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Topics in gynaecology - part one - menopause

concentration of these hormones. Although the type ofoestrogen responsible for the menstrual cycle is no longer This series of articles addresses the health problems produced, there is still a form of active oestrogen prduced particular to women in their forties, fifties and onwards, after menopuase. Now the ovaries and adrenals produce i.e. the sorts of things occurring in the years leading up androstenadione which is changed to oestrone (a type of to, during and after the menopause. Large numbers of oestrogen) in the fat cells of the body. Many women put women in these age groups are consumers of health care on weight after menopause possibly in an attempt to and they frequently present a clinical challenge. They produce enough of this oestrogen. Even if other forms of have in the past been a neglected area of the population oestrogen are given as treatment after menopause, the and yet in modern society an ever increasing percentage body rapidly changes this oestrogen to oestrone.
of the population comprises this age group.
Let us first look in detail at what happens to a woman’s THE CLINICAL PICTURE
physiology as she approaches menopause, usuallyaround age 50 but sometimes as much as ten years 20% of women suffer marked symptoms at the earlier. We shall do this first from a western scientific menopause, 20% have none and 60% suffer mild medical (WSM) perspective and examine the social and symptoms. Those 20% of women who suffer badly at cultural context of the menopause. We shall then look at menopause and perhaps some of the 60% who suffer a traditional Chinese medical (TCM) understanding of mild symptoms are the women who present themselves at doctor’s surgeries requesting help. Hence it is easy tosee why the medical profession has adopted the attitudethat menopause is a disease requiring treatment. The WHAT HAPPENS DURING MENOPAUSE
assumption is made that when the ovaries stop producing The ovaries are covered with eggs (like sago). Each oestrogen all women must necessarily be deficient in month one egg ripens under the influence of a hormone oestrogen (see later for discussion of hormone produced by the pituitary gland, viz. follicle stimulating hormone (FSH), and the ovary will begin to produce Implicit in the idea of oestrogen deficiency is the oestrogen. The egg is released from the ovary and leaves notion that women need the same level of oestrogen after behind it a structure known as the corpus luteum. The menopause that they needed in the reproductive years, corpus luteum continues to produce oestrogen and and that for one third of their lives the body is malfunc- progesterone unless there is no pregnancy. The follicles tioning. But a woman whose body is no longer preparing are depleted month by month and the ovaries gradually for pregnancy each month does not need the same high become scarred. There are however plenty of unripened levels of oestrogen that went with the reproductive follicles left when a woman reaches middle age. Ovulation becomes less frequent until it eventually stops. This Another theory/idea used to explain the physical process is called involution of the ovaries. Oestrogen symptoms of menopause is the rate theory i.e. the symp- blood levels fall below the point necessary to produce toms are a temporary reaction to the relatively sudden it is easy to see why the medical profession
has adopted the attitude that menopause is a
disease requiring treatment
until it becomes stable with virtually no oestrogen pause as a period of adjusting to changing levels and types of sex hormones which adversely affects some WSM describes a connection between ovarian involu- women a great deal, some women not at all, and the tion and the brain in physiological terms and psycho- majority of women in a mild and transient way.
logical functions, e.g. emotional changes like vulnerabil- (NB - TCM with its emphasis on balance can certainly ity, loss of concentration, irritability etc.
help smooth the way in times of adjustment and may The feedback mechanism to the brain (pituitary) when well be able to predict those women likely to suffer more the oestrogen and progesterone fall, is no longer operat- during the menopause years. see TCM section follow- ing and the pituitary keeps producing FSH and luteinis- ing hormone (LH) at high levels. Blood tests to deter- So just what exactly are the symptoms of menopause? mine if a woman is going through menopause test the Looking at medical literature reveals an inconsistent and JOURNAL OF CHINESE MEDICINE NUMBER 33 MAY 1990
varied list of symptoms. Similarly publications of TCM with tedious and boring factory jobs report the most and Kanpo (traditional Japanese medicine) origin list a symptoms, even more than those without jobs at all. 6 variable number and type of symptoms. In 1976 there As well as different cultural stereotypes producing was an international medical conference held to try and different experiences of menopause, the expectations of clear up the disagreements. Its proceedings state that the female population of different countries also influ- informed medical opinion considered only hot flushes ences their experience. Women in Australia and the USA and vaginal atrophy to be true oestrogen deficiency have similar expectations of what menopause will bring and indeed report similar symptoms in type and fre- Hot flushes and sweating (either severe or mild) occur quency. However women in Norway dread the meno- in 70-80% of menopausal women, while vaginal atrophy pause more and have an even more difficult time on occurs in 10% of women. Other associated symptoms which were universally agreed to be part of the clinical Whether it is the expectation or the perception of symp- complex were palpitations, pain in the joints, headaches, toms that brings about the wide variation in the experi- insomnia, psychological disturbances (anxiety, irritabil- ences of women around the world is not known. It is ity, nervousness, and moodiness), and osteoporosis.
possible that women do in fact have similar symptoms All these symptoms can occur in women without but perceive them differently. S.Ballinger and menopause or in men (except vaginal atrophy). How- W.L.Walker give the example of childbirth, which in ever it is the clustering or combination of these symp- some countries is a medical crisis and in others is an toms that forms the “menopausal syndrome”.
event which hardly interrupts the daily routine. Anotherway of looking at this is that if an event is perceived SOCIAL AND CULTURAL FACTORS
positively then it is experienced differently from oneperceived negatively, e.g. the nausea and abdominal Many health workers believe that there is an overlap discomfort of pregnancy can be severe but cause much between menopausal symptoms and stress symptoms.
less distress than similar symptoms experienced by a Why is it that stress occurs in menopausal women more woman with a pelvic tumour for which she is receiving than other women? Or is it that a special sort of stress nausea-producing chemotherapy. So while menopause occurs which produces the above constellation of symp- continues to be promoted as a disease in our society it toms? Or is it the change in hormones that makes a tends to guarantee or create the symptoms and the To answer this we need to look at menopause in its In addition to the largely unconscious stresses of re- cultural and social context. This has been covered by S.
duced status and the expectations of the appearance of Ballinger and W.L.Walker in their excellent book on symptoms at menopause, there are some other very real menopause called “Not the Change of Life”.2 stresses that tend to occur during the years of 40-60, as Let’s look first at cultural stereotypes. Stereotypes are big lifestyle adjustments have to be made, e.g. a radical powerful tools which mould the social reality of change of role in the home or workforce, empty nest individuals. Cultures like the Rajput caste in India where syndrome, retirement, and changes of relationship within a woman’s status increases after menopause and she no the family such as the retirement of the husband, the longer has to wear a veil over her face and is given certain arrival of granchildren etc. S.Ballinger and W.L.Walker privileges report virtually no symptoms related to hold that in fact the physiological adjustment to changed menopause.3 Similarly the Lugbara women in Uganda hormone levels may contribute very little to the overall who also gain status after menopause say they experience stress inherent in this phase of life, i.e. menopause is not no menopausal symptoms.4 The Indian women of Mexico necessarily a major influence on how a woman feels in become heads of their married sons’ families and these middle years. They maintain that as more under- households when they reach menopause and sail through standing of middle age and menopause is gained it is it without a hiccup. 5 This is obviously in sharp contrast becoming clearer that the biological event of menopause to our society where youth and beauty in women is does not appear to be the central event in women’s
The Indian women of Mexico become heads
the psychological impact
of their married sons’ families and house-
holds when they reach menopause and sail
age (above), only one of
through it without a hiccup.
of menopausal difficulties then we would expect it to be a greater problem here than in China where women are TCM in its description of menopausal syndrome does appreciated more for what they offer society than for take this into account, even though it is not specifically their youth or looks. It is my impression that this is so, i.e.
stated. Rather then being seen as an oestrogen deficiency it is a common presenting problem in my clinic but not disease, it is understood to be a time of particular changes so frequently seen in TCM clinics in China compared to and stresses which produce certain patterns of dishar- mony. In Kanpo medicine a set of symptoms is recog- More evidence that backs up the effect of positive or nised which Japanese doctors call by the rather horrify- negative cultural factors on the severity of menopause is ing title of “women’s erratic syndrome”. Another catch seen in surveys of women in societies similar to our own.
phrase frequently heard referring to women in Japan is Frequency and severity of symptoms is associated with “autonomic nervous system disorder” - a term used to low status or self esteem. Most notably those women describe the middle age dilemmas of Japanese women.
Herbal formulae (see next section for details)
TCM theory talks about the Chong, Ren and Kidney channels rather than the ovary, pituitary and oestrogen.
According to the theory of the 7 year cycles for women, the Kidney-Qi begins to decline as the 7th cycle is ap-proached. Thus it is at about the age of 49 years that theKidney-Qi begins to decline or the Tian Gui becomes 2. Kidney-Yang-Xu (with or without
exhausted, and the Chong and Ren channels are no Spleen Yang Xu)
longer nourished. This manifests in the irregular nature of the periods which come at erratic intervals and with The imbalanced functioning of the Chong and Ren chan- nels and the declining Kidney-Qi often lead to predispo- sition to Yin and Yang disequilibrium, giving rise to symptoms typical of Kidney-Yin (or less frequently Kid- - abdominal distention, fullness of the epigastrium ney-Yang) deficiency. This may then give rise to defi- ciency in other organs, e.g. Spleen-Yang-Xu or Heart- Blood-Xu or Liver-Yang rising. Chinese gynaecology texts describe the symptoms of menopause as: irregular periods, emotional lability, irritability, listlessness, flush- ing and sweating, dizziness, vertigo, palpitations, in- Treatment principle: warm the Kidney, regulate Qi, somnia, thirst, poor appetite, 5 hearts hot, tinnitus, for- resolve Phlegm, and invigorate the Spleen.
getfulness, hypertension, lumbar soreness, abnormal Acupuncture
bowel movements, dry skin and vagina, and formication Shanzhong REN-17, Zhongwan REN-12, Qihai REN-6 - (a sensation of insects crawling on the skin).
to regulate Qi and resolve phlegm. Use moxa.
These symptoms are grouped into three main catego- Guanyuan REN-4 - to warm the Kidney. Use moxa ries, and for the purpose of herb prescribing, a 4th type: Zhigou SJ-6 - to promote the smooth circulation of Qi i. Kidney-Yin-Xu (with Liver-Yin-Xu and Liver- Sanyinjiao SP-6 - to invigorate the Spleen and Kidney ii. Kidney-Yang-Xu (with Spleen-Yang-Xu).
Herbal formulae
iii. Heart-Blood-Xu.
iv. Kidney Yin and Yang Xu.
You Gui WanBa Wei Di Huang Wan(Lui Jun Zi Tang) DIFFERENTIATION AND
3. Heart-Blood-Xu
This type is often an outcome of Kidney-Yin-Xu or may 1. Kidney-Yin-Xu (with Liver-Yin-Xu and
be caused directly by constant mental stress. A defi- Liver-Yang rising)
ciency of Blood may also be related to Spleen deficiency.
Rising heat is the distinguishing feature of this type - flushing in the face (especially after midday) and - dizziness, vertigo, headache, blurred vision, tinnitus - weakness and soreness of the lower back and legs - fullness of the epigastrium or low appetite Treatment principle: tonify Heart-Blood, nourish Kid- ney-Yin, strengthen the Stomach and Spleen.
Treatment principle: nourish Yin, calm the Liver, sub-due Yang and tonify the Stomach and Spleen.
Xinshu BL-15 - to tonify the Heart and calm the mindPishu BL-20 - to tonify the Spleen to manufacture Blood; Acupuncture
Taichong LIV-3 or Ququan LIV-8 - to calm the Liver and Shenshu BL-23 - to tonify Kidney-Yin and harmonise the Fengchi GB-20 - for dizziness etc. from Liver Yang rising Sanyinjiao SP-6 - to tonify the Spleen to nourish Blood; Daling P-7 - for irritability etc. from Liver Yang rising Shenshu BL-23 - for lower back pain from Kidney Xuehai SP-10 - to tonify Blood to reduce internal Wind; Pishu BL-20 or Zusanli ST-36 - to strengthen Acquired Qi JOURNAL OF CHINESE MEDICINE NUMBER 33 MAY 1990
Herbal formulae
unlike the others which belong to the tonification catego- Sheng Di Huang (Radix Rehmanniae Glutinosae) - coolsthe Blood; Xuan Shen (Radix Scrophulariae Ningpoen- 4. Kidney Yin and Yang Xu
sis) - cools the Blood; Tian Men Dong (Tuber Asparagi This type is a mixture of Kidney-Yin and Kidney-Yang Cochinchinensis) - Yin tonic; Mai Men Dong (Tuber deficiency where signs of both heat and cold are present.
Treatment principle: reinforce Kidney-Yin and warm These are all used to nourish Heart Yin.
Fu Shen (Poriae Cocos Pararadicis Sclerotium) - calms Acupuncture
the Shen; Yuan Zhi (Radix Polygalae Tenuifoliae) - calmsthe Shen; Bai Zi Ren (Semen Biotae Orientalis) - calms the Taixi KID-3, Zhaohai KID-6, or Fuliu KID-7 - to tonify Shen; Suan Zao Ren (Semen Ziziphi Spinosae) - calms the Rangu KID-2 - to reduce blazing fireGuanyuan REN-4 - to tonify the Kidney These all soothe the nerves of the Heart and replenish Zusanli ST-36 - to support the Acquired Qi Sanyinjiao SP-6 - to support the Acquired Qi and the Wu Wei Zi (Fructus Schisandrae Chinensis) - consoli- dates Heart-Yin; Dang Gui (Radix Angelicae Sinensis) - Herbal formulae
tonifies Heart-Blood; Dang Shen (Radix Codonopsis Pi-losulae) - tonifies the Qi; Jie Geng (Radix Platycodi Er Xian Tang combined with Zuo Gui Wan.
Grandiflori) - raises herbs to the Upper Heater; soothes Herbal formulae commonly used in
and consolidates the Yin of the Heart.
menopausal patterns 8
This formula is useful in nourishing Yin, tonifying Blood 1. Zhi Bai Di Huang Wan or Zhi Bai Ba Wei Wan
and soothing the nerves. It is chosen when menopausalsymptoms are accompanied by extreme insomnia and This is Anemarrhena, Phellodendron and Rehmannia formula or 8 Flavour Tea and consists of Lui Wei DiHuang Wan (Rehmannia Six formula) plus two herbs to 4. Zuo Gui Wan
clear heat. When used in menopausal patterns it is often This is a Yin tonifying formula, based on Liu Wei Di suggested to add a further two herbs to calm the spirit.
Huang Wan. It tonifies the Liver and Kidney and replen- Shu Di Huang (Radix Rehmanniae Glutinosae Conqui- ishes Yin and Blood more strongly than does Liu Wei Di tae) a Blood tonic herb which also nourishes Yin and Huang Wan, i.e. for more depleted and possibly older tonifies the Kidney; Shan Yao (Radix Dioscoreae Opposi- patients, with Kidney and Liver weakness. It does not tae) - Qi tonic to invigorate the Spleen; Shan Zhu Yu (Fructus Corni Officinalis) - an astringent herb which Shu Di Huang (Radix Rehmanniae Glutinosae Conqui- warms and tonifies the Liver and Kidney and consoli- tae) - Blood tonic; Shan Yao (Radix Dioscoreae Opposi- dates the essence (especially Liver-Yin); Fu Ling (Scle- tae) - Qi tonic; Shan Zhu Yu (Fructus Corni Officinalis) - rotium Poriae Cocos) - a diuretic herb which helps to astringent. This is the base of Liu Wei Di Huang Wan.
remove damp produced by the tonifying herbs, and Tu Si Zi (Semen Cuscutae) - Yang tonic; Gou Qi Zi tonifies the Spleen; Ze Xie (Rhizoma Alismatis Plantago- aquaticae) - a diuretic herb but used here to preventKidney fire flaring; Mu Dan Pi (Cortex Moutan Radicis) These two herbs tonify the Liver and Kidney.
- a cooling herb to purge fire from the Liver and Kidney Lu Jiao Jiao (Colla Cornu Cervi) - Yang tonic; Gui Ban Zhi Mu (Radix Anemarrhenae Asphodeloidis) - clears heat; Huang Bo (Cortex Phellodendri) - clears heat; Long These herbs replenish Yin and Blood.
Gu (Os Draconis) - calms the Shen; Mu Li (Concha Niu Xi (Radix Achyranthis Bidentatae) - regulates Blood This herb is used to strengthen the tendons and bones.
This formula is used to nourish Yin, tonify the Kidney,and control flaring up of fire due to Yin deficiency.
5. Er Xian Tang
2. Da Bu Yin Wan
This is a Yang tonifying formula designed specificallyfor use in menopause because it tonifies the Kidney, This is available in pill form. It tonifies the Yin and is removes fire and regulates the Chong and Ren channels often used for menopausal disorders if there is fire (therefore useful if the periods are coming erratically in early menopause). It can be combined with Zuo Gui Wan Shu Di Huang (Radix Rehmanniae Glutinosae Conqui- tae) - tonifies Kidney Yin; Gui Ban (Plastrum Testudinis) Xian Mao (Rhizoma Curculiginis Orchioidis) - Yang - subdues Yang; Huang Bo (Cortex Phellodendri) - clears tonic; Xian Ling Pi (Herba Epimedii) - Yang tonic; Ba Ji heat ; Zhi Mu (Radix Anemarrhenae Asphodeloidis) - Tian (Radix Morindae Officinalis) - Yang tonic 3. Tian Wang Bu Xin Dan or Bu Xin Wan
Huang Bo (Cortex Phellodendri) - clears heat; Zhi Mu This formula (available in pill form) also tonifies the (Radix Anemarrhenae Asphodeloidis) - clears heat Kidney and lowers blazing fire but pacifies the heart Dang Gui (Radix Angelicae Sinensis) - Blood tonic. This more strongly than the previous formula. It belongs to herb nourishes Blood to regulate the Chong channel.
the Tranquillising and Sedating category of formulae, JOURNAL OF CHINESE MEDICINE NUMBER 33 MAY 1990
NB Care should be taken with long term use because 8. You Gui Wan
Xian Ling Pi (also known as Yin Yang Huo) can damage This is a tonification formula used in menopausal pat- Yin. It has androgen like activity on male organs and no terns with Yang deficiency (usually with some addi- demonstrable oestrogen effects. This formula can be tions). It warms the Yang of the Kidney. It is appropriate used in menopausal patterns of deficient Liver and to use when there is evidence of failing of Ming Men fire.
Kidney Yin (and rising Yang), as well as deficient Kidney It is based on Fu Gui Ba Wei Wan (Rehmannia Eight Yin and Yang patterns where it is combined with Zuo Formula) minus Fu Ling, Mu Dan Pi and Ze Xie. This formula may also be used in menopausal patterns where 6. Gui Pi Tang , or Kwei Pi Tang (Ginseng and
the symptoms are due to deficiency of both Yin and Yang Longan formula)
of the Kidney. However You Gui Wan has a strongeraction in warming and tonifying Kidney.
This is another useful menopausal formula. It soothesthe nerves and nourishes the Heart but its main action is Shu Di Huang (Radix Rehmanniae Glutinosae Conqui- to invigorate the Spleen and replenish Qi. It is especially tae) - Blood tonic; Shan Yao (Radix Dioscoreae Opposi- useful if the periods in early menopause are very heavy.
tae) - Qi tonic; Shan Zhu Yu (Fructus Corni Officinalis) - (Radix Ginseng) - Qi tonic; Huang Qi (Radix Astragali) - Qi tonic; Bai Zhu (Rhizoma Atractylodis This group nourishes the Kidney, Liver and Spleen Yin.
Macrocephalae) - Qi tonic; Fu Ling (Sclerotium Poriae Lu Jiao Jiao (Colla Cornu Cervi) - yang tonic; Tu Si Zi Cocos) - diuretic; Zhi Gan Cao (Radix Glycyrrhizae Uralen- (Semen Cuscutae) - Yang tonic; Du Zhong (Cortex Eu- sis) - Qi tonic; Hong Zao (Fructus Zizyphi Jujubae) - Qi commiae Ulmoidis) - Yang tonic; Gou Qi Zi (Fructus These all invogorate the Spleen and replenish Qi.
This group of herbs warm and tonify the Kidney.
Suan Zao Ren (Semen Ziziphi Spinosae) - calms the Shen; Dang Gui (Radix Angelicae Sinensis) - Blood tonic Yuan Zhi (Radix Polygalae Tenuifoliae) - calms the Shen; Fu Zi (Radix Aconiti Carmichaeli Praeparatae) - warms Long Yan Rao (Arillus Euphoriae Longanae) - Blood the interior; Rou Gui (Cortex Cinnamomi Cassiae) - warms tonic; Dang Gui (Radix Angelicae Sinensis) - Blood tonic.
This group tonify Blood to nourish the Heart and soothe These two herbs warm and tonify the Yang of the Kid- Mu Xiang (Radix Saussureae seu Vladimirae) - regulates N.B. Warming herbs are contraindicated in Yin defi- Qi; Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) ciency cases with heat, but note that a symptom like flushing can occur in Yang deficiency cases where the If Shu Di Huang (Radix Rehmanniae Glutinosae Conqui- deficient Yang floats upwards. In this case the heat in the tae) is added to this formula it is called Hei Gui Pi Tang upper body would be combined with severe cold symp- and provides stronger Blood tonification.
toms in the lower body, e.g. cold in the back and legs and 7. Ba Wei Di Huang Wan
diarrhoea. In such cases a herb like Rou Gui (CortexCinnamomi Cassiae) can be used to lead fire back to its This is used for patterns of menopause due to deficiency of Kidney-Yang since it warms and tonifies the Yang of Some common additions to this formula are the follow- the Kidney. It is based on Liu Wei Di Huang Wan with the addition of warming herbs. It treats Kidney-Yangdeficiency syndrome, i.e., cold and sore legs and lower Dang Shen (Radix Codonopsis Pilosulae) - Qi tonic; Bu back, difficult urination, incontinence, frequent nocturia Gu Zhi (Fructus Psoraleae Corylifoliae) - Yang tonic; Yin and diarrhoea etc. and associated Spleen-Yang defi- Yang Huo (Herba Epimedii) - Yang tonic; Xian Mao ciency symptoms such as retention of body fluids and accumulation of phlegm, i.e. it warms the lower body.
Shu Di Huang (Radix Rehmanniae Glutinosae Conqui- 1. P.A.Van Keep, R.Greenblatt and M.Albeaux-Fernet (eds) tae) - Blood tonic; Shan Yao (Radix Dioscoreae Opposi- Concensus on Menopausal Research, MTP Press, Lancaster tae) - Qi tonic; Shan Zhu Yu (Fructus Corni Officinalis) - 2. S.Ballinger and W.L.Walker, Not the Change of Life, Breaking the Menopause Taboo, Penguin Books 1987.
These herbs are three tonics for the Kidney, Spleen and 3. M.P.Flint, Transcultural Influences in Perimenopause, in A.A.Haspels and H.H. Musaph (eds), Psychosomatics in Peri- Fu Ling (Sclerotium Poriae Cocos) - diuretic; Ze Xie menopause, MTP Press, Lancaster, 1979.
(Rhizoma Alismatis Plantago-aquaticae) - diuretic.
4. J.Middleton, The Lugbara of Uganda, Holt, Rinehart and To improve diuresis to remove damp and/or stagnation 5. Y.Beyene, Climacteric Expression in a Cross Cultural Study, Paper presented at the fourth International Congress on Mu Dan Pi (Cortex Moutan Radicis) - cools Blood. Used to clear heat from the Liver and Kidney.
6. P.A.Van Keep and J.M.Kellerhalls, The impact of Socio- Cultural Factors on Sympto Formation, in Psychotherapy and (Ramulus Cinnamomi Cassiae) - Yang tonic; Fu Psychosomatics, 1974, vol. 23, p.251.
Zi (Radix Aconiti Carmichaeli Praeparatae) - Yang tonic 7. M.Hepworth, “Sociological Aspects of Mid-life” in P.A.Van To warm and tonify Kidney Yang. Because these last two Keep, W.M.Utian and A.Vermeulen (eds) The Controversial herbs are very drying and warming, this formula should Climacteric, MTP Press, Lancaster, 1982 pp 19-28.
not be used if there is any deficiency of Yin or fluids.
8. Handbook on TCM (Zhejiang college) and The Shanghai

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