When the patient first visited my clinic in March of 2010, she was already 40 years old and had a history of thyroid disease for the past ten years. Her hyperthyroidism had been under control for the last six years with the help of Western medicine. After this term of treatment for hyperthyroidism, however, she was diagnosed with hypothyroidism and abnormalities of T3, T4 and TSH. She was then treated with Western medicine for the ensuing hypothyroidism for a year, and her T3, T4 and TSH returned to the normal range. With the condition successfully under control, she gradually discontinued this treatment and stopped taking Western medicine. She has also suffered from cluster migraines for ten years, with episodes occurring once every two to three months lasting around ten to fifteen hours per episode. She experienced the majority of the migraine pain on the right side of her head, and subsequent to every attack she experienced anxiety and insomnia. She also had allergic rhinitis, and had to take anti-allergy medicine when the symptoms worsened. She also reported pain in her lower back, hips, limbs and muscles, which had led to a diagnosis of fibromyalgia five years before. Four years prior to her visit to my clinic, she had been pregnant but unfortunately miscarried at about the seventh week of pregnancy, after which she had been unable to become pregnant again.
When she first visited, she ased help for her pregnant. she had aches in her whole body, especially pain in her neck, upper back, lower back and hips. She felt tenseness and distension pain in her whole head sometimes, and suffered from migraines on the right side of her head once every two to three months. During these episodes, the pain would spread to the right eye, with discharge, drooping, and a burning sensation under her lower eyelid. At times she had nasal congestion with white discharge, phlegm irritation of her throat in the morning. In general her sleep was normal, but she always felt that she did not get enough sleep, and was reluctant to get up immediately when she woke in the morning. She often felt anxiety, depression, fatigue and a heavy sensation in her body, and was sometimes exhausted. There were times where she felt coldness in her lower limbs, and hot flashes in her upper body. Sometimes she felt distention and discomfort in her abdomen, and had gas and belching; however, her appetite was normal, bowel movements occurred once a day, and she had normal urination. She had no history of hypertension or diabetes. Her first period occurred when she was thirteen, and came once a month, but was always irregular, coming four to five days early or late, with twenty-five to thirty days for each cycle, had a median volume of bleeding with pink colored blood containing small clots. Two to three days before menstruation she would have lower abdominal pain, discomfort and a sensation of fullness, with simultaneous breast distension and discomfort. Her libido was normal.
Assessment showed that she had a moderate voice, was tall and had a slightly puffy face. There was a slightly dark color on her face and around her eyes, on her lower eyelids. Her tongue body was swollen with teeth marks on the edges, a slight groove in the center of her tongue; it had a pale color and was moist with thick white coating. Her pulse was floating weak in both distal positions, slight wiry in the middle positions, and weak on both sides of the proximal positions. The Ear Pressure Test showed there was significant painful sensation with slight touch on the corresponding parts of the brain, endocrine, neck, chest, back, leg and stomach, with a severity of pain she described as 7-8/10. Slight touch to the face produced a painful sensation with a severity of 4-5/10. Slight touch produced a painful sensation in her neck at about C4-7, with a severity of 5-6/10. A painful sensation with slight touch was felt in her upper back in T1-T4, with a severity of 5-6/10. There was a painful sensation with slight touch in her shoulder, with a severity of 5-6/10. There was a painful sensation with slight touch in her lower back from L3-S2, with the severity about 6-7/10. There was a painful sensation with slight touch on her hips, with a severity of about 4-5/10. Finally there was a painful sensation with slight touch on her lower limbs, a severity of about 3-4/10.
Based on the Traditional Chinese Medicine, she was deficient in spleen and kidney, as well as having qi and blood stagnation and shen disorders, with occasional exterior cold invasion with simultaneous yang deficiency, though fundamentally her issues were due to deficiency in spleen and kidney. The treatment principle used was to tonify of spleen and kidney, combined with regulation of qi and blood, to warm the body, expelling wind and cold, and to calm shen to help her anxiety and stress.
After three weeks of the treatment, her symptoms were improved, especially her lassitude, anxiety and back pain. After six months of the treatment, the symptoms were markedly improved, especially the cluster migraines. With these successes, she hoped to use acupuncture with Chinese medicine to treat her infertility, in order to make possible her dream of becoming a mother. Considering her history of thyroid disease and miscarriage and that she was nearly 41 year-old, she had been advised to choose IVF – however, she wanted a natural pregnancy. According to the patient’s request and condition, I did a modified electric acupuncture treatment protocol. The Chinese herbal Formula I was modified and used after menstruation. The second formula below was taken one week before ovulation. This protocol was used consistently for five months.
Results: Two weeks after the New Year of 2013, she called to make an appointment for her son (6 week-old) – she had been successful in getting pregnant naturally, two months after her last visit, and had successfully given birth to a child at the age of 42.