Traditional Chinese Medicine (TCM) Case Summary
Clinic: Dr Hao TCM Healthcare
Address: 16 Fulham High Street, London SW6 3LQ
Phone: 020 3633 8886
Date: 22 May 2025
Patient: Ms. Anna Li, Age 35, Primary School Teacher
Chief Complaint:
Irregular menstruation for 5 years, worse in 6 months; hair loss, white sticky discharge, fatigue, and lower abdominal discomfort.
History:
Cycles 30–60 days, scanty dark flow with clots. Ovarian cyst (5.0×4.2 cm). Fatigue and distension noted.
Tongue/Pulse:
Pale enlarged tongue with greasy white coat. Pulse deep and slippery.
Diagnosis:
Spleen deficiency with dampness and blood stasis obstructing Chong and Ren.
Treatment Principles:
Tonify spleen, eliminate damp, move blood, resolve stasis, regulate menses, and reduce masses.
Herbal Decoction (Daily Dose):
Dang Shen, Bai Zhu, Fu Ling, Chen Pi, Cang Zhu, Shan Yao, Dan Pi, Chuan Xiong, Chi Shao, Tao Ren*, E Zhu*, Yi Mu Cao*, Xiang Fu, Zhi Gan Cao.
(*May require substitution per UK regulation.)
Instructions:
Take twice daily for 2 months. Pause during menstruation.
Acupuncture Plan:
Points: CV3, CV4, SP6, ST36, LR3, Zigong.
Frequency: 2–3 times/week; 10 sessions/course; 2–3 courses recommended.
Expected Effects:
Helps regulate menstruation, may reduce cysts, improve energy, discharge, and hair loss with consistent treatment.
