Atypical Polycystic Ovary Syndrome (PCOS) Cases and Their Treatment with Traditional Chinese Medicine

Ginger Zhang, Massachusetts, USA

Abstract: A year ago, I treated a 31-year-old patient diagnosed with infertility due to PCOS. She was a slim Caucasian woman with no obvious signs of PCOS, such as obesity. She had no facial acne, and no noticeable body hair on her face or around her lips. To address this, I reviewed the theories of PCOS in both Western and Traditional Chinese Medicine (TCM), integrating my knowledge of both to treat her. I applied the principles of basal body temperature during the menstrual cycle, the hormonal changes associated with temperature fluctuations, and the ascending and descending patterns of kidney yin and kidney yang, guided by pattern identification as the basis for determining treatment. I used TCM and acupuncture to achieve excellent results. I share my thoughts and insights in the following report.

Keywords: Polycystic Ovary Syndrome (PCOS), infertility, basal body temperature, kidney yin and kidney yang, traditional Chinese medicine, acupuncture

Traditional Chinese Medicine (TCM) classifies PCOS within the scope of “menstrual irregularity”, “amenorrhea”, “infertility”, “vaginal discharge” and “concretions and conglomerations”. Its primary causes are: liver depression and qi stagnation, in which depressed emotions and constrained liver qi transform into fire over time, disrupting the thoroughfare and controlling vessels; spleen vacuity stirring wind, where movement and transformation failure due to spleen vacuity leads to internal accumulation of water-damp, which condenses into phlegm and obstructs the thoroughfare and controlling vessels; and kidney vacuity with disharmony of the thoroughfare and controlling vessels, in which insufficiency of earlier heaven or kidney qi depletion leads to insecurity of the thoroughfare and controlling vessels. The underlying pathomechanism is characterized by disharmony of the thoroughfare and controlling vessels, obstruction by phlegm-damp and stasis, and liver depression and kidney vacuity as the primary cause.

I. Normal Basal Body Temperature Fluctuations, Hormonal Changes, and Their Yin-Yang Properties

1. Normal Body Temperature. During the menstrual period (days 1–5) of a normal woman of childbearing age, the lower temperature phase begins, with the basal body temperature maintained at 36.1–36.4°C. During the follicular phase (days 6–13), the body temperature remains in the lower temperature phase (stable around 36.2–36.4°C). During the ovulatory phase (day 14 ± 2), the body temperature may drop slightly on the day of ovulation (a sign of ovulation), then rapidly rise by more than 0.3°C, entering the high-temperature phase. During the luteal phase (days 15–28), the body temperature rises to around 36.5–36.9°C. If conception does not occur, the corpus luteum shrinks, progesterone levels decrease, body temperature drops, and menstruation begins, marking the beginning of the next menstrual cycle. This cycle is shown in Figure 1.

Figure 1:The normal basal body temperature cycle curve shows a clear low-temperature period before ovulation and a high-temperature period after ovulation. 

2. Hormonal Changes During the Menstrual Cycle

The follicular phase (post-menstrual phase) is when estrogen levels rise from low to high, nourishing the growth, development, and maturation of the ovarian follicle (yin exuberance). Kidney yin dominates, and essence and blood gradually increase. Body temperature stabilizes in the low-temperature phase, reducing energy expenditure.

During ovulation, luteinizing hormone (LH) levels surge, like the kidney yang life gate fire, triggering the egg to emerge. When yin is exuberant, it descends. During this transition, body temperature rebounds from a low level and begins to rise (kidney yang begins to dominate).

During the luteal phase, LH produces progesterone, which acts like the yang energy of the spleen and kidneys, strengthening the weak kidney yang. If conception occurs, it supports embryo implantation and pregnancy, exerting warming, securing, and moistening effects. The kidneys’ yin and yang are strengthened simultaneously. As stated in the chapter of Neijing [The Inner Canon] entitled “The Spirit”: “The origin of life is called essence; the contention of 2 essences is called spirit”. Life originates from the essence of yin and yang. The union of male and female essence and blood gives rise to life (spirit). After rising, the body temperature remains high.

The menstrual period takes place when conception has not occurred. When yang is exuberant, it descends, leaving no support for the kidney yin, causing the yin blood to flow downward (menstruation). The body temperature drops and the low-temperature period begins. This marks the beginning of the next cycle of kidney yin gradually strengthening, the next physiological cycle of the rise and fall of yin and yang. (See Figure 2.)

Figure 2: Fluctuations of estrogen, progesterone, and LH in a normal menstrual cycle.

3. The Process of Kidney Yin and Yang Transformation

During the follicular phase after menstruation, kidney yin gradually increases, follicles develop, and body temperature remains stable and low to save energy and store essence. During the ovulation phase, yin reaches its peak and yang is engendered. At this point when yin transforms into yang, the egg is released and the body temperature rebounds. During the luteal phase, the corpus luteum forms to support implantation, the kidney yang is exuberant, the body temperature rises and is maintained, and if conception occurs, yin and yang will be even stronger. During the menstrual phase, if pregnancy does not occur, yang declines and yin rises, yang cannot secure yin, yin blood leaks out (menstruation occurs), the body temperature drops, and the next round of kidney yin accumulation begins. (See Figure 3.)

Figure 3: The yin and yang transformation of the kidneys during the menstrual cycle

II. Case History

1. Symptoms and Signs: Erica, a 31-year-old bank employee, had been married for 3 years. She had her first menstrual period at 15. Her menstrual cycles were never regular, often missing 2 to 3 periods. She was thin since childhood and had a poor appetite. She later used birth control pills to regulate her periods. After marriage, she stopped using birth control pills, hoping to conceive naturally. For 3 years, her periods were irregular, occurring every 60-80 days, and she never conceived. She was under a lot of stress at work. She experienced mood swings before her periods as well as breast distention, and she had abdominal pain 2 days before her period. Her menstrual flow was scanty and light, lasting only 3 days. She had to go to a beauty salon to shave her face monthly, otherwise dark, profuse hair would grow on her face and upper lip. She suffered from chronic stool irregularity, with either constipation or diarrhea. She had difficulty falling asleep, lack of strength, and cold hands and feet. Her tongue was pale and slightly swollen; the edges were smooth and bare with little tongue fur, while there was slightly thick, white fur in the center of the tongue. Her pulse was fine and soft, and the cubit pulse was very deep. 

The diagnosis of PCOS by her gynecologist provided crucial evidence. An ultrasound revealed 12-15 small follicles, ranging from 3 to 7 mm, in both ovaries. Blood tests also revealed a high ratio of luteinizing hormone (LH) to follicle-stimulating hormone (FSH), elevated total testosterone, low progesterone, and elevated fasting insulin.

I always require my infertility patients to measure their basal body temperature as part of their diagnostic criteria. This patient measured her basal body temperature for 2 months. See Figure 4 for her temperature chart from the month before her visit.

Figure 4: This chart shows the basal body temperature (BBT) before treatment. The temperatures fluctuate between 95.6°F and 97.2°F (35.3°C and 36.2°C) without a clear biphasic pattern.

2. Diagnosis and Treatment

Compared to the cyclical fluctuations of normal basal body temperature, the patient’s basal body temperature not only did not fluctuate between low and high temperatures, but in fact, the normal body temperature after ovulation was approximately 0.3-0.5°C higher than before ovulation, entering the high temperature range. This temperature chart shows that, first, the patient did not ovulate, and second, that her body temperature was low. The body temperature of a normal young woman typically fluctuates between 36°C and 37°C, but the patient’s temperature consistently hovered between 35°C and 36°C. This indicates insufficiency of both kidney yin and kidney yang. Based on her symptoms, the following diagnosis can be made:

Traditional Chinese Medicine Diagnosis: Liver depression and spleen vacuity, disharmony of the thoroughfare and controlling vessels, and insufficiency of kidney yin and yang.

Treatment Principle: Course the liver and resolve depression, fortify the spleen, supplement kidney yin, and strengthen kidney yang. 

Treatment:

During the initial session, a basic Chinese medicine formula (Formula 1) was prescribed. Ingredients: bupleurum 0.5g, Chinese angelica 1g, white peony 1g, poria 1g, white atractylodes 1g, cooked rehmannia 1g, dioscorea 1.5g, ligustrum 1.5g, lycium 1g, eclipta 1g, flowery knotweed stem 1g.

The aforementioned formula was given as a concentrated Chinese medicine powder, to be taken warm twice daily, 6g each time, in the morning and evening. The patient took this formula continuously for 14 days.

For acupuncture treatment, the basic point prescription included: Pass Head [CV-04], Celestial Pivot [ST-25], Return [ST-29], Sea of Qi [CV-06], Central Pole [CV-03], Qi Thoroughfare [ST-30], Inner Pass [PC-06], Hundred Convergences [GV-20], Union Valley [LI-04], Supreme Surge [LV-03], Leg Three Li [ST-36], Three Yin Intersection [SP-06], Liver Transport [BL-18], Spleen Transport [BL-20], Spirit Gate [HT-07], and Great Ravine [KD-03].

Acupuncture treatment can target 5-7 points per session, using a bilateral supplementing needling technique. Acupuncture treatment should be performed weekly. Moxibustion was applied to the Pass Head [CV-04], Qi Thoroughfare [ST-30], and Leg Three Li [ST-36] points for 10-15 minutes each, until the local area was slightly warm and pink (the patient was instructed to perform moxibustion at home 2-3 times per week).

At the second visit, the treatment was the same as above.

At the third visit, 3 weeks later, the patient reported improved sleep, decreased fatigue, and an increase in basal body temperature, no longer falling below 96.3°F (39°C). A formula (Formula 2) was developed to supplement kidney qi, strengthen kidney yang, quicken blood, and promote ovulation.

Ingredients: chuanxiong 1.5g, red peony 1g, Chinese angelica 1g, cooked rehmannia 1g, morinda 1g, carthamus 1g, fennel 2g, cinnamon bark 1.0g, aconite 0.5g, salvia 1.0g, leonurus 1.0g, achyranthes 1.0g, poria 1.0g.

This formula was to be taken twice daily, 7g each time, for 1 week.

Acupuncture was performed at the aforementioned acupuncture points and 2 pairs of points were selected for strong electroacupuncture stimulation to promote ovulation. From this point on, this procedure was repeated monthly before ovulation. 

At the fourth visit, 1 week later, an ovulation test strip indicated possible ovulation, but the color was not dark and basal body temperature was slightly elevated.

Another formula (Formula 3) was formulated to consolidate the kidney yang qi and enhance corpus luteum function.

Spleen-Returning Variant Decoction: eucommia, cistanche, dipsacus, complanate astragalus seed, morinda, ligustrum, cuscuta seed, rubus, and eclipta.

Similarly, this formula was to be taken twice daily, 6g each time, for 2 weeks.

Regarding acupuncture point selection, 1 week after ovulation, certain points are contraindicated for acupuncture treatment. The contraindicated points for pregnancy include those on the lower abdomen, lumbar, and sacral regions, as well as Three Yin Intersection [SP-06]. If it is confirmed that the patient is not pregnant, one can resume using these points. 

After 5 weeks of treatment, her temperature dropped slightly and her period started. The blood was pale pink and accompanied by abdominal pain. During her menstrual period, I prescribed a variant of Formula 1 to be taken for 10 days. The treatment principle was to fortify the spleen, course the liver, and supplement the kidneys. Acupuncture treatment was performed at the Pass Head [CV-04], Sea of Qi [CV-06], Union Valley [LI-04], Supreme Surge [LV-03], Three Yin Intersection [SP-06], and Sea of Blood [SP-10] points, focusing on supplementation. Moxibustion was also used.

3. Results: Acupuncture and moxibustion treatment was used according to the above principles, with specific prescriptions adjusted based on symptoms. The patient became pregnant 6 months later. Her symptoms of cold hands and feet improved, her strength increased, and her sleep quality improved (which the patient attributed to following the guidance of a sleep specialist). Although work stress occasionally caused insomnia, she made an effort to relax by doing yoga. Her stool became more regular and formed. Her tongue was pale red with relatively pale edges, thin white tongue fur, and a slightly red tip. Her pulse was slippery, soft, and rapid. After 2 months of consistent biphasic temperature fluctuations, a blood test confirmed the pregnancy. 

Figure 5: Six months after starting treatment, the body temperature returned to a normal biphasic pattern and conception occurred.

III. Case Analysis

1. Etiology and Pathogenesis Analysis: The average age of menarche for girls worldwide is 12-13.5 years old. This patient’s menarche at age 15 was relatively late; moreover, her period was delayed and always irregular. She also had a poor appetite and thin body, suggesting a possible congenital insufficiency of kidney qi and acquired spleen vacuity disharmony. Furthermore, high work stress has led to liver qi binding depression over time, a finding echoed by the patient’s specific symptoms. Poor appetite, reduced eating, and loose stools indicate failure to move due to spleen vacuity. Cold hands and feet along with prolonged menstruation indicate kidney yang vacuity as well as thoroughfare and controlling vessel vacuity cold, leading to delayed ovulation. Premenstrual distending pain in the breast and mood swings are due to liver qi binding depression, disharmony of coursing and draining , and obstruction of the thoroughfare and controlling vessels, resulting in delayed menstruation. Stress can lead to effulgent heart and liver fire as well as dual vacuity of the heart and spleen, resulting in insomnia. Mental stress and sleep disorders can disrupt ovulation, leading to anovulation or infrequent ovulation, a condition associated with polycystic ovary syndrome (PCOS). In summary, the pathomechanism is dual vacuity of the spleen and kidneys, liver depression and qi stagnation, and disharmony of the thoroughfare and controlling vessels causing delayed menstruation and infertility.

For this type of atypical, thin PCOS patient, modern medicine believes the mechanism is as follows:

Causal mechanisms of chronic psychological stress and increased sympathetic tone in PCOS (polycystic ovary syndrome)

2. Medication Analysis: 

Based on the aforementioned causes and pathomechanism, I often use variants of Four Agents Decoction, Chinese Angelica and Peony Powder, Free Wanderer Powder, Right-Restoring Pill, and Spleen-Returning Decoction in the follicular phase. In this case, I used bupleurum to course the liver, resolve depression, and regulate menstruation; Chinese angelica to nourish and quicken blood; white peony to nourish blood, emolliate the liver, relax tension, and relieve pain; poria and white atractylodes to fortify the spleen and quiet the spirit; cooked rehmannia to supplement the kidneys and replenish essence; dioscorea to fortify the spleen and supplement the kidneys; eucommia and cinnamon bark to warm the kidneys, reinforce yang, and warm the thoroughfare and controlling vessels; cyperus to course the liver, regulate qi, regulate menstruation, and relieve pain; flowery knotweed stem to quiet the heart and spirit and promote sleep; and licorice to harmonize the various medicinals. In summary, these medicinals course the liver, fortify the spleen, and warm and nourish the kidney essence. Studies have shown that Four Agents Decoction [1] and Chinese Angelica and Peony Powder [2,3] can improve ovarian function. Essence and blood are mutually transformed and generated. For example, in dual vacuity of the spleen and kidneys, the root of later heaven is depleted. Over time, the source of qi and blood formation will be insufficient, and the blood will not be able to transform into essence, resulting in insufficient kidney essence of earlier heaven, dual vacuity of the spleen and kidneys, depletion of the controlling vessel, and delayed menstruation. Therefore, Spleen-Returning Decoction combined with Right-Restoring Pill and other yang-supplementing medicinals can warm and supplement the spleen and kidneys [4] [5]. In addition, during the follicular phase, I use medicinals such as ligustrum, cuscuta, rubus, lycium, eclipta, morinda, and cistanche to improve egg quality and promote follicular development. When inducing ovulation, I like to use medicinals that quicken the blood and transform stasis, such as salvia, carthamus, leonurus, and achyranthes, to improve blood circulation in the pelvic cavity. For patients with uterine cold and insufficient kidney yang, such as the patient in this case, I increase the amount of warm-natured medicinals such as fennel and cinnamon, and add a small amount of aconite to warm the uterus to promote ovulation. After ovulation, using medicinals such as dipsacus, eucommia, chuanxiong, cistanche, epimedium, morinda, astragalus, and ligustrum promotes corpus luteum development and prolongs its lifespan. This patient suffers from congenital weakness, so Spleen-Returning Decoction is used to fortify the spleen, supporting the kidney qi of earlier heaven with spleen qi of later heaven.

3. Key Acupuncture Point Selection Analysis

Regulating the controlling, governing, thoroughfare, and girdling vessels is crucial in gynecological disorders. Therefore, Pass Head [CV-04] on the controlling vessel, Qi Thoroughfare [ST-30] on the thoroughfare vessel, and Life Gate [GV-04] and Dai meridian points on the governing vessel are often used. Qi Thoroughfare [ST-30] is the confluence point of the thoroughfare vessel and stomach channel. Sea of Qi [CV-06], Pass Head [CV-04], and Central Pole [CV-03] on the controlling vessel have the effects of supplementing original qi, warming the kidneys and invigorating yang, securing essence, and regulating the thoroughfare and controlling vessels. The selection of other points is mostly determined by pattern identification, such as Leg Three Li [ST-36], which fortifies the spleen, supplements qi, and helps with movement and transformation; Liver Transport [BL-18] and Spleen Transport [BL-20], which course the liver, fortify the spleen, and regulate qi and blood; Union Valley [LI-04] and Supreme Surge [LV-03], which regulate emotions and help ovulation; and Spirit Gate [HT-07] and Great Ravine [KI-03], which quiet and stabilize the heart and kidneys, and help with sleep. Three Yin Intersection [SP-06] is the confluence point of the 3 yin channels of the foot (liver, spleen, and kidney), and is connected to the controlling, thoroughfare, and governing vessels and the uterus through the channels and network vessels. It can simultaneously treat diseases of 6 channels, namely the spleen, kidney, and liver channels, as well as the controlling, thoroughfare, and governing vessels; it also has the effect of regulating the thoroughfare and controlling vessels, and nourishing the liver and kidneys. It is the first choice point for treating women’s menstruation, leukorrhea, pregnancy, childbirth, and related thoroughfare and controlling vessel diseases. Studies have shown that acupuncture at Earth’s Crux [SP-08], Great Manifestation [KI-12], Central Pole [CV-03], Three Yin Intersection [SP-06], Leg Three Li [ST-36], and Sea of Blood [SP-10] can improve corpus luteum function, increase progesterone secretion, and increase the likelihood of conception [6]. There are also studies that show that electroacupuncture at Celestial Pivot [ST-25], Return [ST-29], Sea of Qi [CV-06], Central Pole [CV-03], Three Yin Intersection [SP-06], Supreme Surge [LV-03], Inner Pass [PC-06], and Hundred Convergences [GV-20] can significantly improve the blood LH, FSH, and E2 levels of patients compared with the placebo group (P < 0.05), with a high ovulation rate. The ovulation rate of the treatment group reached 59.4%, which was higher than the placebo rate of 19.8%. The conclusion is that acupuncture can significantly increase the ovulation rate of PCOS patients and improve their reproductive function [7]. Depending on what patients need, I use electroacupuncture about 5 days before ovulation to enhance the momentum for ovulation. However, the patient in this case did not like electroacupuncture stimulation because it made her nervous, so electroacupuncture was not used. Although there were signs of ovulation in the early stage (such as biphasic body temperature), they were not stable. In the following months, the patient gradually relaxed and accepted electroacupuncture. I also believe that Chinese medicinals combined with acupuncture treatment is more helpful to patients than Chinese medicinals or acupuncture alone [8]. Sang Haili’s research has shown that comprehensive Chinese medicine therapy can regulate the function of the hypothalamus-pituitary-ovarian axis, induce LH peaks, and lead to ovulation[9].

IV. Experience

The latest progress in laboratory and clinical research on acupuncture for PCOS has benefited greatly from the review by Yang Ye et al. [10]. As described in the review, polycystic ovary syndrome (PCOS) is a common endocrine metabolic disease in women of childbearing age. Current standard treatments include lifestyle changes, oral medications, and surgical treatment. However, the efficacy of these therapies is currently unsatisfactory. Clinical evidence shows that acupuncture can effectively regulate hormone levels, promote ovulation, and reduce insulin resistance in PCOS patients. Acupuncture may affect the production of β-endorphin, which in turn leads to the secretion of gonadotropin-releasing hormone, thereby affecting ovulation, the menstrual cycle, and fertility.

PCOS patients are often seen in our TCM clinic, and most of them have typical symptoms and signs, such as obesity, irregular menstruation or amenorrhea, and increased body hair around the face and lips. However, PCOS patients are not necessarily overweight. Furthermore, fluctuations in basal body temperature during the menstrual cycle not only reflect a patient’s hormone levels, but can also be used to assess the yin and yang of the kidneys. The absence of a biphasic temperature shift indicates an imbalance in the rise and fall of yin and yang in the kidneys, leading to an abnormal dynamic balance. A chronically low body temperature indicates weakness of kidney yang, with debilitated life gate fire that is unable to warm spleen yang. The vacuous spleen is unable to generate qi and blood, leading to qi and blood depletion and emptiness of the thoroughfare and controlling vessels. We should use basal body temperature as an objective indicator to help guide the diagnosis and treatment of menstrual disorders. In addition to traditional Chinese medicine pattern identification, incorporating and applying modern research findings into the selection of medicinals and acupuncture points can help us prioritize and target our approach. It can also help patients understand the scientific basis of our treatments and boost their confidence. This case, after over 6 months of TCM treatment without the use of Western medication, must have improved ovarian function. Because of the successful conception, the patient did not undergo scheduled Western medical tests such as ultrasound and blood tests.

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