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From the Townsend Letter
April 2009

Chinese Medicine
A Suggested Pattern Discrimination for Premature Ovarian Failure (POF)
by Bob Flaws, L.Ac., FNAAOM (USA), FRCHM (UK)

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Since the mid-20th century, doctors in the People's Republic of China (PRC) have been attempting to work out the Chinese medical pattern discrimination of modern Western diseases. When first advanced, typically in the Chinese medical journal literature, these pattern discriminations are only provisional. It is not until broad consensus is subsequently achieved that a particular method of pattern discrimination becomes standard for a particular Western medical disease. Premature ovarian failure (POF) is such a modern Western disease category; and, at the moment, any suggested methods of its pattern discrimination are merely provisional. However, on pages 86–87 of Xin Zhong Yi (New Chinese Medicine) 2008, issue 3, Wang Cui-ping of the First People's Hospital of Luoyang, Henan, published an article titled "The pattern discrimination treatment of 40 cases of premature ovarian failure." Since POF is such a popular topic in contemporary reproductive medicine, a summary of this article is presented below.

Cohort Description
All 40 subjects enrolled in this cohort study had a confirmed diagnosis of POF. This meant that they were less than 40 years of age, their menses had ceased for at least three months, and their serum follicle-stimulating hormone (FSH) was more than 40 IU/L. Women who were pregnant or had polycystic ovarian syndrome, high serum prolactin levels, or other such conditions leading to the cessation of menstruation were excluded from this study. In fact, all 40 women in this study were 27 to 39 years of age. Twenty-four had been amenorrheic for three months or more within the previous six months. The other 16 cases presented with abnormally scanty or infrequent menstruation. All these women had previously been pregnant and given birth.

Pattern Discrimination
The following three patterns were discriminated for the purposes of this study:

1. Liver-kidney yin vacuity pattern (19 cases): The signs and symptoms seen in this case included amenorrhea or abnormally scanty or infrequent menstruation; scanty vaginal tract secretions; dry external genitalia; hot flashes; vexatious heat in the five hearts; night sweats; dizziness; dry eyes; dry mouth; red tongue with scanty fur; and fine, rapid pulse. In addition, FSH was abnormally high, but the ratio of FSH to luteinizing hormone (LH) was less than 2:1.

2. Spleen-kidney yang vacuity pattern (17 cases): The signs and symptoms seen in this case included marked aversion to cold; spontaneous perspiration; lack of strength; slight hot flashes; a sallow yellow facial complexion; possible floating edema in both lower extremities and/or the face and eyes; decreased sexual desire; insomnia; profuse dreams; a fat, enlarged tongue with white fur; and deep pulse. Most of the women presenting this pattern had amenorrhea or delayed, scanty menstruation. Serum FSH in this group was mostly markedly elevated, and the FSH to LH ratio was more than 2:1 and as much as 3:1.

3. Liver qi depression and binding (4 cases): The signs and symptoms in this case included amenorrhea or a lengthy menstrual cycle; vexation and agitation; irritability; extremely labile emotions; sweating; hot flashes; insomnia; breast distention and pain or lumps within the breasts; a red tongue; and a deep, slippery or deep, bowstring pulse. Serum FSH levels were only slightly elevated in those who presented this pattern.

Treatment Method

1. Liver-kidney yin vacuity pattern
Formula: Zuo Gui Yin Jia Wei (Restore the Left [Kidney] Beverage with Added Flavors) in order to enrich yin and supplement the kidneys, nourish the liver and clear heat

Shu Di Huang (cooked Radix Rehmanniae)
Shan Yao (Radix Dioscoreae)
Gou Qi Zi (Fructus Lycii)
Nu Zhen Zi (Fructus Ligustri Lucidi)
Tu Si Zi (Semen Cuscutae)
Han Lian Cao (Herba Ecliptae)
Di Gu Pi (Cortex Lycii)
Xiang Fu (Rhizoma Cyperi), 15g each
Huang Bai (Cortex Phellodendri)
Mu Dan Pi (Cortex Moutan), 10g each
Dang Gui (Radix Angelicae Sinensis)
Bai Shao (Radix Alba Paeoniae)
Long Gu (Os Draconis), 20g each

Note: Based on an analysis of the ingredients in this formula, the author recognizes that these women's main pattern was complicated by liver depression qi stagnation, blood vacuity, and vacuity heat.

2. Spleen-kidney yang vacuity pattern
Formula: You Gui Wan (Restore the Right [kidney] Pill) combined with Er Xian Tang (Two Immortals Decoction) with additions and subtractions to boost the kidneys and foster essence, warm yang, and fortify the spleen

Yin Yang Huo (Herba Epimedii)
Xian Mao (Rhizoma Curculiginis)
Fu Zi (Radix Lateralis Praeparata Aconiti)
Xiang Fu (Rhizoma Cyperi)
Shan Zhu Yu (Fructus Corni)
Tu Si Zi (Semen Cuscutae)
Shan Yao (Radix Dioscoreae)
Dang Gui (Radix Angelicae Sinensis), 15g each
Du Zhong (Cortex Eucommiae)
Lu Jiao Pian (Cornu Parvum Cervi), 10g each
Dan Shen (Radix Salviae Miltiorrhizae)
Fu Ling (Poria)
Yi Mu Cao (Herba Leonuri)
Suan Zao Ren (Semen Zizyphi Spinosae), 20g each

Note: Based on an analysis of the ingredients in this formula, the author recognizes that these women's main pattern was complicated by liver depression qi stagnation and blood stasis, as well as possible or even probable blood vacuity.

3. Liver qi depression and binding pattern
Formula: Xiao Yao San Jia Wei (Rambling Powder with Added Flavors to course the liver and rectify the qi, quicken the blood, and fortify the spleen

Chai Hu (Radix Bupleuri)
Zhi Qiao (Fructus Aurantii)
Dang Gui (Radix Angelicae Sinensis)
Bai Shao (Radix Alba Paeoniae)
Bai Zhu (Rhizoma Atractylodis Macrocephalae)
Ci Ji Li (Fructus Tribuli)
Yin Yang Huo (Herba Epimedii)
Tu Si Zi (Semen Cuscutae)
Ji Nei Jin (Endothelium Corneum Gigeriae Galli)
Ye Jiao Teng (Caulis Polygoni Multiflori), 15g each
Fu Ling (Poria)
Mai Ya (Fructus Germinatus Hordei)
Dan Shen (Radix Salviae Miltiorrhoizae), 20g each
Yu Jin (Tuber Curcumae), 10g

Note: Based on an analysis of the ingredients in this formula, the author recognizes that these women's main pattern was complicated by spleen and kidney vacuity, as well as blood vacuity and possible blood stasis.

One packet of these medicinals was decocted in water and administered per day for a continuous 20 days. Then 10 milligrams of medroxyprogesterone acetate was given once per day for five continuous days. Then Tao Hong Si Wu Tang Jia Wei (Persica & Carthamus Four Materials Decoction with Added Flavors) was administered at a rate of one packet per day decocted in water two times. My assumption is that these medicinals were administered beginning on the 26th day of treatment and continuing to day 30 or day 2 of the new cycle. This formula was meant to quicken the blood and transform stasis in order to promote the endometrium and uterus and improve the blood circulation of the ovaries. Outcomes were assessed after three such courses of therapy.

Study Outcomes
"Cure" was defined as disappearance of clinical symptoms and resumption of normal menstruation, which was also normal in amount as well as FSH levels. "Marked effect" was defined as a marked decrease in the clinical symptoms, the occurrence of menstruation after the administration of the medroxyprogesterone acetate, and almost normal FSH levels. "Some effect" was defined as remission of the main symptoms and a lowering of FSH levels, and "no effect" meant that there was no obvious improvement in the clinical symptoms. Based on these criteria, 10 cases were considered cured, 17 experienced a marked effect, 7 others got some effect, and 6 got no effect. Therefore, the total effectiveness rate was given as 85%.

Based on the idea that "the kidneys govern reproduction," Wang believes that this root of the treatment of this condition should be to foster kidney essence and regulate the chong and ren, and that regulating the chong and ren means that one must regulate the viscera and bowels and harmonize the qi and blood. However, in this case, special attention must be placed on the liver, spleen, and kidneys. This is because the liver governs the storing of blood and is a woman's former heaven. The kidneys govern the storing of essence and are the root of the essence and blood. The spleen governs movement and transformation and is the origin of the engenderment and transformation of the qi and blood. If the function of these three viscera is regulated and harmonious, then the qi and blood are automatically enriched and the chong and ren are automatically regulated. Modern research has shown that enriching yin and supplementing the kidney medicinals can increase estrogen levels, while at the same time decreasing FSH levels. In addition, medicinals that fortify the spleen and supplement the kidneys, foster the essence and boost the marrow, course the liver and rectify the qi, and quicken the blood and transform stasis are good at improving pituitary and ovarian function.

Readers should note that the author, beyond suggesting a threefold pattern discrimination for POF, is also suggesting that these three patterns can be correlated with FSH levels and/or FSH:LH ratios. This attempt at integrating Chinese and Western medicines and the establishment of objective biological markers for Chinese medical patterns is a major movement in Chinese medicine in the PRC.

Copyright © Blue Poppy Press, 2008. All rights reserved.

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


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