Premature Ovarian Failure (POF) is the loss of ovarian function before the age of 40. Hormonally, it is defined by abnormally low levels of estrogen and high levels of FSH, demonstrating that the ovaries are no longer responsive to circulating FSH, do not produce estrogen, nor do they develop fertile eggs. The ovaries tend to be atrophied.
Premature ovarian failure falls within the scope of “ovarian induced amenorrhoea”, where menstruation has ceased during the normal reproductive years. From the Chinese medicine perspective, it is described as “cessation of menstruation due to the exhaustion of blood”.
P xx 31 years old
She first consulted Professor Xu on 21st October 2011.
Chief complaint: Cessation of menstruation for six months; tidal fever, sweating and vaginal dryness for ten months. Her menstruation cycle was 28-29 days with 5 days of menstrual flow. The flow was heavy with clots, pain, nausea, vomiting and diarrhoea. In 2009 she was diagnosed by a Beijing hospital with adenomyosis and uterine fibroids. Subsequently, from January to May in 2010, she was given Gossypol Acetic Acid tablets with potassium chloride. In August 2010 she complained of tidal fever, hot flushes and sweating, and her medication was changed to Estradiol acid and Dydrogesterone tables for one course of treatment. In March and April 2011 she menstruated twice. There was no pain but the menstrual flow was scant. After that she did not menstruate for six months.
History: Since her marriage she conceived five times but only one conception proceeded to an established pregnancy, which ended in miscarriage.
Current S/S: Hot flushes, copious spontaneous sweating every 30 minutes accompanied by a flushed face, vaginal dryness, genital itch, painful intercourse, hair loss, joint pain, heart vexation, fright, insomnia, dry mouth and thirst, a pale and dull tongue with a thin, white tongue coat, and a wiry, thready and slippery pulse. She was very depressed.
Supplementary tests in October 2011
FSH: 60 IU/ml; LH: 33.94 ml/IUml; E2 : 4.58 pg/ml; Progesterone: 0.31 ng/ml; Prolactin (PRL): 5.65 ng/ml; Testosterone: 11.99 ng/ml.
Chinese Medicine diagnosis: Cessation of menstruation due to blood exhaustion.
Treatment: Nourish yin and clear heat, tonify liver and kidneys.
Prescription: Sheng Mu Li ; Fu Xiao Mai; Shou Wu Teng ; Zhen Zhu Mu. Xu Duan ;Sang Ji Sheng, Ji Xue Teng 30g each; He Huan Pi, Yu Jin, Bie Jia, Qing Hao 10g each; Bai He, Fu Ling, Nu Zhen Zi 20g; each; Tu Si Zi 30g, Lian Zi Xin 3g. 14 packs.
Analysis: The patient was diagnosed with adenomyosis and uterine fibroids. The pathogenesis was liver constraint with qi stagnation and blood stasis causing abdominal mass (zhen jia). The Western medication she was prescribed caused amenorrhoea. The Western medication Gossypol Acetic Acid can be considered to introduce toxic heat into the body, damaging essence blood and thus causing menstruation to cease. Damage to the kidney water with the subsequent inability to nourish liver blood will result in vaginal dryness, genital itch, and painful intercourse. The lower jiao kidney deficiency means that the kidneys fail to interact with the heart, resulting in hyperactive heart fire – hence the hot flushes.
Sheng Mu Li and Fu Xiao Mai sedate and calm the heart shen, clear heat, restrain the yang, secure the exterior and stop the spontaneous sweating, as well as dissipating the bind and augmenting qi; Xu Duan, Sang Ji Sheng enter the liver and kidney channels, augment the kidney and nourish yin; Ji Xue Teng, Bai He, Qing Hao, Yu Jin nourish and invigorate blood; Bie Jia nourishes yin, sedates the yang, dissipates bind and clears heat; Fu Ling augments the spleen and calms the heart; Shou Wu Teng, Zhen Zhu Mu sedate and calm the shen. The combined effect of this formula is to clear heat, calm the shen, nourish yin and blood, dissipate the bind and relieve the constraint.
Second consultation: 4th November 2011
After two weeks of that formula, her hot flushes and sweating decreased in frequency, occurring approximately once every 5-6 hours. The vagina was less dry with an increase in vaginal discharge, but she still suffered from lower back pain, joint pain and insomnia. Her tongue was pale and dull with a thin, white tongue coat and her pulse was submerged, wiry and thready. Her BBT was single phase. Ultrasound: Uterus: 4cm x 4.3cm x 3.7 cm; Endometrial thickness: 0.5cm; Right ovary 1.4cm x 1.0cm; Left overy 1.7cm x 0.9cm. No follicles were visible suggesting ovarian atrophy.
Prescription: Sheng Mu Li, Fu Xiao Mai, Sang Ji Sheng, Shou Wu Teng, Zhen Zhu Mu, Xu Duan, Ji Xua Teng 30g; each; He Huan Pi, Du Zhong Tan, Qing Hao, Dan Dou Chi, Yu Jin 10g each; LIan Zi Xin 3g. Tu Si Zi 15g, Bai He, Nu Zhen Zi 20g each.
After two weeks of this formula, she continued to improve. There were fewer hot flushes and sweating but she still suffered from joint pain, heart vexation and insomnia. Bie Jia and Fu Ling were omitted, and Dan Dou Chi, Du Zhong Tan were added to strengthen the formula’s action of tonifying kidney qi, and to support the health of the back and knees, as well as clear constrained liver heat.
At each subsequent consultation the patient reported continued improvement, and after taking Chinese medicine for three months her BBT was elevated for two consecutive days with an increase in translucent vaginal discharge. There were no hot flushes. From January to February 2012 the patient menstruated twice: once on the 26th January and again on 23rd February 2012. On 15th May 2012 it was confirmed that she was pregnant. Subsequently on 28th September 2012 when she was 27 weeks into the pregnancy she visited Professor Xu to to express her thanks.
Blood exhaustion was first discussed in Suwen: Fu Zhong Lun Pian: “…blood exhaustion can be attributed to extensive haemorrhage or intercourse when drunk which can exhaust the qi and damage to the liver. Hence there is no menstruation…treat with four parts of Wu Zei Gu (Hai Piao Xiao) and two parts of Lu Ru (Qian Cao) pill.” It can be seen that the pathogenesis of premature ovarian failure can be ascribed to haemorrhage, damage to essence and liver constraint resulting in damage to the liver and kidneys. In the above case study multiple miscarriages had caused damage to the Chong and Ren (penetrating and conception) vessels and also damaged the kidney qi; constrained liver qi further obstructed to the normal flow of qi and blood in the Chong and Ren (penetrating and conception) vessels. This eventually led to blood stagnation and blood stasis forming abdominal mass. Professor Xu’s clinical approach to this is to clear heat, nourish yin, and regulate and tonify the liver and kidneys in order to enhance the movement of qi and blood.
Compiled and Translated by Dr. Greta Young Jie De
COURSES WITH PROFESSOR XU XIN
Health World Pearls 2014 – Infertility and Gynaecological Disorders