Case 13: Uterine Fibroids

Female, 32 years old.2010 April 12, Initial Visit:

General Appearance: medium build, robust; whitish skin color; slightly dusky-red face; dusky-purple lips; eyes had spirit.

Relevant Medical History: She has experienced frequent bouts of insomnia for the last several months; she was a light sleeper who wakes early and has a few dreams. Her eyes were dry and rough; she feels a pulling-discomfort [from the eyes] to the back of her head. Her appetite was fair; urination and defecation were regular. Her menstrual cycles were regular; she experiences premenstrual breast distention. She reports the presence of uterine fibroids.

Physical Examination: her tongue was dusky; her pulse was deep, wiry, and forceful.

Formula: jiāng bàn xià 15g, fú líng 15g, hòu pò 15g, zi sū gěng 15g, chái hú 15g, bái sháo 15g, zhǐ ke 15g, zhì gān cǎo 5g, gān jiāng 5g, hóng zǎo 15g; dispense 10 bags total; take 5 bags per week.

2010 April 26, Second Visit:

After taking the formula, her sleep improved; the dryness and roughness of her eyes disappeared. Her pulse was deep and wiry. She was to continue taking the original formula for 15 bags; when filling the formula[1], its composition was not to be changed, but both the cooking and dosing could be adjusted. When not experiencing symptoms, the dosage could be decreased or the formula could be discontinued, and then she should return for another visit.

[1]: in China, patients have a bìnglì, which is a book they bring to doctor visits containing all of the prescriptions they have had. Patients commonly fill their own formulas. Here, Dr. Huang is indicating that the person filling the formula should not adjust the formula.

2011 May 31, Third Visit:

After taking the formula, sleep had been normal for 1 year. Now she is seeking treatment for uterine fibroids. Like before, sleep had not been very good for nearly the past half of the month. She has occasional soreness and discomfort in the lumbosacral region. If she catches a chill, she will have diarrhea. Premenstrually her breasts visibly swell. In 2009 April, a uterine fibroid was discovered; ultrasound indicated its size was about 0.9 cm x 0.7 cm. She took Chinese medicines for about one year, but she has not seen a reduction [in its size]. On 2010 June 14, a repeat ultrasound indicated the uterine fibroid was 2.0 cm x 1.8 cm.

Formula: chái hú 15g, bái sháo 15g, zhǐ ke 15g, shēng gān cǎo 5g, dāng guī 10g, chuān xiōng 15g, fú líng 15g, bái zhú 15g, zé xiē 15g, jīng jiè 10g, fáng fēng 15g, bàn xià 15g, gān jiāng 10g, hóng zǎo 20g; dispense 15 bags total; take 5 bags every week.

2011 July 5, Fourth Visit:

Her complexion was ok and had luster. After taking the formula, she felt her body's condition improved; she had not experienced diarrhea since; the soreness of the lumbosacral region decreased; the premenstrual breast distention improved, but her left breast occasionally felt hot. Her menstrual cycle was 28 days, and her last period was on July 1st and lasted 6 days. Her tongue body was slightly purple. 

Formula: Original formula, and add dǎng shēn 10g; dispense 15 bags; take 5 bags every week.

2011 August 13, Fifth Visit: After taking the formula, her complexion improved; her food intake and sleep were good; her urination and defecation were normal. Her last period was on July 29; she did not experience premenstrual breast distention; her period was easy.

Formula: Formula from May 31, but remove jīng jiè; dispense 15 bags; take 1 bag every other day.

2011 September 5, Sixth Visit: An ultrasound was performed earlier in the day: her uterus and surrounding [structures] were without abnormalities. The uterine morphology was normal; its outline was smooth. [The ultrasound] indicated the original uterine fibroid had disappeared. Everything seemed fine. [She was instructed to] continue the formula, taking 2 bags every week.

Case Notes: (1) The patient's constitutional type is Sì Nì Sǎn. However, first she sought help for sleep difficulties; later she sought help for uterine fibroids. So when considering a prescription, one needs to match the formula with the person, but one also needs to match the formula with the illness.
(2) Doctor Huáng has said the following: "As for uterine fibroids, there are hot, or cold; deficient, or excess. They certainly cannot only be an issue of stasis. Furthermore, whenever blood or qi condense and then take form, you will want to disperse it, which is also extraordinarily difficult." A patient [who presents with] "a partially dusky complexion, lips, and tongue; dry and rough eyes; lumbosacral pain; and occasional tendency to experience diarrhea" has a Dāng Guī Sháo Yào Sǎn pattern.
(3) Initially, the emphasis was on regulating the Heart-Spirit when treating insomnia by giving Jiě Yù Tāng, which reduces psychological pressure. Later, the emphasis was on treating the body [rather than the spirit] when treating uterine fibroids by giving Jīng Fáng Sì Nì Sàn combined with Dāng Guī Sháo Yào Sǎn.

Case 14: Polycystic Ovarian Syndrome (PCOS), #1

Female, 18 years old; a student. 2011 July 19, Initial Visit:

General Appearance: rotund; white skin, but areas with dark patches; dusky-red acne lesions of non-uniform size over her face and back; weighed 62 kg (137 lbs).

Chief Complaint: irregular menses for over 4 years.

Medical History: Ever since menarche at 14 years old, menses have not been regular; she would 1 period every 2 to 3 months; she had not tried to treat it. Originally she was slim. Two years ago she went to the United States to attend school, and her weight rose about 7.5 kg (16.5 lbs); every 2 months she received progesterone injections, and immediately menses would follow. In the past 6 months, she has not used progesterone; instead she changed to Diane-35 [cyproterone - ethinyl estradiol] (until July when she discontinued it), and afterward menses would still occur. A 2008 test indicated testosterone was slightly high, but a gynecologic ultrasound found no abnormalities; she was diagnosed with PCOS. In June of this year, she returned to her home country; her last menstrual period was on July 1; she had slight dysmenorrhea, scanty flow with clots, and the menstrual discharge was a dusky color; she did not experience premenstrual breast distention.

She lacks strength, and experiences unexplained drowsiness. The palm of her hand tends to be warm; her feet perspire but not a lot; in winter, her buttocks and both legs are sensitive to cold. Her bowel movements are dry, hard, and difficult to pass; she has anal fissures. Her appetite and sleep are ok. She has no relevant family history.

Physical Examination: Abdomen not tender to palpation; red yet dry tongue body; white and greasy tongue fur; slightly distended sublingual veins.

Formula: má huáng 10g, gé gēn 30g, guì zhī 15g, chì sháo 15g, gān cǎo 5g, mǔ dān pí 15g, táo rén 15g, fú líng 15g, huái niú xī 30g, zhì dà huáng 15g, gān jiāng 5g, hóng zǎo 20g; dispense 15 bags; take 1 bag every other day after meals.

Doctor's instructions: decrease raw, cold food consumption.

2011 August 15, Second Visit: Her period began on August 20 and lasted 7 days; she experienced slight dysmenorrhea; the menstrual flow color was brighter than before, but she still had clots. Her weight decreased by 2 kg (4.4 lbs); her skin became lustrous, and the scattered wounds on both her cheeks faded a little; the acne on her back disappeared. Her defecation was unobstructed. Her tongue body was red, and its fur was thin greasy; her sublingual veins were slightly distended.

Formula: Original formula; dispense 15 bags; take 1 bag every other day.

Additional advice: increase physical exercise to the point of moderate perspiration.

2011 October 8, Third Visit: She recently stopped taking the medicine. During the period when she was taking the medicine, the frequency of her bowel movements increased. At night, she had difficulty going to sleep; during the daytime she was full of vitality. Her last menstrual period was on 2011 Sept 6; the flow was scanty and lasted for 4 days. Recently her weight has not been changing; her lesser abdomen was slightly painful. She felt her breasts swell premenstrually. Her tongue tip was red.

Formula: Original formula; dispense 15 bags; take 1 bag every other day.

2011 November 29, Fourth Visit (Her mother provided this update): For the last 3 months, her periods were late by 7 to 10 days; she was nearly without dysmenorrhea; her menstrual flow color was red, and the amount had become copious. Her facial acne had faded by quite a bit, but she retained a small amount acne scars. Her weight had not changed noticeably. The remainder [of her symptoms were] all regulated.

Formula: Original formula; dispense 15 bags; take 1 dose every day after breakfast, but after taking for 5 days, stop for 2 days.

2012 April 14, Fifth Visit: Currently, her periods occur every 40 days and last for about 7 days; in total, her weight decreased by 5 kilograms; her tongue fur was thick.

Formula: Remain on formula; dispense 15 bags; take 1 bag after meals every other day.

Case 15: Polycystic Ovarian Syndrome (PCOS), #2

Female, 23 years old, married; a nurse. 2011 September 4, First Visit:

General Appearance: slightly ample, medium build; yellow skin, red face; height 158 cm (5 ft 2.2 in), weight 50 kg (110 lbs).

Relevant Medical History: Upon a physical examination 6 months ago, an abnormal blood glucose level was discovered; she uses metformin 0.5g daily and insulin 8U every other day. Soon afterward an unusual thyroid function arose; first she experienced hyperthyroidism, and later she experienced hypothyroidism; she takes Letrox (levothyroxine sodium) 50μg daily. She has not had a period in the last 4 months; after undergoing an examination, she was diagnosed with PCOS. She ordinarily tends toward having diarrhea; her sleep is poor, and her appetite is fair. Recently, she has maintained her blood glucose at about 8 mmol/L. In childhood, she was prone to tonsilitis. There is no family history of endocrine system illnesses.

Physical Examination: muscles were solid; tongue was light red, and fur was yellow and greasy; pulse was slippery.

Formula: huáng lián 10g, huáng qín 10g, gé gēn 60g, gān cǎo 5g, ròu guì 10g; dispense 15 bags; take 1 bag every day

2011 Sept 15, Second Visit (Intake taken by Lǐ Xiǎo-Róng): Her blood glucose decreased to 7 mmol/L; her doctor advised reducing her every-other-day insulin dosage from 8U to 7U. She has not had a period yet. Her face was red, and her mouth was dry; she easily perspires; her appetite was fair, but her sleep was poor; bowel movements were formed. Her limbs were cold, and her abdominal muscles were tight. There were clearly signs of uncomfortable fullness in the chest and hypochondriac areas; her tongue was light red, and its fur was greasy; her pulse was wiry.

Formula: Dà Chái Hú Tāng combined with Guì Zhī Fú Líng Wán; dispense 7 bags.

2011 October 6, Third Visit: Her period had still not arrived; her face was red; her pulse was slippery.

Formula: má huáng 5g, gān cǎo 5g, jié gěng 10g, shí gāo 30g, jīng jiè 15g, fáng fēng 15g, prepared dà huáng 5g, dāng guī 10g, chuān xiōng 15g, bái sháo 15g, cāng zhú 10g, bò hé 10g, zhī zǐ 10g; Dispense 15 bags; take 1 bag every other day.

2011 November 4, Fourth Visit: On November 1, her menses came; the flow color was dark with clots, and the volume was moderate. She experienced premenstrual breast distention. Her tongue was pale red, and the fur was greasy and slippery. She had abundant hair below her navel. She was taking insulin 7U every other day; her Letrox and metformin dosages were unchanged.

Formula: above formula, and increase prepared dà huáng by 10g; dispense 15 bags; take 1 bag every other day.

2011 December 18, Fifth Visit: After a reexamination of her thyroid function last month, the Letrox dosage increased. After taking the medicine, her weight rose by 1.5 kg. Her period started on December 14; the flow was scant, and its color was brown. Her body hair has become considerable, with more hair below her navel as well as on her legs. Her appetite and sleep were air; her bowel movements were unobstructed. Her tongue was light red, and the fur was thin yet dry. 

Formula: Above formula, and increase má huáng to 15g; dispense 20 bags; take 5 bags after meals every week.

2012 February 16, Sixth Visit (Intake taken by Lǐ Xiǎo-Róng): She has not had a period for 2 months. Her insulin dosage was increased to 10U, and after 2 days, her blood glucose control was ideal; her metformin Letrox dosages were unchanged. Since New Year’s Day, she had been afflicted with Bell's Palsy; she had a left-sided facial paralysis; it was managed with combined Chinese and Western Medical Treatments, and the condition improved. However, after applying a medical plaster, she had an allergic reaction on her left cheek, so there was redness, swelling, and pruritus. He had raised pustules on her anterior chest; she had abdominal distention and dry bowel movements.

Formula: Dà Chái Hú Tāng combined with Guì Zhī Fú Líng Wán; dispense 9 bags; take 1 bag every day.

2012 February 26, Seventh Visit: She had many red and shiny pustules over her entire face. She had not had a period yet, but she feels her breasts were swelling. She has bilateral pressure pains in her lesser abdomen.

Formula: dà huáng 10g, máng xiāo 6g, gān cǎo 5g, guì zhī 20g, táo rén 20g; dispense 9 bags; take for 3 days and stop 2 for days.

2012 March 14, Eighth Visit (Intake taken by Lǐ Xiǎo-Róng): She has not had a period in 3 months; her breasts were distended and painful. Her appetite and sleep were ok; bowel movements tended to be watery. Her tongue was light red, and the fur was greasy and moist; her pulse was wiry and had strength. Her abdominal musculature was tight; her hands were cold.

Formula: chái hú 12g, bái sháo 12g, zhǐ ké 12g, gān cǎo 3g, dāng guī 12g, chuān xiōng 12g, cāng zhú 12g, fú líng 12g, zé xiè 12g, bò hé 6g, má huáng 9g, xìng rén 6g, yì yǐ rén 18g; dispense 7 bags.

2012 March 21, Ninth Visit (Intake taken by Lǐ Xiǎo-Róng): Her last menstrual period was on March 18; the amount was relatively scant, and the color was dusky-red; menstruation was rather easy. Her appetite was reduced; her bowel movements tended to be dry; she had 1 bowel movement every 2 days. Her sleep was ok.  Her hands and feet were cold.

Formula: chái hú 12g, bái sháo 12g, zhǐ ké 12g, gān cǎo 3g, nǚ zhēn zǐ 15g, mò hàn lián 15g, unprocessed mài yá 20g; dispense 7 bags.

2012 April 25, Tenth Visit: She was taking metformin 1.5g daily; Letrox 1 tablet 50μg daily; insulin 6U every other day. Her blood glucose level was stable. Her bowel movements were watery, and she has 1 bowel movement daily. Her breasts were distended and painful. Her complexion was dusky-red; her tongue tip was red, and the fur was white and greasy. Her hands were cool. She was not using any contraception. Her blood HCG was being regularly monitored, and ultrasounds were used to diagnose pregnancy. [The patient] inquired about whether the Chinese medicinals that she was taking would negatively affect a fetus. She was told that taking the Chinese medicinals was safe, and that she need not worry.

Postscript: Telephone follow-up on September 17: The patient was pregnant without any hitches. She regularly goes to work, and for the time being she feels pretty good. She continues to use Western medicines like insulin and Letrox.

Case notes
(1) The degree of difficultly in treating PCOS is unusually great, and the success rates are relatively low. In the long-term, there needs to be continual adjustments to things like avoiding raw food, controlling food and drink, and increasing the exercise-type way of life. It is important that he patient has confidence in the work being done.
(2) In this case, using metformin helped with the insulin resistance. The patient's fundamental constitution was chái hú. Over time, after falling ill as well as receiving medical interventions, how could she became a má huáng- type? Clinically, [the má huáng-type can be seen] above in her appetite hyperfunction, weight increase, body hair density, saltwater retention, and changed ovary structure. Má huáng can reduce appetite and activate sweating; it also activates ovary-type functions, exocrine glands, and endocrine glands. Má huáng regulates the functional state of this disorder.
(3) This case illustrates that body constitution, although relatively stable, can be covered by layers, which are mutable. How can we clinicians approach these cases?