**5. Traditional Chinese medicine**

Traditional Chinese medicine formulas and herbs have been used to manage the health problems of women for hundreds of years. Classically, Chinese medicine prescription is composed of many herbs to treat a specific disease. According to the principles of TCM syndrome patterns for PCOS, one study showed that Shen deficiency with blood-stasis syndrome was the most frequent pattern noted in these patients, followed by Pi-deficiency with phlegmdampness syndrome, Pi-Shenyang-deficiency syndrome, and Shen-yin deficiency syndrome [71]. Another study demonstrated that TCM syndrome patterns presented in patients with PCOS were mostly amalgamative, of which Shen deficiency and Gan stagnancy are the basic syndromes [72]. One earlier study revealed that elevated levels of testosterone correlated more with the TCM syndrome pattern of Shen-Yi deficiency compared to other patterns [73]. Interestingly, there is one study that describes the correlation between TCM syndrome patterns of PCOS and ovulation induction effects [74]. The effects of clomiphene on patients with phlegm-dampness accumulation syndrome and Shen-yin deficiency syndrome were poorer than in patients with Shen-yang deficiency syndrome and Gan-stagnancy transformed heat syndrome, which suggested the degree of reproduction endocrine dysfunction or the metabolism disturbance of the former two syndrome patterns were more severe than the latter two syndrome patterns [74].

#### **5.1. Chinese herbal formulas for PCOS**

#### *5.1.1. Jia-Wei-Xiao-Yao-San*

Unfortunately, lifestyle interventions are associated with low adherence and sustainability, and engagement, compliance, and sustainability remain challenging [55]. Medical treatment of PCOS is indicated if lifestyle modifications are a failure or unsuitable. Medical treatments include clomiphene citrate, metformin, oral contraceptives (OCPs), anti-androgen, steroids, and statins. One-year randomized clinical trial (RCT) showed that combined oral contraceptives plus spironolactone can decrease hirsutism score, androgens, and DHEA levels with fewer menstrual dysfunction [56]. Another randomized, controlled crossover study demonstrated that both metformin and myoinositol significantly reduced the insulin response to OGTT and

**Medical agents Indication and effect Limitations**

\*Nonsteroidal synthetic hormone consisting of a racemic mixture of two stereoisomers (40% enclomiphene [EnC] and 60% zuclomiphene [ZuC]), with anti-estrogenic properties

PCOS as first-line monotherapy or in combination with anti-androgen medications and OCPs \*Improve hyperandrogenemia and symptoms of

\*Recovery ovary function with normal menses

\*Reduce in metabolic parameters of insulin

\*Decrease androgens and block the effect of androgens by inhibiting of ovarian androgen production and by increasing SHBG

(spironolactone (SPA), cyproterone acetate, flutamide) or suppression of 5α-reductase (5αR, such as finasteride) to prevent the conversion of 5α-dihydrotestosterone into free testosterone \*Suppress the effects of androgen in the hair follicle

dexamethasone can reduce androgen output

\*Combined with an OCP can improve hirsutism

\*Advantageously combined with an anti-androgen to attain a better effect when treating hirsutism

\*Possible fetal malformations, mainly neural tube defects and hypospadias \*Increased risk of endometrial cancer, especially at doses greater than 2000 mg and high (more than 7)

number of cycles

controversial

patients.

OCPs only

teratogenicity

hirsutism

\*Promoting ovulation is still

period of intervention

\*Maybe increase IR after a 2-year

\*Progestins, such as chlormadinone and drospirenone, may increase venous thrombosis events and may be contraindicated in severe obesity

\*Little effect in blocking mild to moderate hirsutism or alopecia with

\*SPA may induce hyperkalemia, breast discomfort, dry skin, gastritis,

\*Intermenstrual spotting may occur if the women taking SPA as monotherapy

\*Less effective for the treatment of

\*Statins alone do not improve hirsutism, menstruation, or BMI

headaches and dizziness

\*SPA has the potential for

Clomiphene citrate \*As an ovary-stimulating drug in subfertile /infertile women

96 Debatable Topics in PCOS Patients

Metformin \*Usually used in young girls and adolescents with

\*Assist in weight reduction

ethinylestradiol) and a progestin

Anti-androgens \*Competitive antagonism of the androgen receptor

or in the pilosebaceous unit

Statins \*Lipid-lowering agents with multiple actions to improve dyslipidemia

Steroids \*Physiologic doses of prednisolone or

**Table 3.** Current medical agents and limitations for PCOS.

directly

androgen excess

Oral conceptions \*Contain estrogen (almost exclusively

and alopecia

resistance

Jia-Wei-Xiao-Yao-San, also called Dan-Zhi-Xiao-Yao-San, consists of Moutan Radicis Cortex, Radix Paeoniae Rubra, Bupleuri Radix, Angelicae Sinensis Radix, Poria, Glycyrrhizae Radix, Atractylodes Ovatae Rhizoma, Zingiberis Rhizoma Recens, and Menthae Herba. According to the principles of TCM, Jia-Wei-Xiao-Yao-San disperses stagnated liver qi for relief of qi stagnation and suppresses heat and nourishes the blood. One study showed that a danzhi xiaoyao pill could improve ovulation rates and pregnancy rates in anovulation infertility patients with PCOS complicated by IR [75]. It was also reported as the most frequently prescribed formula for patients with PCOS in north Taiwan [76].

*5.2.2. Radix Salvia Miltiorrhiza*

*5.2.3. Coptidis Rhizoma*

**6. Acupuncture and moxibustion**

and far-infrared moxibustion.

*Radix Salvia Miltiorrhiza*, also called Dan Shen in Chinese, originates from dried roots of *Salvia miltiorrhiza Bunge*. According to the principles of TCM, Dan Shen can promote blood flow to regulate menstruation, cool blood, and dispel blood stasis. Tanshinone, the main ingredient of *Salvia miltiorrhiza Bunge* [83], may decrease the level of androgen and improve the index of lipid metabolism, such as lower total cholesterol and TG, and increase HDL levels, in patients with PCOS [84]. Some animal studies have shown that Cryptotanshinone can reverse reproductive disturbances by decreasing the levels of SHBG, testosterone, estradiol, and LH, as well as the LH/FSH ratio, and can improve metabolic disturbances, such as abnormal levels of

Complementary Therapy with Traditional Chinese Medicine for Polycystic Ovarian Syndrome

http://dx.doi.org/10.5772/intechopen.71654

99

*Coptidis Rhizoma*, also called Huang Lian in Chinese, originates from dried roots of *Coptis deltoidea C.y.Cheng et Hsiao*. or *Coptis chinensis Franch*. or *Coptis teeta* Wall. According to the principles of TCM, *Coptidis Rhizoma* can clear heat, eliminate dampness, spill fire, and induce detoxification. The isoquinoline alkaloid and the major constituent, berberine, are derived from this herb [86]. A previous randomized study showed that berberine, compared with metformin, could decrease BMI, lipid parameters, and total FSH requirements, and increase the live birth rate with fewer gastrointestinal adverse events in patients with PCOS undergoing IVF treatment [87]. Another earlier randomized study demonstrated that berberine, compared with metformin, could reduce total cholesterol, TG, LDL-C, WC, and waist-to-hip ratio, as well as elevate HDL-C and SHBG in patients with PCOS [88]. *Coptidis Rhizoma* may have potential for the management of PCOS.

As with TCM formulas and single Chinese herbal therapy, acupuncture and moxibustion have also been used to treat clinical manifestations of PCOS for hundreds of years. Traditionally, acupuncture and moxibustion were performed by inserting needles into or burning moxa sticks upon specific points (acupoints) on the meridians of the body surface. Acupuncture and moxibustion work by regulating energy flow, also called Qi in Chinese, over the meridians. Newer therapeutic methods include electro-acupuncture (EA), laser-acupuncture, burning moxa granules on the top of the needle, points pasting,

Clinical effects of acupuncture are mediated by activation of somatic afferent nerves innervating the skin and muscle, which, via modulation of the activity in the somatic and autonomic nervous system, may regulate metabolic and endocrine functions in patients with PCOS [89]. One analysis showed that the acupoints of Sanyinjiao (SP 6), Guanyuan (CV 4), Zigong (EX-CA 1), Zhongji (CV 3), and Qihai (CV 6) are most frequently used in the clinical management of acupuncture for patients with PCOS [90]. This report also demonstrated the meridians of the main acupoints are the conception vessel, stomach meridian of the foot-yangming, and the spleen meridian of

LDL-C and FINS by dehydroepiandrosterone (DHEA)-induced PCOS [84, 85].

#### *5.1.2. Wen-Jing-Tang*

Wen-Jing-Tang consists of *Cinnamomi Ramulus, Evodiae Fructus, Ligustici Rhizoma, Angelicae sinensis Radix, Paeoniae Radix, Ginseng Radix, Glycyrrhizae Radix, Zingiberis Rhizoma Recens, Moutan Radicis Cortex, Ophiopogonis Tuber, Pinelliae Tuber,* and *Asini Corii Gelatinum.* According to the principles of TCM, Wen-Jing-Tang would promote blood circulation to dispel blood stasis, dispels cold by warming the meridians, benefits qi, and nourishes the blood. One study showed that Wen-Jing-Tang was effective in regulating endocrine conditions in the treatment of ovulation disorders in patients with PCOS [77]. It suggested that Wen-Jing-Tang is adequate for the clinical management of PCOS in women with various constitutions (as determined by the matching theory of eight-principle pattern identification) [77].

#### *5.1.3. Cang-Fu-Dao-Tan-Wan*

Cang-Fu-Dao-Tan-Wan consists of *Atractylodes Lanceae Rhizoma, Cyperi Rhizoma, Pinelliae Rhizoma, Citri Reticulata Pericarpium, Poria, Citrus aurantium L., Glycyrrhiza Radix,* and *Arisaema heterophyllum Bl.* According to principles of TCM, Cang-Fu-Dao-Tan-Wan resolves phlegm and dissipates masses, eliminates dampness, and relieves depression. One study evaluated the efficacy of a modified Cangfu Daotan pill combined with clomiphene in patients with PCOS. The results showed that the modified Cangfu Daotan pill could improve symptoms, increase ovarian artery blood flow, and lower FSH and LH [78]. Another study evaluated a modified Cangfu Daotan Decoction (MCDD) on endometrial receptivity in infertility patients with PCOS [79]. MCDD could increase pregnancy rates with improving insulin resistance, endometrial blood flow, endometrial receptivity, and increasing the uncoupling protein (UCP2) expression [79]. UCP2 expression, negatively regulating the hypersensitivity of insulin, has been reported to be significantly higher in early stage follicles of ovary tissue in PCOS patients [80], but the mechanism and function in the endometrium remains unknown.

## **5.2. Single Chinese herbs for PCOS**

#### *5.2.1. Cyperi Rhizoma*

*Cyperi Rhizoma*, also called Xiang Fu in Chinese, originates from dried roots of *Cyperus rotundus L*. According to the principles of TCM, it can disperse and rectify depressed liver-energy, regulating menstruation, and arresting pain. *Cyperi Rhizoma* was also reported as the most frequently prescribed single herb in north Taiwan for patients with PCOS [76]. It may have potential for PCOS treatment due to its pharmacological benefits resulting in anti-androgenic, anti-diabetic, anti-lipidemic, anti-obesity, and weight-control effects in obese patients according to the present research results [81, 82].

#### *5.2.2. Radix Salvia Miltiorrhiza*

to the principles of TCM, Jia-Wei-Xiao-Yao-San disperses stagnated liver qi for relief of qi stagnation and suppresses heat and nourishes the blood. One study showed that a danzhi xiaoyao pill could improve ovulation rates and pregnancy rates in anovulation infertility patients with PCOS complicated by IR [75]. It was also reported as the most frequently pre-

Wen-Jing-Tang consists of *Cinnamomi Ramulus, Evodiae Fructus, Ligustici Rhizoma, Angelicae sinensis Radix, Paeoniae Radix, Ginseng Radix, Glycyrrhizae Radix, Zingiberis Rhizoma Recens, Moutan Radicis Cortex, Ophiopogonis Tuber, Pinelliae Tuber,* and *Asini Corii Gelatinum.* According to the principles of TCM, Wen-Jing-Tang would promote blood circulation to dispel blood stasis, dispels cold by warming the meridians, benefits qi, and nourishes the blood. One study showed that Wen-Jing-Tang was effective in regulating endocrine conditions in the treatment of ovulation disorders in patients with PCOS [77]. It suggested that Wen-Jing-Tang is adequate for the clinical management of PCOS in women with various constitutions (as deter-

Cang-Fu-Dao-Tan-Wan consists of *Atractylodes Lanceae Rhizoma, Cyperi Rhizoma, Pinelliae Rhizoma, Citri Reticulata Pericarpium, Poria, Citrus aurantium L., Glycyrrhiza Radix,* and *Arisaema heterophyllum Bl.* According to principles of TCM, Cang-Fu-Dao-Tan-Wan resolves phlegm and dissipates masses, eliminates dampness, and relieves depression. One study evaluated the efficacy of a modified Cangfu Daotan pill combined with clomiphene in patients with PCOS. The results showed that the modified Cangfu Daotan pill could improve symptoms, increase ovarian artery blood flow, and lower FSH and LH [78]. Another study evaluated a modified Cangfu Daotan Decoction (MCDD) on endometrial receptivity in infertility patients with PCOS [79]. MCDD could increase pregnancy rates with improving insulin resistance, endometrial blood flow, endometrial receptivity, and increasing the uncoupling protein (UCP2) expression [79]. UCP2 expression, negatively regulating the hypersensitivity of insulin, has been reported to be significantly higher in early stage follicles of ovary tissue in PCOS

patients [80], but the mechanism and function in the endometrium remains unknown.

*Cyperi Rhizoma*, also called Xiang Fu in Chinese, originates from dried roots of *Cyperus rotundus L*. According to the principles of TCM, it can disperse and rectify depressed liver-energy, regulating menstruation, and arresting pain. *Cyperi Rhizoma* was also reported as the most frequently prescribed single herb in north Taiwan for patients with PCOS [76]. It may have potential for PCOS treatment due to its pharmacological benefits resulting in anti-androgenic, anti-diabetic, anti-lipidemic, anti-obesity, and weight-control effects in obese patients accord-

mined by the matching theory of eight-principle pattern identification) [77].

scribed formula for patients with PCOS in north Taiwan [76].

*5.1.2. Wen-Jing-Tang*

98 Debatable Topics in PCOS Patients

*5.1.3. Cang-Fu-Dao-Tan-Wan*

**5.2. Single Chinese herbs for PCOS**

ing to the present research results [81, 82].

*5.2.1. Cyperi Rhizoma*

*Radix Salvia Miltiorrhiza*, also called Dan Shen in Chinese, originates from dried roots of *Salvia miltiorrhiza Bunge*. According to the principles of TCM, Dan Shen can promote blood flow to regulate menstruation, cool blood, and dispel blood stasis. Tanshinone, the main ingredient of *Salvia miltiorrhiza Bunge* [83], may decrease the level of androgen and improve the index of lipid metabolism, such as lower total cholesterol and TG, and increase HDL levels, in patients with PCOS [84]. Some animal studies have shown that Cryptotanshinone can reverse reproductive disturbances by decreasing the levels of SHBG, testosterone, estradiol, and LH, as well as the LH/FSH ratio, and can improve metabolic disturbances, such as abnormal levels of LDL-C and FINS by dehydroepiandrosterone (DHEA)-induced PCOS [84, 85].

#### *5.2.3. Coptidis Rhizoma*

*Coptidis Rhizoma*, also called Huang Lian in Chinese, originates from dried roots of *Coptis deltoidea C.y.Cheng et Hsiao*. or *Coptis chinensis Franch*. or *Coptis teeta* Wall. According to the principles of TCM, *Coptidis Rhizoma* can clear heat, eliminate dampness, spill fire, and induce detoxification. The isoquinoline alkaloid and the major constituent, berberine, are derived from this herb [86]. A previous randomized study showed that berberine, compared with metformin, could decrease BMI, lipid parameters, and total FSH requirements, and increase the live birth rate with fewer gastrointestinal adverse events in patients with PCOS undergoing IVF treatment [87]. Another earlier randomized study demonstrated that berberine, compared with metformin, could reduce total cholesterol, TG, LDL-C, WC, and waist-to-hip ratio, as well as elevate HDL-C and SHBG in patients with PCOS [88]. *Coptidis Rhizoma* may have potential for the management of PCOS.
