Adam Miramon, DACM, Dipl. OM, LAc
Chinese herbal formulas play an important role in the treatment of our patients. However, finding the right formula sometimes can be challenging. Patent formulas are a great starting point for patients who have minimal or limited experience with herbs, but patent formulas have their limitations. This is where the skill of customizing a Chinese herbal formula can shine.
Patient Profile
A 55-year-old patient came to our clinic for treatment of perimenopausal symptoms. The patient was experiencing irregular menstrual cycles accompanied by low back pain and very mild menstrual cramping. Other reported symptoms included hot flashes, sweating, anxiety, fatigue, emotional stress, and weight gain. The patient’s primary concern was profuse light-yellow vaginal discharge.
The patient’s tongue was enlarged and the body was normal in color. There were teeth marks on the right and left sides, and large fissure from the root to the center of the tongue. The tip of the tongue was red. There was tongue fur on the body, and it was white and peeled.
Initial Recommendations
It was recommended that the patient receive weekly acupuncture treatments. The patient was prescribed herbs at her second visit.
The initial herbal prescription was a vaginal douche of 10% solution of a patent herbal wash containing she chuang zi, bo he, jin yin hua, zhi zi, huang bai, huang qin, ku shen, di gu zi, yin chen hao, du huo, can zhu, shi chang pu, ai ye, and tu jing pi for five days, along with a patent formula of Long Dan Xie Gan Tang. The vaginal douche was to be repeated for five days upon completion of her menstrual cycles. The patient continued with Long Dan Xie Gan Tang patent formula for two months.
Two-Month Assessment
The patient reported a moderate reduction of vaginal discharge that ranged from light to moderate. The patient had not had a menstrual cycle in two months; however, she began having light breakthrough bleeding following disagreements with her teenage child. The patient continued to have very light-yellow vaginal discharge. She also noted that the level of her vaginal discharge would increase during increased stress due to challenges with her teenage child. There had been no notable changes in the tongue diagnosis of this patient.
After two months, the vaginal douche and the patent Long Dan Xie Gan Tang were discontinued. The patient continued with weekly acupuncture treatments, and was prescribed the custom formula Wen Dai Tang, which included:
- Bai zhu (chao)
- Shan yao
- Ren shen (bai)
- Cang zhu (fu chao)
- Chen pi
- Che qian zi (yan zhi)
- Bai shao (chao)
- Chai hu
- Jing jie
- Gan cao
After taking the formula for two weeks, the patient reported only two episodes of spotting and a significant reduction in vaginal discharge. The vaginal discharge was sporadic and dark yellow in color. The breakthrough bleeding and vaginal discharge resolved after an additional two weeks of taking the formula.
Four-Month Assessment
The patient noticed an increase in clear vaginal discharge, and she also noted vaginal bleeding specifically associated with stress and disagreements with her teenage child. The base formula of Wen Dai Tang was modified with the following herbs:
- Mo han lian
- Nu zhen zi
- Zhi zi
The level of discharge reduced significantly after a week of taking the modified formula. The patient noted about one episode per week of breakthrough bleeding that was always associated with stress and disagreements with her teenage child.
The patient began drinking cinnamon tea and using castor oil packs without being advised to do so. The patient experienced a major breakthrough bleeding episode after four weeks. She was advised to stop drinking cinnamon tea and using the castor oil packs. The formula was changed to Yi Huang Tang (modified):
- Shan yao
- Qian shi
- Huang bai
- Che qian zi (yan zhi)
- Bai guo
- Cang zhu (fu chao)
- Bai shao (chao)
- Chen pi
10-Month Assessment
The patient continued to take the Yi Huang Tang (modified) for six months. During this time, the patient reported one menstrual cycle and averaged one episode of vaginal spotting per week. The quality and consistency of the spotting changed from red and viscous to pink and watery. Her episodes of vaginal discharge became sporadic and always accompanied the vaginal spotting.
The quality of the vaginal discharge was always thin and ranged from clear to light yellow. The amount of vaginal discharge was consistently light, with approximately two episodes of moderate to profuse. The breakthrough bleeding and vaginal discharge were managed without assistance or by using a panty liner. The episodes of breakthrough bleeding and vaginal discharge occurred after arguments or disagreements with the patient’s teenage child.
The patient’s tongue diagnosis remained unchanged. Her tongue continued to show signs of kidney yin deficiency and heart heat. Her tongue was normal in color with a thin, white, peeled coat. The tip of her tongue was red, indicating heart heat. The base formula was changed due to the lack of resolution of symptoms. The patient was prescribed Bu Shen Cu Pain Luan (modified):
- Dang gui (jiu zhi)
- Chi shao
- Bai shao (chao)
- Shan yao
- Shu di huang
- Nu zhen zi (jiu zhi)
- Mu dan pi
- Fu ling
- Bu gu zhi (yan zhi)
- Tu si zi
- Wu ling zhi
- Hong hua
- Mo han lian
- Jing jie
- Zhi zi
- Bai guo
- Qian shi
- Shan zhu yu (jiu zhi)
- Jin ying zi
The immediate results from this formula were an alternating between vaginal discharge and spotting. Both were managed with the use of a panty liner. After one month of taking this formula, the patient reported a significant reduction in spotting and discharge. The vaginal discharge was consistently straw colored, and she commented that she felt dryer than she had in the past.
The patient continued to take Bu Shen Cu Pai Luan (modified) for three months. The patient reported a significant reduction in symptoms and continued to feel dryer than she had in the past, and she did not report episodes of breakthrough bleeding or vaginal discharge during this time.
Reflection / Conclusion
Patent formulas play an important role in East Asian medicine. Many patent formulas are excellent at addressing a host of acute symptoms and problems, and they can be a starting point for hesitant patients. However, patent formulas have their limitations, and this is where the ability to customize formulas can shine.
This case study reviewed the patent and customized, compounded formulas taken by a 55-year-old perimenopausal patient. The patient was initially hesitant to take Chinese herbs, and a patent formula with a topical treatment became a gateway for customized herbal care. Once the patient experienced a reduction in her symptoms, she was more willing to begin taking a customized, compounded formula.
The formula was changed or modified when either the previous formula had minimal positive results or the patient experienced an increase in symptom presentation. The first two customized, compounded formulas are widely used for vaginal discharge and spotting, which was the driving rationale for their selection. However, while the patient did experience a reduction in her symptoms when using these two formulas, she reported that her symptoms failed to resolve completely.
The decision to rely on my tongue diagnosis skills and prescribe a typical fertility-based formula for a perimenopausal patient came with some hesitation. However, I believed that taking this formula for one month would not negatively impacting the patient’s symptom presentation and could provide us with valuable information regarding her condition. The decision proved to be successful because the patient experienced a complete resolution of her symptoms.
While some base or patent Chinese herbal formulas are successful for a large selection of the population, customized, compounded formulas can have greater results and demonstrate our herbal expertise. Customizing formulas that are based on an individual patient’s presentation can greatly enhance the care we provide.
The ability and willingness to try something new can be initially scary, but we need to become creative sometimes for the health of our patients.
