17.05.

2023

POLYCYSTIC OVARY SYNDROME &

CHINESE HERBAL MEDICINE
TCM KONGRESS 2023 ROTHENBURG OB DER TAUBER, GERMANY
THURSDAY 18TH MAY 09:00 – 12:30

Lily Lai, PhD

Acupuncturist and Chinese herbal medicine practitioner
Manchester UK
info@acupunctureandherbs.co.uk
+44 7815 885 947
Instagram @acupuncturebylily
Facebook Lily Lai – Acupuncture and Herbs

 Definition of PCOS
 Biomedical treatment approaches

OVERVIEW
 Chinese medicine understanding of PCOS
 CM Treatment strategies
 Herbs & Formulas
 Case studies

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DEFINITION

 Polycystic ovary syndrome (PCOS), also known as Stein-Leventhal syndrome

 A very common female endocrine disorder, affecting 5-20% of women of reproductive age
 Common symptoms: menstrual irregularities, hirsutism, acne, difficulty with weight control, anxiety and depression
 Rotterdam (2003) diagnostic criteria the most widely accepted
 At least TWO of the following three criteria must be met:
 Polycystic ovaries found on ultrasound
 Irregular or absent ovulation (oligo- or anovulation)
 Clinical or biochemical evidence of hyperandrogenism

 AND exclusion of thyroid disorders, hyperprolactinaemia, congenital adrenal hyperplasia, androgen-secreting tumours,
Cushing’s syndrome

PHENOTYPES
A B C D
Classic Non-PCO Ovulatory Non-
PCOS PCOS PCOS hyperandrogenic
PCOS
Hyperandrogenism ✓ ✓ ✓ -

Ovulatory disorder ✓ ✓ - ✓

PCO ✓ - ✓ ✓

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CAUSES AND AGGRAVATING FACTORS

 Strong familial links identified

 Genetic predisposition
 Environmental factors e.g. nutritional status and lifestyle
 Pathological mechanisms: Hyperandrogenism (60-80%),
hyperinsulinaemia (50-70%)
 Chronically elevated luteinizing hormone (LH) due to excess levels of
androgens, exacerbated by hyperinsulinaemic state
 Chronic inflammation
 Gut/reproductive microbiome

Cutaneous Mental health

COMMON SIGNS AND SYMPTOMS
Acne, hirsutism, Anxiety, depression,
androgenic alopecia psychosexual dysfunction

Reproductive
Irregular/absent
periods, subfertility,
infertility Metabolic
Abdominal obesity,
impaired glucose
tolerance, insulin
Long term risks resistance, hypertension,
Type II diabetes, dyslipidaemia, sleep
cardiovascular disease, apnoea, non-alcoholic fatty
endometrial hyperplasia liver disease

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TESTS AND INVESTIGATIONS

 Ultrasonography: 12 or more follicles on one ovary measuring 2-9mm in diameter, or

ovarian volume >10ml; ↑ antral follicle count (AFC)
 Biochemical tests:
 Hyperandrogenism: ↑ total / free serum testosterone , ↑ free androgen index (FAI)
 ↑ Luteinising Hormone (LH), normal Follicle Stimulating Hormone (LH:FSH ratio
often elevated 2:1 or 3:1)
 ↑ Anti-Müllerian hormone (AMH)
 Thyroid, prolactin, 17-OHP
 Hirsutism: Ferriman and Gallwey Scale (9 areas)
 Acne: Leeds technique counting method
 Research studies: Inflammatory markers (WBC, C-reactive protein, cytokines e.g. IL-6,
IL-18,TNF-alpha), appetite hormones (leptin, cholecystokinin, ghrelin), mitochondrial
function, microbiome

Primary complaint Biomedical treatments * Unavailable to

those actively trying
BIOMEDICAL TREATMENTMetformin
Menstrual irregularities
APPROACHES
Hormonal contraception*
to conceive

Anovulation or infertility Clomiphene/letrozole

Metformin
Laparoscopic ovarian drilling (LOD)
In vitro fertilisation (IVF)
Insulin resistance Metformin
Obesity Lifestyle modification
Orlistat*
Topiramate*
Hirsutism Hormonal contraception+/- anti-androgens*
Electrolysis and light-based therapies
Spironolactone*
Eflornithine
Finasteride
Metformin
Acne Hormonal contraception*
Topical creams
Spironolactone*

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 Whole systems approach

 TCM categories of ‘Bi Jing’ (Amenorrhoea), ‘Yue Jing Bu Tiao’
(Irregular menses) and ‘Bu Yun’ (Infertility)
 Some modern authors categorise according to Kidney Yin
CHINESE deficiency or Kidney Yang deficiency and ‘thin’ or ‘obese’
types of PCOS
MEDICINE  Evidence gap for using CHMs in PCOS – lack of alternatives
APPROACH due to side-effects or ineffective treatments offered
 Complex condition → poor understanding amongst
mainstream healthcare professionals, poor application of
guideline recommendations, healthcare system not designed
for collaborative/integrative practice, lack of time to discuss
management/long-term health consequences

REASONS FOR JOINING THE ORCHID STUDY

‘I have not had very much support or suggestions for treatment from my doctors’

‘I’m at a point in this journey where if there is something better out there to really
help my body feel better and help my PCOS, I’m all in!’

‘I have struggled with the symptoms of my PCOS for 22 years. In that time I have
tried Dianette (came off it 2 years ago), Metformin and various self-prescribed
vitamins. Nothing has worked so I would like to try an alternative therapy.’

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CHINESE MEDICINE APPROACH TO PCOS

二七而天癸至，任脈通，太衝脈盛，月事以時下，故有子。

‘During the fourteenth year, the tiān guǐ arrives, the flow in the Rènmài
penetrates, the great Chōngmài is exuberant, and the menses descend in a
timely manner. Therefore they can have children.’

Su Wen (Plain questions) from the Huang Di Nei Jing

TCM PHYSIOLOGY & FEMALE REPRODUCTIVE

SYSTEM
stores
Kidney Jing Tian Gui

Heart Dai Mai

controls

moves
Chong,
Liver Blood Ren, Du Uterus
stores Mai
makes
Spleen
makes

Lung Qi
governs

(Lyttleton 2013, p11)

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COMMON
PATTERNS IN
PCOS?

IT’S…

COMMON PATTERNS: TRIANGULATING DATA FROM DELPHI STUDY

OF UK HERBALISTS (2011)
Excess patterns – STRONG consensus
 Phlegm-Damp accumulation
 Blood stasis
 Liver Qi stagnation
 Excess Cold in the Uterus
 Stagnated Liver Heat

Deficiency patterns – STRONG consensus Deficiency patterns

 Kidney Yang deficiency  Blood deficiency (Moderate consensus)
 Spleen Qi deficiency  Kidney Yin deficiency (Weak consensus)
 Spleen Yang deficiency

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TRIANGULATING DATA: SYSTEMATIC REVIEW 2015

Deficiency patterns
 Kidney deficiency
 Yang deficiency
 Spleen deficiency
 Qi deficiency

Excess patterns
 Phlegm stasis
 Dampness accumulation
 Liver stagnation
 Qi stagnation and Blood stasis

PATTERNS: ORCHID RESEARCH STUDY 2014

(LONDON & HERTFORDSHIRE)

 Blood stasis
 Stagnated Liver Heat
 Blood Heat
 Liver Qi stagnation
 Phlegm-damp accumulation
 Spleen Qi deficiency

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TCM PATHOGENESIS OF PCOS

Yin/Yang
Kidney deficiency
Jing Tian Gui
Pre-heaven
Heart Shen Dai Mai
Emperor Blood
Stasis Chong,
Liver Qi stagnation Ren, Du Uterus
Heat Mai

Spleen Post-heaven Phlegm-

Dampness
stagnation
Lung Controls skin, body
hair Qi
Controls dispersing stagnation
and descending

• Dry • Amenorrhoea

SYMPTOMS
• AND SIGNS OF PCOS
skin/hair/nails/lips
Night sweats
Period pain •
•
•
Infertility
Low libido
• Malar flush • Family history
(warmth)
• Lower back pain Jing
Kidney • Cold limbs
• Lethargy
• Period pain
Tian Gui
Heart
• Anxiety Blood • Clotted
• Sleeplessness periods
• Anovulation • Hirsutism/ Abdominal obesity
Dai Mai
acne
Liver
• Depression Heat • Anxiety
• Irritability
Chong,
• Abdominal bloating • Cysts on Ren, Du Uterus
Phlegm- ovaries
• Obesity Mai
Spleen • Sugar cravings Dampness • Bulky
• Tiredness ovaries
• Blocked • Menstrual
fallopian irregularity
Lung • Hirsutism Qi tubes • Infertility
• Acne • Vaginal
• PMS discharge
• Breast
tenderness
• Cysts in
breasts

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REVISITING THE PHENOTYPES

A B C D
Classic PCOS Non-PCO PCOS Ovulatory PCOS Non-
hyperandrogenic
PCOS
Hyperandrogenism ✓ ✓ ✓ -

Ovulatory disorder ✓ ✓ - ✓

PCO ✓ - ✓ ✓

TREATMENT STRATEGIES (CLINICAL EXPERIENCE)

 Regulate Chong/Ren
 Blood and Phlegm stasis
 Support Kidney
 Distribute Lung Qi
 Support the Middle Jiao
 Move the Liver

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• Xu Duan
• Shu Di
• Yin Yang Huo
• Dang Gui
• Wu Zhu Yu • Zi He Che
• Bai Shao
SYMPTOMS AND SIGNS OF PCOS
• Rou Gui • E Jiao
• Chi Shao
Kidney • Gan Jiang
• Chuan Xiong
• Tu Si Zi Jing
• Yan Hu Suo
• Gou Qi Zi
• Wu Ling Zhi
• Nu Zhen Zi
Blood Tian Gui
• Suan Zao Ren • Mu Dan Pi
Heart • Yuan Zhi • Dan Shen
• He Huan Pi • Xuan Shen Dai Mai
• Shi Chang Pu Heat • Sheng Di
• Da Huang
• Xiang Fu • San Huang
Chong,
Ren, Du Uterus
Liver • Chai Hu Phlegm- • Hu Zhang
• Mei Gui Hua Dampness Mai
• Bai Zhu • Cang Zhu
Spleen • Fu Ling Qi • Ban Xia
• Shan Yao • Hou Po
• Chai Hu
• Jie Geng • Zhi Ke
Lung • Chen Pi • Qing Pi
• Da Huang
• Huang Jing

DUI YAO IN PCOS

Dang Gui + Bai Shao
Chi Shao + Bai Shao
Hong Hua + Tao Ren
San Leng + E Zhu
Zhi Ke + Jie Geng
Cang Zhu + Xiang Fu
Cang Zhu + Huang Bai
Chai Hu + Huang Qin
Nourish and harmonise Yin and Blood, Blood deficiency Heat
Cool Blood, dispel stasis, tonify Blood and Yin, antispasmodic
Reduce levels of vascular endothelial growth factor (VEGF)
Strongly dispersing Blood stasis – immobile masses e.g. fibroids
Ascending + descending, spreading Lung Qi
Strongly dries Dampness from LJ, regulates Liver Qi
Warm and draining, cold and bitter
Regulate Shaoyang, eliminate Dampness and Heat

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TAIWANESE PRESCRIPTIONS ANALYSIS (LIAO 2018)

10 most commonly used single herbs 10 most commonly used formulae Jia Wei Xiao Yao San
- Xiang Fu - Jia Wei Xiao Yao San
Gui Zhi Fu Ling Wan
- Da Huang - Gui Zhi Fu Ling Wan
Dang Gui Shao Yao San Dang Gui Shao Yan San
- Yi Mu Cao -

- Yan Hu Suo - Wen Jing Tang Wen Jing Tang

- Dan Shen - Ma Zi Ren Wan
Shao Fu Zhu Yu Tang
- Gan Cao - Chuan Xiong Cha Tiao San

- Tu Si Zi - Gui Pi Tang Cang Fu Dao Tan Tang

- Huang Qin - Ge Gen Tang
You Gui Wan
- Bei Mu - Shao Fu Zhu Yu Tang

- Du Zhong - Xue Fu Zhu Yu Tang Gui Shao Di Huang Tang

KEY FORMULAS

Jia Wei Xiao Yao San Dang Gui, Bai Shao, Fu Ling, Bai Zhu, Chai Hu, Mu Dan Pi, Zhi Zi, Zhi Gan Cao, Bo
He, Sheng Jiang
Gui Zhi Fu Ling Wan Gui Zhi, Fu Ling, Shao Yao, Mu Dan Pi, Tao Ren
Dang Gui Shao Yao San Dang Gui, Shao Yao, Bai Zhu, Fu Ling, Ze Xie, Chuan Xiong, Rice Wine
Wen Jing Tang Wu Zhu Yu, Gui Zhi, Dang Gui, Chuan Xiong, Bai Shao, E Jiao, Mai Men Dong, Mu
Dan Pi, Dang Shen, Gan Cao, Sheng Jiang, Ban Xia
Shao Fu Zhu Yu Tang Xiao Hui Xiang, Pao Jiang,Yan Hu Suo, Dang Gui, Chuan Xiong, Mo Yao, Rou Gui, Chi
Shao, Pu Huang,Wu Ling Zhi
Cang Fu Dao Tan Tang Cang Zhu, Xiang Fu, Fu Ling, Ban Xia, Chen Pi, Gan Cao, Dan Nan Xing, Zhi Ke, Shen
Qu, Sheng Jiang
You Gui Wan Fu Zi, Rou Gui, Lu Jiao Jiao, Shu Di Huang, Shan Zhu Yu, Shan Yao, Gou Qi Zi, Tu Si Zi,
Du Zhong, Dang Gui
Gui Shao Di Huang Tang Dang Gui, Bai Shao, Shu Di Huang, Shan Zhu Yu, Shan Yao, Fu Ling, Mu Dan Pi, Ze Xie

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SUBSTITUTES

Herb Suggested substitutes

E Jiao Shu Di Huang, Dang Gui
Lu Jiao Jiao Yin Yang Huo, Ba Ji Tian, Xian Mao, Tu Si Zi
Wu Ling Zhi E Zhu, Chuan Xiong, Dan Shen,Yi Mu Cao
Fu Zi Rou Cong Rong, Tu Si Zi, Du Zhong
Zi He Che Shu Di Huang, Gou Qi Zi

CHM MECHANISMS OF ACTION – CLINICAL

AND PRECLINICAL
 Reduce fasting insulin and fasting blood glucose levels
 Reduce elevated free and total testosterone
 Reduce elevated LH
 Reduce inflammatory factors (plasma TNF-α, IL-6, C-reactive protein, nerve growth factor)
 Improve insulin response
 Improve ovarian morphology
 Improve metabolic profile (increase lipid decomposition, inhibit fat production)
 Regulate expression of relevant pathway genes
 Regulate secretion of appetite hormones
 Increase diversity of gut microbiota (increase levels of short chain fatty acids, regulate bile
acids)
 Improve reproductive microbiomes

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PCOS & GUT MICROBIOME

 ↓ gut diversity in the gut in women with PCOS, esp in those with pre-diabetes
 Prenatal androgens linked to ↓ abundance of gut microbiota involved in production of SCFAs (rodent
model) (Sherman et al. 2018)
 ↓ Gamma-aminobutyric acid-producing bacteria in PCOS
 Escherichia coli associated with ↑ serum LH, ↑ LH:FSH ratios, ↑ AFC and irregular cycles (Xu et al. 2020)
 Hyperandrogenism, total testosterone and hirsutism negatively correlated with alpha diversity (Torres et
al 2018)
 Dysbiosis of gut microbiota can also be exacerbated by poor dietary habits, hyperandrogenism, obesity,
hyperinsulinism, and disturbances in the glucose and lipid metabolism in PCOS
 This could be contributing to increased gut permeability, dysbiosis, and altered gut metabolites, leading
onto hallmarks of PCOS

CHM, DIABETES MARKERS, INTESTINAL DYSBIOSIS

 Gegen Qinlian decoction (GQD) can alleviate type 2 diabetes by modulating the gut microbiome (Xu et al. 2013)
 (Ge Gen, Huang Qin, Huang Lian, Zhi Gan Cao)
 Research study compared patients with low dose GQD and placebo against high and moderate dose GQD
 High and moderate dosages showed remarkable reductions in adjusted mean changes from baseline of FBG
 GQD also enriched bacteria which have protective effect against HBA1c and FBG
 In rodent studies, Huang Jing (Polygonatum kingianum) has actions that relate to diabetes and lipid metabolism
disorders (Yan et al. 2017, Dong et al. 2021)
 Major active constituents are saponins and polysaccharides
 These improve intestinal microecology by increasing abundance of Firmicutes and decreasing Bacteroidetes and
Proteobacteria (Yan et al. 2017)

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CANGFU DAO TAN TANG (ANIMAL STUDIES)

 Cang Zhu, Xiang Fu, Fu Ling, Zhi Ban Xia, Chen Pi, Gan Cao,
Dan Nan Xing, Zhi Ke, Shen Qu, Sheng Jiang
 Metabolic and anti-inflammatory effects possibly due to the
polyphenols:
 quercetin which can improve gut dysbiosis by increasing
Lactobacillus and increase SCFA production (Uyanga et al 2021)
 kaempferol which improves Firmicutes to Bacteroidetes ratio and
reduces serum inflammation levels (TNF-alpha, CRP, IL-6, IL-8, IL-
18) (Qu et al. 2021)
 Reduces body weight and central adiposity
 Restores menstrual cycles and improves ovarian function
 Alleviates fatty liver
 Downregulates proteins and upregulates gene expression in
the insulin signalling pathway in the inflammatory environment
 May alleviate mitochondrial dysfunction at ovarian level (Jiang
et al. 2022)

BREAK

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HOW SOON TO EXPECT IMPROVEMENTS? (DELPHI STUDY)

 In PCOS, an initial response to Chinese herbs is observed within 3 months

 When prescribing Chinese herbs for delayed periods in PCOS (cycles longer than 35 days), a regular menstrual
cycle is observed within 6 months
 When prescribing Chinese herbs for absent periods in PCOS (no period for 6 months or more), a regular
menstrual cycle is observed within 9 months

TREATMENT APPROACHES TO CONSIDER

Supporting the Biao and the Ben

Clearing excess prior to nourishing deficiencies
2-phase or 4-phase treatment approaches
Supportive alongside biomedical treatment e.g. ovulation-induction, IVF

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PCOS, INFERTILITY & CHM (RCT)

 Study aim: To explore effects of CHM on immune function and
intestinal flora in women with PCOS and infertility (Chen et al. 2022)
n=80
 Control group: Lifestyle modification + Dydrogesterone
 Treatment group: Lifestyle modification + Dydrogesterone + CHM
 Lifestyle modification: Restricting dietary fat, sugar and salt, regular
exercise, balanced work and rest
 Dydrogesterone 10mg/dosage every 12h from CD15 for 10 days
 Wenshen Quzhuo Tang modified (Warm the Kidney and Remove
Turbidity decoction) – as self-prepared decoction
 400ml, take warm, two dosages daily, for three menstrual cycles

PRESCRIPTION

Invigorate Kidney and Essence, replenish Spleen Qi, activate Blood, harmonise Chong
Ren
Zi Shi Ying 20g Dang Gui 12g Chen Pi 10g Lian Qiao 15g
Ba Ji Tian 12g Sheng Shan Zha 15g Qing Ban Xia 12g Pi Pa Ye 12g
Xiao Hui Xiang 12g Dan Shen 15g Fu Ling 12g Xiang Fu 10g
Chao Bai Shao 15g Ji Xue Teng 20g Ze Xie 15g Chuan Niu Xi 15g
Chuan Xiong 10g

Modifications:
Light menses and light colour + Shu Di Huang 15g, Dang Gui 12g
Light menses with dark colour + Yi Mu Cao 24g, Ze Lan 15g
Menstrual pain + Xiang Fu 10g, Yan Hu Suo 10g

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RESULTS

 Total effective rate: Control group 82.5%, Treatment group 90%

 Improved volume of bilateral ovaries and number of follicles from baseline in both groups, significantly better in
treatment group
 Improved levels of T lymphocytes in both groups, statistical significance reached for treatment group
 Treatment group had significantly higher levels of Lactobacilli and Bifidobacterium and lower levels of pathogenic
bacteria such as Escherichia at the end of the study

PCOS AND CLOMID + IUI PREPARATION

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PCOS AND CLOMID + IUI PREPARATION

Cycle day 5 to day of IUI Post IUI

Zi He Che 6g Ba Ji Tian 6g
Nu Zhen Zi 15g Chuan Duan 15g
Shu Di 15g Shu Di 15g
Gou Qi Zi 15g Dang Shen 10g
Xian Ling Pi 6g Shan Yao 15g
Tu Si Zi 15g He Shou Wu 15g
Dang Gui 15g Huang Jing 15g

Kidney Yin and Essence Kidney Yang and Blood

Blood and Kidney Yang Qi and Yin

ORCHID STUDY – STANDARDISED FORMULA

FOR REGULATING MENSES
Chai Hu 9g
Chai Hu Shu Gan San
Xiang Fu 12g
Zhi Ke 9g
Chen Pi 9g
Bai Shao (Chao) 15g ‘Individualised herbs are
Dang Gui Wei 9g more effective than
Gou Qi Zi 9g
standardised herbs’
Gui Zhi 9g
Tu Si Zi 12g
Chuan Xiong 9g
Hong Hua 9g
TRUE
Tao Ren 9g Standardised RR 50%
Yi Mu Cao 15g Individualised RR 72%
Gan Cao (Mi Zhi) 6g

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CASE HISTORIES

CASE HISTORY 1: PCOS AND FERTILITY

 Female, aged 35, stay at home mum
 Dx PCOS aged 29, classic PCOS
 1 child already after support with Clomid, TTC for second child in the last 12m
 Symptoms: Amenorrhoea, 1-2 periods a year, thick bleeding, reddish purplish, no clotting, hirsutism ’15-minute job
every morning’, very little fertile mucus/discharge, no twinges in ovaries, tendency to feel the cold, quite irritable
generally as well as pre-menstrually, pre-menstrual tiredness, irritability and tendency to feel low, emotional eating
in general that worsens pre-menstrually, minor breakouts premenstrually, prone to oily/greasy skin, sleep is okay,
back and knee aching and heaviness when on period
 Ovarian drilling carried out last year - ‘successful’ procedure but periods did not resume, metformin poorly
tolerated, Clomid attempted in recent 3m without success, left tube found to be obstructed, recommended IVF as
next step and advised to lose weight in preparation for IVF
 Plan to start IVF in 6m after losing weight, referred by acupuncturist
 T: Pinkish, flabby with teethmarks, red spots at anterior edge, thick white greasy coating
 P: Full, slippery at cun/guan, chi deep

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PRESCRIPTION 1
Cang Zhu 9
Diagnoses: Bi Jing due to Chen Pi 9
Phlegm-Dampness obstructing
Fu Ling 15
Chong/Ren, MJ Qi stagnation,
Blood stasis, Kidney Jing and Bai Shao (Chao) 9
Yang deficiency Chuan Xiong 9
Shu Di Huang 12
Treatment strategies: Shan Zha 6
• Dry Dampness, eliminate
Gui Zhi 12
Phlegm
• Move Qi and Blood Tu Si Zi 12
• Nourish Kidney Jing and Du Zhong 9
Yang Xiang Fu 9
Zhi Ke 9
Yuan Zhi 9
Gan Cao (Zhi) 6

FOLLOW-UP
 55 day cycle
 Thicker bleeding, brighter and more reddish in colour, premenstrual tiredness still evident,
less depression
 Period pain on day 1, skin is fine in general, sleep fine, no back or knee pain, skin has been
very sensitive and has come out ‘blotchy’
 Quite warm and sweaty on prescription
 T: Pinkish, flabby, red spots at anterior edge, thinner slightly sticky white coating
 P: Slippery at cun/guan, chi deep

 Decision to move to pre and post ovulation prescriptions

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PRESCRIPTIONS 2 AND 3

‘Pre-ovulation’ ‘Post-ovulation’

Bai Shao (Chao) 12 Dang Gui 9

Chi Shao 12 Bai Shao (Chao) 12

Dang Gui Wei 9 Bai Zhu 9

Sheng Di Huang 12 Sheng Di Huang 9

Shu Di Huang 12 Mu Dan Pi 9

Shan Zha 6 Bo He 9
Shan Yao 12 Chai Hu 9
Shan Zhu Yu 12 Chen Pi 9
Cang Zhu 12 Yi Yi Ren 15
Chen Pi 9 Gou Qi Zi 9
Fu Ling 15
Tu Si Zi 12
Xiang Fu 9
Yin Yang Huo 12
Shi Chang Pu 9
Gan Cao (Zhi) 6
Gan Cao (Zhi 6)

FOLLOW-UP

 Small amount of discharge on D18 for three days,

 Tender breasts
 51 day cycle
 A lot of mucus 3 days premenstrually
 Mucus-y bleeding, thick bleeding and heavy, dark blood, no pain or back pain, blocked
pores in the skin but no breakouts, night sweats
 Hair on face appears less thick, but still taking 15 minutes to take care of facial hair in
the morning

 Decision to continue with alternating pre-post ovulation prescriptions – no changes

made for a further 2 months

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FINAL FOLLOW-UP

 Follow up at cycle day 86 – due to go on holiday

 Very tired and feeling very flat, bloating, urgency with bowel movements
 Aching knees as if period is due
 Hot and sweaty, pulses full and rolling
 Very bad tempered!
 Advised to carry out a pregnancy test prior to next prescription
 Positive pregnancy test, healthy pregnancy, healthy baby boy

REFLECTIONS
 Using a clearing excess strategy first before moving to a biphasic formula was effective for this patient
 Would have adopted stronger Blood moving approach for next prescription if negative test, hence need to test
for pregnancy
 Patient initially very sceptical of herbs – referral from her acupuncturist helped build trust in herbs
REFLECTIONS

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CASE HISTORY 2: PCOS, WEIGHT LOSS, APPETITE CONTROL

 Female, 42, HR consultant and coach

 Main complaint: Difficulty with losing weight despite being very active and being careful with diet
 Medical history: Classic PCOS and fibroids dx 14 years prior (age 28), endometriosis dx 4 years prior (age 38),
mother underwent early menopause at 43 yo
 Secondary symptoms/signs: Appetite very difficult to control, incorporates mindful eating, Keto diet helped with
hormones previously but found difficult to maintain, 10,000 steps daily since lockdown, irregular periods prior to
IUD, mood affected by hormones and eating patterns (feels negative and lack of focus), mild hirsutism on face,
upper lip, sides of the face (hair removal products and shaves), wakes with sweats at night which disturbs sleep,
stressful and high-pressured job
 T: Bright pink, swollen, slight teethmarks, greasy coating, slightly yellowish at root, sublingual veins pink
 P: Not taken (COVID)

DIAGNOSIS AND PRESCRIPTION 1

Zhi Mu 9
Diagnoses: Kidney yin deficiency Huang Bai 9
with deficient Fire and Damp Bai Hua She She Cao 9
Heat, Qi stagnation, Heat toxicity
Shu Di Huang 9
Shan Yao 9
Treatment strategy:
• Clear Heat, drain Fire Fu Ling 9

• Move the Qi Mu Dan Pi 9

• Nourish Kidney Yin Ze Xie 9
Chuan Xiong 9
2 weeks Bai Shao 9
Xiang Fu 9
Zhi Ke 9
Jie Geng 9
Wu Wei Zi 12
Zhi Gan Cao 6

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FOLLOW-UP 1

 Feeling very well, sleeping very well, energy levels ‘through the roof’ despite working weekends
 Work is stressful but finding not reacting to stress
 Skin has improved considerably, feeling and looking great
 Less facial hair, feels finer and taking longer to grow
 Feeling less hungry now, snacking a lot less
 Has only woken up one night feeling a little warm but without sweating and did not disturb sleep
 Continuing to lose weight, feeling better physically and emotionally
 Had a cold which went away very quickly – would usually have suffered from sinusitis
 T: Pinkish tongue, teethmarks reduced, greasy coating remains but thinner

 No changes required to prescription 1 - 4 week prescription

FOLLOW-UP 2

 A lot of stress at work this month, very busy and finding training online exhausting.
Sleeping very well but more out of exhaustion.
 Skin is ‘amazing’, hair is finer and not having to shave as often or in as large an area
 Body better tolerates the heat
 Weight loss has stabilised, possibly due to comfort eating with being busy and tired
 Mental activity – very noisy, some irritability and would like more focus
 Some frontal headaches in the morning and sleep in eyes

 T: Pink tongue, teethmarks remain the same, slightly yellowish sticky coating

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PRESCRIPTION 2
Zhi Mu 9

Treatment strategy: + Huang Lian 6

• Adjusted to support MJ Damp Bai Hua She She Cao 9
Heat Shan Yao 9
• Support Heart/Kidney Mu Dan Pi 9
communication
Ze Xie 9
Bai Shao 9
Xiang Fu 9

2 weeks Zhi Ke 9
Jie Geng 9
+ Chen Pi 9
Removed
+ Bai Zhu (Sheng) 9 Shu Di Huang 9
Fu Ling 9 Chuan Xiong 9
Huang Bai 9
+ Suan Zao Ren 12 Wu Wei Zi 12
Zhi Gan Cao 6

FOLLOW-UP 3

 Feeling much calmer and mentally well-rested these last two weeks, brain fog cleared
and able to focus more easily
 Heat continues to be kept at bay, sleeping well
 Eating is under control and weight is starting to come off again, feeling more motivated
to maintain activity levels
 Skin feels very healthy and hair growth remains slower
 Regular bowel movements but less smelly and less bloating, clothes fitting more
comfortably
 T: Pink tongue, less flabby/swollen, slight teethmarks, white sticky coating

 Continue on previous prescription +/- for another 4 weeks

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REFLECTIONS

 Medical history suggests severe Blood stasis – underlying but not that apparent in medical history and chose not to
address as priority for this patient in early stages of treatment
 Prior (positive!) experience of herbs helped cement this patient’s compliance for this course of treatment
REFLECTIONS
 Used the CHMs in exactly the same manner as she did with ORCHID study – completely changed her mindset
towards weight loss which encouraged her to make lasting changes to eating habits/activity levels

CASE HISTORY 3: PCOS, OLIGOMENORRHOEA AND ACNE

 25, marketing executive
 Dx PCOS 4 months prior, PCO on U/S, elevated T, other hormone tests normal, classic
PCOS
 Main complaint: Oligomenorrhoea – cycles vary from 2-8 weeks, longer cycles more
recently
 Secondary symptoms: Painful cystic acne since 15yo, fatigue, low mood, low libido, bloating
and diarrhoea with periods, dysmenorrhoea, pain improves with heat, very heavy and clotty
bleeding on days 1-2, tendency to overthink and worry, thin frame
 Cutting down on dairy has helped acne in the past, antibiotics and Roaccutane worsened
acne
 Phenotype: Classic
 P: Thin and slippery, taut T: purplish-red, sticky white coating, teethmarks

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DIAGNOSIS AND PRESCRIPTION 1

Chai Hu 12
Yu Jin 9
Diagnoses:Yue Jing Bu Tiao due
to Liver Qi stagnation and Blood Yi Mu Cao 9
stasis, Spleen Qi deficiency and Tao Ren 9
Blood Heat Hong Hua 9

Treatment strategies: Chi Shao 9

• Move Liver Bai Shao 9
• Move Blood Dang Gui 9
• Support Spleen Qi
• Clear Blood Heat/drain Fire Bai Zhu 12
Dan Shen 9
Lian Qiao 12
4 week prescription
Huang Qin 9
Gan Cao 6

FOLLOW UP AND PRESCRIPTION 2

Lian Qiao 12
 Cycle improved but still Huang Qin 9
delayed (42d cycle), quite a + Ye Ju Hua 12
painful period
+ Bai Hua She She Cao 15
 More breakouts
Chi Shao 9
 Aching in stomach 2 weeks
prior to period as well as Bai Shao 9
more discharge (?Ovulation) Dang Gui 9
 Poor sleep and low energy, Dan Shen 9
more irritable Bai Zhu 12
Removed
Yi Mu Cao 9 Hong Hua 9
+ Yan Hu Suo 9 Tao Ren 9
 6 week prescription + He Huan Pi 9 Chai Hu 9
Yu Jin 9
Gan Cao 6

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FOLLOW UP AND PRESCRIPTION 3

Lian Qiao 12
 Shorter cycle length (35d) Huang Qin 9

 Period pain still evident, not Ye Ju Hua 12

as painful as before Bai Hua She She Cao 15
+ Zhi Zi 9
 Energy and sleep much
+ Sheng Di Huang 9
better
Chi Shao 9
 Breakouts calming down + Yu Jin 9
but still apparent
Bai Shao 9
Dang Gui 9
 4 weeks Dan Shen 9
Bai Zhu 12
+ Fu Ling 12 Removed
He Huan Pi 9 Yan Hu Suo 9
Yi Mu Cao 9
Gan Cao 6

FOLLOW UP AND PRESCRIPTION 4

Lian Qiao 12
 Skin much improved, Huang Qin 9
smaller whiteheads now Ye Ju Hua 12
and no cystic acne Zhi Zi 9
 Flow not as heavy, Sheng Di Huang 9
noticing abdominal aching + Ku Shen 9
at regular intervals + Pu Gong Ying 6

 Good energy, sleeping Chi Shao 9

well Yu Jin 9
Bai Shao 9
Dan Shen 9
 4 weeks, moved house Bai Zhu 12
and continuing treatment Fu Ling 12
with local practitioner He Huan Pi 9
Removed Bai Hua She She Cao 15
Gan Cao 6

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REFLECTIONS

 Primary complaints matter and sometimes patients aren’t sure how to prioritise all the different PCOS
symptoms they’re experiencing
 Initial strong moving approach with this patient to support oligomenorrhoea led to quite a painful period, acne
REFLECTIONS
and also tiredness
 Highlighted importance of getting the balance right – too much movement potentially exacerbated Heat
symptoms in this patient
 In the end an alternative approach focusing on the patient’s key complaint of acne was ultimately the most
effective for this patient

CASE HISTORY 4: PCOS, OLIGOMENORRHOEA AND

OVULATION-INDUCTION

 42yo, cancer specialist

 2 children (Clomid, thyroxine), trying for 3rd in last 12m, poor tolerance to metformin
 Non-hyperandrogenic PCOS phenotype
 Oligomenorrhoea since periods started - support from nutritional therapist has helped reduce cycle lengths from
50 days to 35 days in the last 3m, gradually losing weight, digestion generally fine but tendency to constipation,
typically light red/brownish spotting premenstrually for 3 days, periods 4 days duration, watery bleeding initially and
flow establishing by day 2, no abdominal pain but breasts can get sore/tender
 Very busy, stressed, and bad tempered since lockdown, sleep good quality but only 5 hours due to juggling
childcare with work during lockdown, some milky discharge from left breast in recent months, low energy which is
improving with nutritional therapist support, positive and happy by nature
 Plan to carry out 2 Clomid cycles, first cycle without IUI, second cycle with, and proceed to IVF if necessary

 T: Pale, swollen, sticky white coating

 P: Not taken during COVID

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PRESCRIPTION 1

Diagnoses
Wu Zhu Yu 9
- MJ/Kidney Yang deficiency Gui Zhi 12
- Blood and Yin deficiency Yin Yang Huo 9

- Phlegm-Dampness Dang Gui Wei 9

obstructing Chong and Bai Shao (Chao) 12
Ren Shu Di Huang 9
Shan Zha 6
Mai Men Dong 9
Treatment strategies Huang Jing 9
- Warm the MJ/Kidney Yang Mu Dan Pi 9

- Nourish Blood and Yin Chuan Xiong 9

Da Huang 6
- Dry Dampness
Fa Ban Xia 9
Gan Cao 6
4 weeks

FOLLOW UP 1

 Next cycle 31 days in length, bleeding improved in quality – reduced to 1.5-2 days premenstrual spotting,
bleeding less watery and thicker, remains 4 days in duration
 Planned to start Clomid on day 2 of cycle and offer CHM support during cycle, lost contact with patient until
the next period came after the failed Clomid cycle
 Tracking scans during 1st Clomid cycle showed good follicular development but little fertile mucus and lining
thin at 7mm on CD 12, timed intercourse
 1-2 days’ premenstrual spotting, very light and watery bleeding, some pre-menstrual breast tenderness,
irritability and headaches
 Next cycle of Clomid with IUI and CHM support

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PRESCRIPTION 2 AND 3
Pre-ovulation Post-ovulation

Shu Di Huang 12 Shu Di Huang 9

Shan Zha 6
Shan Zha 6
Shan Zhu Yu 12
Shan Zhu Yu 12
Shan Yao 12
Shan Yao 12
Dang Gui 9
Gui Zhi 9
Bai Shao (Chao) 9
Yin Yang Huo 9
Nu Zhen Zi 9
Mu Dan Pi 9 Tu Si Zi 12
Chuan Xiong 6 Chen Pi 9
Ji Xue Teng 9 Fu Ling 15
Xiang Fu 9 Xiang Fu 6
Zhi Ke 9 Mu Dan Pi 9
Zhi Gan Cao 6 Zhi Gan Cao 6

FOLLOW UP 2

 Started 2nd Clomid cycle on Day 2

 D11 Scan showed multiple follicles with lead at only 15/16mm
 D16 scan showed 2 follicles at 26mm, lining over 9mm, good amount of cervical mucus, consultant feeling very
positive
 IUI carried out
 Negative test, 30 day cycle, bright red bleed from the start, 4 day bleed, felt like a ‘proper’ period
 Feeling fantastic due to better work-life balance, sleeping more deeply, continuing to lose weight, feeling much
more positive with nutritional and Chinese herbal support
 Suggested additional sperm tests for husband in the meantime as basic semen analysis was not ideal (morphology
issues) which came back with high DNA fragmentation
 Husband used nutritional supplements and lifestyle modification to improve parameters
 Patient continued on variations of prescription 1 for another 2 cycles before next stimulated cycle
 T: Brighter, firmer body, slightly sticky white coating, red spots at the tip

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FOLLOW UP 3

 3rd cycle with Letrozole

 ‘Textbook’ cycle – lead follicle at 18mm on CD13, good amount of cervical fluids, trigger
shot, IUI carried out
 Pre and post-ovulation prescriptions remained mostly the same as before
 Positive test – heartbeat visible at 7 week ‘viability’ scan
 Pregnancy-related nausea, tiredness, dizziness
 CHM support during pregnancy

PRESCRIPTION 4 - PREGNANCY

Huang Qi 15
Bai Zhu 12 Continued into Week 12,
and then subsequently
Fang Feng 9 stopped CHMs
Chen Pi 6
Delivered healthy baby girl!
Zhu Ru 9
Tu Si Zi 9
Xu Duan 9
Dang Gui 12
Shu Di Huang 15
Sha Ren 6
Gan Cao 6

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REFLECTIONS

 For fertility cases, remember it takes two! Consultants will sometimes

miss important details and forget to see the bigger picture
 More time to support patient’s Kidney energy alongside husband’s
REFLECTIONS
lifestyle/dietary changes was enough to help this couple avoid IVF
 Poor result from unsupported Clomid cycle followed by much improved
results from supported Clomid ultimately improved patient’s compliance
 Pregnancy support not always necessary but offered due to concerns re
existing Kidney and Blood deficiencies

SUMMARY

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SUMMARY AND PRACTICE POINTS

 CHMs can be effectively used for managing various symptoms of PCOS
 Setting the right expectations will maximise commitment to treatment – women with PCOS usually
appreciate it will not be a quick fix
 Variety of treatment strategies can be used successfully, even amongst patients appearing to have more severe
presentations (amenorrhoea, hyperandrogenism, hirsutism, elevated LH/cholesterol/triglycerides or showing
early signs of insulin resistance)
 Continually review current working diagnosis and current treatment strategy
 Collaboration with other healthcare professionals (gynaecologists, fertility consultants, nutritionists)
advantageous
 Understanding of PCOS has evolved rapidly in the last 5-10 years – continually incorporate new knowledge
and evidence, esp. with research into gut/reproductive microbiome

THANK YOU TO ALL WHO CONTRIBUTED TO THIS WORK!

• Supervision team: Prof George Lewith, Prof Michael Moore, Dr

Andrew Flower
• Delphi study practitioners
• ORCHID study participants
• George He and his team at Phoenix Medical
• Funding and recruitment support from healthcare organisations

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THANK YOU FOR YOUR

ATTENTION!

ANY QUESTIONS OR
COMMENTS?

info@acupunctureandherbs.co.uk

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