Chapter 58 Menopausal Syndrome
Menopause usually occurs between the ages of 48 and 55 and the median age in industrialized countries is about 51. It will be remembered that the very first chapter of the Simple Questions describes the 7-year cycles of women, according to which menopause occurs at 49 (7 × 7): this is not far from the above-mentioned median age of 51. Furthermore, data analyses indicate that the menopausal age has remained unchanged for centuries.1 Indeed, the mean age at menopause is just over 50 and this is remarkably constant not only throughout the Western world but also in other countries. A survey of Malaysian women showed a mean age at menopause of 50.7 years, and another of seven Asian countries found that most women reached menopause at around 50.2
The primary basis for the progressive decline of reproductive power in women is in the ovary itself, as ovarian follicles are greatly depleted by the time of the menopause. It is interesting to note that there is a progressive decline of follicles even from the time before birth. In fact, at the time the ovaries are formed in the fetus, there are approximately 6 000 000 primordial follicles, which decrease to about 600 000 at birth, to 300 000 at menarche and to about 10 000 at the time of the menopause. This would seem to confirm that the menopause is not an event that takes place suddenly in a woman’s life but one that reflects a gradual physiological process throughout her lifetime, starting even before her birth.
The implications of this are two-fold. First, it confirms that the biological basis of the menopause is determined during a woman’s lifetime and that, therefore, her lifestyle and dietary habits from childhood onwards determine what kind of menopause she is going to have. If a woman has a poor diet and if she overworks for several years prior to the onset of the menopause, she will be more likely to develop problems during the climacteric years. Second, the fact that there are 6 million primordial follicles in the fetus, gradually declining to about 10 000 at menopause, seems to confirm the Chinese medicine view according to which the Essence (which is the biological basis for the development of follicles) performs many functions other than purely reproductive ones: basis of our hereditary constitution, it flows in the Extraordinary Vessels, it determines energy, drive and strength, it influences our resistance to pathogenic factors and is the foundation for the immune system. Thus any detrimental lifestyle habits influence a woman’s reproductive system and, vice versa, a taxation of the reproductive energy (through having too many children too close together or through having an active sexual life at too early an age) affects her body and mind in other areas.
As the follicle activity decreases and then ceases, there is a lack of oestrogen and therefore a cessation of the menses. Although Western medicine seems to place all the emphasis on oestrogen depletion occurring during the menopause (reflected at a therapeutic level with the use of hormone replacement therapy which is mostly based on supplying oestrogen), it should not be forgotten that during menopause there is obviously also a decrease of progesterone, which is secreted by the corpus luteum after ovulation occurs: no ovulation, no progesterone.
Menopause is not a disease, it is the normal physiological transition in a woman’s life from a reproductive to a non-reproductive age: indeed, many women experience no ‘symptoms’ during this time. The menopause needs medical intervention only when a woman experiences uncomfortable symptoms which affect her life to a greater or lesser degree. In a minority of cases, such symptoms may be very severe and make the woman’s life a misery. From a Chinese perspective, menopausal symptoms (if there are any) are generally due to a decline of Kidney-Essence in its Yin or Yang aspect; however, within this basic pathology there can be many variations of pattern. Moreover, the deficiency of the Kidneys may often be combined with excess patterns, especially Dampness, stagnation of Qi, stasis of Blood, Empty-Heat or Liver-Yang rising. In a few cases, premature menopause may be caused by stagnation and Phlegm rather than by a Kidney deficiency.
Of course, I am now discussing the menopause as the natural transition that occurs as a result of the decline in ovarian function. The menopause that occurs abruptly in a woman under the menopausal age as a result of oophorectomy (the removal of ovaries during a hysterectomy) is quite different. This is not the result of a gradual, natural decline in Kidney-Essence but purely the result of the removal of the ovaries.
Also, early menopause is quite different than the one occurring as a result of the natural, gradual decline of Kidney-Essence. Early menopause, defined in my opinion as that occurring under 40 years of age, is not due to the natural decline of Kidney-Essence (which is physiological) but to a pathology such as Blood stasis and/or Phlegm.
The severity of the problems a woman experiences during the menopause depends, as we have mentioned above, on the lifestyle and dietary habits throughout her life. The main problems she is likely to experience with varying degrees of severity are: hot flushes (flashes), vaginal dryness, headaches, tiredness, lethargy, irritability, anxiety, nervousness, depression, insomnia, inability to concentrate and sweating. By far the commonest symptom is hot flushes (flashes), from which 85% of menopausal women suffer; 45% may experience them for 5–10 years after the menopause. Indeed, some gynecologists say that, strictly speaking, only hot flushes and vaginal dryness are oestrogen-deficiency-related manifestations in their opinion; most of the other manifestations are due to increased stress at this time of life. Considering the increased stress posed on women through work and family in the past 40–50 years, there is some truth in this view. However, seen from a Chinese perspective, it does not really matter which symptoms are due to oestrogen deficiency and which are not, as the underlying pattern in most of them is a Kidney deficiency.
Aetiology
Having just said above that the menopause is not a disease, it may seem contradictory to discuss its ‘aetiology’. Although the menopause is not a disease, its symptoms are influenced by the lifestyle factors, chief among them emotional stress, overwork and diet. Thus, the factors discussed below are not the causes of the menopause but simply factors that would aggravate its symptoms.
Emotional stress
Emotional stress is an extremely important cause of menopausal problems, building up for year after year before the onset of the menopause. Worry, anxiety, anger, guilt and fear weaken the Kidneys and would aggravate the decline of Kidney-Essence.
Overwork, too many children too close together
Overwork, in the sense of working long hours without adequate rest usually combined with irregular diet and worry, is the most important and frequent cause of Kidney deficiency (and especially Kidney-Yin). Having too many children too close together also contributes to weakening the Kidneys.
Irregular diet
Excessive consumption of greasy foods
Excessive consumption of greasy foods and dairy foods over many years leads to the formation of Phlegm. In my experience, Phlegm is common in many menopausal women and it aggravates the symptoms of hot flushes, insomnia and mental restlessness.
Diet lacking in nourishment
Women who have a vegetarian diet for many years may suffer from Blood and/or Yin deficiency if they do not pay particular attention to food combining and to getting enough vegetable protein.
Smoking
Tobacco is hot and drying and it damages Blood, Fluids, Essence and Yin. Tobacco was introduced into China in 1575 and Chinese doctors analysed its effects to see if it could be used as a medicinal herb. They came to the conclusion that it cannot as it is toxic: they also identified its energy as hot and drying.
It is interesting that although the ancient Chinese doctors realized that tobacco injures the Lungs, they seemed to place more emphasis on injury of the Essence and of the Kidneys. As such, it therefore injures the Kidney-Essence and would aggravate menopausal symptoms.
Pathology
As mentioned above, menopausal problems are fundamentally due to a decline of Kidney-Essence which can take the form of Kidney-Yin, Kidney-Yang or a combined Kidney-Yin and Kidney-Yang deficiency. Some sources say that menopausal symptoms are due to Kidney-Yin deficiency: this is not accurate as they are due to a decline of Kidney-Essence that can take the form of Kidney-Yin or Kidney-Yang deficiency. Indeed, I would say that roughly half of the menopausal women I see have a Pale tongue and therefore suffer from Kidney-Yang deficiency.
However, the most common situation in the menopausal age is that there is a deficiency of both Kidney-Yin and Kidney-Yang albeit in differing proportions; if Kidney-Yang deficiency predominates, the tongue will be Pale. As mentioned in Chapter 3 on pathology, a combined deficiency of both Kidney-Yin and Kidney-Yang in women over 40 is very common: indeed, it is probably more the rule than the exception. With Kidney-Yin deficiency, it is easy to explain the hot flushes (flashes): when Yin is deficient, Empty-Heat develops. How to explain hot flushes in Kidney-Yang deficiency? This is due to the fact that when Kidney-Yang is deficient, Kidney-Yin is also deficient (albeit to a lower degree) and therefore some Empty-Heat also develops. Quite simply, in a menopausal woman, if the tongue is Pale, Kidney-Yang deficiency predominates: if the tongue lacks a coating (completely or partially), Kidney-Yin deficiency predominates (see Figures 3.2 and 3.3 in Chapter 3). For this reason, when using prepared remedies, one can often use two remedies simultaneously (each with a reduced dosage): the Yin-nourishing remedy can be given in the evening and the Yang-tonifying one in the morning, with the dosages of each reduced (compared with when a single remedy is used) and adjusted according to the predominant deficiency, e.g. a higher dose of the Yin-nourishing remedy if deficiency of Kidney-Yin predominates and vice versa if deficiency of Kidney-Yang predominates.
Although a deficiency of the Kidney-Essence (in its Yin or Yang aspect) is always at the root of menopausal problems (with the exception of premature menopausal problems from Phlegm), such deficiency does not occur in a vacuum and there will be some other pathology that has been accumulating over the years preceding the menopause. Thus, the menopause is often accompanied by some other pathology, notably Dampness, Phlegm, Liver-Yang rising, stagnation of Qi or stasis of Blood. So, if a tailored formula is used, this should be modified to treat the above patterns too. If the above Full patterns are pronounced, then it might be advisable to deal with these first by using a decoction that resolves Dampness, moves Qi or invigorates Blood. For example, were the deficiency of the Kidneys accompanied by a pronounced stasis of Blood, one might invigorate Blood and eliminate stasis first by using for a few weeks a formula such as Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction. Similarly, were Dampness pronounced, one might start with a decoction to resolve Dampness in the Lower Burner such as Si Miao San Four Wonderful Powder.
Identification of patterns and treatment
Before discussing the treatment of various patterns, it should be clarified that if a woman is taking hormone replacement therapy (HRT or ERT), treatment with Chinese herbs is not in contradiction with it as the two work in markedly different ways. If the woman desires, HRT (ERT) can be stopped without dangerous reactions, but she should be warned that the menopausal symptoms may return before the Chinese herbs have time to take effect (which is about 2 months). For a discussion of HRT (ERT), see the end of this chapter.
Kidney-Yin deficiency
Clinical manifestations
Dizziness, tinnitus, malar flush, night sweating, hot flushes, lower backache, dry mouth, dry hair, dry skin, itching, constipation. Tongue: without coating (completely or partially); Red if there is Empty-Heat. Pulse: Floating-Empty, or Fine-Rapid, or very Deep-Weak on both Rear positions and Overflowing on both Front positions.
Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, KI-10 Yingu, Ren-4 Guanyuan, KI-13 Qixue, SP-6 Sanyinjiao, HE-6 Yinxi, KI-7 Fuliu, L.I.-4 Hegu. All with reinforcing method, except for HE-6 which should be needled with even method. No moxa.
Herbal treatment
a Prescription
b Prescription
Explanation
This formula is also primarily for Yin deficiency without much Empty-Heat. Compared with the previous formula, it is more absorbent and therefore better suited to sweating.
c Prescription
Explanation
This formula places the emphasis on nourishing Yin, absorbing fluids and calming the Mind: it is therefore used for hot flushes with sweating and mental restlessness.
d. Prescription
Explanation
The first six herbs constitute the formula Liu Wei Di Huang Wan which nourishes Liver- and Kidney-Yin.
This formula nourishes both Kidney-Yin and Kidney-Yang, but primarily Kidney-Yin.
Modifications
These modifications apply to all the above formulae.
Table 58.1 compares and contrasts the four above formulae for menopausal problems from Kidney-Yin deficiency.
Women’s Treasure remedy
This remedy nourishes Kidney-Yin, clears Empty-Heat and absorbs fluids, and is specific for menopausal problems from Kidney-Yin deficiency.
Kidney-Yin deficiency
Clinical manifestations
Dizziness, tinnitus, malar flush, night sweating, hot flushes, lower backache, dry mouth, dry hair, dry skin, itching, constipation. Tongue: without coating (completely or partially); Red if there is Empty-Heat. Pulse: Floating-Empty, or Fine-Rapid, or very Deep-Weak on both Rear positions and Overflowing on both Front positions.
Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, KI-10 Yingu, Ren-4 Guanyuan, KI-13 Qixue, SP-6 Sanyinjiao, HE-6 Yinxi, KI-7 Fuliu, L.I.-4 Hegu. All with reinforcing method, except for HE-6 which should be needled with even method. No moxa.
Kidney-Yang deficiency
Clinical manifestations
Hot flushes but cold hands and feet, night sweating in the early morning, pale face, depression, chilliness, backache, oedema of ankles. Tongue: Pale. Pulse: Weak, Deep.
Treatment principle
Tonify and warm the Kidneys, tonify Yang, warm the Centre, strengthen the Spleen.
Acupuncture
BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-15 Jiuwei, KI-7 Fuliu. All with reinforcing method; moxa can be used.
Herbal treatment
Women’s Treasure remedy
This remedy tonifies Kidney-Yang and is specific for menopausal problems from Kidney-Yang deficiency: for this reason, the remedy also clears Empty-Heat. The tongue presentation appropriate to this remedy is a Pale body.
Kidney-Yang deficiency
Clinical manifestations
Hot flushes but cold hands and feet, night sweating in the early morning, pale face, depression, chilliness, backache, oedema of ankles. Tongue: Pale. Pulse: Weak, Deep.
Treatment principle
Tonify and warm the Kidneys, tonify Yang, warm the Centre, strengthen the Spleen.
Acupuncture
BL-23 Shenshu, BL-52 Zhishi, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-15 Jiuwei, KI-7 Fuliu. All with reinforcing method; moxa can be used.
Kidney-Yin and Kidney-Yang deficiency
Clinical manifestations
Hot flushes but cold hands and feet, night sweating, frequent, pale urination, flushed around the neck when talking, slightly agitated, chilliness, dry throat, dizziness, tinnitus, backache. Tongue: Pale or without coating, depending on which deficiency predominates. Red if there is Empty-Heat. Pulse: Floating-Empty or Weak-Deep.
Acupuncture
KI-3 Taixi, LU-7 Lieque and KI-6 Zhaohai, Ren-7 Yinjiao, HE-6 Yinxi, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, SP-6 Sanyinjiao. Reinforcing method; moxa can be used if deficiency of Yang predominates.
Herbal treatment
a Prescription
b Prescription
c Prescription
Explanation
The first five herbs constitute the formula Xiao Chai Hu Tang Small Bupleurum Decoction which harmonizes the Lesser Yang and therefore treats feeling of heat and cold alternating.
This formula tonifies Liver and Kidneys and harmonizes Yin and Yang when they are both deficient. It is especially for sweating and hot flushes and to calm the Mind.
d Prescription
Formula I
e Prescription
Explanation
Table 58.2compares and contrasts the above five formulae for menopausal problems from deficiency of both Kidney-Yin and Kidney-Yang.
Table 58.2 Comparison of formulae for menopausal problems from Kidney-Yin and Kidney-Yang deficiency
Women’s Treasure remedy
Ease the Journey-Yin is a variation of Zuo Gui Wan Restoring the Left [Kidney] Pill, with the addition of herbs to stop sweating and hot flushes, and Ease the Journey-Yang is a variation of You Gui Wan Restoring the Right [Kidney] Pill, with the addition of herbs to clear Empty-Heat and stop hot flushes. If deficiency of Kidney-Yin predominates, use three tablets of Ease the Journey-Yin in the evening and one of Ease the Journey-Yang in the morning; vice versa if deficiency of Kidney-Yang predominates. Ideally, the evening tablets are best taken with very slightly salted warm water. The above dosages are merely a guideline and they can be increased or, in some cases, even decreased.
Kidney-Yin and Kidney-Yang deficiency
Clinical manifestations
Hot flushes but cold hands and feet, night sweating, frequent, pale urination, flushed around the neck when talking, slightly agitated, chilliness, dry throat, dizziness, tinnitus, backache. Tongue: Pale or without coating, depending on which deficiency predominates. Red if there is Empty-Heat. Pulse: Floating-Empty or Weak-Deep.
Acupuncture
KI-3 Taixi, LU-7 Lieque and KI-6 Zhaohai, Ren-7 Yinjiao, HE-6 Yinxi, Ren-4 Guanyuan, BL-23 Shenshu, BL-52 Zhishi, SP-6 Sanyinjiao. Reinforcing method; moxa can be used if deficiency of Yang predominates.
A 50-year-old woman had started experiencing menopausal problems 2 years previously after her periods stopped. She complained of hot flushes, night sweating, some hair loss, nails breaking easily and backache. Her tongue was slightly Pale and her pulse was Weak in general and especially Weak and Deep on both Rear positions.
Diagnosis
Although she had few symptoms, the prevailing patterns are those of Kidney-Yang deficiency and some Liver-Blood deficiency. The menopausal symptoms of hot flushes and night sweating indicate Empty-Heat from Kidney deficiency, as do the backache and hair loss. Since the pulse is Weak on both Rear positions, the only factor that points to Kidney-Yang deficiency is the Pale colour of the tongue. As explained in Chapter 3 on pathology, in women over 50 a deficiency of the Kidneys nearly always involves a deficiency of both Yin and Yang, albeit always in differing proportions. Thus, when Kidney-Yang is primarily deficient, Kidney-Yin also becomes slightly deficient, giving rise to the Empty-Heat symptoms that cause the menopausal problems. Figures 3.1, 3.2 and 3.3 illustrate this clinical situation. In this patient, the brittle nails indicate some Liver-Blood deficiency.
Treatment principle
The treatment principle in this case is to tonify Kidney-Yang primarily and nourish Kidney-Yin secondarily, and to nourish Liver-Blood. She was treated only with herbal medicine.
Herbal treatment
Since her menopausal symptoms were not very severe and she did not have many other symptoms, I opted for treating her only with prepared remedies. I used the Women’s Treasure remedies Ease the Journey-Yang combined with Ease the Journey-Yin: I suggested two tablets of the former in the morning and one of the latter in the evening. The combination of these two remedies at such a low dose controlled the menopausal symptoms very effectively after 2 months and she felt much better in general. I suggested to her that she should continue taking the remedies for quite a long time to help her during the transition years.
A 53-year-old woman complained of menopausal problems for the previous 3 years, after her periods stopped. Her main problems were severe hot flushes, night sweating, depression, anxiety, mood swings, a tingling feeling all over and insomnia. She also complained of severely cold feet and frequent urination. Her tongue was Red with a slightly rootless, yellow and dry coating (Plate 10) and her pulse Rapid, Overflowing on both Front positions and Weak and Deep on both Rear positions. Although most of these symptoms started after her periods stopped, she had a history of severe stress in the years leading up to the menopause (husband’s redundancy, father’s death and daughter’s breakdown) and this obviously accounted for the severity of the menopausal symptoms. As explained in Chapter 4 on aetiology, the kind of menopause a woman experiences depends on her lifestyle in the years preceding it.
Diagnosis
Most of this patient’s symptoms are due to deficiency of Kidney-Yin with Empty-Heat affecting the Heart and harassing the Mind. The symptoms of Kidney-Yin deficiency are hot flushes, night sweating, Red tongue with a slightly rootless coating and a Weak and Deep pulse on both Rear positions. The symptoms of Empty-Heat affecting the Heart and harassing the Mind are depression, anxiety, mood swings, insomnia and a pulse that is Rapid and Overflowing on both Front positions. As in the previous case history, in this case too there is an overlapping of Kidney-Yin and Kidney-Yang deficiency; although the primary condition is one of Kidney-Yin deficiency, there is also some Kidney-Yang deficiency as evidenced by the cold feet and frequent urination.
Treatment principle
The treatment principle adopted was to nourish Kidney- and Heart-Yin, clear Heart Empty-Heat and calm the Mind; a secondary aim was to tonify Kidney-Yang. She was treated with acupuncture and prepared remedies.
Acupuncture
The points used were selected from the following:
Herbal treatment
Initially, I treated this patient only with acupuncture for 2 years (at infrequent intervals, see below); after that, I prescribed the Women’s Treasure remedies Ease the Journey-Yin to nourish Kidney-Yin combined with Ease the Journey-Yang: I prescribed three tablets of the former to be taken in the evening and only half of the latter to be taken in the morning.
This patient came quite infrequently as she found that one acupuncture treatment controlled her menopausal symptoms for up to 4 months. After 2 years, I prescribed the above remedies to consolidate results: using these remedies, she found that she no longer needed to have acupuncture.
Kidney- and Liver-Yin deficiency with Liver-Yang rising
Clinical manifestations
Irritability, dizziness, tinnitus, blurred vision, dry eyes, dry skin, hot flushes, ache in joints, night sweating, sore back, headaches. Tongue: without coating; Red if there is Empty-Heat. Pulse: Floating-Empty, Wiry on the left Middle position.
Treatment principle
Nourish Kidney- and Liver-Yin, subdue Liver-Yang, calm the Mind, settle the Ethereal Soul.
Acupuncture
KI-3 Taixi, LIV-8 Ququan, Ren-4 Guanyuan, LU-7 Lieque and KI-6 Zhaohai, LIV-3 Taichong, Du-24 Shenting, G.B.-13 Benshen, G.B.-20 Fengchi, P-7 Daling. KI-3, LIV-8 and Ren-4 with reinforcing method, the others with reducing method.
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