The term polycystic—or better: polyfollicular—ovaries refers to ovaries that contain 10 or more immature follicles with a maximum 9 mm diameter and whose central connective tissue is increased.

Under ultrasound, multiple antral follicles—without a dominant follicle—and, as a whole, clearly enlarged ovaries are detected. The follicles fail to mature into a tertiary follicle ready for ovulation. Ovulation fails to take place and menstrual periods are accordingly irregular or absent.

The so-called PCO syndrome (PCOS) includes several symptoms, among which hyperandrogenism (increase of male sex hormones) is the obligatory key symptom. The source of the androgens can be the ovaries themselves or the adrenal cortex. The consecutive disturbance in follicular maturation is an important cause of unwanted childlessness and absent menstruation.

Potential findings in PCOS:

• menstrual disorders (absent or rare menstrual periods)
  
• increased body hair in a typical male pattern (hirsutism)
  
• obesity
  
• sterility
  
• changes in the fat and carbohydrate metabolism (insulin resistance)
  
• acne
  
• hair loss

What appear to be polycystically changed ovaries are encountered in many young women (20–25%). Among these, however, only a relatively small percentage develops a true PCO syndrome. Nevertheless, the practitioner will often be confronted with this syndrome in fertility treatment. Elevated levels of androgen—the key symptom of PCOS—are found in almost all patients.

Different hormonal (obesity) and cellular regulatory disturbances (androgen receptor polymorphism), which we are unable to discuses in detail here, form the basis of PCOS. To summarize, we can state that the proper cooperation of hypothalamus, hypophysis, and ovaries—as the so-called axis of reproduction—is disturbed. Follicular maturation is impaired, which is due to insulin resistance in the follicle and increased production of androgens.

Especially in obesity (i. e., in an increase of visceral fat tissue), elevated ovarian, as well as more rarely adrenal, production of androgen can result—discernible by an obvious “masculinization” with regard to the distribution of body fat and hair; this can be compounded by a diabetic metabolism.

As the first step, the pituitary gland and ovarian functions are temporarily suppressed by means of oral ovulatory inhibitors, that is, the “pill.” In this context, antiandrogen progestagens are preferred. The excess weight must be reduced in order to lower the elevated estrogen levels and therefore also the rise in LH secretion that was caused by the increase in fat tissue. In patients with a diabetic metabolism, oral anti-diabetic drugs can be prescribed as well, to lower insulin resistance. This covers the treatment of PCOS; to additionally assist in the promotion of fertility, the following are indicated:

Ovarian overstimulation syndrome and an undesired multiple pregnancy are a risk of these therapies, which should only be employed by experienced professionals.

The ovarian stimulation desired in the framework of these biomedical concepts must be distinguished from an overstimulation syndrome. This rare but serious complication can vary in its manifestation—from mildly affected well-being to a life-threatening clinical picture. The pathogenesis of overstimulation syndrome is still unclear; it involves a massive increase in vessel permeability. This leads to the formation of edemas, ascites, and pleural and pericardial effusions. We can also see a thickening of the blood with an increased hematocrit and the risk of thromboembolic complications.

From the perspective of TCM, we can describe PCOS in terms of root vacuity (ben xu) and tip repletion (biao shi).

The kidneys are responsible for reproductivity. Most patients with infertility suffer from kidney vacuity. According to TCM, the kidneys store essence (jing); essence and blood (xue) share the same source. A lack of essence and blood impairs the functions of the extraordinary vessels chong mai and ren mai; under these conditions, it is difficult to become pregnant. Kidney vacuity hence forms the basis, whence phlegm-dampness repletion, fire resulting from liver qi stagnation, or qi stagnation with blood stasis follow and facilitate each other.

Affected organs are the liver, spleen, and kidneys; the disturbance manifests in the chong mai and ren mai. We differentiate the following four patterns:

• kidney vacuity
  
• phlegm-damp
  
• liver fire
  
• qi stagnation with blood stasis

Treatment focuses primarily on replenishing kidney vacuity. To complement this, we can choose to:

• strengthen the function of the spleen, to regulate qi and transform phlegm
  
• soothe liver qi, to resolve stagnation and reduce fire
  
• quicken the blood, to resolve the stasis and regulate menstruation

Both the treatment principle and the choice of medicinals follow this pattern differentiation in accordance with the presenting pathology.

The goal of treatment is always to regulate menstruation and thereby harmonize the interplay of kidneys—tian gui—chong mai and ren mai—uterus. In this way, we can effectively treat an existing infertility.

Expressed in biomedical terms, a regular menstrual cycle stems from the correct cooperation of hypothalamus, hypophysis, and the ovaries. To regulate menstruation means here to regulate this connection (axis of reproduction).

The following section describes the four above-mentioned patterns in more detail, including their symptoms and the corresponding treatment principles. Basic formulas and modifications follow. Complementing this, we give acupuncture points that can accompany treatment with Chinese medicinals. Treatment with the Chinese patent medicines that are also listed here should be regarded as an alternative to the recommended formulas. Because in this case the practitioner has no way of influencing the dosage of individual ingredients in relation to each other, the possibilities for tailoring treatment to the particular condition of individual patients are limited.

• delayed menstruation, brightly colored blood, or amenorrhea
  
• infertility
  
• tinnitus
  
• pain in the lower back
  
• cold sensations
  
• polyuria
  
• soft stools
  
• reduced libido
  
• overweight

Tongue: pale, with a thin white fur

Pulse: fine, sunken

Nourish the kidney, replenish essence, regulate the chong mai and ren mai.

• BL-23 (shen shu): supplements the kidney, yang, essence and yin, warms the uterus
  
• GV-4 (ming men): supplements kidney yang and the ming men fire
  
• CV-6 (qi hai): supplements the kidney, yang, and qi, regulates qi and harmonizes the blood
  
• SP-6 (san yin jiao): supplements the kidney and harmonizes the liver, regulates menstruation, quickens blood, and stimulates the channels

• scant or delayed menstruation
  
• amenorrhea
  
• infertility
  
• leukorrhea
  
• dizziness, feeling of heaviness in the head
  
• feeling of pressure in the thorax
  
• nausea
  
• feeling of heaviness in the extremities
  
• soft stools
  
• obesity

Tongue: enlarged, white slimy fur

Pulse: slippery

Dissolve phlegm, transform dampness, regulate qi and menstruation.

Rx. Cang Fu Dao Tan Wan (Atractylodes and Cyperus Phlegm-abducting Pill):

___________

Modifications:

• For obesity and change in body hair (to dissolve phlegm and activate the network vessels):
  
  
  
  • shan ci gu (Cremastrae seu pleiones pseudobulbus), 10 g (beware: toxic!)
    
  • xia ku cao (Prunellae spica), 10 g
    
  • zao jia ci (Gleditsiae spina), 15 g
    
  • shi chang pu (Acori tatarinowii rhizoma), 10 g
  
  
• For masses in the lower abdomen (to soften hardenings and disperse accumulations):
  
  
  
  • kun bu (Laminariae/Eckloniae thallus), 15 g
    
  • hai zao (Sargassum), 15 g
    
  • xia ku cao, 10 g
    
  • e zhu (Curcumae rhizoma), 12 g

Patent Medicine

Qi Zhi Xiang Fu Wan (Sevenfold Processed Cyperus Pill): 6 g daily.

• CV-6 (qi hai): supplements the kidney, yang, and qi, regulates qi and harmonizes the blood
  
• SP-8 (di ji): regulates menstruation and quickens the blood
  
• ST-30 (qi chong): regulates the chong mai and qi in the lower burner
  
• SP-6 (san yin jiao): supplements the kidney and harmonizes the liver, regulates menstruation, quickens the blood, and stimulates the channels

• amenorrhea
  
• scant or irregular menstruation
  
• infertility
  
• muscle growth
  
• increased or thick hair
  
• facial acne
  
• feeling of tension or pain in the thorax, hypochondrium, or breasts
  
• galactorrhea
  
• dry mouth, desire to drink water
  
• constipation

Tongue: yellow, thin fur

Pulse: rapid and tight

Soothe liver qi and clear heat, to reduce fire.

Rx. Dan Zhi Xiao Yao San (Moutan and Gardenia Free Wanderer Powder)—Modification for the Treatment of Infertility in PCOS:

• mu dan pi (Moutan cortex), 10 g
  
• zhi zi (Gardeniae fructus), 10 g
  
• dang gui, 10 g
  
• bai shao yao (Paeoniae radix alba), 15 g
  
• chai hu (Bupleuri radix), 6 g
  
• bai zhu (Atractylodis macrocephalae rhizoma), 10 g
  
• gan cao, roasted, 5 g
  
• chuan niu xi, 10 g

Additional Modifications:

• for constipation:
  
  
  
  • da huang (Rhei radix et rhizome), 6 g, to clear heat, reduce fire, and support bowel movement
    
  • mai ya (Hordei fructus germinatus), roasted, 60 g
    
  • ku ding cha (Ilicis folium), 10 g
  
  
• For tension pain in the thorax, hypochondrium, or breasts (to soothe liver qi and free the network vessels):
  
  
  
  • yu jin (Curcumae radix), 15 g
    
  • wang bu liu xing (Vaccariae semen), 15 g
    
  • lu lu tong (Liquidambaris fructus), 10 g

Patent Medicine

Xiao Yao Wan (Free Wanderer Pill): 10 g, three times a day.

• LR-3 (tai chong): soothes liver qi, regulates menstruation, regulates the lower burner, nourishes liver blood and yin
  
• LI-4 (he gu): activates the channels, relaxes in combination with LR-3
  
• LR-2 (xing jian): clears liver fire, soothes liver qi, regulates the lower burner

• delayed, scant, or interrupted menstruation
  
• abdominal pain that is aggravated by pressure
  
• menstrual period with clots, pain that is relieved by discharge of clots
  
• amenorrhea
  
• infertility
  
• depression
  
• feeling of fullness in the thorax and hypochondrium

Tongue: crimson, with dark spots on the margin and tip

Pulse: sunken and tight

Regulate qi, quicken the blood, resolve stasis, regulate menstruation.

Rx. Ge Xia Zhu Yu Tang (Infradiaphragmatic Stasisexpelling Decoction)—Modification for the Treatment of Infertility in PCOS:

• dang gui, 10 g
  
• chuan xiong (Chuanxiong rhizom), 5 g
  
• chi shao yao (Paeoniae radix rubra), 10 g
  
• tao ren (Persicae semen), 10 g
  
• hong hua (Carthami flos), 6 g
  
• zhi ke, 10 g
  
• yan hu suo (Corydalis rhizoma), 10 g
  
• wu ling zhi (Trogopteri feces), 10 g
  
• mu dan pi, 10 g
  
• bai shao yao, 10 g
  
• xiang fu, 10 g
  
• gan cao, 5 g

Additional Modifications:

• For feeling of tension in the thorax or breasts, tension pain in the lower abdomen, depression, and PMS, to soothe liver qi, resolve stagnation, and activate qi, for pain relief:
  
  
  
  • qing pi (Citri reticulatae pericarpium viride), 10 g
    
  • mu xiang (Aucklandiae radix), 9 g
    
  • chai hu, 6 g
  
  
• for masses in the abdomen, to quicken blood, resolve stasis, and disperse masses:
  
  
  
  • san leng (Sparganii rhizoma), 10 g
    
  • e zhu, 10 g
    
  • mo yao (Myrrha), 10 g
    
  • lu lu tong, 10 g

Patent Medicine

Da Huang Zhe Chong Wan (Rhubarb and Ground Beetle Pill): one pill, two to three times a day in hot water or ginger decoction.

• LR-3 (tai chong): soothes liver qi, regulates menstruation, regulates the lower burner, nourishes liver blood and yin
  
• LI-4 (he gu): activates the channels, relaxes in combination with LR-3
  
• ST-30 (qi chong): regulates the chong mai and qi in the lower burner
  
• ST-29 (gui lai): regulates menstruation
  
• SP-10 (xue hai): moves blood and resolves stasis

Bibliography

1. Feige A, Rempen A, Würfel W, Caffier H, Jawny J. Frauenheilkunde. Munich: Urban & Schwarzenberg; 1997.
   
2. Lyttleton J. Treatment of Infertility with Chinese Medicine. London: Churchill Livingstone; 2004.
   
3. Zuo Y. Gynecology of Traditional Chinese Medicine. Shanghai: University of TCM Publishing House of Shanghai; 2002.