Case study: Herbs while on BCP?

Samantha -

I think it's perfectly appropriate to administer herbs while the patient is on the Oral Contraceptive Pill (OCP) in order to prevent more hormonal stimulation of her endometrial implants. Vitalizing blood, moving Qi and eliminating stasis are compatible treatment principles with the OCP, and there are a number of common formulas that can address this patient's presentation:

A. Shao Fu Zhu Yu Tang
B. Ge Xia Zhu Yu Tang
C. Zhe Chong Yin
D. Xue Fu Zhu Yu Tang
C. Gui Zhi Fu Ling Tang

and so on...

Most of the above formulas are of course simply variations on a theme, and they can be modified according to what you see in your patient's presentation. When it comes to tonifying or warming Kidney Yang while the patient is on the OCP, you may have to be a bit more judicious in your choices because kidney tonic herbs tend to stimulate ovarian function/i.e. follicles, estradiol, etc. Although I personally think that the OCP is usually too strong to be counteracted by herbs (this is just my personal experience/opinion), it would be wise to closely monitor the patient for signs of ovarian/hormonal activity if you prescribe Kidney tonifying herbs. Also, I don't think it's any problem at all to keep her on the formula for the entire time she is on the OCP if her system - especially the IBS - can handle it.

Ray Rubio D.A.O.M., L. Ac. FABORM
President ABORM
www.westlakecomplementarymedicine.com

Hi Samantha

I'm with Ray on this one. I routinely use herbs while women are on the pill. Treat the symptoms and pattern that this woman presents. I haven't had a case yet were the herbs overrode the BCP either. It looks like she has a lot of liver qi invading spleen/stomach causing all her digestive symtpoms. Cold hands and feet without a cold body are often a sign of liver qi stag and not so much kidney yang. Saying that Kidney Yang is the root of all qi movement in the blood and often kd yang def underlies liv qi stag ( if we do not have the strength of drive (kd yang def) to assert ourselves properly often this leads to frustration and liver qi stag). Have confidence in your diagnosis, proscribe herbs according to your diagnosis, watch the patient for changes once she is taking the formula and modify your formula or not according to how she responds and you will be fine.

Kaleb

Thanks for your replies! I feel more confident prescribing these herbs now.

By the way, I thought to tonify Kidney Yang in addition to moving blood because of her inability to concieve despite several IUI's and and IVF. She actually did concieve with the IVF but miscarried early. Also, I just completed Jane Lyttleton's Infertility seminar and she recommends tonifying K Yang in most endometriosis cases as well as moving blood. Do you find the need for this in cases of severe stagnation as well? I did consider that her cold hands and feet are probably due to the stagnation more than the Yang def., but thanks for the reminder!

I usually don't post but I read your replies all the time and have gained from them in many ways. Thank you to both of you for taking the time to be so thorough in your answers.

Aloha!
Sam

Hi gang,
The synthetic estrogens and progestins both have a negative feed back suppression of hypothalamo-pituitary-ovarian (HPO) function. If you run their LHs and FSHs, and I had, you will see that both those pituitary hormones are completely shut down. Without FSh, you don't get E2 peak, without LH, there is no effect on corpus luteum, there is no ovulation, there is no ovulation, there is no pregnancy. That said, I think that there is a huge benefit from Chinese herbs. OC's effect on liver is primary area where your treatments can be beneficial. In particular, OCs affect glutathione conjugation, acetation and methylation. All must be supported. In short with methyl donors, glutathione and its promoters. Another thing is GB function needs to be supported as well...
I am sure you are aware that there are ton of S/E of using OC, and the long term effects are the ones are not being talked about, check out post birth control syndrome. I ve seen LH and FSH not able to ever come back, and estrogen levels are set to double of normal. In particularly, post IVF, drugs such Lupron and synthetic LH and FHSs totally suppress HPO axis, coming of them, best is to detox, get them out of her system. It may take a while, but she will be able to tell as her periods normalise, or not, happens after these heavy drugs.
She also should be on selective estrogen receptor-site modulators, your Dong-Gui and black cohoshes, to help th offset the synthetic estrogen and their effects on E receptors and other hormones...such as thyroid.
Its another thing if she won't get off the OC, then I recomment ALL my OC patients, sublingual progesterone in luteal phase. It helps to keep the receptor site sensitivity and competes against synthetic progestins. A lot of people forget that medroxy-progesterone-acetate is not same as progesterone, but acts on same receptors, so the presence of bio-identical P helps with some receptor site sensitivity/exposure, but don't worry, there is more than enough of synthetic stuff around to turn-off pituitary.
I also wanted to comment on insomnia during luteal phase. It is possible to be related to Hashimoto's I have seen this pattern before. Check for inward trembling, hair loss, nervousness, irritability and/or anxiety. I am not jumping to conclusions here, but in her case there are few indications that point me in auto-immune direction (including inability to maintain pregnancy). Do a fT3, fT4, TSH, anti-TPO Antibody, and Thyroglobulin Antibody. Also, she already has a history of autoimmune, that another clue.
Hope this post helps,
Good luck,
One last thing, I personally suggest to all my OC patients to perhaps consider have their male partners on OC pill, they make one for males you know!

Arthur Gazaryants, L.Ac., M.S.O.M., B.S.
20315 Ventura Blvd, Suite A
Woodland Hills, CA 91364
Tel.818.999.0300

www.Artupuncture.com

My pleasure Sam

I am happy to hear that you find my ramblings useful. I also tonify kd yang when I move blood, same thing about kd yang being the base energy behind all movement in the body. I usually use a kd yang herb that moves as well like Rou gui, Du zhong or xu duan.

Kaleb

I have a related question about Acupuncture in conjunction with the oral birth control pill before an IVF cycle. I have a patient who was put on a low dose of OBC due to her AMA so as not to over suppress her ovaries. She ended up with a cyst and has had to postpone her stimulation. Is it possible that the acupuncture in combination with the low dose contributed to her body's resistance to being suppressed?

Hi Samantha/Kaleb/Arthur -

Thanks for the thorough review of the HPO Axis and the action/function of synthetic estrogens and progestins Arthur. I'm pretty sure that most of that is understood by those of us who specialize with reproductive disorders/infertility, but I suppose it never hurts to hear it again. My understanding of Samantha's original post was that the decision to go on the OCP was a done-deal, and she wanted to know if Chinese Herbs were appropriate to use in conjunction with the OCP.

Samantha, considering that your patient is proceeding with the OCP in order to "quiet" her uterus for a few months, and to prevent further hormonal stimulation of the endometrial implants, as I mentioned previously, you can aid this process safely by prescribing blood/qi invigorating herbs. Given this patient's tongue and pulse presentation, and the dark pigmentation of the endometrial implants, I think you are correct in diagnosing a component of Kidney Yang Xu in addition to the qi/blood stasis. This is not uncommon in patients with Endometriosis. The question you rightly pose is whether or not it's ok to use Kidney Yang tonifying herbs in addition to the qi/blood invigorating herbs while she is on the OCP. Perhaps the answer is not yes or no. Perhaps the answer is when.

Maybe begin her for the first 2 cycles on a simple, warming, and qi/blood invigorating formula such as Shao Fu Zhu Yu Tang, or Zhe Chong Yin. Then, during the final month, add some Kidney Yang Tonics and Interior Warmers to her formula in order to augment her ming-men fire. I would thing appropriate choices might be Fu Zi, Rou Gui, Xu Duan, Xian Mao. (Obviously Fu Zi/Rou Gui complement each other, as due Xu Duan/Xian Mao). This type of staging of the treatment will allow the hormonal stimulation of her ovaries to rest during the first couple of months without fear of the Kidney Yang Tonics or Interior Warmers overriding the OCP.

I think that this discussion answers the question about Acupuncture during low-dose OCP in prep for IVF, and whether or not the Acup. could have produced an ovarian cyst. My general rule of thumb during down-regulation of any type - whether it's Lupron or OCP, or both - is to avoid stimulation of the Chinese Kidney System - whether that means herbs or meridians. I avoid Kidney Tonic herbs, and I avoid the kidney meridian during down-regulation. Once ovulation induction (COH) has begun, I use the Kidney channel a great deal, and I try to move blood and warm the uterus. This treatment approach during stimulation aids in a vigorous follicular recruitment, and nice uterine lining primed for implantation.

Lastly, Samantha, I agree with Arthur that you should encourage this patient to have her thyroid evaluated for Hashimotos. This condition is quite common in patients with failed IVF's, and Infertility, and it's also quite common in patients with a history of endometriosis.

Thanks for this case Samantha, and thanks for the discussion everyone. Very stimulating.

Ray Rubio, D.A.O.M., L. Ac. FABORM
President ABORM
www.westlakecomplementarymedicine.com