Case Study with Thomas

Thomas June 10, 2025

We will have a student presentation this week (tomorrow) for the case study. Please review the case and be

Initial Consultation Date 12/9/24
Case Study Details Gender: F Age: 47 Height: 5’6” Weight: 150 Ethnicity: European Occupation: Licensed acupuncturist and RN
Primary Complaint: Peri-menopause symptoms including hot flashes, weight gain, sweating, hair thinning, dryness, bloating, and fatigue. Brief History: Symptoms began in 2021, when she was still in acupuncture school. Client lives in humid Texas. Stress at work. Recently, she hired a colleague, who prescribed a custom formula, resulting in the client feeling a little better. But significant relief was elusive. The client stopped working with that colleague and is now taking an herbal supplement called “Gleefull Hormone Supplement” (a Yang tonic), which is helping with the sweating and weight gain. Secondary Complaint: none Diet and lifestyle: Client eats fairly healthy and mostly avoids processed foods. She eats a lot of nuts and has two glasses of wine in the evening. Sweating: At night in the early morning Sleep: 8-9 hours per night. Difficulty falling asleep (sometimes racing thoughts, worries). Doesn’t feel rested when she wakes up. Energy: 4 out of 10 Pain: Lower back aching and soreness (doesn’t call it pain). Stabbing menstrual pain in low belly and low back pain. Urination: Pale and clear, occasionally smelly, cough/sneeze incontinence Stool: Pencil-thin and loose, once daily Appetite: Low appetite Mental State: Depression & anxiety. Client tends to be more depressed than irritated. Irritation happens during menses. Temperature: She lives in very humid Texas. Her body feels Hot, but hands and feet are cold. Dislikes the cold. When she was younger, she was always cold. Hearing: no issues Thirst: Thirsty but only desire to drink small sips Other: Two months ago, she had all thyroid labs run (TSH, free T3, free T4, reverse T3, Thyroid Peroxidase Antibodies, Thyroglobulin Antibodies); they came back normal-low but ALL within normal limits. Phone consultation (client lives in a different state). I’ve met her once in person. Client speaks in
a quiet, measured way. She looks pale in photos. Experiencing stomach fullness and sleepiness after meals. Hypochondriac stiffness/tightness. Stuffiness of chest or epigastrium. Feeling of heaviness. Dry mouth especially in the morning. Swollen breasts before period. Menstrual blood is “gooey” and red. Undigested food in stools when she’s extremely stressed approximately once per month. A little vaginal discharge always. Poor memory. Low libido. Medical History: C-section – 28 yo. Childhood tonsillectomy & ear tubes, lumpectomy – 2017. Family Medical History: Mom – emphysema, aFib, HBP. Dad – lung cancer, HBP, alcoholic. Grandparents – cancer, stroke, HBP. Medications: None Supplements: Gleefull Herbal Hormone Supplement (contains vitamins and epimedium, dang gui, ashwagandha, catuaba bark, damiana leaf, ginger root, maca root, mucuna pruiens, muira puama, sarsaparilla, tribulus terrestrius, black pepper). Also takes collagen powder and NAC powder. Tongue: swollen, mostly pale, red edges, scallops, depressed areas in the front and middle/back, purple sublinguals especially in the back Pulse: Rapid, thin, slippery, weak and deep in left rear position (pulse was taken by one of her colleagues) ANALYSIS: Yang and Yin Vacuity (Yang predominant), Liver Invading Spleen TREATMENT STRATEGY: Supplement Kidney Yang and Yin, Subdue and Course Liver and Supplement Spleen HERBAL RECOMMENDATIONS: Variation on You Gui Wan with epimedium and Jia Wei Xiao Yao San Explanation: Client shows predominantly Yang Vacuity symptoms with poor libido, some incontinence, lassitude, subdued and quiet manner, clear urination, pale tongue with white fur. Yin Vacuity symptoms include hot flashes at night and early morning, dry mouth, hair loss, mental restlessness and anxiousness at night (tends to run hot, poor memory, dryness). Liver Yin vacuity has led to a disharmony of the Liver’s function to order the Qi, which has led to irregular menstruation. Irritability is related to the Liver Yin Vacuity and the Vacuity Heat.
Herb
Pin Yin / Pao Zhi
Amount
Epimedium
Yin yang huo
30g
Prepared rehmannia
Shu di huang
12g
Lycii, dry fried
Gao qi zi, chao
12g
Chinese Wild Yam, dry fried
Shan Yao, chao
12g
Cornus, dry fried
Shan zhu yu, chao
12g
American ginseng
Xi yang shen
12g
Eucommia
Du zhong, dry-fried w/ginger juice
12g
Herb
Pin Yin / Pao Zhi
Amount
Bupleurum root
Chai hu
9g
Angelica sinensis, dry fried slightly
Dang gui, chao
15g
White peony
Bai shao
9g
White atractylodes
Bai zhu
9g
Poria
Fu ling
9g
Baked licorice
Zhi gan cao
4.5g
Moutan peony
Mu dan pi
9g
Gardenia fruit, dry fried
Zhi zi, chao
9g
Codonopsis
Dang shen
9g
Vitex berry
Vitex agnus-castus
9g
Motherwort herb
Leonurus cardiaca
9g
Dietary and lifestyle recommendations: Focus on meat protein, whole grains and legumes (legumes contain phytoestrogens), cooked vegetables including dark leafy greens, a little cooked fruit in season. A little seaweed is beneficial, and fermented foods support the gut microbiome responsible for metabolizing estrogen. Avoid nuts and nut butters, avocados, alcohol, caffeine, chocolate, greasy fatty foods, and dairy (as they congest the Liver) with the exception of walnuts, flaxseed, black sesame seeds. Avoid foods that are cool and damp in nature like juices, raw foods, cooling foods like bananas, melons, cucumbers, and soy milk. Evening primrose and borage oils are good for dryness. Vitamin E (300-600 IU daily) can reduce hot flashes, vaginal dryness, breast tenderness. Walnuts, flaxseeds (contains phytoestrogens), black sesame seeds, and honey make a nice snack.
Gentle movement – yoga or Qi gong – can be beneficial. Expression through writing and/or spending time in nature can be beneficial.

January 10, 2025 – Update She has been taking herbs for two weeks, but isn’t taking vitex. Can’t tolerate the vitex in tincture form; it’s too bitter. She will switch to a vitex capsule. Can only take herbs twice daily. I recommended that she increase morning and evening dose, since she’s only taking twice daily. Also recommended increasing motherwort from 10 drops twice daily to 30 drops twice daily. Please retake photo (blurry and drank coffee). weight gain – no hot flashes (3 out of 10 – occasionally) Sweating (2 to 10) hair thinning (5 to 10) Dryness (8) Itchy skin and scalp is worse. Suggested Vitamin E (300-600 IU daily). Bloating (4) Fatigue (6 to 10) holidays were very stressful Last period? Now 21 days late. Irritable. Motherwort 10 drops twice day. She had two episodes of “burning butt diarrhea” (ate chicken & veg, fish and veg – not spicy). Fire hot and foul smelling. Happened hours after taking herbs. No glass of wine with dinner. No recurrence. Holiday stress was very high. Diet and lifestyle: Reduced nut intake Sweating: At night in the early morning Sleep: 8-9 hours per night. Difficulty falling asleep on occasion. Wakes up not feeling rested. Energy: 4 out of 10 Pain: No lower back pain. Urination: Pale and clear, occasionally smelly, cough/sneeze incontinence Stool: More formed Appetite: Poor until 3pm, then hungry. Mental State: Depression & anxiety. Client tends to be more depressed than irritated. Irritation happens during menses. Temperature: Same. Her body feels Hot, but hands and feet are cold. Dislikes the cold. When she was younger, she was always cold. Hearing: no issues Thirst: Same. Thirsty but only desire to drink small sips.

Jan 31, 2025 update Client finally had a period on 1/15. It was 21 days late and had cramps for the first 2 of the 3 days. Bled for 2-3 days. After the onset, her anger/irritability was greatly improved. Client is pleased with her progress.
Increased the Motherwort to a full dropper twice a day. She gave the Vitex tincture another try and was able to tolerate 20 drops twice daily in hot water. She started taking evening primrose capsules at least once a day. She admits that the evening dose of all her herbs has been inconsistent. She typically forgets the evening dose on the weekends when she is out of her normal routine.
Client ran out of the Si Jun Zi Tang on 1/24. She placed an order for the tincture and is awaiting its arrival to resume. She just ran out of the Custom Formula this morning and reordered. weight gain – no hot flashes – none Sweating – same
hair thinning – same Dryness – no improvement. Hasn’t been taking herbs and evening primrose consistently. Bloating (4) Fatigue (4 out of 10 ) less fatigued Last period? Jan 17. Two days of bleeding. One day spotting. (when she was younger she had 5 days bleeding) No more diarrhea. Diet and lifestyle:Reduced nut intake Sweating: At night in the early morning Sleep: 8-9 hours per night. Difficulty falling asleep on occasion. Wakes up not feeling rested. Energy: 4 out of 10 Pain: No lower back pain. Urination: Pale and clear, occasionally smelly, cough/sneeze incontinence Stool: Still more formed. She has improved her diet. Appetite: Feeling hungry in the morning. Mental State: Feeling a bit better. Irritation is much more in check. Less depression & anxiety. Temperature: Same. Hearing: no issues. Thirst: More thirsty. Waking up with a dry mouth. Drinking more.

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Thomas June 10, 2025

We will have a student presentation this week (tomorrow) for the case study. Please review the case and be

Initial Consultation Date 12/9/24
Case Study Details Gender: F Age: 47 Height: 5’6” Weight: 150 Ethnicity: European Occupation: Licensed acupuncturist and RN
Primary Complaint: Peri-menopause symptoms including hot flashes, weight gain, sweating, hair thinning, dryness, bloating, and fatigue. Brief History: Symptoms began in 2021, when she was still in acupuncture school. Client lives in humid Texas. Stress at work. Recently, she hired a colleague, who prescribed a custom formula, resulting in the client feeling a little better. But significant relief was elusive. The client stopped working with that colleague and is now taking an herbal supplement called “Gleefull Hormone Supplement” (a Yang tonic), which is helping with the sweating and weight gain. Secondary Complaint: none Diet and lifestyle: Client eats fairly healthy and mostly avoids processed foods. She eats a lot of nuts and has two glasses of wine in the evening. Sweating: At night in the early morning Sleep: 8-9 hours per night. Difficulty falling asleep (sometimes racing thoughts, worries). Doesn’t feel rested when she wakes up. Energy: 4 out of 10 Pain: Lower back aching and soreness (doesn’t call it pain). Stabbing menstrual pain in low belly and low back pain. Urination: Pale and clear, occasionally smelly, cough/sneeze incontinence Stool: Pencil-thin and loose, once daily Appetite: Low appetite Mental State: Depression & anxiety. Client tends to be more depressed than irritated. Irritation happens during menses. Temperature: She lives in very humid Texas. Her body feels Hot, but hands and feet are cold. Dislikes the cold. When she was younger, she was always cold. Hearing: no issues Thirst: Thirsty but only desire to drink small sips Other: Two months ago, she had all thyroid labs run (TSH, free T3, free T4, reverse T3, Thyroid Peroxidase Antibodies, Thyroglobulin Antibodies); they came back normal-low but ALL within normal limits. Phone consultation (client lives in a different state). I’ve met her once in person. Client speaks in
a quiet, measured way. She looks pale in photos. Experiencing stomach fullness and sleepiness after meals. Hypochondriac stiffness/tightness. Stuffiness of chest or epigastrium. Feeling of heaviness. Dry mouth especially in the morning. Swollen breasts before period. Menstrual blood is “gooey” and red. Undigested food in stools when she’s extremely stressed approximately once per month. A little vaginal discharge always. Poor memory. Low libido. Medical History: C-section – 28 yo. Childhood tonsillectomy & ear tubes, lumpectomy – 2017. Family Medical History: Mom – emphysema, aFib, HBP. Dad – lung cancer, HBP, alcoholic. Grandparents – cancer, stroke, HBP. Medications: None Supplements: Gleefull Herbal Hormone Supplement (contains vitamins and epimedium, dang gui, ashwagandha, catuaba bark, damiana leaf, ginger root, maca root, mucuna pruiens, muira puama, sarsaparilla, tribulus terrestrius, black pepper). Also takes collagen powder and NAC powder. Tongue: swollen, mostly pale, red edges, scallops, depressed areas in the front and middle/back, purple sublinguals especially in the back Pulse: Rapid, thin, slippery, weak and deep in left rear position (pulse was taken by one of her colleagues) ANALYSIS: Yang and Yin Vacuity (Yang predominant), Liver Invading Spleen TREATMENT STRATEGY: Supplement Kidney Yang and Yin, Subdue and Course Liver and Supplement Spleen HERBAL RECOMMENDATIONS: Variation on You Gui Wan with epimedium and Jia Wei Xiao Yao San Explanation: Client shows predominantly Yang Vacuity symptoms with poor libido, some incontinence, lassitude, subdued and quiet manner, clear urination, pale tongue with white fur. Yin Vacuity symptoms include hot flashes at night and early morning, dry mouth, hair loss, mental restlessness and anxiousness at night (tends to run hot, poor memory, dryness). Liver Yin vacuity has led to a disharmony of the Liver’s function to order the Qi, which has led to irregular menstruation. Irritability is related to the Liver Yin Vacuity and the Vacuity Heat.
Herb
Pin Yin / Pao Zhi
Amount
Epimedium
Yin yang huo
30g
Prepared rehmannia
Shu di huang
12g
Lycii, dry fried
Gao qi zi, chao
12g
Chinese Wild Yam, dry fried
Shan Yao, chao
12g
Cornus, dry fried
Shan zhu yu, chao
12g
American ginseng
Xi yang shen
12g
Eucommia
Du zhong, dry-fried w/ginger juice
12g
Herb
Pin Yin / Pao Zhi
Amount
Bupleurum root
Chai hu
9g
Angelica sinensis, dry fried slightly
Dang gui, chao
15g
White peony
Bai shao
9g
White atractylodes
Bai zhu
9g
Poria
Fu ling
9g
Baked licorice
Zhi gan cao
4.5g
Moutan peony
Mu dan pi
9g
Gardenia fruit, dry fried
Zhi zi, chao
9g
Codonopsis
Dang shen
9g
Vitex berry
Vitex agnus-castus
9g
Motherwort herb
Leonurus cardiaca
9g
Dietary and lifestyle recommendations: Focus on meat protein, whole grains and legumes (legumes contain phytoestrogens), cooked vegetables including dark leafy greens, a little cooked fruit in season. A little seaweed is beneficial, and fermented foods support the gut microbiome responsible for metabolizing estrogen. Avoid nuts and nut butters, avocados, alcohol, caffeine, chocolate, greasy fatty foods, and dairy (as they congest the Liver) with the exception of walnuts, flaxseed, black sesame seeds. Avoid foods that are cool and damp in nature like juices, raw foods, cooling foods like bananas, melons, cucumbers, and soy milk. Evening primrose and borage oils are good for dryness. Vitamin E (300-600 IU daily) can reduce hot flashes, vaginal dryness, breast tenderness. Walnuts, flaxseeds (contains phytoestrogens), black sesame seeds, and honey make a nice snack.
Gentle movement – yoga or Qi gong – can be beneficial. Expression through writing and/or spending time in nature can be beneficial.

January 10, 2025 – Update She has been taking herbs for two weeks, but isn’t taking vitex. Can’t tolerate the vitex in tincture form; it’s too bitter. She will switch to a vitex capsule. Can only take herbs twice daily. I recommended that she increase morning and evening dose, since she’s only taking twice daily. Also recommended increasing motherwort from 10 drops twice daily to 30 drops twice daily. Please retake photo (blurry and drank coffee). weight gain – no hot flashes (3 out of 10 – occasionally) Sweating (2 to 10) hair thinning (5 to 10) Dryness (8) Itchy skin and scalp is worse. Suggested Vitamin E (300-600 IU daily). Bloating (4) Fatigue (6 to 10) holidays were very stressful Last period? Now 21 days late. Irritable. Motherwort 10 drops twice day. She had two episodes of “burning butt diarrhea” (ate chicken & veg, fish and veg – not spicy). Fire hot and foul smelling. Happened hours after taking herbs. No glass of wine with dinner. No recurrence. Holiday stress was very high. Diet and lifestyle: Reduced nut intake Sweating: At night in the early morning Sleep: 8-9 hours per night. Difficulty falling asleep on occasion. Wakes up not feeling rested. Energy: 4 out of 10 Pain: No lower back pain. Urination: Pale and clear, occasionally smelly, cough/sneeze incontinence Stool: More formed Appetite: Poor until 3pm, then hungry. Mental State: Depression & anxiety. Client tends to be more depressed than irritated. Irritation happens during menses. Temperature: Same. Her body feels Hot, but hands and feet are cold. Dislikes the cold. When she was younger, she was always cold. Hearing: no issues Thirst: Same. Thirsty but only desire to drink small sips.

Jan 31, 2025 update Client finally had a period on 1/15. It was 21 days late and had cramps for the first 2 of the 3 days. Bled for 2-3 days. After the onset, her anger/irritability was greatly improved. Client is pleased with her progress.
Increased the Motherwort to a full dropper twice a day. She gave the Vitex tincture another try and was able to tolerate 20 drops twice daily in hot water. She started taking evening primrose capsules at least once a day. She admits that the evening dose of all her herbs has been inconsistent. She typically forgets the evening dose on the weekends when she is out of her normal routine.
Client ran out of the Si Jun Zi Tang on 1/24. She placed an order for the tincture and is awaiting its arrival to resume. She just ran out of the Custom Formula this morning and reordered. weight gain – no hot flashes – none Sweating – same
hair thinning – same Dryness – no improvement. Hasn’t been taking herbs and evening primrose consistently. Bloating (4) Fatigue (4 out of 10 ) less fatigued Last period? Jan 17. Two days of bleeding. One day spotting. (when she was younger she had 5 days bleeding) No more diarrhea. Diet and lifestyle:Reduced nut intake Sweating: At night in the early morning Sleep: 8-9 hours per night. Difficulty falling asleep on occasion. Wakes up not feeling rested. Energy: 4 out of 10 Pain: No lower back pain. Urination: Pale and clear, occasionally smelly, cough/sneeze incontinence Stool: Still more formed. She has improved her diet. Appetite: Feeling hungry in the morning. Mental State: Feeling a bit better. Irritation is much more in check. Less depression & anxiety. Temperature: Same. Hearing: no issues. Thirst: More thirsty. Waking up with a dry mouth. Drinking more.

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