The American Acupuncturist Spring 2005
Premature Ovarian Failure (POF)
By Ray Rubio, LAc., ECTOM Doctoral Candidate
Premature Ovarian Failure – The Western Definition
Premature Ovarian Failure (POF) also referred to as Primary Ovarian Insufficiency (POI), and Premature Menopause, is defined as a decline and stop in the normal functioning of a woman’s ovaries before the age of 40. Signs and symptoms of POF may include irregular menses, amenorrhea (completely stopped periods), vaginal dryness, hot flashes, painful intercourse, and
|infertility. Approximately 1-4% (250,000) adult women under the age of 40 in the United States are diagnosed with POF1.|
Although western science has not been able to determine an exact cause if this disorder, it is associated with several other conditions such as: autoimmune diseases (Systemic Lupus, Rheumatoid Arthritis), genetic disorders (Turner’s Syndrome), surgical conditions (oopharectomies), radiation and chemotherapy, endocrine diseases (graves disease), blood disorders (thalasemia) and unexplained or unknown factors.
Because POF is related to a decline in the normal functioning of the ovaries, it is usually heralded by a series of hormonal events related to this. Whether due to follicle depletion (genetic absence or diminished number of ovarian follicles, or accelerated follicle atresia), or due to follicle dysfunction (enzyme deficiencies, autoimmunity, Lymphocytic oopharitis, signal defects, gene mutations, iatrogenic and idiopathic causes) – the end result is that there is a resulting lowering of the circulating levels of serum estradiol (estrogen) in the body resulting in the above mentioned signs and symptoms.
Because estradiol is one of the hormones produced by the ovaries under the prompting of the pituitary gland and follicle stimulating hormone (FSH) – when the hypothalamus detects the diminished levels of circulating serum estradiol, it will direct the pituitary to secrete greater and greater amounts of FSH in order to prompt the ovarian follicles to produce more estradiol. Therefore – elevated FSH levels (>30-40 mIU\mL on two occasions at least one month apart) and decreased estradiol levels (<20 mIU/mL), with amenorrhea lasting more than four months in a woman under the age of 40 – are the primary diagnostic criteria for POF.
Although there is no cure for POF in western medicine, treatment for this condition will encompass any related conditions or diseases and involve administration of hormone replacement therapy at higher doses than normal for a menopausal woman. This is to prevent some of the side effects and conditions associated with estrogen deficiency such as the night sweats, hot flushing, vaginal dryness, lowered energy and libido, and osteopenia.
Perhaps the most debilitating aspect of POF is the termination of a woman’s reproductive capacity. Although women with POF will occasionally spontaneously ovulate and menstruate, and therefore occasionally conceive, it occurs in less than 10% of women diagnosed with this disorder. For a working woman who has waited to begin a family due to career responsibilities, to then be diagnosed with POF is obviously devastating.
Premature Ovarian Failure-The Classical Traditional Chinese Medicine View
In Chapter 1 of the Huang Di Nei Jing Su Wen (Simple Questions), it says, “For a woman, her kidney energy becomes prosperous when she is seven, as kidney determines the condition of the bone, and teeth are the surplus of bone, her milk teeth fall of and the permanent teeth emerge when her kidney energy is prosperous. Also, as hair is the extension of blood and the blood is transformed from the kidney essence, her hair will grow when the kidney is prosperous.
Her tiangui – the substance necessary for the promotion of growth, development and reproductive function of the human body – appears at age 14 (2x7). At this time, her Ren Channel begins to flourish, and her Chong Channel becomes prosperous and her menses begin to appear. As all her physiological functions mature, she can become pregnant and bear a child.
The growth of the kidney energy reaches the normal status of an adult by the age of twenty-one (3x7), her wisdom teeth have matured, and the rest of her teeth are fully developed.
By the age of twenty-eight (4x7), her vital energy (Qi) and blood become substantial, her extremities become strong, the development of the tissues and hair of her whole body are flourishing, and the female body is at it’s apex of strength and health.
The physique of the woman begins a gradual decline at the age of thirty-five (5x7). By this time, her Yangming channel begins to deteriorate, her face becomes wrinkled, and her hair begins to fall out.
By the age of forty-two (6x7), her three yang channels (Taiyang, Yangming, and Shaoyang) all begin to decline. By this time, her facial complexion becomes wan, and her hair begins to turn white (grey).
After the age of forty-nine (7x7), her Ren and Chong channels both are declining, her menstruation ends, and her tiangui is exhausted. Her physique becomes older and weaker, and she can no longer conceive.”2
As we can see from this discourse in the Huang Di Nei Jing Su Wen, from the Traditional Chinese Medicine (TCM) point of view, a normal woman’s reproductive capacity should endure into her mid-to-late forties. At this time (age 49 or 7x7), there will be a natural cessation of the menses, and an end to the woman’s ability to procreate with the natural onset of menopause. Because the function of the female cycles of growth and development every seven years is under the control and governance of the Kidney Energy according to TCM, any dysfunction or deterioration of these seven-year-cycles – such as that in POF – must be related to a decline in the function of the Kidney Energy.
The Kidney Energy according to TCM theory involves yin, yang and essence. If any of these substances of the Kidneys are deficient, it may result in cessation of the menses, or problems with reproduction. Although the Ancient Chinese had no knowledge of modern medical science and theory at the time of the Yellow Emperor, they were astute observers of nature and the seasons of life. We now know that much of what the ancients were describing in the passage above from the Huang Di Nei Jing Su Wen was what is today attributed to the function of the hypothalamus-pituitary-ovarian axis.3 It is the interplay between the Chong, Ren, and Du Channels, as well as their circulation of the vital substances of the Kidneys (yin, yang and essence/jing), which controls the normal functioning female reproductive cycle.
When describing some of the signs and symptoms of POF, it is helpful to try to relate them to patterns of differential diagnosis in TCM so that we may in turn, seek a principle of treatment. The table below will illustrate this relationship:
Kidney Yin Deficiency
Night Sweats Hot Flushes Vaginal Dryness Irritability Infertility
Kidney Yang Deficiency
Low Libido Low Energy Infertility
Kidney Jing Deficiency
Anovulation Amenorrhea Osteopenia Infertility
The TCM Etiology of POF
According to TCM, disease is expressed as patterns of disharmony (bian zheng), such as Kidney Yin Deficiency, Kidney Yang Deficiency, and Kidney Essence Deficiency, etc. However, it is important not to confuse the pattern for the cause of the disharmony. TCM looks to the cause of disharmony in imbalance or intemperance in the person’s life; or, inherited weaknesses from the parents (genetics); or, emotional disturbances of a prolonged or excessive nature.
Some of the factors that may result in imbalance in the person’s life, and subsequently the development of disease or disharmony are: exposure to severe climate, or out-of-season climate; poor diet; excessive work or overexertion; trauma; poisonous chemicals or parasites; excessive sexual activity; and, wrong treatment (iatrogenesis).
How do emotions, constitution, and lifestyle imbalances relate to POF as causative factors? Firstly, we know that prolonged stress – emotional, work related, or otherwise – can lead to dysfunction of the hypothalamus and atrophy of the pituitary – both of which are vital to the proper functioning of the ovaries. Because stress stimulates the sympathetic nervous system, which in turn stimulates the adrenals to secrete adrenaline and cortisol in excessive amounts and inappropriate times, thereby leading to fluctuating insulin levels, the Hypothalamus – which functions like a thermostat in reading blood levels of circulating hormones – begins to malfunction. Because the Hypothalamus secretes gonadatropin releasing hormones (GnrH) to prompt the pituitary to secrete FSH, any malfunction of this relationship will cause a disruption of the Hypothalamic-Pituitary-Ovarian axis.
Constitution as a causative factor in POF is obviously related to genetics. Those women whose genetic makeup is lacking certain chromosomal factors – such as in Turners Syndrome – may have developmental issues related to reproduction and normal gynecological function. Gene mutations could also fall into this category.
Lifestyle factors influencing POF are perhaps the most intriguing aspect of this discussion from a TCM perspective. The late Dr. John H.F. Shen used to say, “It is more important to understand life, than to understand disease, because disease usually comes from life”4 Science has demonstrated in numerous studies that poor diet, overwork, exposure to environmental toxins (whether chemical or electromagnetic), and improper medical treatment/iatro-genesis (i.e., incorrect or excessive medications), can each lead to malfunction of the human organism and disease – often in the form of the person’s own immune system attacking itself. Of course, the relationship between autoimmune disorders and POF is widely recognized. In fact, in the most recent issue of Sexuality, Reproduction & Menopause, the following facts about POF were mentioned:
In addition, it was furthermore pointed out, “that the evidence for an autoimmune etiology (in POF) is threefold: the presence of lymphocytic oophoritis, auto-antibodies to ovarian antigens, and associated autoimmune disorders.”6
What do we make of this autoimmune connection from a TCM perspective? We know that fire as a pathogen tends to consume yin over time, and we know that fire is a secondary pathogen, i.e., it follows after other prolonged pathogenic factors have lingered. For example, intemperate dietary factors such as too much spicy or greasy food or alcohol can lead to damp-heat internally. Over time, the heat consumes the damp and continued on page 8 (POF) continued from page 7 leads to the formation of phlegm and fire. The fire in turn consumes the yin. Because yin is substance (blood, essence, menses, oocytes) the depletion of yin over time can be related to the development of POF.
Another way to view this same process would be the following: A female works sixty-plus hours in a demanding career, and because children are not in the picture for the moment, she is on birth control. Overwork, as we know in TCM, leads to the exhaustion of kidney and liver yin and blood, and eventually kidney yang. Overwork is obviously associated with a fair amount of stress, or liver qi stagnation as well. Prolonged liver Qi stagnation will eventually lead to depressive-heat, which in turn consumes yin and blood. Also, because qi guides the blood, the prolonged qi stagnation will lead to blood stasis. On top of all of this, the hypothetical woman in this exercise is taking birth control medication that has been shown to “thicken” the blood and contribute to blood stasis. Because much of the body’s immune function is humoral (i.e. blood mediated), this blood stasis may lead to autoimmune dysfunction such as the lymphocytic ovarian inflammation mentioned above.
Also, the kidney and liver are dependent on an abundant supply of essence, yin and blood to carry out their functions properly. Without enough yin and essence, it will be impossible for the kidneys to nourish the Chong, Ren and Du channels, thereby disrupting the feedback mechanism of the hypothalamic-pituitary-ovarian axis. Without enough yin and essence, an ovarian follicle cannot mature and produce an ovum.
Blood stasis, on the other hand, will deprive the reproductive system of the post-natal essence required to function, and the accompanying heat in the system can confuse the body into interpreting it as a lingering heat pathogen, signaling the body to martial it’s defenses (immune system) against it. This in turn leads to destruction of the follicles.
As we can see, the pathology and etiology of POF in TCM and Allopathic terms meshes adequately to help us understand this disorder, determine the pattern of disharmony (bian zheng), and develop a treatment principle.
The TCM Diagnosis and Treatment of Premature Ovarian Failure
Traditional Chinese Medicine prefers to look at dysfunction of the part as a manifestation of imbalance of the whole. One cannot be separated from the other. Therefore, within the broad categories of patterns of disharmony, attention must be paid to the individual details of the person’s disease signs, symptoms and history. Although western differential and laboratory diagnoses can help in determining a prognosis for individual cases of POF – i.e., a patient with POF secondary to chromosomal disorders such as Turner’s Syndrome will be more difficult to help than someone with POF secondary to hypothyroidism – the TCM differential diagnosis/bian zheng is the guiding factor in developing a treatment strategy. Tongue, pulse, skin, hair, complexion, and other physical signs must be interpreted in light of the patient’s own medical, and family medical history. However, the patterns of disharmony which occur in patients with POF tend to fall into a few basic categories:
Kidney and Liver yin deficiency with empty heat and dryness of the Chong and Ren
Symptoms and Signs: Hot flushing, night sweats, insomnia, thirst, malar flush, tidal fever, low back pain, tinnitus, vaginal dryness, amenorrhea, scanty menses, dry skin and eyes, joint pain. Tongue: Dry, Red, with little or no coating. Possible cracked.
Pulse: Thready, weak in the left guan and qi positions, possibly rapid.
Treatment Principle: Nourish Kidney and Liver yin, clear empty heat, replenish the Chong and Ren.
Acupuncture: Ren 4/Guanyuan, Spleen 6/Sanyinjiao, Kidney 6/Zhaohai, Extra Point Zigong, Urinary Bladder 23/Shenshu, Kidney 5/Shuiquan, Stomach 25/Tianshu, Ren 24/Chengjiang, Heart 6/Yinxi.
Chinese Herbal Prescription: Zhi Bai Di Huang Tang with additions.
Kidney and Liver Yin and Blood Deficiency with Blood Stasis
Symptoms and Signs: The above mentioned Kidney and liver yin deficiency signs plus, painful menses possibly with clotting (if there are menses), dark and lusterless complexion, spider nevi on the liver and kidney meridians, pain at ovulation (if there is ovulation), amenorrhea, possible history of ovarian cysts,
Chinese Herbal Medicine: Gui Shao Di Huang Tang with additions.
Kidney and Liver yin and blood deficiency with Liver Qi Stagnation
Symptoms and Signs: The above-mentioned kidney and liver yin deficiency signs plus: irritability, premenstrual tension, breast tenderness, irregular menses (if they come at all), frequent sighing, constipation, ovulatory pain (if there is ovulation), work-related stress, symptoms worse with stress and emotional lability, patient may have diagnosed pituitary microadenoma/prolactinemia, hypochondriac feeling of distension. Tongue: Dusky or reddish with dark edges and possible liver stagnation spots. Pulse: Tense to wiry depending on the patient’s stress levels. Thin. Guan position will be the most tense.
Treatment Principle: Relax and course the liver qi, nourish kidney and liver yin and blood.
Acupuncture: Large Intestine 4/Hegu, Liver 3/Taichong – AKA “Four Gates”, Liver 14/Qimen, Liver 8/Ququan, UB 17/Geshu, UB 18/Ganshu, UB20/Pishu, UB 23/Shen-shu, Pericardium 6/Neiguan, Spleen 6/Sanyinjiao, Kidney 3/Taixi, Extra Points Yintang and Zigong.
Chinese Herbal Medicine: Yi Guan Jian with additions.
Symptoms and Signs: Low back pain, subjective feeling of cold when others are warm, preference for warm weather, cold extremities (particularly the feet and ankles), fatigue, an appearance of being prematurely aged, primary amenorrhea, underdeveloped sexual characteristics (small hips and breasts), low libido, withdrawn personality, pale/wan complexion, history of delayed onset of puberty.
Case Study/Female Patient age 36 with POF
Susan originally presented at my office at the age of 35 with a 12-year history of ulcerative colitis. She had been on low-dose prednisone for most of that period to control the inflammation and bleeding, as well as Asacol and Rewasa suppositories. During this time she had been hospitalized 3 times and her symptoms were barely under control most of the time. Her symptoms and signs included abdominal cramping and bloating, urgent and loose stools with blood and mucous in them, fatigue, depression, nausea and a feeling of cold. She also had a past history of Asthma that was always worse in the winter.
Her tongue was tender and pale and the coating was wet. Her pulse was thin and weak and deep, especially in the right guan, left guan and both qi positions, with a slippery-tight quality in each lower jiao. Her TCM diagnosis related to her ulcerative colitis was Kidney yang and spleen qi deficiency and liver blood deficiency with lingering damp-heat in the Large Intestine.
I treated Susan for most of the next year on a weekly basis with herbs an acupuncture to help her bring her Ulcerative Colitis under control and to help her get off of her medications – both of which were her stated goals when she first came to me. Over the year of treatment, many herbs to clear heat and drain damp were employed, as well as herbs to fortify the spleen qi and kidney yang. Gradually Susan felt stronger and healthier, her stools normalized, and she was able to discontinue her medication. However, concurrently during this year of treatment, Susan’s menses unexpectedly stopped – right about the time, or soon thereafter getting off of her prednisone. She also started to develop some menopausal symptoms such as hot flushes, vaginal dryness, night sweats, insomnia, irritability, and joint pain. She was obviously concerned and so was I.
I referred Susan to a reproductive endocrinologist that I worked closely with, and after some testing she confirmed our worst suspicions: Susan’s ovaries continued on page 10 (POF) continued from page 9 were failing. Susan’s Follicle Stimulating Hormone (FSH) levels were very high at 109 mIU/mL – with normal age for a reproductive female being <10 mIU/mL. Of course, with Susan’s perimenopausal signs and symptoms combined with this serum FSH level, and with her lack of any menses for the previous 6 months – Susan was given the heart-breaking diagnosis of POF. Even though she was only 36 years old, she was informed that her child baring years were over and that she should look into either an egg-donor or adoption if she hoped to have a family. Just to be sure of the diagnoses, a repeat FSH was drawn 60 days later, and the levels were still above 100.
When Susan came to me in tears with the news of her presumptive diagnosis, I could tell how distraught she was. Susan came from a large family and despite the fact that she was not currently in a relationship, she still held out the hope of having a family of her own one day. Because she had had such success with TCM in the treatment of her ulcerative colitis, she thought there might be hope for her POF despite what the doctor had told her. I didn’t have the heart to tell her that I had personally never encountered a woman with an FSH that high at her age. Yes, I had definitely dealt successfully with many women diagnosed with diminished ovarian reserve who were undergoing treatment for infertility with IVF or IUI, but their FSH levels were considered high at 14-20 mIU/mL. Susan’s was 109 mIU/mL! Also, these other patients were having regular menstrual cycles, whereas Susan had not had a period in close to six months. Furthermore, she was exhibiting all the signs of premature menopause. Lastly, I knew that if we were to have any hope of helping to return the tide of Susan’s menses, and restore her ovarian function, it would require large and long term doses of rich tonic herbs. Given her history of bowel disease, I was not sure that her system would be able to handle this. However, if she was willing to give it a try, I was determined to give it my best. The following is a summary of Susan’s TCM diagnosis, treatment principle, acupuncture and herbal medicine:
Kidney and Liver yin and blood deficiency with empty heat and dryness of the Chong and Ren, and Underlying Spleen Qi deficiency.
Tonify the Kidney and Liver yin and blood, clear empty heat, replenish the Chong and Ren. Protect and support the Spleen Qi.
Spleen 6/Sanyinjiao, Spleen 7/Lougu, and Spleen 9/Yinglingquan – this combination is called the 3 Emperors in the Tong Family style of Acupuncture and they are said to simultaneously replenish the spleen and kidneys. Lung 7/Liexie and Kidney 6/Zhaohai to open the Renmai. Spleen 4/Gongsun and Pericardium 6/Neiguan to open the Chongmai.
Stomach 30/Qi Chong, Kidney 13/Qixue, Ren 4/Guanyuan, and Ren 7/Yinjiao, and Ren 24/Chengjiang – all of which are intersecting points on the trajectory of the Chongmai. UB 11/Dazhu, UB 17/Geshu, UB 18/Ganshu, UB 20/Pishu, UB 23/Shenshu, Du 4/Mingmen, and GB 39/Xuanzhong – all of which help to replenish the marrow and blood. Spleen 3/Taibai, Stomach 36/Zusanli, Stomach 37/Shangjuxiu, and Ren 12/Zhongguan – all of which fortify and protect the spleen, thereby producing post-heaven qi and essence. And of course, Kidney 3/Taixi, the earth point on the water/kidney channel which therefore builds the kidney energy while simultaneously fortifying the earth/spleen and stomach energies.
*Note: The points above were mixed and matched with variations from treatment to treatment based upon Susan’s symptoms and signs. Not all of above were used at every session.
Chinese Herbal Medicine
Zhi Bai Di Huang Tang with additions.
*Susan took variations of the above formula in granulated extracts over the next 9-month period.
Results of Treatment
To my great surprise and Susan’s pleasure, the vast majority of her menopausal symptoms such as hot flashes, joint pain, night sweats and vaginal dryness, and insomnia were resolved within the first 30-40 days of treatment. Within three months of beginning treatment, her periods had started again and remained on regular 28-day cycles from there forward. Within 9 months of beginning treatment, with no more menopausal symptoms and regular periods for the previous 6 cycles, I recommended to Susan that she repeat her day-3 serum FSH levels. To our great astonishment and delight, her new serum FSH levels came back at 9.1 mIU/mL, with normal reproductive levels being <10/mIU/mL – drop of over 100 points in only 9 months. We repeated the test two-cycles later just to be sure, and the results were virtually the same – FSH 9.0 mIU/ml.
I chose this case study because it encompasses so many of the aspects of the patient suffering with POF: An autoimmune component etiology, cessation of menses for several months, elevated serum FSH levels on consecutive cycles, and menopausal vasomotor signs and symptoms.
I also chose this case because it represents the quandary often faced by the doctor of TCM when attempting to match the Chinese medicinals to the pattern of disharmony while baring in mind the patient’s constitutional history.
Would that all cases of POF responded this favorably. POF is a devastating disease with serious health risks if left untreated. It is littered with emotional and physical landmines that can detonate without warning if not navigated with care, discernment and compassion.