Polycystic ovary syndrome:
three cases treated with
Elaine Stern,
150 5th Avenue, #706,
New York, NY10011.
Tel: +1(212) 633 1687
Clinical Acupuncture and Oriental Medicine (1999) 1, 19–29 © 1999 Harcourt Publishers Ltd
acupuncture, herbs and
nutrition
Elaine Stern
INTRODUCTION
This is an article based around three case histories
of treatment of polycystic ovary syndrome. We
begin with an overview of this problem from the
biomedical, TCM and nutritional points of view.
The case histories that follow each have a slightly
different TCM profile. However, I hope to demon-
strate that, while treatment of the differences is
important, there are certain underlying problems
consistent in all three cases. When this key factor is
understood, treatment outcome can benefit.
WHAT IS POLYCYSTIC OVARY
SYNDROME
Polycystic ovary syndrome, or disease (formerly
called Stein–Leventhal syndrome) was first described
in 1935. At that time, the description of presenting
symptoms included obesity, hirsutism, infertility,
polycystic ovaries and oligomenorrhea (infrequent
menstruation).
Now it is understood that women with polycystic
ovary syndrome (PCOS) may present with only part
or pieces of this picture. Obesity is often absent.
Amenorrhea or oligomenorrhea are almost always
present. Hirsutism is frequently seen (70% of cases),
as is a life-long history of anovulatory bleeding,
bilaterally enlarged and polycystic ovaries, inferti-
lity (75%) and insulin resistance (without frank
diabetes). Acne and a receding hairline are also
common (Goroll et al 1995).
In epidemiologic studies, PCOS is the most com-
mon cause of secondary amenorrhea and the ultra-
sound features of PCOS are found in approximately
10% of the female population.
BIOMEDICAL PROFILE OF PCOS
The exact pathophysiology of PCOS is not well
understood. However, certain markers are usually
seen. Patients with PCOS may have continuously
elevated LH secretion without the normal midcycle
surge, i.e. the levels remain high throughout the
cycle but do not show the usual pattern of an abrupt
rise just prior to ovulation. The overall ratio of LH
to FSH may be increased, although the meaning of
this is unclear (Laycock & Wise 1996).
Other biomedical markers include excessive
androgen levels (which cause acne) and atresia of
follicles. (The follicle does not develop properly
and is not discharged from the ovary into the fallo-
pian tube.)
The single most definitive diagnostic feature for
PCOS is the ultrasound appearance of the ovaries,
with many cysts found on the peripheries of both
enlarged ovaries.
MORE BIOMEDICAL
INFORMATION: ANDROGENS AND
INSULIN
The normal ovary does secrete a small quantity of
androgen, including testosterone, androstenedione
and dehydroepiandrosterone (DHEA), but the
20 Clinical Acupuncture and Oriental Medicine
amounts are too small to induce hirsutism. The main
source of androgens in most women is the adrenal
cortex. In normal PCOS, the ovaries secrete excess
androgens while adrenal secretion continues, adding
up to an overall excess of these hormones. SHBG
(sex hormone binding globulin) is usually decreased,
which means that free testosterone levels are even
higher. The testosterone is not bound and removed
from circulation by the SHBG. In some women the
adrenal glands over-produce testosterone as well.
One intriguing finding is that most patients mani-
fest insulin resistance (Prelevic 1997). That is, for a
given ‘load’ of glucose, the amount of insulin
secreted is excessive.1 This is a common phenome-
non in obesity and in NIDDM (non-insulin depen-
dent diabetes mellitus, or, formerly, Type 2 diabetes),
but is present even in the non-obese PCOS patient.
The reason for this associated symptom is unknown,
but some researchers believe that the hyperinsuline-
mia precedes and may even instigate hyper-secretion
of androgens.2
In any case, as we shall see, blood-sugar regula-
tion, as well as hormonal regulation, may prove to
be an important therapeutic tool.
BIOMEDICAL DIAGNOSIS AND
TREATMENT OF PCOS
As mentioned above, there is no single, fixed marker
that is diagnostic for PCOS. Any of the common
symptoms (i.e. amenorrhea, hirsutism, acne, infer-
tility) may be due to a myriad of other causes. The
patient who presents with a definitive medical diag-
nosis of PCOS has probably been diagnosed with
the characteristic polycystic ovary sonogram. She
may or may not have been tested for elevated levels
of testosterone and LH. Often, the diagnosis is not
definitive, and is based only on the patient’s mens-
trual history and physical appearance. In this case
the patient was most likely told ‘you probably have
PCOS’ (Moor et al 1993).
Until a woman is having trouble conceiving,
many physicians do not feel it is important to
definitively diagnose and treat, except with palli-
ative measures such as depilatories for the sake of
appearance. The birth-control pill is often recom-
mended if the hirsutism is severe. This is because
the additional estrogens can partially suppress
androgen production, slowing, but not stopping or
eliminating the excess hair growth. Anti-androgen
drugs may be used for this purpose as well.
Corticosteroids may be used to suppress excess
adrenal cortical output of androgens, but the dangers
of long-term corticosteroid use outweigh the advan-
tages, and this approach is rarely used.
If a woman with PCOS desires to become preg-
nant, she may be treated with clomiphene citrate to
induce ovulation. Approximately 50% of women
conceive with this treatment.
Some researchers are also working on medica-
tions to reverse hyperinsulinemia as this may be a
‘way in’ to treatment. We will discuss this later in
conjunction with our nutritional treatment.
RESULTS OF BIOMEDICAL
TREATMENT
Biomedical treatment is chiefly used to suppress
hirsutism and it has varying degrees of success in
this regard. Anti-androgen drugs are used for this
purpose along with monthly administration of pro-
vera to induce menstruation.
The more recent use of clomiphene citrate to
induce ovulation is often successful. However, it is
a treatment with several potential side effects.3 In
addition, treatment is only for one cycle at a time.
Therefore, while it may help a woman to conceive
(50% of women who take this treatment do con-
ceive), it does not help to establish a regular cycle.
Another biomedical approach is use of the birth-
control pill to cause more regular cycling. However,
this only presents the ‘appearance’ of menstruation,
not the ‘reality’, i.e. this is no solution for infertility.
In addition, many women do not choose to take the
birth-control pill.
We will discuss this approach from the point of
view of Chinese medical treatment later. However, the
suppressive nature of hormone replacement (here, the
birth-control pill) is quite contrary to the approach
of Chinese medicine, and the implications of this
must be clearly understood by the practitioner.
In summary, there is no standard biomedical
treatment that claims to cure or improve the hormone
and/or sonogram profile of a PCOS patient. These
markers may change during the time a patient is on
the birth-control pill, but the improvement will
generally not outlast the duration of medication.
POLYCYSTIC OVARIES IN TCM
Since PCOS is definitively diagnosed by sonogram,
there is no classical TCM mention of this exact syn-
drome. TCM treatment would therefore follow the
differentiation of signs and symptoms, with treatment
focussing, most likely, on amenorrhea or infertility.
Modern TCM does, of course recognize this problem
as a distinct entity and there have been several arti-
cles written from both a theoretical standpoint and as
a result of clinical trials (Dharmananda 1995).

TCM treatment of amenorrhea or infertility is
done by pattern differentiation. The extrapolation of
these patterns is beyond the scope of this article and
is readily available in any discussion of TCM gyne-
cology. The patterns seen most often in relation to
PCOS seem to include kidney deficiency (especially
kidney yang deficiency), dampness and liver stag-
nation. These patterns will be discussed in more
detail in the case study section below.
In modern China, the use of sonograms has re-
vealed the presence of ovarian cysts as part of the
syndrome. Treatment principles have therefore been
altered slightly to take into account this additional
physical finding. In other words, treatment of PCOS
will include differentiation, not only of amenorrhea
or infertility by syndrome, but the presence of cysts
(accumulations of dampness or blood stagnation) in
the ovaries will be included as part of the differenti-
ation as well.
Lastly, some practitioners, the author included,
have considered the hormonal profile and basal
body temperature as part of the differentiation. This
is a yin/yang or eight-principle perspective on what
are essentially biomedical findings. Again, this ap-
proach will be discussed further in the case studies
below.
For a discussion of published studies (in English)
and descriptions of PCOS treatment in China, please
see Subhuti Dharmananda’s Treatment of Ovarian
Cysts with Chinese Herbs (Dharmananda 1995).
CASE STUDIES
Case 1
L.M. is 31 years old. She presents with infertility.
Intake
She has been trying to conceive for one year.
She has irregular periods and a medical diagnosis
of Stein–Leventhal syndrome (PCOS). Her menar-
che was late at 16 years old and was very irregular,
coming once in 6 months at first. By age 17 or 18,
her periods came once in 3 months, but were very
light. At age 21 she was put on the birth-control pill,
which she stayed on for 9 months. After coming off
the pill, her periods were again quite irregular and
she was bothered by excess hair growth. She was
treated medically with spiranolactone, which blocks
the testosterone receptors, and with periodic doses of
provera. With this treatment, she experienced
decreased hair growth and regular menstruation.
She discontinued this treatment 1 year ago, at
which time she began trying to conceive. She did
Polycystic ovary syndrome 21
have fairly regular cycles; however, many of them
were anovulatory. She also experienced a gradual
return of excess hair growth, oily skin and fatigue.
Other symptoms include frequent strep infections,
colds and sinus infections, constipation, depression,
fatigue and sweet cravings.
Diet. Mainly vegetarian with a little chicken, vege-
tables, starches and fruit. Long history of difficulty
with sweet cravings.
Pulse. Moderate at 72 b.p.m. The cun and guan
positions on the right side are full (excess) and slip-
pery. The overall pulse quality is quite soggy and
slippery with the chi positions on both sides deep,
deeper on the right.
Tongue. Tongue body is pale and slightly swollen.
Tongue coat is medium-thick greasy and mostly
white; slightly yellow in the lower warmer.
Color. She is pale, somewhat sallow in her com-
plexion. She has mild to moderate acne. Skin is oily.
Affect. She seems like a healthy, well-balanced
person with a straightforward and pleasant disposi-
tion. She is very enthusiastic about trying Chinese
medicine and is willing to change her diet, take herbs
and even travel long distance (as much as possible)
to take treatment.
Diagnosis
TCM diagnosis is kidney and spleen qi and yang
deficiency with dampness above and below. Liver qi
stagnation is mild and secondary to the deficiency.
Lungs are also qi deficient with dampness accumu-
lating.
In addition, the author felt that there was a pro-
blem with the intestinal environment, probably
contributing to the yang deficiency and overall
dampness. While she may not have had a condition
of frank ‘candida’, her signs and symptoms war-
ranted direct attention to improvement of the intes-
tinal environment. This is an indirect approach to
improving the kidney yang.4
Treatment
TCM treatment included acupuncture, herbs and
some dietary advice. Acupuncture was used to
stimulate ovulation and especially to move the qi
and clear stagnation of qi in the three burners. Herbs
were used primarily to tonify the yang, qi and blood
and to dispel dampness. Dietary advice was used to
strengthen the spleen, thereby reducing sweet
cravings, reducing phlegm and indirectly improving
22 Clinical Acupuncture and Oriental Medicine
the blood via the spleen. At the time of this treat-
ment the author was unaware of the connection
between insulin resistance and PCOS; however, by
addressing spleen deficiency, the treatment did
(inadvertently) address this issue.
Acupuncture. Chong mai (Sp4, P6, St30, Ki16,
20, 21), K6, Sp6 & 9, Zigong, CV4 & 6 with moxa
of the lower abdominal points as well. These are
representative points. Points would be selected ac-
cording to time in the cycle and other presenting
signs and symptoms at the time of treatment.
Herbs. Patient did not feel able to take tangs.
Therefore a combination of tableted and granulated
herbs was used as follows.
1. Mu Xiang Shun Qi Wan. This patent formula is
very helpful for mild constipation and bloating
due to qi stagnation. It was used along with
probiotics5 to help clear and move the qi and
dampness of the large intestine. A low dose of 8
before bed was sufficient in this case.
2. Cinnamon and Rehmannia. This is a 7 Forests
formula based on research formulas for ovarian
cysts. If focuses on warming the lower burner to
clear damp accumulations and moving blood in
the lower burner to treat blood stagnation.
Rehmannia and gelatin are included to tonify
the kidney and prevent over-drying. Huang jing
tonifies the qi. The herbs in the tablet are shu di
huang, huang jing, e jiao, rou gui, bu gu zhi, bai
jie zi, zhe bei mu, kun bu, tao ren, e zhu, san
leng.
3. Woman’s Treasure. This is a 7 Forests formula
based on research formulas to treat infertility.
The formula is used to tonify blood, yin and
strongly tonifies kidney yang. It also has herbs
to circulate blood and warm the uterus. The
contents are: zi shi ying, rou cong rong, xian
mao, dang gui, bai shao, shu di huang, suo yang,
lu rong, chi shao, dan shen, huang qi, xiang fu,
niu zhen zi, gui ban, fu ling, yin yang huo, tu su
zi, gan cao.6
4. Special granule formula to encourage ovulation.
Shu di, he shou wu, gou qi zi, han lian cao, niu
zhen zi, rou cong rong, xu duan, yin yang huo,
xian mao, tu su zi, shan yao, dang gui, e jiao,
zao jiao ci. This formula is based on a research
formula for fertility (Dharmananda 1989). The
last herb, zao jiao ci, is added to treat the atresia.
(See comments on this usage below.)
Together, these formulas addressed the major
issues in this case. The dosage was:
All month: Cinnamon and Rehmannia –
3, 33/day.
Pre-ovulatory phase: Special granule formula –
1 tsp, 33/day.
Woman’s Treasure –
2, 33/day.
Post-ovulatory (begin only after temperature has
risen and remained high for 3 days):
Special granule formula –
1 tsp, 33/day.
This approach allowed an ongoing treatment of
the lower warmer accumulations (with Cinnamon
and Rehmannia) and strong tonification of blood,
yin and yang to support the creation of ovulation
(good yin base transforming into yang). The patient
took her basal body temperature daily so that we
could be very sure of the timing. Once ovulation had
definitely occurred, the yang tonics were reduced
(she stopped taking Woman’s Treasure during this
phase) while the main support of the granules con-
tinued until menstruation. During menstruation, she
continued Cinnamon and Rehmannia, but stopped
all other treatment for several days.
Nutritional supplements. A probiotic formula in-
cluding lactobacillus, bifidus and F.O.S.7 was used
to treat the intestinal environment. Vitamin E 400
IU per day was also used.
Dietary advice. The patient was advised to reduce
sweets and dairy products and to eat more vegeta-
bles, chicken and fish, as she was willing or able.
Outcome
Month 1. Patient followed the regimen and dietary
advice except for taking the probiotic. She did not
menstruate and the basal temperature remained low
all month. Energy improved, sinus improved and
digestion remained the same.
Month 2. Patient ovulated after treatment as per
basal chart. She also began the probiotic. She con-
tinued all other treatment. Her digestion improved
dramatically and sinuses improved considerably.
Period came 2 weeks after ovulation. Flow was
heavier (not as scanty) with bad cramps. She still
felt tired and was craving sweets. Treatment was
adjusted slightly to address sinus problems; other-
wise continued as before.
Month 3. Patient conceives. Pregnancy is carried
to term with normal delivery and healthy infant.
Discussion
This was the most rapid response to treatment I
have seen in my experience of treating PCOS. It is
interesting to note that once L.M. did conceive, she

had virtually no problems carrying to term. There-
fore, apparently, the ‘quality’ of her ovum was not a
problem; the only problem was the support of
development and release of the ovum. In TCM
terms, we would perhaps say that the jing was
intact; only the more superficial post-heaven energy
was deficient.
Case 2
H.L. is 27 years old. She presents with a diagnosis
of PCOS.
Intake
Gynecologic history. Menarche age 14. Periods
have been irregular since menarche, with both long
and short cycles. She experiences a ‘fair amount’ of
pain and the left ovary is often enlarged on physical
exam. At age 17 she was put on the birth-control pill
for several months, then came off. She then had no
menstruation for 6 months. Subsequently, her periods
returned and were somewhat more regular, but
extremely painful. At age 23 she went back on the
birth-control pill for several years. At age 25 she
began to experience severe menstrual cramps and
left ovarian pain (while on the birth-control pill).
Ultrasound exam revealed many fluid-filled cysts in
the left ovary. She came off the birth-control pill
and had no menstruation for 5 months, at which
time she was given provera. Her response to the
provera was to have 1 day of bleeding. She pre-
sented 6 weeks after this, with no further menstrua-
tion at that time.
Current gynecologic status. H.L. presents after
the above history. She is off all medication. The
pain in the left ovary is gone and it is not enlarged
by palpation at this time. However, she is not mens-
truating. She is concerned about recent worsening
of hair growth and acne. She has had a comprehen-
sive hormone panel, which she has been told is
unremarkable. (She does not have actual results.)
Other. Frequent yeast infections and herpes out-
breaks. Fatigue. Depression has been a significant
problem with a history of one hospitalization. She
has just stopped taking Zoloft. She has a tendency to
digestive disturbance with bloating, constipation
and diarrhea.
Pulse. 60 b.p.m. – slow, deep and tense. Chi posi-
tion is very slippery and choppy.
Tongue. Pale tongue body with a medium white
coating. Tip is red and peeled.
Polycystic ovary syndrome 23
Eyes. Dark circles and swelling under the eyes.
Eyes are injected and slightly yellowed.
Complexion. Pale without red; sallow color. Acne
especially in lower third of face.
General appearance and impression. She lacks
brightness. She speaks with a lack of intonation and
‘fire’, and a tendency to over-explain. She is clean
and dressed normally for student life. She presents
with a willingness to do what is necessary for
treatment.
Basal temperature chart. The chart is all very low,
in the 96–97 range. There are several ‘false peaks’,
where the temperature begins to rise but falls back
down. Eventually, when ovulation does occur, the
temperature rises to the low 98° range, but the rise is
gradual. The characteristic jump in temperature
(which indicates LH surge) prior to ovulation is
rarely seen.
Diagnosis
H.L. is a clear case of spleen and kidney qi and yang
deficiency. The pulse and tongue, her demeanor and
history all support this diagnosis. The interpretation
of the basal temperature chart also indicates yang
deficiency, as well as an inability to make the mid-
cycle transformation from yin to yang.8
Other patterns of importance include blood defi-
ciency, liver qi stagnation leading to intermittent
blood stasis (pain, cysts, clots) and heart yin defi-
ciency. Dampness due to the qi and yang deficiency
is also present (sinus, yeast, ‘foggy thinking’, etc.).
Treatment
Taking time and money into account, we settled on
treatment twice per month. The patient was unable
to tolerate tangs, so granulated herbs were used
along with nutritional advice and supplements.
It is something of a challenge to report on a treat-
ment which has proceeded over a 2-year period. I
will endeavor to give what I believe are the most
essential elements of the treatment.
First of all, the patient was asked to keep a BBT
chart as continuously as possible. Although this is
arduous for the patient, in a case of such irregular
menstruation this chart can be an invaluable tool to
guide the treatment week by week. The main treat-
ment principles (in order of importance) were to
tonify and build the qi and yang of the spleen and
kidney; to open and activate the chong and ren
channels; and to nourish the liver blood and relieve
stagnation. These ‘tasks’ were divided up between
the different treatment modalities.
24 Clinical Acupuncture and Oriental Medicine
At the beginning there was virtually no cycle,
and to establish a cycle required strong yang tonifi-
cation. Although the blood was also deficient and
the liver qi not circulating well, I felt that these were
the result, rather than the cause of the yang deficiency
(i.e. qi and yang were too weak to create blood;
therefore liver lacked both blood and qi to do its
job). In order to build the qi and yang, treatment
must also address blood and yin substrates. Yang is
built on a basis of good yin and blood. Without these
the yang cannot grow or flourish and the result of
treatment may simply be to create fire. Without the
liver qi moving properly, tonification will simply
result in stronger stagnation.
Acupuncture was used to directly treat the chong
and ren channels, to move the liver, and nourish the
heart. The choice of points varied according to the
time of the cycle.
General treatment. A selection of these points was
almost always included in treatment. Chong mai
(Sp4, P6, etc. – see above), Sp6, Sp9, St30, Zigong,
GB27, UB14, 15, 17, 20, 23, 26, 27 Mingmen.
Moxa was used during the pre-ovulatory phase of
the cycle on various spleen, kidney and lower
abdominal points. This was especially important
just prior to ovulation.
Points relating to phases in the cycle. In general,
the extra meridians Ren and Chong were treated in
the pre-ovulatory phase, Dai Mai at the point of
ovulation and points to move qi and blood in the
lower abdomen (i.e. Liv3, Sp10, Sp4, UB 26, 27,
etc.) were done pre-menstrually.
The most important times for treatment were the
pre-ovulatory and ovulatory phases. During the
period is a good time to activate the qi and blood in
the chong mai and the uterus. Clearing stagnation at
this time is important to the subsequent task of
building the blood for the next cycle. The most
crucial part of the treatment is to then encourage
and facilitate the ovulation, the transformation from
yin to yang. The blood (and yin) being well nourished
provides the groundwork for this transformation.
Beginning just prior to midcycle, the treatment
method shifts from nurturing blood to tonifying
yang. For this phase the dai mai vessel is helpful. It
opens the ‘belt’, allowing energy to circulate better
to the chong and ren and lower abdomen.9 Dai mai
is also shao yang, the pivot between internal and
external, yin and yang. In addition, points to tonify
the kidney are added. These can include points like
UB23, GV4, Shiqihuixia,10 the lower CV points,
Ki7, 6, 3, St36 and Sp6 will support the spleen qi
and yang thereby giving a ‘leg up’ to the kidney.
Moxa can be used on these points as well.
At the time of ovulation, tonifying yang and
moving qi are both crucial. This reflects the bio-
medical understanding that PCOS is a problem of
incomplete development of the primary follicle and
atresia (inability of the follicle to move out of the
ovary into the fallopian tube).
Points to address the liver qi stagnation are most
important from midcycle on. As mentioned above.
Dai Mai (especially GB41) is important at midcycle.
As the cycle draws to a close, the tendency is for the
qi and blood to become more stagnant. This is nor-
mally true in the menstrual cycle and even more so
when the liver is not supported by a rich foundation
of blood, yin and yang. Once ovulation has occurred
in this case, the patient may experience quite severe
‘PMS’ signs which can be addressed by moving the
liver qi (Liv 3, 14, UB 18, etc.).
Both the heart and the pericardium are affected
in this case. On the one hand, the blood and yin are
insufficient, causing a heart blood and yin deficit.
This will be manifest especially right after the
period. On the other hand, stagnation of liver qi will
impact on the heart as well as the jue yin (affecting
the pericardium above). Appropriate points include
H7, P6 CV 14, 17, UB14, 15 or others as indicated
by the condition of the patient at the time. For
severe anxiety and sleeplessness, H3 may be help-
ful, if palpitations H5, etc. as appropriate.
Herbal treatment. Whereas acupuncture shines in
its moving and draining effects, herbal medicine is
truly impressive in its ability to gradually tonify the
body substances. Most of the work in this case was
directed toward tonification of kidney yang with
strong support of kidney and liver yin and blood. In
addition, herbs were used to treat damp accumula-
tions, this being specifically directed toward the
cysts. Over 2 years of treatment, there were many
variations on this approach. At times tonification of
spleen qi was predominant, while at other times
liver qi stagnation had to be addressed. Also, the
prescription was adjusted as I kept trying to make it
more effective, simply by trial and error. In the end,
the most effective approach was a formula like the
one below:
1. Special granule formula. Shu di, he shou wu,
gou qi zi, niu zhen zi, han lian cao, dang gui,
e jiao to nourish the yin and blood. Yin yang
huo, xian mao, xu duan, rou cong rong to tonify
yang, and shan yao for the spleen. This
prescription is based on any of a number of
tonic formulas; however, it was mostly derived
from a research formula for fertility
(Dharmananda 1989). Zao jiao ci was added to
transform cold damp and for its particular
function of reducing swelling and discharging
pus. This herb is used to help the ovum to

‘escape’ from the ovary. The cysts in PCOS are
usually ova which are not fully developed and
which do not achieve discharge into the fallopian
tubes. Zao jiao ci is used to treat this aspect.11
2. Cinnamon and Rehmannia. As above, used for
the same purpose, in the same way.
During the first year of treatment there was a
general trend for ovulation to be very late and
the second phase of the menstrual cycle to then
be very short. This is a sign that while the yin is
transforming into yang, the yang is not
sustainable for the full 14 days of the luteal
phase. The above special granule formula
(hereafter referred to as the ‘ovulatory formula’)
was therefore continued for the entire cycle,
stopping only for the first 5 days of the month.
Herbs to move the liver qi and address heat
were added as necessary.
At the beginning, when the luteal phase was
very short, qi stagnation and heat (which
manifest as PMS symptoms) were minimal.
However, as the luteal phase lengthened, this
became more of a problem. The treatment was
then divided into pre- and post-ovulatory
phases. Observation of the BBT at this time
showed that, although ovulation was difficult to
achieve, once it did occur, the second phase of
the cycle was now maintained for a full 14 days.
Therefore the ‘ovulatory formula’ was
discontinued several days after ovulation. A
second formula was then used to address the
second half (post-ovulatory phase) of the month.
In the case of H.L. this meant addressing liver
stagnation and heat. Symptoms of depression,
anxiety, restless sleep, inability to focus, acne
and constipation were the main concern.
3. A representative prescription used for this phase
was: chai hu, bai shao, dang gui, sheng di, gui
zhi, ban xia, zhi shi, ren shen, huang qin, jie
geng, jing jie, lian qiao, ku shen, bai shen pi,
xuan shen. This is a base of Xiao Chai Hu tang
with herbs added to treat the acne, depression
and constipation. Dang gui and sheng di move
and support the blood and yin, respectively.
Nutritional treatment included dietary changes
and supplementation. She was asked to reduce sim-
ple carbohydrates, increase complex carbohydrates
and increase the frequency of protein intake. These
changes address the issue of excess insulin. By
decreasing the intake of simple carbohydrates and
sugar, the demand for insulin is reduced. Increase of
protein intake provides more steady, longer lasting
energy. This should help the PCOS and be very
helpful in stabilizing mood and energy. Nutritional
supplements were used, including B vitamins and
Polycystic ovary syndrome 25
magnesium to support blood sugar regulation. This
combination is very good for PMS and also protects
the nervous system by modifying the stress response.
Vitamin E with selenium was used for the reproduc-
tive system and a tyrosine-based supplement was
used to support a sluggish thyroid. Her blood tests
were in the low-normal range for thyroid, but since
her body temperature was always low and she was
chronically tired, I decided to try this mild approach
to support thyroid function. H.L. responded well to
these interventions, reporting significant improve-
ment in both energy and mood.
Outcome
There has been significant improvement over the
course of treatment. After approximately 2 years, she
is menstruating regularly. Her cycle is approximately
35–40 days (the pre-ovulatory phase is still some-
what extended) and the periods have a moderate
flow for about 5 days. Her PMS symptoms fluctuate,
but overall are greatly improved.
H.L. has recently received a full gynecologic
work-up. This included full blood tests at different
phases of her cycle and sonograms. The sonogram
was ‘inconclusive’ for PCOS. The blood values for
all phases of the cycle were within normal limits.
The gynecologist’s interpretation of all findings was
that she no longer showed the hormonal profile of
someone with PCOS.
Follow-up
The patient is still taking treatment, in a modified
form. She has acupuncture once a month and con-
tinues to take herbs and supplements. She feels
overall much better, with more energy and less
depression, although these are ongoing problems
for her. Our treatment is now shifting to address
these concerns more directly.
Comments
Although fatigue, anxiety and depression are clearly
part of the TCM patterns being treated, it is a fact
that the physical symptoms have responded much
more readily than these more ‘intangible’ ones. I
think this is an important point. Mental and physical
energy in this case, may be ‘the icing on the cake’.
In other words, although she has improved enough
that the organ physiology has normalized, the more
‘refined’ energy of physical and mental well-being
is not yet established. It may be that, in order to truly
affect a lifelong depression, it is necessary to engage
the mind itself in treatment. I would like to address
this further in a subsequent article.
26 Clinical Acupuncture and Oriental Medicine
One phase of treatment was not addressed above
and is of interest. After the cycle was established,
there were many months when the patient had pe-
riods of extreme fatigue and depression during her
extended pre-ovulatory phase. Examination of the
BBT showed what I am going to call ‘false ovula-
tion’ at those times, i.e. the temperature would drop
(at approximately day 14 or 16) and begin to rise as
though she were going to ovulate. However, the
temperature would not rise enough to actually create
ovulation and it was at these times she experienced
the debilitating fatigue and depression. I interpreted
this as an inability to transform to the yang phase
(and an insufficient LH surge to produce ovulation).
This is consistent with the typical PCOS picture. By
increasing the dosage of formula #1 and adding
stronger yang tonics (i.e. lu jiao, rou gui, bu gu zhi),
this problem has greatly improved in recent months.
Case 3
S.L. is 28 years old. She presents with amenorrhea.
S.L. did not present with a medical diagnosis.
Technically, since she had no sonography to confirm
a diagnosis, we do not know for sure that this is a
case of PCOS. However, she has a long history of
irregular and ceasing menstruation, as well as some
excess hair growth. Since it is well known that
much PCOS goes undiagnosed as such and since
S.L. has the profile of a PCOS patient, I will include
her case.
Intake
Gynecologic history. She has a long history of
irregular cycles, always long, never short. At age 23
she entered graduate school and began to have more
serious problems. She was on a low-dose birth-
control pill (as a smoker!) and developed a throm-
bosis. She had to come off the birth-control pill and
go onto coumadin for 9 months. She began to have
very irregular and extended cycles. When she
missed several cycles in a row she was treated with
provera.
Other. History of alternating diarrhea and consti-
pation with IBS. Pre-menstrual constipation and
depression. She has debilitating dysmenorrhea with
some cycles. Her sleep is poor and easily disturbed.
She has difficulty focussing and is easily distracted.
She feels her energy and productivity are seriously
affected by the hormonal problems. She complains
of constantly cold hands and feet, frequent yeast
infections and cystitis once or twice a year.
Pulse. 72 b.p.m., somewhat deep. The right side
was deep and weak; the left side was sometimes
deep and weak, sometimes choppy.
Tongue. Pale tongue body with a swollen tip.
Tongue coating normal.
Complexion. Sallow and pale with dark circles
under the eyes.
Affect. Somewhat low. She speaks softly and
appears either depressed or depleted. She has a good
sense of humor and is not overly self-involved. She
is tired of not feeling well.
BBT. At the beginning of treatment, BBT remained
low (below 98°) for many weeks. There was the
occasional ‘false peak’ and finally a rise in tempera-
ture for 6–8 days. At that time there would be a
scanty flow, sometimes with cramps. She would
also experience cramps for a short time during the
‘false peaks’.
Diagnosis
Again, we see a profile of spleen and kidney yang
deficiency. In the case of S.L. blood deficiency was
also significant. Poor large intestine function along
with energetic spleen deficiency were both playing
a part in this problem. In this case (as opposed to
that of H.L.), yang deficiency was important, but
secondary.
Again, the issue of yeast and large intestine
dysfunction can be seen both as an obstacle to
absorption (therefore contributing to blood defi-
ciency) and as a problem of the kidney yang, as dis-
cussed above.
Treatment
This treatment was carried out over 10 months. The
main strategies were to normalize the large intestine
function and environment, to nourish blood and to
tonify yang. She had acupuncture treatments bi-
weekly for the first 2 months, after which acupunc-
ture was administered once per month. Again, this
was the most treatment she could manage. Herbal
treatment was therefore very important. Some nutri-
tional substances were used, but at that time I did
not know much about supplementation, nor was I
aware of the connection of PCOS to insulin. We
did address her diet to improve both her digestive
system and her blood.
Acupuncture was similar to the case outlined
above, with more emphasis on the spleen and large
intestines.
Herbal and nutritional treatment began slowly
and was increased as the digestive system improved.
At first we discussed the importance of a good diet
 Polycystic ovary syndrome 27
according to TCM principles of warming the spleen Conclusion
and with plenty of fiber and less ‘junk food’ to help
It is my experience that Chinese medicine can be an
the intestine. She took a broad-spectrum probiotic
excellent treatment method for PCOS. While cases
along with Mu Xiang Shun Qi Wan and some mag-
1 and 3 above responded easily, case 2 took a great
nesium before bed. Altogether this strategy did very
deal of perseverance by both the patient and practi-
well in treating the yeast and constipation. In addi-
tioner. It required a level of commitment by the
tion, the magnesium was very beneficial for her
patient to keep taking herbs and treatment and be
sleep problems. She used a douche of grapefruit
willing to take quite a few different herbs and sup-
seed extract and acidophilus when necessary and
plements. From the point of view of the practitioner,
the yeast cleared up fairly quickly. A variation on Ba
it required repeated re-analysis and synthesis of
Zheng Tang and Shi Wei San (7 Forest formula
several ways of thinking to effect lasting positive
‘Akebia 14’12) was used as needed to treat urinary
change. The lesson here is, I think, that not all prob-
tract symptoms.
lems respond quickly and we should not be too
As her digestion improved, the herbal regimen
easily daunted if things do not move at the speed we
was stepped up to address amenorrhea more aggres-
expect or would like them to. I hope that my experi-
sively. The regimen was divided into pre- and post-
ences will help other practitioners to have the
ovulatory sections. Beginning day 5 and through
confidence to keep treating and thinking and then
ovulation (again, monitored by BBT), she took:
treating some more.
1. Special granule formula #1, as above. Dosage: 1 In addition, it is important to reiterate that the
tsp, 23/day. biomedical solutions to PCOS all involve hormonal
2. Wu Qi Bai Fen Wan, the patent remedy, to repression (except clomiphene). This type of treat-
nourish the blood. This patent is very gentle and ment, while it may control symptoms, does not allow
well tolerated and has the added benefit of for normalization of the patient’s own hormones.13
containing black chicken for greater blood In fact, if we extrapolate from our knowledge of the
nourishment. side effects of long-term corticosteroid treatment,14
it is not unreasonable to think that years and years of
PMS was not a problem once the digestion was
treatment with the birth-control pill could actually
better and the cycle more regular. Therefore, the
further inhibit the patient’s ability to maintain a
post-ovulatory treatment was simply Wu Qi Bai Fen
regular cycle.
Wan. There were no serious problems with liver qi
stagnation or heat.
Addendum
Outcome For those readers not familiar with the basal body
temperature chart, I am including a brief description
The first period came on day 42. This was 42 days
here. In order to understand the implications of dif-
after a provera-induced period and was the first
ferent BBT patterns, it is suggested that the reader
normal, non-induced period she had had in several
look closely at the ovarian and hormonal cycles and
years. By this time, sleep and digestive symptoms
their timing during the month. Any good gyneco-
were markedly improved as well. The next period
logy text will provide this information.
came on day 38. There was a normal flow and no
To use the BBT, the patient must take her tem-
pain. She experienced 1 day of premenstrual depres-
perature every morning upon awakening, before
sion. At this point she had several similar cycles
getting out of bed. This should be at approximately
with the BBT showing some ‘false peaks’ (some of
the same time every morning. (A variation of more
which were accompanied by pain for a few hours)
than 30–60 min will invalidate that day’s reading.)
and ovulation occurring about day 20.
The patient should purchase a basal body ther-
By the ninth month, S.L. was having regular
mometer which focuses on the 96°–99° point range,
cycles of about 32 days with ovulation occurring
enabling the user to precisely chart tenths of a
on day 17 or 18. Her overall health was better, as
degree in that range.
was her energy and focus. At that time we discon-
The patient takes her temperature beginning about
tinued acupuncture and she gradually reduced the
day 3 of her cycle (day 1 is the first day of bleeding)
herbal treatment over the course of the next 3 months.
and every morning thereafter until the next period.
I saw her about a year later for another digestive
The chart is then examined and analyzed.
problem. At that time her periods continued to be
regular and problem-free. 1. ‘Normal’ BBT (note – this is an example of a
28 Clinical Acupuncture and Oriental Medicine
Day 1 Day 14
98º
97º
Figure 1 Normal BBT chart.
Day 1 Day 14
98º False peaks
97º
Figure 2 Typical PCOS BBT chart.
‘perfect’ BBT and is not often found in any
actual individual). Figure 1 shows a ‘perfect’
cycle. The temperature stays in the 97.5° range
for the first 13 days, at which point it drops
down and then rises a minimum of 0.4°, all at
once. It then remains above 98°15 for a full 14
days before dropping down again. The drop will
represent onset of the period.
2. Typical PCOS temperature chart (Fig. 2). This
chart will remain low for several weeks, without
ovulation. The ‘false peaks’ described in the
article are shown here. Ovulation is shown, for
the purposes of this demonstration, at day 25,
but in PCOS, it may not occur for many more
weeks or even months.
There are other BBT profiles of interest but
they are outside the purview of this article and
will not be demonstrated here.
REFERENCES
Dharmananda, S. Treatment of Ovarian Cysts with Chinese
Herbs. START Group subscription series. Portland:
Institute for Traditional Medicine; 1995.
p. 5–7.
Dharmananda S. Treatment of Infertility and Miscarriage
with Chinese Herbs. Portland: Institute for Traditional
Medicine; 1989. p. 24.
Goroll AH, May LA, Mullins AG. Primary Care Medicine.
Philadelphia: J.B. Lippincott; 1995.
p. 9.604–5.
Laycock J, Wise P. Essential Endocrinology. Oxford: Oxford
University Press; 1996. p. 194–7.
Moor TR, Reiter RC, Rebar RW, Baker VV. Gynecology &
Obstetrics. New York: Churchill Livingstone; 1993.
Day 28
Day 28
True
ovulation
Prelevic GM. Insulin resistance in polycystic ovary
syndrome. Curr Opin Obstetr Gynecol 1997; 9(3):
193–201.
NOTES
1. Insulin resistance may be measured by fasting glucose
tolerance tests. However, people who are insulin
resistant will often be aware of such symptoms of
frequent hunger, craving for carbohydrates, tiredness
after meals and easily feeling shaky, dizzy or irritable
with delayed meal times.
2. An important side issue here is that insulin resistance is
associated with hyperlipidemia and atherosclerosis and
therefore these markers must be watched, even in a
young woman with PCOS.
3. Side effects include headaches, hot flushes and
occasionally visual disturbance. Clomiphene is an anti-
estrogen and as such inhibits cervical mucus and has an
adverse effect on endometrial development. 25–50% of
women have inadequate luteal phase endometrium on
this medication.
4. The connection between the large intestine environment
and the kidney yang is discussed by B Flaws, Scatology
and the Gate of Life. Blue Poppy Press; 1990.
5. Probiotics are ‘gut-friendly’ bacteria which re-colonize
the bowel. Commonly used are Lactobacillus
acidophilus and bifidobacteria.
6. For more information on these tableted formulas,
including the common English names of the herbs, see
Dharmananda S. Bag of Pearls. Portland: Institute for
Traditional Medicine.
7. Fructooligosaccharides; these are food for the beneficial
bacteria of the intestines.
8. See discussion of the BBT chart.
9. ‘The girdling vessel encircles the waist and binds the
Penetrating and Conception vessels and the Kidney,
Liver and Spleen channels . . . GB 41 is indicated
for . . . menstrual disorders and inhibited

menstruation . . .’. In Deadman P, A1 Khafaji M,
Baker K. Manual of Acupuncture. Cushing Malloy;
1998. p. 461.
10. This is an extra point on the GV line at the level of UB
26. It is below the 5th lumbar vertebrae. This point,
known as ‘josen’ in Japanese, if frequently used in Japan
for problems of the lower back and kidney.
11. From Iectures by Dr Shu Rong Zhu, Professor of
Gynecology, Emperor’s College, Los Angeles, CA, USA.
12. Akebia 14: mu tong, shi wei, qu mai, bian xu, hua shi,
che qian zi, ze xie, hai hin sha, hu po, shi chang pu,
dong kui zi, zhi zi, yi zhi ren, bi xie. See Dharmananda
S. Bag of Pearls. Portland: Institute for Traditional
Medicine.
13. At this time it is not known what percentage of PCOS
Polycystic ovary syndrome 29
patients will respond to alternative therapies and what
percentage do not respond to these treatments and
therefore require hormone replacement.
14. One of the potential problems encountered in extended
use of corticosteroids is atrophy of the patient’s own
adrenal gland. This can result in the need for life-long
steroid supplementation due to the patient’s inability to
produce sufficient endogenous cortisol.
15. The pattern of one phase low/one phase high is more
important than the actual numbers. If the chart clearly
shows this biphasic pattern, but the numbers are all
below 98°, this still indicates ovulatory cycling. The
jump of 0.4°–0.6°, followed by a sustained period of
higher temperature, is the key indication that ovulation
has occurred.