive disorders that we will see in our clinics. While there is no doubt there are inherited factors in many cases, it is also perhaps caused by what we are doing to our bodies – the OCP, poor diet and too much sugar, adverse influences on female fetuses in utero and the stresses that young girls are subjected to today.

We are well placed with our Chinese medicine sensibilities to find ways to unravel this clinical challenge and find ways to effectively treat it. TCM sits more comfortably with clinical complexity than does Western medicine with its emphasis on analysis and isolation of causative factors.

By gathering all the signs and symptoms (and heeding the information that laboratory and clinical investigations and research have provided us) we can synthesize a known TCM pattern or patterns of disharmony and customize it for each PCOS patient. Thus emerges a clear guiding principle of treatment appropriate for the various presentations of this challenging condition and accordingly, we hope to create effective and holistic ways to help these patients.

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Treatment goal	Acupuncture points
To reinforce Spleen function to produce Blood	Ren-12, ST-36, BL-20 and SP-6
To activate Qi in the Chong vessel	KI-13 and ST-30
To supplement Heart Blood and calm the mind	HE-7

Treatment goal	Acupuncture points
To calm the spirit, open the Bao vessel and regulate Qi in the chest	PC-5
To calm the spirit and soothe the Heart	PC-6
To regulate Qi around the ovaries	Abdomen Zigong
To calm the spirit and treat dream disturbed sleep	HE-7
To supplement Kidney Yin (Water) to maintain balance between Heart-Fire and Kidney Water	KI-3 and SP-6
To regulate Heart Qi and the Chong vessel	KI-19

Chuan Bei Mu	6 g	Bulbus Fritillariae Cirrhosae
Bai Shao	9 g	Radix Paeoniae Lactiflorae
Qing Pi	6 g	Pericarpium Citri Reticulatae Viride
Gou Teng	9 g	Ramulus Uncariae Cum Uncis
Chuan Niu Xi	9 g	Radix Cyathulae
Mu Li	15 g	Concha Ostreae
Mai Ya	30 g	Fructus Hordei
Chuan Lian Zi	9 g	Fructus Meliae Toosendan

Treatment goal	Acupuncture points
To regulate Liver Qi and drain Liver-Fire	LIV-2 and LIV-8
To move Liver Qi in the upper body and relieve pent up emotions and irritability	PC-7 and PC-5
To remove stagnation of Qi in the breasts and promote normal breast function (if there is inappropriate lactation)	LIV-14 and ST-18
To support Spleen and Stomach function	ST-36
To regulate Qi around the ovaries	Abdomen Zigong
To activate the Chong vessel	SP-4

Treatment goal	Acupuncture points
To regulate Qi in the reproductive tract, especially the cervix	LIV-1, LIV-5 and LIV-8
To regulate Qi in the Uterus	LIV-11
To encourage Qi movement and regulate function of glands in the cervix	Ren-3
To reinforce the movement of Qi in the lower abdomen and genital area	ST-30 and Ren-1

Stagnation of Heart Qi Amenorrhea

Stagnation of Liver Qi Amenorrhea

Phlegm-Damp Accumulation Amenorrhea

Blood Stasis Amenorrhea

Polycystic Ovarian Syndrome

Defining PCOS: Clinical Presentation and Diagnosis

Etiology

Genetics, Epigenetics, Uterine and Early Life Factors

Androgens and Folliculogenesis

Insulin Resistance

Stress

PCOS, Fertility and Aging

Metabolic Effects of PCOS

Risks During Pregnancy

PCOS and Emotions

Treatment Strategies (Western Medicine)

Losing Weight

Pharmaceutical

Surgical

PCOS and TCM

TCM Analysis and Diagnosis: Analyzing Symptoms and Signs

Irregular Periods

Weight Gain or a High Waist-to-hip Ratio

Acne, Hair Loss, Hirsutism, Cardiovascular Disease

Precocious Puberty, Small Birth Size (or Large)

Surgery, Scans, and Blood Tests

Making a Diagnosis

Clinical Progression

Treatment with TCM

PCOS with Weight Gain

Mobilizing Damp and Phlegm primarily

Supporting Kidneys Primarily

Patent Medicines

PCOS without Weight Gain

Liver Qi Stagnation Leading to Localized Damp Accumulation

Liver Qi Stagnation causing Obstruction to Qi and Blood Flow in the Chong and the Ren Vessels

Research in PCOS and TCM

Combining TCM and Western medicine

References

Ren-12	Zhongwan
ST-36	Zusanli
SP-6	Sanyinjiao
BL-20	Pishu
KI-13	Qixue
ST-30	Qichong
HE-7	Shenmen

Bai Zi Ren	9 g	Semen Biotae Orientalis
Dan Shen	9 g	Radix Salviae Miltiorrhizae
Xu Duan	9 g	Radix Dipsaci
Shu Di	9 g	Radix Rehmanniae Glutinosae Conquitae
Chuan Niu Xi	9 g	Radix Cyathulae
Ze Lan	9 g	Herba Lycopi Lucidi
Yu Jin	9 g	Tuber Curcumae
He Huan Pi	9 g	Cortex Albizziae Julibrissin
Yuan Zhi	6 g	Radix Polygalae Tenuifoliae
Fu Ling	9 g	Sclerotium Poriae Cocos

LIV-2	Xingjian
LIV-8	Ququan
PC-7	Daling
PC-5	Jianshi
LIV-14	Qimen
ST-18	Rugen
ST-36	Zusanli
SP-4	Gongsun
Abdomen Zigong

LIV-1	Dadun
LIV-5	Ligou
LIV-8	Ququan
LIV-11	Yinlian
Ren-3	Zhongji
Ren-1	Huiyin
ST-30	Qichong

Treatment goal	Acupuncture points
To clear local stagnation of Blood in the abdomen	ST-28, ST-29 and SP-12
To remove stagnation of Blood in the Chong vessel	KI-14, KI-18 and KI-19
To clear both Blood stagnation and Phlegm-Damp accumulation in the lower Jiao	LIV-8
To facilitate movement of Blood	SP-10
To clear Damp from the lower Jiao	SP-9 and SP-5, Ren-3
To promote ovulation, which is delayed or disrupted due to Blood stagnation	KI-5

Tao Ren	12 g	Semen Persicae
Hong Hua	9 g	Flos Carthami Tinctorii
Dang Gui	9 g	Radix Angelicae Sinensis
Chuan Xiong	6 g	Radix Ligustici Wallichii
Chi Shao	9 g	Radix Paeoniae Rubra
Chuan Niu Xi	9 g	Radix Cyathulae
Chai Hu	6 g	Radix Bupleuri
Yi Mu Cao	9 g	Herba Leonuri Heterophylli
Xiang Fu	9 g	Rhizoma Cyperi Rotundi
Zhi Ke	9 g	Fructus Citri seu Ponciri
Sheng Di	9 g	Radix Rehmanniae Glutinosae
Gan Cao	3 g	Radix Glycyrrhizae Uralensis

Treatment goal	Acupuncture points
To regulate Qi and Blood in the lower abdomen and specifically the uterus	ST-29
To clear Blood stagnation in the Chong vessel	KI-14 and KI-19
To regulate Blood in the uterus	SP-10 and SP-6
Useful in the treatment of all Blood disorders	BL-17

ST-29	Guilai
KI-14	Siman
KI-19	Yindu
SP-10	Xuehai
SP-6	Sanyinjiao
BL-17	Geshu

TCM category	Disease or condition
Kidney Jing deficiency	Resistant ovary disease
	Primary ovarian failure
	Polycystic ovary syndrome
Kidney Yin deficiency	Premature menopause
	Long-term illness
	Weight loss
	Severe hemorrhage
	Polycystic ovary syndrome
Blood deficiency	Malnutrition or undernutrition
	Excessive exercise
	Hemorrhage after miscarriage, abortion or childbirth
Heart or Liver Qi stagnation	Shock or extreme stress
	Hyperprolactinemia
	Post-pill amenorrhea
	Drug use
	Polycystic ovary syndrome
Phlegm-Damp accumulation	Polycystic ovary syndrome
	Ovarian cysts
Blood stasis	Asherman syndrome
	Pituitary, ovarian or adrenal tumor