The menstrual cycle

2


The menstrual cycle




Becoming a Specialist in Female Infertility


There is an oft quoted saying in Chinese medical texts, ‘the treatment of women is ten times more complicated than that of men’ (Fig. 2.1). By the time we have examined all the different parts of the menstrual cycle you may feel this is an understatement!



To be a specialist in any field, we have to know our chosen material intimately. In this chapter, I set out what we need to know about the pathways, the fluids, the cells, the tissues, the chemical messages and the changes that happen in every menstrual cycle. We will examine in detail all the complex events that happen in a woman’s body when the glands in the brain communicate with the reproductive glands and induce a myriad of different effects in different tissues – an incredible orchestration of events, which require correct timing and constant feedback. The result is a woman’s body full of fertile potential (Fig. 2.2).



The theories of both traditional Chinese medicine (TCM) and the Western medical model contribute to our understanding of the physiological processes of the menstrual cycle. When a TCM practitioner is treating a woman for infertility it is very helpful to have a good grasp of the hormonal and anatomical reality of the reproductive processes. At the same time he or she needs to have a deep understanding of the same processes in terms of the Qi and Blood, Yin and Yang.


In this chapter, I consider the roles of the Yin and the Yang, the Qi and the Blood, the Chong and the Ren vessels, the Jing and the Shen, and more. And I also consider estrogen and progesterone, the pituitary and hypothalamus glands, the follicle in the ovary containing the egg, the fallopian tubes and the endometrium lining the uterus.



The Chinese and Western Medicine Approach


Chinese medicine describes processes inside and outside the body in energetic terms: i.e., the tendency to change or develop in a certain direction. Western medicine describes physiologic processes of the body in terms of the biochemical changes that occur and how they influence the actions of organs – this action is also described in terms of the resultant biochemical changes.


Historically, of course, Chinese medicine was practised with very little understanding of the biochemistry of internal physiological processes. All treatments were determined by subtle diagnostic techniques based on careful and detailed observation of external signs. This ability to make a diagnosis based on expert observation of symptoms and signs is one of the very great strengths of TCM (another being the mildness of its treatments and consequent lack of side-effects).


The knowledge we now have available, thanks to recent scientific research in reproductive medicine, adds to this strength. Skilled TCM doctors will still apply their well-tested theoretical framework and treatments but will add another level of sophistication to their clinical approach by using their knowledge of internal reproductive physiology. They will be able to communicate with patients and their gynecologists in a language they understand. Such bridge building, in the end, benefits everyone.


Although it is not appropriate to make exact equivalences between traditional Chinese medicine concepts and modern scientific medical descriptions (representing two profoundly different paradigms) we can make parallels – identical processes viewed from different perspectives. These will be summarized once we are familiar with all the terms (see Table 2.2).



The following sections provide a brief explanation of terms used to describe organ systems, channels and substances relevant in TCM gynecology. For further explanation of such TCM concepts, the reader is referred to TCM texts on internal medicine.1



The Organs



The Kidney, the Heart and the Uterus


TCM describes all the aspects of female reproduction – the organs, the glands and their secretions, and the psyche – in terms of Kidney function, Heart function and the Uterus. TCM texts say, ‘the Uterus, the Heart and Kidney form the core of reproductive activity.’


In broad terms, what the doctors in China 2000 years ago were referring to when they described the Kidney Jing is what modern Western medical science refers to as the gametes or eggs and sperm themselves. Kidney Yin and Yang include the influence of the hormones which regulate the different parts of the cycle.


The Heart encompasses the mind and the activity of the hypothalamus and pituitary, which controls the whole cycle.


The Uterus describes the arena where all of this happens. When we use the term ‘Uterus’ in a Chinese medicine context, it is a translation of the term Bao Gong, which includes all the reproductive organs: uterus, ovaries, fallopian tubes and cervix.


The pathways or channels, called the Bao Mai (Uterus vessel) and Bao Luo (Uterus channel), provide the means of communication between the Heart, Uterus and Kidneys (Fig. 2.3).



It is interesting to note that old Chinese medicine texts describe the Heart as the master controller (the Emperor) of the other organs. In the same way, Western medicine often refers to the hypothalamus and the pituitary as the master controllers of other glands in the body.



The other organs


While the kidneys and the heart control the processes necessary for female fertility, they are not the only organs or systems necessary for the effective functioning of the menstrual cycle. Figure 2.4 shows the relationship between all the body’s Yin organs and the Uterus.



It is said in TCM that the Kidneys ‘dominate reproduction’ and are the store of reproductive essence, or Jing, which is discussed below. The Kidney Jing plays a key role in female physiology at all its stages – puberty, pregnancy and menopause. Aspects of Kidney also influence libido and sexual function. The Heart houses the mind or spirit – ‘Shen’ in TCM terms – and, as such, exerts a subtle but powerful influence over many aspects of the menstrual cycle. The Spleen and Liver also contribute in a less direct way to aspects of reproduction and fertility. The Spleen produces the Blood and the Liver stores and moves it; therefore both can have an effect on the nourishment of the Uterus. The Spleen also controls circulation of Blood in its vessels. The Liver is responsible for smooth movement of Qi and therefore plays a critical role during events surrounding ovulation and menstruation, both of which involve movement and change. The Lungs are less directly involved, but also influence Qi. More detailed explanations of Yin organ function can be found in TCM texts on internal medicine.1



The Substances



Jing


Jing is translated as ‘reproductive essence’. In Western medical terms, Kidney Jing encompasses the function of the ovaries and some aspects of pituitary function. Plentiful Jing increases fertility and contributes to longevity. It has been observed that women who are successful in having babies in their 40s (i.e. have strong Kidney Jing) often live longer than average.


Kidney Jing is said to be inherited from our parents and stored in the Kidneys. The quality of our Jing determines our genetic predisposition and also reflects how we developed in the womb (this latter, of course, is influenced by our mother’s health during the pregnancy). Parents with strong and vital Jing will, barring any unexpected traumas in the womb, pass on strong Jing to their offspring. Less than ideal Jing may be inherited if the parents are older than 40, of poor constitution or if the mother has had many pregnancies close together.


Jing is not only an important first determinant of our basic constitution, but it is also directly related to our ability to produce children of our own. If a girl is born with very deficient Jing, then it is likely that the ovaries or uterus may not develop properly and there will be complete sterility. Puberty, if it comes at all, will be very late, as will development of secondary sexual signs. In women, Jing deficiency (Table 2.1) manifests as primary amenorrhea, resistant ovary syndrome or sporadic and intermittent cycles (oligomenorrhea) or premature menopause (see Ch. 5). Or there may be less severe levels of Jing deficiency, which may manifest as delayed puberty, or very intermittent ovulation or the production of poor quality eggs which do not easily fertilize and make strong embryos. In men, we may see very low sperm counts or even no sperm (see Ch. 7). All degrees of Kidney Jing deficiency spell problems with fertility.



TCM texts say that Kidney Jing is the source of Tian Gui. Tian Gui, which translates as ‘heavenly water,’ is an aspect of Jing which ripens as a young girl reaches puberty. The ripening of the Tian Gui heralds the filling of the Chong vessel with Blood and the Ren vessel with Qi and the periods begin. The quality of the Tian Gui (and hence the Kidney Jing) is important in all the menstrual cycles that follow, and in conception and pregnancy.


According to TCM theory, strong Jing is the basis of healthy Shen or spirit. Human worth can be evaluated in many ways, not just by physical strength and ability to reproduce. Such human attributes as altruism, artistic endeavor and scientific genius make great (non-biological) contributions to human society. Many of these attributes stem from aspects of our spirit or the Shen. Inheritance of good Jing is necessary, therefore, not only for a healthy physical constitution and the ability to reproduce but also for the development of other human attributes which contribute to humanity in ways other than continuing its genetic lines.



What causes decline in Kidney Jing?


Kidney Jing gets used up with the hundreds of menstrual cycles a woman experiences. Life itself also exhausts our stores of Jing, sometimes more rapidly than others, depending on the nature of the lifestyle and life circumstance.


The mother’s Jing (and Blood and Yin) is consumed somewhat during the pregnancy by the rapidly forming fetus and Chinese families were traditionally advised to space out their children (ideally by 5 years) so that the mother’s Jing could be replenished before the next baby consumed it again.


The decline of Kidney Jing as we age, is the reason fertility declines in women after more than two decades of producing eggs. It is also the reason that more miscarriages occur and that more babies with genetic disorders like Down syndrome are born to older women. Of course, women in their 20s and 30s can also have miscarriages, or babies with genetic disorders. However, in this case, it is less likely to be Kidney Jing quality which is responsible but other factors, such as sperm quality or external mutagens. By the middle 40s, the Kidney Jing has declined to such a degree that pregnancy is rare. We have all heard stories about miraculous pregnancies to ‘mature’ women, from Sarah in biblical times, to cover stories in glossy magazines. These stories gain legend status simply because they are extraordinary – and rare.


In my 20 years in the clinic, I have come across just two women who have had babies after 45 (and who have not received donor eggs). In both cases, there had been a long period of amenorrhea, where eggs that might have been spent were conserved.


Kidney Jing can be consumed more rapidly by some types of lifestyle or circumstance than others (see Ch. 12). Epigenetic effects of assisted reproduction technology may also be of concern as far as Jing is concerned (see Chs 9–11).



How is Kidney Jing deficiency treated?


To address inadequacy or decline of Tian Gui, the TCM doctor will treat the Kidney Jing. This is usually done with herbs and sometimes with animal products. As the deficiency is deep, treatment needs to be strong, persistent and lengthy.


When someone is born with very poor Jing and experiences primary amenorrhea, resistant ovary syndrome or sporadic and intermittent cycles, drastic measures are sometimes required to increase the chances of reproducing. It is here that assisted reproduction technology (ART) has produced some startling results. For example, in women who do not ovulate but do have ovaries, drugs can be used to induce ripening of the dormant eggs. If Kidney Jing is not too severe, then sufficient eggs will ripen to be collected for in vitro fertilization (IVF).


In some men with no or very few sperm, testicle biopsies can be taken and immature sperm cells cultured. These can then be used for in vitro fertilization by injecting them directly into the egg (see Ch. 9).


From a TCM perspective, the implications of such techniques can be worrying. If a man or woman has such low Jing energy that they are unable to produce gametes, then it is better from a biological and community point of view that they do not reproduce. This is because, theoretically, the low Jing will be passed onto their offspring born with the aid of ART because the natural brakes to such a possibility have been circumnavigated. One extreme example of this (and a strange paradox), is a congenital form of male infertility (carried on the Y chromosome), which can be passed onto male offspring if certain ART techniques are employed to enable the sperm to fertilize the egg. Thus, a form of Jing deficiency is perpetuated from one generation to the next.


Babies born to parents with congenital gonadal dysfunction or with unexplained infertility with the aid of ART seem to be, in the current broad view, as healthy as other babies. However, research reveals that babies born as a result of these procedures are more at risk of major birth defects2 and will tend to have lower birth weights.3 This may reflect the original cause of the infertility as much as the effects of the procedures (for more discussion of these effects, please see Ch. 10).


The majority of IVF children have not yet reached reproductive age, so the quality of some aspects of their Jing is as yet untested in the early twenty-first century.



Yin


Yin is the term used in TCM to describe the cooling, nourishing and moistening, the substantive and internal aspect of body function, and structure. We might say that Yin represents the elixir of youth, which is consumed throughout life, more rapidly by some lifestyles than others.


In the context of the menstrual cycle, Kidney Yin relates to the hormonal triggers which stimulate follicles to develop, as well as to the factors which support the follicle’s growth and maturation. The concept of Kidney Yin embraces aspects of pituitary function as well as ovary structure and function. The lining of the uterus and its secretions also reflect the quality of Yin. The function of the glands in the cervix gives us a particularly useful indication of Yin function, as they produce one of the most easily observed of its manifestations, the fertile mucus.


People who have insufficient Yin energy tend to be more dry or hot internally. Often this translates into quantifiable signs like scanty production of vaginal and cervical mucus, or in men, scanty ejaculate. Women who are Yin deficient may have thinner uterine linings which are not secreting adequate nourishment to maintain a pregnancy. TCM texts call this a ‘hot dry Uterus’. These women often have scanty periods.


Clinical observations in fertility clinics in China have made a clear connection between ovarian function and Kidney Yin quality. If the Yin energy is inadequate, the follicle in the ovary grows poorly and ovulation may be late (i.e., long cycles) or early if Yin deficiency has given rise to Heat (short cycles) or may happen on a very sporadic basis (intermittent and irregular cycles). A certain threshold quality and quantity of Yin is required before the egg is responsive to hormonal stimulation and can grow to the stage where it is ready to be released and fertilized.


In personality, Yin-deficient people are more restless or anxious; they can be alert and bright-eyed and quick. Often, they are thin and wiry and their skin ages more quickly than others.



What causes Kidney Yin deficiency?


Kidney Yin deficiency may be caused by a constitutional tendency or the Yin may have been damaged by overwork. This is not at all an unusual scenario for women today, particularly those working long hours in stressful conditions. Paid work, for many women, is done before and after the unpaid work of running a household. Add to such conditions poor diet or rushed eating, polluted environment, inadequate sleep and exercise and you have the typical Yin-consuming lifestyle of so many of the women we see in our clinics. Trying to become strong and healthy, let alone pregnant, in such conditions is a challenge.


Kidney Yin may also be damaged by drug abuse and by excess sexual activity or many pregnancies (even if these are terminated). Loss of large quantities of blood (such as prolonged or very heavy periods) or body fluids can damage Yin. Long-term disease in any organ system will eventually damage Kidney Yin.


Yin declines with age, especially from the late 30s. Age-related Yin deficiency is one of the most common reasons for inability to fall pregnant that we see in our clinics in the West.



How is Kidney Yin deficiency treated?


In the clinic, large doses of herbs are prescribed to a Yin-deficient woman to increase the Kidney and Liver Yin so that the ovaries are nourished sufficiently to produce healthy eggs. Such an approach is emphasized in the weeks of the menstrual cycle leading up to ovulation; this treatment also encourages the retention of blood in the uterine lining along with its secretory function. Equally important in the treatment of the Yin is appropriate lifestyle changes. There is usually so little space in our lives these days for stillness and calling a halt to relentless busyness. Even when we say we are resting, we are watching television or movies, and our mind and body, while they may be more relaxed, have not stopped to the point where deep and nourishing rest can replenish reserves. A regular routine and enough sleep are two key first steps in reducing stress and relieving the mind. The capacity to still the mind is an important aim for the Yin-deficient person who is restless and nervous.


A particular challenge of our times, and one which is rarely heeded, is the need to become strong and healthy before conceiving. The rush to fit everything in at the last minute often means that pregnancy is embarked upon with little thought to the constitution of the sought-after child. Pregnancy at any cost is often the prevalent attitude of a society used to getting what it wants and now. A TCM doctor will advise a woman who is very Yin-deficient to make adjustments to her lifestyle and build her Yin before attempting to conceive. There is important ground to be laid. This is sometimes a difficult idea for a Western woman to swallow, particularly if she is in her late 30s and the biological clock is ticking loudly.


Fertility drugs and ART programs will often be tried by women in this category (usually in their late 30s or early 40s). However, when the Yin is very low, using strong ovarian-stimulating drugs is a bit like whipping an exhausted horse which has nothing left to give. Seldom are viable eggs produced.



Yang


Yang energy is the counterpart to Yin. Compared with Yin’s still, cool, moist, and nourishing nature, it is dynamic, active, and warming. The effect of Yang begins to be felt in the menstrual cycle at ovulation. Dispersing obstructions and aiding unfettered movement are important Yang functions at this time. At the moment of ovulation, there is much dynamic activity – the egg is launched out of its follicle and the fimbrial fingers embrace and guide the egg into the fallopian tube.


The journey of the egg down the tube is also a dynamic one, with both the egg and the tube needing to be able to move smoothly and flexibly. It is the action of Yang which ensures that mucus obstructions in the tube are dissolved to allow free passage to the uterus.


The moment of fertilization also relies on sufficient Yang. Yang is the motivating force for all transformations in the body. The moment a sperm’s head finally breaks through the egg’s coating, and its DNA fuses with that of the egg, is the greatest transformation of them all – the beginning of a potential human life.


Kidney Yang performs a very important function after ovulation, when a fertilized egg reaches the uterus and implants and develops. The Chinese have for thousands of years ascribed the inability of some women to fall pregnant as ‘a Cold womb’. In other words, not enough Kidney Yang energy. Nowadays we know that the Cold womb is one supplied with insufficient progesterone, which means that implantation and early development of the embryo will not be supported. When there is insufficient progesterone produced, the body is demonstrably colder – about 0.4°C colder than when the progesterone levels are high.



What causes Kidney Yang deficiency?


Lack of Kidney Yang may be a constitutional trait or it may result from damage, most commonly by an invasion of external Cold. This initially obstructs the flow of Qi and, eventually, if it is not expelled, affects the body’s Yang. Our Western lifestyle provides many opportunities for this so-called Cold invasion, most notably our predilection for icy foods and drinks and the habit many women have of swimming during menstruation. Cold as an external pathogen can enter the body easily via:



The Chinese, and in fact many Asian cultures, strongly advise against behavior which can chill the body during the period. Being chronically exposed to cold, such as living or working in a cold damp environment, can also damage the Yang.


Kidney Yin and Yang depend upon one another and depletion of Kidney Yin will eventually deplete Kidney Yang. This is a commonly seen phenomenon in the infertility clinic, especially in women after their mid-30s. Similarly, when there is prolonged stagnation of Liver or Heart Qi (i.e., emotional disturbances) the Yang of the Kidney can suffer too. The nature of Yang is to move and be active, but in an environment of emotional constraint it cannot move and becomes damaged.


Kidney Yang is consumed by miscarriages, abortions and overtaxing the body physically. Inadequate sleep, specifically going to bed too late, can also be a contributing factor to Kidney Yang deficiency. Certain diseases (e.g. thyroid disease) can compromise the function of Kidney Yang, and prolonged disease of any organ will finally affect the Kidneys, damaging Yin or Yang or both.




Blood


The Blood, or Xue, as it is called in Chinese, embraces the Western notion of blood (the red fluid in our arteries and veins) but goes further to include aspects of tissue nutrition. The Heart is said to govern the Blood (via the circulatory system) and, with the Spleen, plays a role in the production of Blood and therefore contributes to nourishment of the endometrium and thereby the embryo. The Spleen’s role is to manufacture Blood from the nutrients it can extract from food. Someone who is Blood deficient will not only be pale but may also be weak and malnourished.


Blood plays an important role in fertility by nourishing the endometrium (the uterine lining), making it a moist, juicy and nutritious place for an embryo to settle in. Shortly before ovulation, peaks of estrogen (released by the developing egg) prime the lining of the uterus – this means the endometrial tissue is provoked by this hormone into proliferating and growing in size, actually producing more blood vessels and laying down more tissue. Without adequate Blood, this process may be retarded or, in fact, stymied completely. Thus, TCM recognizes that it is not only lack of Yin which can lengthen the first half of the cycle and hold up ovulation but also Blood deficiency.


Blood is stored by the Liver, especially when the body is at rest. Some of this store must be passed onto the Uterus before preparation for pregnancy or menstruation can occur. So if the Liver Blood is deficient, then menstruation may be scanty or there may be infrequent or no periods.


The body loses some of its blood stores during the period and so must quickly make good the loss if the newly forming endometrium is to be adequately supplied. In China, it is very common for women across the entire social and professional spectrum to take Blood tonic foods and herbs after periods to ensure this. The Spleen’s function in digestion and manufacture of Blood is therefore important at this time.


< div class='tao-gold-member'>

Related posts:

  1. A tale of two clinics — the treatment of infertility with Chinese medicine or Western medicine
  2. Assisted reproduction technology and in vitro fertilization
  3. Diet and lifestyle
  4. Gynecologic disorders which can cause infertility

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 11, 2016 | Posted by in PEDIATRICS | Comments Off on The menstrual cycle

Full access? Get Clinical Tree
Get Clinical Tree app for offline access