Menopause And The Perimenopausal Syndrome – Western and TCM approaches

Abstract

Chinese herbal medicine provides safe and effective treatment for perimenopausal symptoms, while also supporting general health and well-being. The Western medical approach, according to which the menopausal transition is regarded as a disease, provides only symptom relief and exposes a woman to increasing risks the longer the treatment is maintained. The main issues in relation to these differing approaches are discussed, illustrating the strengths and weaknesses of each. The paper concludes with clinical protocols for the management of the menopausal transition and perimenopausal syndrome (PS) with ready prepared Chinese herbal formulas and highlights the importance of addressing the often neglected pathodynamic of Blood stasis.

Introduction

Although the menopause is, in fact, a physiological event marking a milestone in the complex process of normal ageing, Western medicine continues to medicalize it and promote hormone replacement therapy (HRT) as the most effective means to alleviate the distressing symptoms experienced by many women around this time. In light of the conflicting ‘evidence’ relating to the benefits and risks of this type of treatment and the changing recommendations over time, an increasing number of women are seeking alternative approaches. In recent years certain pharmaceutical drugs from the antidepressant, anti-hypertensive and antiepileptic classes have also been pressed into service for this new role.  However, the evidence in favour of these ‘new’ treatments is poor and conflicting, while the risk of adverse events remains real but unquantified.

Traditional Chinese medicine, on the other hand, views the menopausal transition as a normal part of life and offers support for women undergoing these changes. Chinese herbal medicine (CHM) treatments have a long history of traditional use and, in addition to this, there is a certain amount of empirical evidence that they are both safe and effective for alleviating the troublesome symptoms associated with menopause. Moreover, CHM may also help to maintain or improve general health and well-being.

Definition of menopause-related terms

In literature that is aimed at the general public, the terms ‘menopause’, ‘menopausal syndrome’ and ‘menopause (or menopausal) transition’ are also used synonymously with perimenopausal syndrome (PS). (Menopause Centre of Australia, 2015; Australian Menopause Society, 2015)

The following definitions of menopause related terms are currently in use, from Stages of Reproductive Aging Workshop (STRAW) + 10:

MENOPAUSE (NATURAL MENOPAUSE)  

The term natural menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. Natural menopause is recognized to have occurred after 12 consecutive months of amenorrhea, for which there is no other obvious pathological or physiological cause. Menopause occurs with the final menstrual period (FMP) which is known with certainty only in retrospect a year or more after the event. An adequate biological marker for the event does not exist. (Soules et al., 2001)

EARLY MENOPAUSAL TRANSITION (Stage −2)

Early menopausal transition is marked by increased variability in menstrual cycle length, defined as a persistent difference of 7 days or more in the length of consecutive cycles. Persistence is defined as recurrence within 10 cycles of the first variable length cycle. Cycles in the early menopausal transition are also characterized by elevated but variable early follicular phase follicle-stimulating hormone (FSH) levels and low antimüllerian hormone (AMH) levels and antral follicle count (AFC).

LATE MENOPAUSAL TRANSITION (Stage −1)

The late menopausal transition is marked by the occurrence of amenorrhea of 60 days or longer. Menstrual cycles in the late menopausal transition are characterized by increased variability in cycle length, extreme fluctuations in hormonal levels, and increased prevalence of anovulation. In this stage, FSH levels are sometimes elevated into the menopausal range and sometimes within the range characteristic of the earlier reproductive years, particularly in association with high estradiol levels. The development of international standards and the availability of substantive population-based data now permit the definition of quantitative FSH criteria, with levels greater than 25 IU/L in a random blood draw characteristic of being in late transition, based on current international pituitary standards that approximate more than 40 IU/L in the previously used urine-based gonadotropin standards. Empirical analyses should be undertaken to confirm this recommendation, and researchers and clinicians should carefully evaluate the appropriate FSH value, depending on the assay they use. Based on studies of menstrual calendars and on changes in FSH and estradiol, this stage is estimated to last, on average, 1 to 3 years. Symptoms, most notably vasomotor symptoms, are likely to occur during this stage.

EARLY POSTMENOPAUSE (Stages +1a, +1b, +1c)

New data on the trajectories of change in mean levels of FSH and estradiol indicate that FSH continues to increase and that estradiol continues to decrease until approximately 2 years after the FMP, after which the levels of each of these hormones stabilize. Therefore, STRAW + 10 recommended that early postmenopause be subdivided into three substages (+1a, +1b, and +1c).

Stages +1a and +1b each last 1 year and end at the time point at which FSH and estradiol levels stabilize. Stage +1a marks the end of the 12-month period of amenorrhea required to define that the FMP has occurred. It corresponds to the end of “perimenopause,” a term still in common usage that means the time around menopause and begins at Stage −2 and ends 12 months after the FMP. Stage +1b includes the remainder of the period of rapid changes in mean FSH and estradiol levels. Based on studies of hormonal changes, Stages +1a and +1b together are estimated to last, on average, 2 years. Symptoms, most notably vasomotor symptoms, are most likely to occur during this stage.

Stage +1c represents the period of stabilization of high FSH levels and low estradiol values that is estimated to last 3 to 6 years; therefore, the entire early postmenopause lasts approximately 5 to 8 years. Further specification of this stage will require additional studies of trajectories of change in FSH and estradiol from the FMP through the late postmenopause.

LATE POSTMENOPAUSE (Stage +2)

Stage +2 represents the period in which further changes in reproductive endocrine function are more limited and processes of somatic aging become of paramount concern. Symptoms of vaginal dryness and urogenital atrophy become increasingly prevalent at this time. However, many years after menopause, it has been observed that there may be a further decline in levels of FSH in very old persons; future studies will be needed to determine whether an additional stage is warranted near the end of life. (Harlow, 2012)

This system of nomenclature, while it may be useful for researchers, appears far too cumbersome for the purposes of this paper. Therefore, we shall continue to use the terms ‘perimenopause’ and perimenopausal syndrome to refer to the variable time period beginning before the menopause and continuing after the menopause, within which a woman may experience the distressing symptoms discussed below.

Physiology

Menopause is due to the loss of ovarian sensitivity to stimulation by gonadotrophins associated with the decline and dysfunction of the ovarian follicles. Ovarian mass and fertility decline sharply after age 35 and this process is accelerated during perimenopause, resulting in the depletion of primary follicles. At this time the menstrual cycle generally becomes shorter, due to an accelerated follicular phase associated with anovulation or irregular maturation of follicles. Follicle-stimulating hormone (FSH) levels rise, due to altered folliculogenesis and reduced inhibin secretion.

Hormone levels in perimenopause are irregularly irregular, whereas menopause is characterised by consistently high FSH and low estradiol levels. The increase in anovulatory cycles that occurs in the perimenopause can produce a hyperestrogenic, hypoprogestagenic environment that may be the cause of the increased incidence of endometrial hyperplasia or carcinoma, uterine polyps, and leiomyoma. Therefore, it is recommended that irregular bleeding in a perimenopoausal woman should be investigated, e.g. with endometrial biopsy or dilatation and curettage. The most dramatic hormone change that appears with menopause is the reduction in circulating estrogen due to the loss of functioning follicles. After menopause, estradiol levels are low, whereas estrone levels generally remain the same, due to production by the adrenals and ovarian stroma.  FSH levels increase more than those of luteinizing hormone (LH), most likely due to the loss of inhibin, as well as estrogen feedback. In addition, there is a decrease in testosterone. The gradual decline of estrogen causes a wide variety of changes in tissues that respond to estrogen—including the vagina, vulva, uterus, bladder, urethra, breasts, bones, heart, blood vessels, brain, skin, hair, and mucous membranes. Over time the lack of estrogen may cause an increased the risk of osteoporosis and possibly also coronary artery disease (CAD). While the pathophysiology of vasomotor symptoms remains unclear, most of the other perimenopausal symptoms are due to irregular ovarian function and the large fluctuations in levels of estrogen, while some, principally the atrophic changes, are due to a deficiency of estrogen (Coney, 2014; Manson & Bassuk, 2015)

To summarise, the essential hormonal changes in the menopausal transition are as follows:

1. Hormonal secretion by the ovarian follicles diminishes and becomes irregular.
2. During the phase of irregular bleeding preceding the final menstrual period, oestrogen levels may become higher than normal due to increased levels of circulating FSH recruiting more than one follicle for maturation, with or without the subsequent formation of a corpus luteum. Even when it does form, the corpus luteum only secretes a limited amount of progesterone. Thus, the endometrium may be exposed to persistent stimulation by estrogen in the absence of the normal cyclic secretion of progesterone.
3. Testosterone continues to be secreted by the ovaries and may exceed levels of premenopause.
4. The adrenals assume a primary role in the production of estrogen through production of estradiol and estrone, the latter being converted to estradiol in peripheral tissues (fat, muscle, liver, bone marrow, fibroblasts and hair roots).

(Nathan, 2013)

Clinical features

The perimenopause can begin 5 -10 years before menopause. However, most women will experience perimenopausal symptoms in their mid to late 40’s (Coney, 2014; Burbos & Morris, 2011). In addition to changes in the menstrual cycle, commonly encountered symptoms during this phase are as follows:

• hot flushes
• night sweats
• insomnia
• mood swings and irritability
• difficulty with memory or concentration
• vaginal dryness and dyspareunia
• sexual disinterest
• heavy bleeding
• fatigue
• depression
• hair changes
• headaches
• heart palpitations
• urinary changes
• weight gain

The most common reason for consultations during the perimenopausal phase is the presence of hot flushes. This is reported in around 75% of women.  (Coney, 2014; Manson & Bassuk, 2015). In around 25% of women these may be severe. (Jane & Davis, 2014) In regard to the above list of signs and symptoms, there is some disagreement over whether they are all directly attributable to ovarian aging, e.g. mood swings, depression, impaired memory or concentration, somatic symptoms, urinary incontinence, or sexual dysfunction.

The symptoms that have been conclusively linked to the physiological changes of perimenopause are hot flushes, night sweats, irregular bleeding and vaginal dryness. (Manson & Bassuk, 2015) Hot flushes not only cause physical discomfort at the time of occurrence, but also social embarrassment, disruption of sleep and emotional lability. In addition, sleep disruption may also lead to memory and concentration problems, mood swings and irritability. (Coney, 2014; Nathan, 2013) It should be borne in mind that these vasomotor symptoms, while they may be distressing and disruptive are, in fact, temporary and although they may continue for more than 5 years in a small percentage of women, for the majority the duration is 3 to 5 years. (Nathan, 2013; Politi, Schleinitz, Col, 2008)) In women with severe vasomotor symptoms, the duration may be between 3.4 and 11.8 years; in more than half of these women the duration is more than 7 years. (Avis, N., Crawford, S., Greendale, G., et al. ,2015) Factors that may alleviate vasomotor symptoms include cessation of smoking, reducing or avoiding alcohol consumption, regular exercise and weight management. (Reid et al., 2014)

Diagnosis

Because of their extreme variability, measurement of FSH and estradiol levels are not useful diagnostic indicators of perimenopause in menstruating women. However, low FSH in the early follicular phase of the cycle excludes a diagnosis of perimenopause. Because of the wide range of symptoms, symptomatic women who have risk factors for a condition other than menopause should undergo thorough medical evaluation.

Treatments

The standard Western medical treatment for PS is hormone replacement therapy (HRT) or oral contraceptive pills (OCPs) in order to stop the hormone fluctuations that are thought to cause these symptoms. There is high level evidence that HRT is highly effective in alleviating hot flushes and night sweats. (Maclennan et al, 2004). However, there is good evidence that both estrogen replacement therapy (ERT) and HRT do not prevent cognitive decline in older postmenopausal women when given as short term or longer term (up to five years) therapy. (Lethaby et al., 2008).

Alternative medications targeting vasomotor symptoms (flushes and night sweats) include tibolone (a steroid precursor derived from Mexican yam), various antidepressants, clonidine and gabapentin. However only tibolone has been shown unequivocally to provide clinical efficacy.

Medications targeting osteoporosis include raloxifene, calcitonin, and bisphosphonates such as alendronate and risedronate. Statin drugs may be used if the patient has dyslipedimia (for prevention of CAD) and antidepressants for mood disorders.  (Coney, 2014; Reid et al., 2014; Burbos & Morris, 2011)

Safety issues

The Womens Health Initiative Study (WHI), published in 2002, dramatically changed the clinical landscape of pharmaceutical management for perimenopausal and postmenopausal women. (WHI, 2002) Up until this time it was generally believed that all forms of HRT (both oestrogen combined with progesterone and oestrogen alone) not only alleviated hot flashes, but also had a protective effect against cardiovascular events such as cardiovascular disease (including acute myocardial infarction), venous thromboemboli or stroke. (Genazzini,, et al., 2000). The benefits of HRT in relation to reduction in non-vertebral fractures, (Torgerson & Bell-Syer, 2001) depressed mood, (Zweifel & O’Brien, 1997) and cognitive function (Hogervorst et al, 2002) were additional reasons for prescribing HRT. However, even in 2001 it was recognized that ‘Lack of confidence in the espoused benefits of hormone replacement therapy (HRT) coupled with a significant array of side effects of HRT, results in fewer than 1 in 3 women choosing to take HRT’ and the medical profession has become increasingly aware of the burgeoning use of herbal alternative treatments. (American College of Obstetricians and Gynecologists Committee on Practice Bulletine –Gynecology, 2001).

Subsequent to the WHI study, several systematic reviews have confirmed the increased risks, such as an increase in breast cancer (particularly with combined oestrogen-progesterone, (Schairer, Lubin, Troisi, Sturgeon, Brinton, Hoover, 2000) and ovarian cancer. (Zhou, Sun, Cong, Gu, Tang, Yang & Wang, 2008). A review published in 2005 spelt the death knell for the use of HRT as a preventative for cardiovascular events: ‘No protective effect of HRT was seen for any of the cardiovascular outcomes assessed: all-cause mortality, cardiovascular death, non-fatal MI, venous thromboemboli or stroke. Higher risks of venous thromboembolic events (Relative risk (RR) 2.15, 95% CI 1.61 to 2.86), pulmonary embolus (RR 2.15, 95% CI 1.41 to 3.28), and stroke (RR 1.44, 95% CI 1.10 to 1.89) was found in those randomised to HRT compared with placebo.  (Gabriel et al., 2005) Additionally, a more recent systematic review failed to find any protective effect of HRT on cognitive function in post-menopausal women (Lethaby et al., 2008)

Although a considerable body of more recent research has aimed to preserve HRT as the standard treatment for perimenopausal symptoms, (Coney, 2014; Manson & Bassuk, 2015) in view of the risks, it is best to take HRT if at all, for a maximum duration of 3 years. (Willett, Colditz, Stampfer, 2000) Moreover, as noted by the same authors. ‘The first issue is whether hormone use is needed at all; reducing risks of fractures and coronary heart disease rarely will provide sufficient justification because avoidance of smoking, performance of regular exercise, and consuming a good diet are effective preventative measures.’ (Willett et al., 2000)

In light of the above considerations, it is important that a clinically effective treatment to provide relief from the unpleasant symptoms of perimenopause be made available and accessible. TCM treatments – Chinese herbal medicine in particular – hold much promise in this area, with the additional benefit of improvement in general health. Although research to date is considered to be of poor quality, there is encouraging evidence that TCM herbal treatments may help to alleviate menopausal symptoms with a considerably better safety profile. (Zhong, et al., 2013; Xu et al., 2012; Zhou et al., 2007; Kwee et al., 2007; Lai et al., 2005; Ushiroyama, et al., 2005; Zhang et al., 2005; Qiu et al, 2004; Zhao, et al., 2003; Chen et al., 2003; Ding, et al.,1995) These will be discussed in the following section.

MENOPAUSE SYNDROME IN TCM

In the Huang Di Nei Jing, the Huang Di poses the question: ‘When one grows old one cannot bear children. Is this due to heredity or to the loss one’s procreative energy’ In reply, Qi Bo answers: ‘In general the reproductive physiology of woman is such that at seven years of age her Kidney energy becomes full, her permanent teeth come in and her hair grows long…..At forty nine years the Chong and the Ren channels are completely empty, and the tian kui has dried up. Hence the flow of the menses ceases, and the woman is no longer able to conceive’. (Ni, 1995, p. 2) Thus, according to TCM, the state of the Kidney Qi (in the broad sense) and specifically the Chong and Ren channels determines the physiological changes around menopause. Although there is a divergence of opinion on the role of the Kidney in menopause (e.g. Scheid, 2006), most authorities agree on the central importance of this organ. (Maciocia, 1998, pp. 741-743; Xuan & Li, 1990, pp. 103-104; Yu, 1998, pp. 22, 149-150)

Pathophysiology

The chapter from the Nei Jing that contains the above quote also includes a reference to the decline of the Stomach channel along with the other Yang channels over approximately 14 years prior to the menopause. (Ni, 1995, p. 2) Thus according to the Nei Jing the main factors underlying the physiological changes in the menopausal transition are: decline of the Stomach-Spleen, decline of the Yang Qi and decline of the Kidney Qi. Modern interpreters of TCM also tend to follow this approach, describing the symptoms around menopause as fundamentally due to decline of the Kidney Essence in its Yin or Yang aspect, commonly manifesting as a deficiency of both the Kidney Yin and the Kidney Yang. In addition to underlying Kidney deficiency, one or more excess-type factors may be present, such as retained Damp (or Phlegm-Damp), Qi stagnation, Blood stasis, Heat or hyperactive Liver Yang.

Premature menopause may arise due to obstruction of the lower Jiao due to accumulation of Phlegm and stagnation of the Qi. (Maciocia, 1998, p.742). Kidney Yin deficiency and associated deficiency of Liver and Heart Yin may, in turn, give rise to Liver Fire, Heart Fire and interior Heat; while Kidney Yang deficiency may give rise to Qi deficiency and Blood stasis. (Yu, 1998, p.150).

As with most other disorders, lifestyle factors may also generate or exacerbate the clinical picture. Chief amongst these are poor dietary choices, lack of exercise, consumption of alcohol and tobacco, stress and emotional strain. (Marchment, 2007, pp. 106-7; Maciocia, 1998, pp.742-3)

Before proceeding to an analysis of the major symptoms as recorded in the literature, it is important to have some idea of the menopausal woman’s personal experience of these changes. This is especially so for male practitioners, particularly young male practitioners, for whom the inner life of a menopausal woman must be completely outside their own range of life experiences. Moreover, these feelings are also experienced, to a lesser degree, by men when testosterone levels plummet in late middle age. It appears to me that the central feature of the menopause experience arises as a result of disruption to the cyclical rise and fall of the female hormones, with loss of the regular rhythm of hormone secretion, together with the gradual decline of estradiol. In TCM terms both of these events, together, equate to decline of the Kidney Qi in a woman, and it is very clearly conceptualized within this paradigm. The Kidney Qi is the root of the body’s vitality: the Qi, the Blood, the Fluids are all supported and stored by the Kidney. When the Kidney Qi declines in menopause, it is as if the bottom has fallen out of the bucket; resilience is gone, energy is limited, resourcefulness fails. The person who was once the backbone of the family, social group and workplace, now finds herself completely overwhelmed by events and situations that she used to handle with ease and finesse.

Pathogenesis of the major symptoms

• Hot flushes may be due to Kidney Yin deficiency (giving rise to deficiency Heat); Kidney Yang deficiency (giving rise to floating Yang); or, most commonly, combined Kidney Yin and Kidney Yang deficiency. 
• Spontaneous and excessive sweating may arise due to deficiency and insecurity of the defensive Qi.
• Vaginal dryness may be due to Kidney Yin deficiency and/or Blood deficiency
• Anxiety and insomnia may arise when Kidney and Heart are not harmonized.
• Emotional volatility may be due to Liver constraint or instability of the Spirit due to Heart deficiency
• Irregular menstruation, may be due to Qi stagnation from Liver Qi constraint, leading to Blood stasis.
• Excessive vaginal bleeding may be due to Yang deficiency, Blood stasis or Blood Heat.
• Edema may be due to retained Fluid caused by Kidney Yang deficiency.

(Marchment, 2007, pp. 103-111; Maciocia, 1998, pp. 741-743; Xuan & Li, 1990, pp. 47,103-104; Yu, 1998, pp. 22, 149-150; Maciocia, 1998, pp.743,744, 755, 756; Huo & Geng, 1997, pp. 241-5; Yan, 1995, pp.55-56, 201-4)

The importance of Blood stasis

Although most of the authorities cited above focus primarily on the deficiency patterns in the pathogenesis of menopausal symptoms, Qi stagnation due to Liver constraint (i.e. emotionally based Liver imbalance) and Blood stasis are both crucial factors that need to be addressed in any clinical protocol that deals with the management of menopausal patients. (Yan, 1995, pp.56, 201-2; Marchment, 2007, p.108; Maciocia, p.757)

Viewed in the light of basic principles, we know that the menstrual flow is controlled by the Liver Qi, which regulates the movement of Blood. (Maciocia, 1998, pp. 8-13) In the menopausal transition when the cycles are becoming irregular, the underlying pathodynamic involves failure of the Liver in its major functions of storage and discharge the Blood as well as the maintenance of the normal even Qi movement throughout the body. (Maciocia, 1998, p. 28; Yan, 1995, p.202) These changes in Liver function, involving both the Liver Qi and the Liver Blood are due to decline of the Kidney and Stomach. This creates a vicious circle in that the emotional volatility experienced by a woman at this time both exacerbates and is, in turn, exacerbated by the Liver dysfunction.

Additionally, this pathodymanic (i.e. Qi stagnation and Blood deficiency) readily leads to the development of Blood stasis, which together with Blood deficiency, is an important pathogenetic factor in the menopausal transition. Thus, while the progressive loss of Kidney Essence underlies all of the other manifestations of deficiency, the concomitant stasis of Blood, together with Blood deficiency, are key components of the core pathological changes that manifest in the distressing symptoms that may occur at this time.

Chinese herbal treatments

Treatments are generally based on the following formulas:

• Kidney Yin deficiency and complications: Zuo Gui Yin, Liu Wei Di Huang Wan, Zhi Bai Di Huang Wan, Er Zhi Wan, Qi Ju Di Huang Wan, Tian Wang Bu Xin Wan, Gan Mai Da Zao Tang
• Kidney Yang deficiency and complications: You Gui Wan, Er Xian Tang.
• Blood stasis: Ge Xia Zhu Yu Tang, Wen Jing Tang, Tao Hong Si Wu Tang, Xue Fu Zhu Yu Tang.
• In addition, Xiao Chai Hu Tang may also be used to treat the hot flushes, especially when they alternate with cold sensations, as well as soothe the Liver in cases with Liver related emotional symptoms.

(Wang, 2011, p. 28; Maciocia, 1998, pp. 744-759; Yu, 1998, pp. 151-152; Huo & Geng, 1997, pp.241-5; Yan, 1995, pp. 201-7; Xuan & Li, 1990, pp. 104-107)

As mentioned above, there are strong indications that CHM is both safe and effective for the main symptoms associated with the perimenopause. Proposed mechanisms of action for CHM include: balancing the autonomic nervous system, increasing estrogen levels, increasing central and peripheral estrogen receptors, acting on the adrenal cortex to increasing plasma cortisol levels (Yu, 1998, p.153; Yu, 2000; Dharmananda, 1999)

Clinical protocols

The following protocols have been compiled from various sources. (Wang, 2011; Marchment, 2007; Maciocia, 1998; Yu, 1998; Huo & Geng, 1997; Yan, 1995; Xuan & Li, 1990) Clinically, the following syndrome-patterns may be seen in perimenopausal women:

• Kidney Essence deficiency (Yin, Yang, or both aspects deficient)
• Spleen Qi deficiency and Heart Blood deficiency
• Liver constraint, Qi stagnation
• Blood stasis
• Stagnation due to Phlegm-Damp

Because treatment should be continued for several months, the following protocols utilize ready prepared Chinese herbal formulas that are available in Australia.

In general, clinical results are seen within 4 to 8 weeks. It will be noted that most of the protocols below utilize the formula Tao Hong Si Wu Tang to address the aspect of Blood stasis and Blood deficiency that are key components of the core pathodynamics in PS.

Kidney Yin deficiency

Hot flushes, night sweats, heat in the five centres, dizziness, tinnitus, insomnia or dream-disturbed sleep, irritability, night-sweating, aching and weakness of loins and knees, dry mouth, dry skin, dry stools, scanty urine, red tongue with little coat, thread-rapid pulse.

P/T:    Nourish the Kidney Yin, clear deficiency Heat

ZUO GUI WAN

Left Returning Formula

Plus

TAO HONG SI WU WAN

Persica, Carthamus & Dang-gui Combination

(a.k.a. BLOOD MOVING 2 FORMULA)

Variations:

• Disharmony between the Kidney and Heart (anxiety, insomnia, restlessness, forgetfulness, inability to concentrate)

TIAN WANG BU XIN WAN

Ginseng & Zizyphus Combination

(a.k.a. CALM THE SPIRIT FORMULA)

Plus

TAO HONG SI WU WAN

Persica, Carthamus & Dang-gui Combination

(a.k.a. BLOOD MOVING 2 FORMULA)

• Pronounced signs of deficiency Heat (hot flushes or sensations of heat, night sweats, dry mouth and throat)

ZHI BAI BA WEI WAN

Anemarrhena, Phellodendron & Rehmannia Combination

(a.k.a. EMPTY HEAT FORMULA)

Plus

TAO HONG SI WU WAN

Persica, Carthamus & Dang-gui Combination**

(a.k.a. BLOOD MOVING 2 FORMULA)

• Headaches due to Liver Yang hyperactivity (irritability, dizziness, red face and eyes, thread-wiry pulse)

QI JU DI HUANG WAN

Lycium, Chrysanthemum & Rehmannia Formula

(a.k.a. CLEAR VISION FORMULA)

Plus

TAO HONG SI WU WAN

Persica, Carthamus & Dang-gui Combination**

(a.k.a. BLOOD MOVING 2 FORMULA)

Kidney Yang deficiency

Sporadic hot flushes, aversion to cold, cold extremities, dull spirit, gloomy complexion, fatigue, poor appetite, abdominal distension, loose stools edema, polyuria or incontinence of urine, possibly heavy vaginal bleeding, pain and weakness of the lower back and knees, pale tongue that is swollen and with teeth marks and a thin white coat, deep, thready-weak pulse. There may also be profuse white and watery vaginal discharge.

P/T:    Warm-tonify the Kidney Yang, strengthen the Spleen

YOU GUI WAN

Right Returning Formula

Plus

FU ZI LI ZHONG WAN

Dangshen & Ginger Formula

Variations:

• With fluid retention and weight gain

MENOPAUSE 1 FORMULA

Plus

TAO HONG SI WU WAN

Persica, Carthamus & Dang-gui Combination**

(a.k.a. BLOOD MOVING 2 FORMULA)

Kidney Yin and Yang deficiency

Hot flushes, night sweats, cold extremities, cold lower abdomen, polyuria, irritability, insomnia, dizziness, tinnitus, low back pain, tongue variable (may show signs of Kidney Yin or Yang deficiency), pulse variable (may show signs of Kidney Yin or Yang deficiency).

P/T:    Nourish the Kidney Yin, tonify the Kidney Yang, calm the Spirit

MENOPAUSE 2 FORMULA

Plus

TAO HONG SI WU WAN

Persica, Carthamus & Dang-gui Combination**

(a.k.a. BLOOD MOVING 2 FORMULA)

Spleen Qi and Heart Blood deficiency

Forgetfulness, insomnia, anxiety, profuse menstrual bleeding, palpitations, shortness of breath, fatigue, muscular weakness, sallow complexion, poor appetite, pale tongue with a thin white coat, thready-weak pulse.

P/T: Tonify the Qi and Blood, strengthen the Spleen and nourish the Heart Blood and calm the Spirit

GUI PI WAN

Ginseng & Longan Combination

(a.k.a. RESTORE THE SPLEEN FORMULA)

Liver constraint, Qi stagnation

Hot flushes brought on or worsened by stress and emotional strain, discomfort of the chest and intercostal area, breast or abdominal distension, insomnia, general body aches, normal or absent tongue coat, wiry pulse.

P/T:    Soothe the Liver to relieve constraint.

JIA WEI XIAO YAO SAN

Bupleurum & Peony Formula

(a.k.a. STRESS RELIEF 1 FORMULA)

Plus

ZHI BAI BA WEI WAN

Anemarrhena, Phellodendron & Rehmannia Combination

(a.k.a. EMPTY HEAT FORMULA)

Variations:

• With severe emotional symptoms, combine with:

GAN MAI DA ZAO WAN

Wheat & Jujube Combination

• Episodes of chills in between the hot flushes:    

XIAO CHAI HU WAN

Minor Bupleurum Formula

(a.k.a. RESISTANCE 2 FORMULA)

Plus

ER XIAN TANG

Epimedium & Circuligo Combination

• To improve clinical efficacy of the above protocols, combine with:

TAO HONG SI WU WAN

Persica, Carthamus & Dang-gui Combination**

(a.k.a. BLOOD MOVING 2 FORMULA)

Blood stasis

Hot flushes, irritability, restlessness, history of very irregular periods, insomnia, dull and dark complexion, purple or dark tongue that may have macules, thin and dry tongue coat, choppy pulse.

P/T: Activate the Blood and dispel stasis

GUI ZHI FU LING WAN

Cinnamon & Hoelen Combination

Plus

XUE FU ZHU YU TANG

Persica & Cnidium Combination

(a.k.a. BLOOD MOVING FORMULA)

Stagnation due to Phlegm-Damp

Obesity or overweight, stifling sensation in the chest, expectoration of sputum, epigastric fullness and distention, belching, acidic regurgitation, nausea, poor appetite, loose stools, possibly premature menopause, tongue has a greasy white coat, slippery or slippery-wiry pulse.

P/T: Resolve Phlegm and strengthen the Spleen, regulate the Qi

WEN DAN TANG

Bamboo & Hoelen Combination

(a.k.a. CLEAR THE PHLEGM FORMULA)

Plus

BAN XIA HOU PO TANG

Pinellia & Magnolia Combination

REFERENCES

Americal College of Obstetricians and Gynecologists Committee on Practice Bulletine –Gynecology. (2001). ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Use of botanicals for management of menopausal symptoms. Obstet Gynecol; 97(6): suppl 1-11.

Australian Menopause Society (2015), For Women, Information Sheets, retrieved July 6, 2015 from: http://www.menopause.org.au/for-women/information-sheets

Avis, N., Crawford, S., Greendale ,G., et al. (2015) Duration of Menopausal Vasomotor Symptoms Over the Menopause Transition.JAMA Intern Med. 175(4):531-539

Burbos, N., Morris, E. (2011). Menopausal Symptoms, in BMJ Clinical Evidence. Retreived 18th June, 2015 from: http://clinicalevidence.bmj.com/x/systematic-review/0804/overview.html

Chen, L., Tsao, Y., Yen, K., Chen, Y., Chou, M., Lin, M. (2003). A pilot study comparing the clinical effects of Jia-Wey Shiau-Yau San, a traditional Chinese herbal prescription, and a continuous combined hormone replacement therapy in postmenopausal women with climacteric symptoms. Maturitas. 44(1):55-62

Climacteric. 10(1):38-45.

Coney, P. (2014). Menopause, in eMedicine Specialties: Obstertrics & Gynecology, General Gynecology. Retrieved June, 19, 2015, from: http://emedicine.medscape.com/article/264088-overview

Davis, S., Briganti, E., Chen, R., Dalais, F, Bailey, M., Burger, H. (2001). The effects of Chinese medicinal herbs on postmenopausal vasomotor symptoms of

Australian women. A randomised controlled trial. Med J Aust; 174(2):68-71.

Dharmananda, S. (1999). The Treatment of Menopausal Syndrome with Chinese Herbs. ITM Online, retrieved, July 10, 2015 from: http://www.itmonline.org/arts/menopaus.htm

Ding, G., Zhang, Z., Zhou, Y. (1995). Clinical study on effect of bushen jiangu capsule on postmenopausal osteoporosis. Zhongguo Zhong Xi Yi Jie He Za Zhi;15(7):392-4.

Gabriel, S., Carmona, L., Roque, M., Sanchez, G., Bonfill, X. (2005).Hormone replacement therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD002229

Genazzini, A., Gembacciani, M. International Menopause Society. (2000). Controversial issues in climacteric medicine I. Cardiovascular disease and hormone replacement therapy. International Menopause Society Expert Workshop. 13-16 October 2000, royal society of medicine, London, UK.V Climacteric. 3(4): 233-40

Hogervorst, E., Yaffe, K., Richards, M., Huppert, F. (2002). Hormone replacement therapy for cognitive function in postmenopausal women. Cochrane Database Syst Rev. 2002;(3):CD003122.

Huo, J., Geng, X. (1997). Traditional Chinese Treatment for Senile Diseases. Beijing: Academy Press.

Jane, F., Davis, S. (2014). A practitioner’s toolkit for managing the menopause. Climacteric. 17(5):564-79

Kwee, S., Tan, H., Marsman, A., Wauters, C. (2007). The effect of Chinese herbal medicines (CHM) on menopausal symptoms compared to hormone replacement therapy (HRT) and placebo. Maturitas. 58(1):83-90

Lai, J., Hwang, J., Chen, H., Wang, J. (2005). Finished herbal product as an alternative treatment for menopausal symptoms in climacteric women. J Altern Complement Med. 11(6):1075-84

Lethaby, A., Hogervorst, E., Richards, M., Yesufu, A., Yaffe, K. (2008). Hormone replacement therapy for cognitive function in postmenopausal women.  Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003122

Maciocia, G. (1998). Obstetrics & Gynecology in Chinese Medicine. Edinburgh: Churchill Livingstone

Maclennan, A., Broadbent, J., Lester, S., Moore, V. (2004). Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD002978

Manson, J., Bassuk, S. (2015). Menopause and Postmenopausal Hormone Therapy. In Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J(Eds), Harrison’s Principles of Internal Medicine, 19e. Retrieved July 06, 2015 from http://accessmedicine.mhmedical.com/content.aspx?

Marchment, R. (2007). Gyneacology Revisited. Sydney: Churchill Livingstone Elsevier.

Menopause Centre of Australia Website (2013), home page. http://www.menopausecentre.com.au/online/index.php

Nathan, L. (2013). Chapter 59. Menopause & Postmenopause. In DeCherney A.H., Nathan L, Laufer N, Roman A.S. (Eds), CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. Retrieved July 06, 2015 from http://accessmedicine.mhmedical.com/content.aspx?

Ni, M., (Transl.) (1995). The Yellow Emperor’s Classic of Medicine. A new Translation of the Neijing Suwen with Commentary. Boston: Shambala Publications Inc.

Politi, M., Schleinitz, M., Col, N. (2008). Revisiting the Duration of Vasomotor Symptoms of Menopause: A Meta-Analysis. Journal of General Internal Medicine, 23(9), 1507–1513.

Qiu, R., Shen, R., Zhang, P. (2004). Treatment of postmenopausal osteoporosis with yang huo san zi tang–a report of 30 cases. J Tradit Chin Med; 24(2):102-4.

Reid, R., Abrahamson, B., Blake, J., Desindes, S., Dodin, S., Johnston, S., et al (Mernopause and Osteoporosis Working Group). (2014). Managing Menopause. J Obstet Gynecol Can. 36(9):830-33

Scheid, V. (2006). Not Very Traditional, Nor Exactly Chinese, So What Kind of Medicine is It? TCM’s Discourse on Menopause and Its Implications for Practice, Teaching, and Research. JCM, 82: 5-20

Schairer, C., Lubin, J., Troisi, R., Sturgeon, S., Brinton, L., Hoover, R. (2000). Menopausal Estrogen and Estrogen-Progestin Replacement Therapy and Breast Cancer Risk. JAMA. 283(4):485-491. 

Stages of Reproductive Aging Workshop (2001), Executive Summary. Park City Utah, Menopause 8 (2001) 402– 407.

Torgerson, D., Bell-Syer, S. (2001). Hormone replacement therapy and prevention of nonvertebral fractures: a meta-analysis of randomized trials. JAMA; 285(22):2891-7

Ushiroyama, T., Ikeda, A., Sakuma, K., Ueki, M. (2005). Comparing the effects of estrogen and an herbal medicine on peripheral blood flow in post-menopausal women with hot flashes: hormone replacement therapy and gui-zhi-fu-ling-wan, a Kampo medicine. Am J Chin Med. 33(2):259-67

Utian, W. (1999). The International Menopause Society menopause-related terminology definitions, Climacteric 2: 284–286.

Wang, S., (2011). How to Use Prepared Chinese Medicines for Commonly Occurring Conditions. Melbourne: China Books Pty Ltd.

Willett, W., Colditz, G., Stampfer, M. (2000). Postmenopausal Estrogens—Opposed, Unopposed, or None of the Above. JAMA. 283(4):534-535. 

Writing Group for the Women’s Health Initiative Investigators (WHI), (2002). Risks and benefits of estrogen plus progestin in healthy menopausal women. JAMA; 288: 321-333

Xu, L., Jia, M., Salchow, R., Kentsch, M., Cui, X., Deng, H., Sun, Z., Kluwe, L. (2012). Efficacy and Side Effects of Chinese Herbal Medicine for Menopausal Symptoms: A Critical Review. Evidence-based Complementary & Alternative Medicine (eCAM). 2012:568106.

Xuan, J., Li, Z (Chief Eds.) (1990) The Chinese-English Encyclopedia of Practical Traditional Chinese Medicine. Vol. 12: Gynegology. Beijing: Higher Education Press.

Yan, D., (1995). Ageing and Blood Stasis. A New TCM Approach to Geriatrics. Boulder, Co: Blue Poppy Press

Yu, J. (1998). Obstetrics & Gynecology in Chinese Medicine. An Integrated Approach. Seattle: Eastland Press

Yu, J. (2000). Public lecture, UWS, Sydney.

Zhang, R., Chen, K., Lu, D., Zhu, X., Ma, X. (2005). A clinical study of Yigu capsule in treating postmenopausal osteoporosis. Chin J Integr Med; 11(2):97-103.

Zhao, G., Cai, D., Dong, S., Fan, Y. (2003). Clinical observation on treatment with the kidney-tonifying prescription in 25 cases of postmenopausal osteoporosis. J Tradit Chin Med. 23(2):103-5.

Zhong, L., Tong, Y., Tang, G., Zhang, Z., Choi, K., Cheng, K., Sze, S., Wai, K., Yu, B. (2013). A randomized, double-blind, controlled trial of a Chinese herbal formula (Er-Xian decoction) for menopausal symptoms in Hong Kong perimenopausal women. Menopause. 20(7):767-76.

Zhou, B., Sun, Q., Cong, R., Gu, H., Tang, N., Yang, L., Wang, B. (2008). Hormone replacement therapy and ovarian cancer risk: a meta-analysis. Gynecol Oncol; 108(3):641-51

Zhou, J., Qu, F., Nan, R., Tang, D. (2007). The effect of chinese medicinal herbs in relieving menopausal symptoms in ovariectomized chinese women. Explore (NY). 3(5):478-84.

Zweifel, J., O’Brien, W. (1997). A meta-analysis of the effect of hormone replacement therapy upon depressed mood. Psychoneuroendocrinology; 22(8):655.

Harlow, S., Gass, M., Hall, J., Lobo, R., Maki, P., Rebar, R., Sherman, S., Sluss, P., de Villiers, T.; STRAW 10 Collaborative Group. (2012). Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause. 19(4):387-95. 

Soules, M., Sherman, S., Parrott, E., Rebar, R., Santoro, N., Utian, W., Woods, N. (2001) Executive summary: Stages of Reproductive Aging Workshop (STRAW). Fertil Steril. 76(5):874-8.