TREATMENT OF OVARIAN CYSTS WITH CHINESE HERBS

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND

There are at least three different types of ovarian cysts: the most common is the fluid-filled cyst that occurs at the site of the egg-producing follicle; alternatively, a cyst may appear in the corpus luteum, as a yellow mass of tissue; in rare cases, a cyst may be a malignant tumor of the ovary (cystadenoma or other type). Simple non-malignant ovarian cysts are usually asymptomatic and benign. In many cases, they spontaneously disappear. They have become a medical issue in the U.S. largely because of the recommendation that women obtain frequent pelvic examinations which then reveal the otherwise asymptomatic cysts, and because of the high frequency of delayed pregnancy which often gives rise to low fertility: ovarian cysts may be one of the suspected causes of the lowered fertility. In some cases, especially if the cysts are large, they may cause symptoms such as abdominal aching, pain during intercourse, menstrual irregularities, or painful periods. Hemorrhage into a cyst is a common cause of painful incidents involving the cysts. If a cyst is elongated and then twists, it can cause severe pain that may bring about the need for immediate surgery. About 5% of cysts may become cancerous. Yet another ovarian disorder, polycystic ovary syndrome, is mentioned following the discussion of treatments for non-malignant cysts.

TREATMENT OF SIMPLE OVARIAN CYST IN CHINA

In China, simple ovarian cyst is not considered a major medical problem. It is not mentioned in the English-Chinese Encyclopedia of Practical Traditional Chinese Medicine volume on gynecology; nor is it a significant subject in the extensive abstract journal, Abstracts of Chinese Medicine, which has been published since 1986; nor in the English language Journal of Traditional Chinese Medicine, published since 1981. Treatments for ovarian cysts with Chinese medicine are considered a relatively easy matter if cysts are diagnosed in the first place. The herbal formulas are reported to be effective with short-term administration. Ovarian cysts are probably most-often treated secondarily and without separate diagnosis, as part of a syndrome of infertility, since some of the formulas used for infertility, such as Tang-kuei and Peony Formula (Danggui Shaoyao San) and Cinnamon and Hoelen Formula (Guizhi Fuling Tang) are reported to resolve ovarian cysts.

From the Chinese medical perspective, a localized accumulation of fluid or a growth of soft (fatty) tissue, as occurs with ovarian cysts, is a type of phlegm accumulation disorder. The Chinese medical concept of phlegm ("tan") crops up repeatedly. It is important in considerations of lung and sinus congestion, it shows up as one of the possible syndromes in cases of arthritis and autonomic nerve disorders, and it is a dominant concern in relation to obesity, in soft swellings of the lymph nodes, skin, and thyroid, and in atherosclerosis. Ovarian cysts fit into the broad category of phlegm disorders and differ from some of the other phlegm disorders that involve swellings, such as those of the lymph nodes, skin, and thyroid, primarily by location-deep in the lower abdomen.

According to the traditional view, the main reason for accumulation of fluids, including phlegm, in the lower body is failure of the kidney to "steam" the water upward. That function is part of the kidney yang. The physiological process that is visualized is that the kidney yang is like a heater, and as the water drains down to it from above, a portion of the water is steamed upward. The other portion drains downward to moisten the lower abdomen and legs, with a portion going to fill the bladder. The water that is steamed upward reaches the top of the body and then condenses, just as water vapor arising from the moist ground heated by the sun condenses after rising to form clouds and rain. This rainy mist moistens the sinuses, eyes, mouth, lungs, heart, and all other parts of the upper body. The lungs, which lay on top of the other organs, help disperse the water downward, moistening the dense internal organs and eventually returning the fluid to the kidney for recirculation.

The water-steaming aspect of the kidney is most often supported by the administration of cinnamon, especially cinnamon bark (rougui), incorporated into herbal formulas. This ingredient is often combined with hoelen (fuling), a moisture-regulating herb, in several important prescriptions for lower abdominal disorders, including Rehmannia Eight Formula (Ba Wei Di Huang Wan) and Cinnamon and Hoelen Formula.

When the water fails to steam upward, its main route of departure is through the bladder and there may be symptoms of frequent urination of clear liquid, which is typically treated with the Rehmannia Eight Formula. However, should the kidney not pass the water on to the bladder, then the water remains in the lower body. It may appear in the form of water accumulation, usually in the legs (with edema around the ankles and knees a common manifestation). The stagnated water can be transformed into phlegm, in which case the fluid takes on the character of a firm mass, such as an ovarian cyst. Abdominal fluid accumulation, including ovarian cyst, has been treated successfully with Cinnamon and Hoelen Formula, a prescription which also vitalizes the abdominal blood circulation.

A soft mass, regardless of its location, comes about from congealing of the otherwise fluid and mobile water. The congealing may result from heat (drying the fluid), cold (congealing the fluid), or pollution of the water (thickening with filth). The ovarian cyst that results from the most common mechanism-cold water congealing and accumulating-is treated by three therapeutic methods: warming up the kidney so as to prevent further accumulation, resolving the phlegm mass that already exists, and restoring normal blood circulation to the area that was affected by the cyst and by the coldness (so as to speed resolution and help prevent recurrence of the accumulation).

In China, simple ovarian cysts are most often treated with herbal combinations addressing these therapeutic requirements, though some prescriptions may focus on only two of the three concerns. The herbal treatments are reported to be very effective with a relatively short period of administration-about thirty days-though few details are given in the rare commentaries about this subject. Many of the treatments are based on the traditional prescription Cinnamon and Rehmannia Combination (Yang He Tang; literally, the yang heartening decoction). The term yanghe comes from an ancient classic where it is used to describe the first rays of spring sun thawing the congealed yin of winter.

Cinnamon and Rehmannia Combination was first described in 1740 (during the Qing Dynasty) in the book Wai Ke Quan Sheng Ji. It is a derivative of the traditional pill and decoction for "restoring the right kidney" (You Gui Wan and You Gui Yin) described many centuries earlier. According to the ancient medical ideas, the right kidney has the dominant function of supporting the yang, while the left kidney has the dominant function of supporting the yin. Cinnamon bark and cooked rehmannia, a pair relied upon for harmonious warming of the kidney, are ingredients found in You Gui Wan, You Gui Yin, Ba Wei Di Huang Wan, and Yang He Tang. Cinnamon is hot, spicy, and invigorating; rehmannia is warm, sweet, and calming.

Yin swellings (yin ju), the congealed fluid resulting from yang deficiency, most often appear just below the skin and are not clearly delineated. They differ from other types of accumulation in that they are not hard, nor are they red, hot, or erupting; they may be slightly painful, but this will be due to pressure from the fluid build-up, not sharp pain from blood stasis or from the action of intense heat-toxin. During treatment, the fluid is not forced outward: this is in contrast to treatments for yang swellings that lead to formation and then elimination of pus as the swelling is resolved, as occurs in therapy for breast cancer lumps. Rather, the congealed fluid is softened and set in motion, to be eliminated by the same means as normal fluids. Cinnamon and Rehmannia Combination is used to treat yin swellings such as lipomas, lymphatic swellings, and bone cysts (the latter two often the result of tuberculosis in the Chinese population). Typically, the patient who requires this type of therapy will reveal a pulse that is soft, sunken, and slow, and the tongue will appear pale with a moist, white coat.

The traditional Cinnamon and Rehmannia Combination has the following ingredients:

In this formula, ma-huang is selected because of its warming action on the superficial skin layers, where it opens the pores and resolves stagnated circulation. Sinapis is selected to warm the lower layers of the skin and remove phlegm obstruction of the channels. Roasted ginger warms the muscles and cinnamon bark warms the interior, including the bones and marrow. Thus, every layer of the body is warmed. Sinapis, the spicy mustard seed, is described as having the ability to eliminate phlegm, disperse lumps, and dredge the channels. Rehmannia and deer antler gelatin nourish the yin and blood and balance the stimulating action of the other herbs, protecting the kidney yin and restraining the diaphoretic action of ma-huang, yet providing a warming action. Raw licorice is a detoxicant and it also helps to harmonize the yin-nourishing and yang-promoting activities of the other ingredients.

A clinical trial for ovarian cyst treatment involving 26 patients receiving a modified Yang He Tang was carried out by Li Xuejun and Liu Wenxi at the Department of Gynopathy, Linyi Prefectural Hospital of Traditional Chinese Medicine The base formula used was:

The above herbs were administered in the form of decoction, and 10 grams of deer antler were added to the strained hot liquid, in which it would dissolve. The formula was modified slightly for each patient according to symptom presentation. For example, for lower abdominal pain:

with qi stagnation syndrome, add 12 grams lindera (wuyao)
with blood stagnation syndrome: add 10 grams sparganium (sanleng) and increase the dose of zedoaria (ezhu) to 10 grams
with stabbing pain (a sign of more severe blood stasis): add 10 grams pteropus (wulingzhi) or 10 grams each of myrrh (muyao) and frankincense (ruxiang)
with cold syndrome: add 10 grams aconite (fuzi) and 10 grams artemisia (liujinu)
with pain focused in the waist area (that is, extending around to the back): add 15 grams each of dipsacus (xuduan) and loranthus (sangjisheng)
for yang deficiency syndrome: add 6 grams aconite (fuzi) and 15 grams cistanche (roucongrong)
for yin deficiency syndrome: add 15 grams ligustrum (nuzhenzi) and 20 grams lycium fruit (gouqizi)
for qi deficiency syndrome (which produces a sensation of aching or pain bearing downward): add 20 grams codonopsis (dangshen), 15 grams astragalus (huangqi), and 6 grams cimicifuga (shengma)

Other modifications, for syndromes beside experience of pain, include tonifying the blood when the complexion is poor and the skin appears withered: add 10 grams gelatin (ejiao) and 12 grams each of tang-kuei (danggui) and peony (baishao); when there is damp-heat syndrome (heat may develop after prolonged stagnation): add 12 grams each of prunella (xiakucao) and gentiana (longdancao) and 15 grams coix (yiyiren); or when there is vaginal discharge: increase the dose of laminaria to 15 grams and add 20 grams oyster shell (muli). The complete formula would typically contain 8-10 herbs with a total of about 80-100 grams of herbal materials.

All patients so treated had a cyst on one side. The treatment time for the patients was from 5 to 36 days, and all but three of the patients were cured, according to ultrasound analysis. Two of the other patients had reduced size of the cyst. The remaining uncured patient had surgery and it turned out that the cyst was malignant (teratoma). At the Institute for Traditional Medicine, a formula related to the traditional Yang He Tang, modified with the results of the above study in mind, has been prepared since 1992 in tablet form for easy administration (called Cinnamon and Rehmannia Tablets). The formula includes psoralea (buguzhi) to help warm the kidney yang and polygonatum (huangjing) to protect the kidney and liver from being overheated or dried by the warming tonics. Laminaria and fritillaria (zhebeimu) are used together to resolve the phlegm mass. Zedoaria, persica, and sparganium are included to break up the local stagnated blood and help to quickly restore a normal blood network in the area. The use of blood-vitalizing herbs, such as these last three ingredients, is a relatively new procedure that was developed at the end of the Qing Dynasty period and brought to full use during recent years. Verbal reports from practitioners applying the simple tablet formula over the past four years have been notably favorable. Short treatment time (about one to two months), as indicated by Chinese experience, seems to be adequate, according to their informal observations.

POLYCYSTIC OVARIES

Polycystic ovary syndrome is somewhat different than simple ovarian cyst. It is usually the result of hormonal imbalance (excess of androgen, and with luteinizing hormone elevated). It can be associated with obvious symptoms of menstrual disorder, especially amenorrhea, which is usually caused by the underlying hormone imbalance rather than by the cysts themselves. Furthermore, women suffering from this disorder may display signs of hirsutism and will often be obese.

Despite the differences between polycystic ovaries and simple ovarian cyst from the Western viewpoint, the Chinese medical treatment is often essentially the same: warming up the kidney. The treatment similarity comes about because of the location of the problem and the fact that cysts are involved. Individual symptoms, observable without specific diagnosis of polycystic ovaries, lead to such treatments: amenorrhea is often treated by warming the abdominal organs and promoting blood circulation, while obesity is treated by resolving phlegm accumulation and enhancing metabolism.

The therapeutic principle and accompanying specific formula called "Kidney Reinforcing Regimen" is described in the book Recent Advances in Chinese Herbal Drugs, where it is mentioned as a treatment for polycystic ovarian disease if it is given along with phlegm-resolving herbs. This modern kidney tonic formula is especially helpful in treatment of allergies, which some women with ovarian cysts experience. Specific formula details are provided in the book Modern Clinical Necessities, under the heading of treatment for chronic bronchitis, an unrelated disorder except that kidney yang deficiency and phlegm obstruction also occur. The formula is given as follows:

Aconite, like cinnamon bark, helps restore warmth to the kidney; epimedium, psoralea, and cuscuta further enhance the kidney yang and produce warmth. Citrus is included here primarily to aid the digestion of the rich tonic herbs, mainly the rehmannia. These amounts are for a one day dosage; the herbs are decocted, dried, and made into tablets; the usual instruction is to take 5 tablets each time, three times daily. To treat polycystic ovaries (or bronchitis in which there is substantial phlegm accumulation), this formulation might be combined with a phlegm-resolving formula such as Tan Yin Wan (pill for phlegm accumulation). Tan Yin Wan contains the many of the same ingredients as Cinnamon and Rehmannia Combination, except that ma-huang and deer antler gelatin are replaced by atractylodes (cangzhu and baizhu), aconite, raphanus (laifuzi), and perilla fruit (zisuzi). This pill treats the combined syndrome of deficiency of spleen and kidney yang.

In the book Clinic of Traditional Chinese Medicine (volume 1), there is a short section of polycystic ovaries. There, it is said that there are two basic types from the viewpoint of traditional Chinese medicine. One type is the kidney deficiency syndrome, as described above. The recommended formula is:

Alternatively, it is said that the polycystic ovaries may arise from phlegm-dampness without underlying kidney cold. Such a syndrome usually occurs as the result of liver qi stagnation, which gives rise to other types of stagnation, such as blood stasis and phlegm accumulation. The recommended formula is:

In this formula, cyperus, prunella, citrus, and chih-ko disperse the stagnated qi; citrus, chih-ko and the remaining ingredients remove accumulation of moisture and phlegm. Pangolin scales are included to disperse stagnant blood.

In young women with amenorrhea, physicians at the Long Hua Hospital in Shanghai found that an excess syndrome was often present. That is, there was liver fire in 21 of 28 patients, while only 6 showed the kidney deficiency syndrome and 1 showed the phlegm-dampness syndrome. These physicians prescribed the traditional Gentiana Combination, which contains the following ingredients:

The amounts of some herbs might be increased, such as using up to 9 grams gentiana, up to 12 grams rehmannia, and up to 3 grams licorice. The formula was given either as decoction or pills. The results of applying this method were mixed. Menstruation resumed in 2/3 of the patients, but it was often irregular; only 8 women had normal menstruation; 9 of the women eventually became pregnant. In the discussion of their work, the authors mention that the methods of tonifying the kidney and resolving phlegm dampness, used by other physicians, had good results. The conclusion one gains is that one should probably be careful to differentiate the syndrome and treat accordingly-not automatically treat with a single method.

According to the general doctrine of Chinese medicine, many diseases develop from an excess condition in the early stage to a deficiency syndrome in the later stage of its development. Thus, young women with polycystic ovaries may tend to have an excess syndrome (as described in the above evaluation, in which the average age of the patients was 24.6 years), and older women may tend to reveal the deficiency syndrome (with kidney yang depleted). However, due to genetic, behavioral, and environmental factors, some young women may already have a deficiency syndrome by the time the particular disease (in this case polycystic ovaries) has developed. Therefore age cannot be used as the sole factor in deciding among treatment strategies.

In a clinical trial by Dr. Yu Jin of the Shanghai Medical University Obstetrics and Gynecology Hospital, 133 patients with polycystic ovary syndrome were treated with the following base formula:

This formula was modified either for signs of cold (adding aconite and cinnamon bark) or for liver qi stagnation (adding moutan, gardenia, bupleurum, tang-kuei, and blue citrus, while removing gleditsia and fritillaria). According to Dr. Yu Jin, 82.7% of the women so treated ovulated and of 76 women that were known to be infertile, 36 became pregnant.

In a study carried out by Dr. Ling Zijun at the Jiangxi Province No. 2 People's Hospital, 27 infertile patients with polycystic ovary syndrome were treated with a group of four consecutive formulas, one each week for a month (stimulating the follicles, inducing ovulation, stimulating the corpus luteum, regulating the menses), with this cycle repeated for as many months as necessary (up to three years in one case) to obtain normal menstruation and fertility. There were four formulas aimed at treating deficiency of kidney yang and an alternative set of four formulas for treating deficiency of kidney yin: both sets contained yang tonics, but for patients with yin deficiency, there were some yang tonic herbs replaced by yin nourishing herbs. According to Dr. Ling, 24 of the 27 women became pregnant.

Women with polycystic ovaries usually show signs of increased testosterone production (hirsutism). It has been shown by several Japanese research teams that this condition may be reversed by using the simple Peony and Licorice Combination, made of equal parts of white peony and licorice. While this formula may not prevent the typical imbalance between FSH and LH (something that could be accomplished, instead, by the kidney reinforcing regimen), it does affect the conversion of androsterones to testosterone and therefore may have immediate beneficial effects by reducing testosterone levels.

OVARIAN CYSTADENOMA

From the Chinese perspective, cancerous ovarian cyst differs from the simple ovarian cyst in that it is complicated by significant blood stasis, which then develops into a polluted syndrome, and finally into a significant deficiency syndrome. According to Dr. Pan Mingji, in his book Treating Cancer with Fu Zheng Pei Ben Principle, the prognosis for this type of cancer depends on many factors, but it has generally poor outcome, with a five year survival rate of 30%. The prognosis is better for those who begin treatment in the early stage, while the tumor cells remain well-differentiated, and while there is strong body resistance. He reports that traditional Chinese medicine used alone does not usually produce satisfactory results, but the combination of traditional Chinese medicine and Western medicine applied to early stage ovarian cancer yields an especially good prognosis. He presents several sample formulas for use along with Western medicine. For the early stage of the disease, he recommends the following prescription:

For the most part, this formula promotes the blood circulation; it includes herbs to increase the qi and improve qi circulation, both in support of enhancing the blood circulation. Dr. Pan suggests that treatment with herbs (and, as may be appropriate chemotherapy) should be undertaken before surgery, so that the tumor mass may be shrunken. This approach of delaying surgery may not be deemed acceptable in the West.

November 1997