First International Congress of the North America

Acupuncture and Oriental Medicine Commission

Acapulco, Mexico, October 1998

© J. E. Williams

Treatment of Menopausal Complaints

through the Integration of Western and Eastern Medicine

by James E. Williams

Menopause is that time in a woman’s life when permanent cessation of menstruation occurs following the loss of ovarian activity.[1] By the age of 48, 50% of women will have reached menopause, with an estimated 25 million women entering menopause each year.[2] This menopausal transition, or perimenopause, is characterized by alterations in menstruation, steroid hormone decline, and the onset of vasomotor symptoms such as hot flushes and night sweating. Using 50 to 52[3] as the average age, most women will have reached the post-menopausal state, after the cessation of menstruation for one year. It is estimated that the number of postmenopausal women worldwide will reach 2.3 billion by the year 2030.[4]

The consensus of modern medicine is that long-term hormone replacement therapy (HRT) is useful in postmenopausal women for reducing the risk of osteoporosis-related fractures and cardiovascular disease.[5] Most women typically come to clinicians for the relief of symptoms. The majority of these women will discontinue conjugated HRT after 3 years,[6] [7] most due to fear of cancer risks. Many women will not be able to take HRT due to breast or endometrial cancer, acute liver disease, acute vascular thrombosis or emboli[8], physiologic sensitivity to supplemental hormones, or due to personal decision or belief.

Traditional Chinese medicine (TCM) has a well established belief and a rich history in promoting women’s health, including conditions related to menopause, and has successfully utilized herbal medicines and diet as long-term therapy for these conditions. In recent years many natural therapies and products, notably in Germany, have been researched and developed as alternatives to conjugated HRT.[9] Additionally, women in the developing countries do not have the economic means to take a long-term course of HRT, therefore more cost-effective treatment options need to be investigated.

Pathophysiology of the menopausal transition

Although menopause occurs at a specific time and symptoms may come on rapidly, the biological changes that lead up to this event occur over a long period of time. Oocytes, declining progressively over the woman’s course of life, reaching critically low levels by the time of menopause. The menstrual cycle becomes disrupted with shortened time between periods, irregular bleeding, and missing of periods. Endocrine changes occur characterized by a rise in the gonadotrophins follicle-stimulating hormone (FSH) and lutenizing hormone (LH), and a decline in steroid hormones principally estradiol.

The Symptoms of Menopause

There are great individual variances in the experience of menopause. Additionally, socio-economic and cultural differences, such as life-style, diet, and cultural conditioning, occur around the subject of menopause. Studies suggest that North American and Northern European women report experiencing more symptoms than Asian women,[10] with a high of 80% and a low of 12% respectively. Symptoms are generally classified as disturbances in menstrual pattern (e.g. anovulation and reduced fertility, decreased or increased flow, irregular frequency including shortening of the cycle and missing of periods), vasomotor changes (e.g. hot flushes and night sweats), atrophic changes (e.g. atrophy of vaginal epithelium causing symptoms of pruritus and dyspareunia, urinary incontinence and urgency, increased frequency of urethritis and cystitis including interstitial cystitis), cognitive and psychological symptoms (e.g. memory lose, anxiety, depression, irritability, and insomnia), and sexual changes principally lose of libido. In some perimenopausal women as follicles fail to mature, corpus luteum formation becomes absent, leading to luteal phase defects and may contribute to episodes of abnormal bleeding.[11]

Evaluation of Menopause

In most instances, menopause can be evaluated and diagnosed by the clinical history, along with a symptom and sign profile. Laboratory evaluation of estradiol and FSH is extremely helpful in determining the stage of menopause and in monitoring HRT. However, a comprehensive profile is recommended for a more complete presentation of the individual woman’s menopausal status. This profile should include: estradiol, FSH, progesterone, free testosterone, and dehydroepiandrosteinedione (DHEA). A bone density study by dual-energy x-ray absorptiometry (DEXA scan) is also highly encouraged. If bone density levels indicate osteoporosis, biochemical markers such as urinary pyridinoline cross-links (Pyrilinks) are recommended to evaluate status of active bone lose and in selecting the appropriate type and dosage of treatment. Blood lipids, CBC, TSH, T3, and T4 should also be included. If estriol is the principle form of estrogen replacement therapy (ERT), then levels should also be obtained.

The Traditional Chinese Medicine Perspective

Several studies indicate that Asian women in general and Chinese women in particular have fewer menopausal symptoms and perceive menopause in a positive and wholistic way.[12] This positive outlook is attribute to reduced symptomology associated with a life-style that includes regular weight bearing activity, a diet high in soy, low in animal protein, and high in vegetable fiber.

Tian Gui

About 2,000 years ago, the cycles of a woman’s life were presented, including a definition of menopause, in the Huang Di Nei Jing (The Yellow Emperor’s Classic of Internal Medicine).[13] The reproductive potential, the tian gui or heavenly fluid, originates from kidney jing (humeral essence), and is produced when a surplus of zang qi (original energy) and xue (blood) develop at puberty. It relies on qi acquired from dietary sources and a balanced life-style to maintain itself; while gradually diminishing in function as the body ages and the kidney qi degenerates. At 42, decline of kidney function is well underway and the yang meridians begin to degenerate causing wrinkles, graying of hair, hair loss, and dry skin. By the age of 49 the tian gui has become exhausted, reproduction ceases, the meridians become blocked, and yin and yang become imbalanced.

TABLE 1. Summary Of TCM View Of The Stages Of A Woman’s Life

Age kidney qi ren mai chong mai tian gui

7 begins to thrive

14 is thriving becomes unblocked is thriving sets in

21 (all are evenly distributed and thriving)

28 (the body is full and strong)

35 degeneration begins

42 continues to decline (the 3 yang meridians begin to decline)

49 continues to degenerate deficient deterioration exhaustion

The Terminology of Menopause

In TCM, menstruation is called yue jing (moon flow) or jing shui (essence water).[14] Duan jing (stoppage of menstruation) and geng nian qi (change of life) are terms associated with menopause. The terminology for perimenopause is jue jing qian hou zhu zheng. It is composed of the characters for jue jing (exhaustion of menses), quan hou (before and after), and zhu zheng (symptoms and signs). Although not described in the classical texts, the modern term for osteoporosis is gu zhi shu song (bone substance penetrating long life).[15]

Wholistic Symptomology

Symptoms in TCM parallel those in Western medicine. However, in TCM a complete profile of symptoms and signs: the patient’s emotional and concomitant complaints, and the organ and meridian relationships, are necessary to form a wholistic pattern. Since the kidney, in TCM, nourishes the brain, bones, and the tian gui, all postmenopausal symptoms can be explained in terms of loss of kidney yin.[16] Kidney yin deficiency leads to deficiency of liver and heart yin, which may transform to liver or heart fire. Kidney yang and qi deficiency may occur simultaneously, as can blood deficiency.

The perimenopause is characterized by kidney yin deficiency symptoms combined with excess or stagnation. For example: a patient may have hot flashes, insomnia, and hypertension, due to kidney and heart yin deficiency with liver yang rising. Postmenopausal symptoms, predominantly deficient in nature, include fatigue, memory loss, dry and thinning skin, graying of hair, poor appetite, and back pain, and are due to kidney yin deficiency concurrent with deficiency of kidney yang and spleen qi.

Table 2. Patterns of Disharmony

Kidney Yin Deficiency Liver Predominating Qi Deficiency Heart Deficiency

kidney yin deficiency	liver yang excess	spleen qi deficient and heart blood deficient	heart qi and blood deficient
kidney yin with liver yang rising	liver yang transforming to fire	spleen qi deficient and kidney yang deficient	heart fire and kidney yin deficient
kidney yin and yang	liver yin and blood deficiency	spleen qi deficient and liver qi stagnant
	stagnation of liver qi and blood in the lower heater

Treatment Strategies

Western Medicine

The primary clinical method of modern medicine is to replace estrogen decline in menopause with conjugated 17 ß-estradiol in dosages ranging from 0.025 to 1.25 mg daily. For the prevention of osteoporosis and cardiovascular disease blood levels should be monitored to remain within a range of 40 to 100 pg/ml.[17] A progestin component, usually medroxyprogesterone, 5 to 10 mg, on a cyclical basis (though low dose, 2.5 mg, is sometimes prescribed), is added to oppose the estradiol and prevent hyperplasia for women who still have a uterus.[18] Testosterone may also be indicated to increase libido and improve mood. Orally administered biphosphonates (Etridonate) and alendronate sodium (Fosamax), and nasal calcitonin are used for the treatment of osteoporosis.

Naturopathic Medicine

Low dose phytoestrogen and progesterone concentrates, derived from soy or wild yam, are used as natural hormone replacement therapy (NHRT). A combined form of estrogen (Tri-Est) in a average dose of 2.5 mg (equivalent to 0.625 of Premarin) in a ratio of 1-1-8 (estrone-estradiol-estriol) is preferred, and administered in oral or topical form.[19] NHRT protocols commonly combine Tri-Est, or single estradiol,[20] with topical (1-2 gm) or oral (100-200 mg) micronized progesterone[21] (5 mg of Provera is equivalent to 100 mg of oral natural progesterone). Androstenedione (25 mg daily), a natural testosterone precursors, DHEA (5 to 50 mg daily), pregnenolone (25 to 100 mg daily), and melatonin (1 to 5 mg daily), are commonly added to provide a balanced hormone prescription.

Many traditional naturopaths contend that hormone replacement is unnecessary for the majority of women.[22] However, they do recommend that hormonal pathways be assisted with naturally occurring substances such as phytoestrogens from herbal preparations,[23] soy isoflavones,[24] [25] [26] and glandular preparations.

In addition, vitamin E, vitamin C, and the bioflavonoid hesperidin (500 mg b.i.d.), are frequently recommended. Also calcium supplements along with supportive factors, such as boron, are recommended to prevent osteoporosis.

A number of studies[27] [28] indicate that phytoestrogen-rich diets raise estrogen levels. Perimenopausal symptom control has been demonstrated by numerous studies. The most common herbal used is black cohosh, Cimicifuga racemosa, (Remifemin).[29] Though not containing phytoestrogens—its action deriving from estrogen receptor binding influences and effects on LH[30] —it has been demonstrated to have considerable effects in reducing vasomotor symptoms.[31]

Traditional Chinese Medicine

Like traditional naturopaths, TCM practitioners believe that concentrated hormone preparations are unnecessary in menopause. Instead, they recommend restoring the harmony of yin and yang, reducing the depletion of pre-natal jing, and nourishing the kidney yin by a balanced life-style, a diet rich in soy and fresh vegetables, and the addition of traditional herbal combinations. The majority of prescriptions for menopausal complaints are based on formulas to tonify yin deficiency.[32] [33] Though it has no phytoestrogens, most formulas for female complaints are constructed around Radix Angelica sinensis (dang gui),[34] therefore in menopausal formulas: dang gui is not a principle herb.[35]

Table 3. List of Commonly Prescribed TCM Formulas for Menopause[36]

Six Ingredient Pill with Rehmania (liu wei di huang tang): tonifies kidney yin

Anemarrhena, Phellodendron, Rehmania Pill (zhi bai di huang wan): tonifies yin & controls fire

Restore the Left (kidney) Pill (zuo gui wan): tonifies kidney and liver yin, & strengthens bones

Two Immortals Decoction (er xian tang): tonifies yang & regulates the chong and ren channels

Great Tonify Yin Pill (da bu yin wan): tonifies yin

Emperor of Heaven Pill to Tonify the Heart (tian wang bu xin dan): tonifies kidney, lowers fire, & pacifies the heart

Restore the Spleen Decoction (gui pi tang): tonifies spleen qi & nourishes the heart

Although not commonly used in China for menopausal symptoms, Acupuncture is also useful to assist the regulation of yin and yang, and remove stagnation of qi: which helps to reduce vasomotor symptoms, improve mood, and promote normal sleep.[37]

Table 4. Commonly Used Acupuncture Points in Menopause

KI-3 (tai xi), KI-6 (zhao hai): tonifies kidney yin

KI-7 (fu liu): tonifies kidney yang

CV-4 (guan yuan): tonifies kidney

ST-36 (zu san li): tonifies qi & supports post-natal qi

SP-6 (san yin jiao): tonifies kidney

LV-3 (tai chong): calms liver yang & regulates liver qi stagnation

LV-8 (qu quan): tonifies liver yin

PC-6 (nei guan): pacifies the spirit

Complications and Contradictions

Although the benefits of HRT are well known, the risks are great: breast cancer being the most serious and most widely studied.[38] Women with undiagnosed abnormal vaginal bleeding, acute liver disease, acute vascular thrombosis or emboli should have these problems resolved, and cancer ruled out, before starting HRT. Patients with a history of breast or endometrial cancer, or a family history of breast or endometrial cancer, should not take HRT, and HRT should be immediately discontinued if a patient is diagnosed with breast cancer while on HRT. The same contraindications apply to NHRT and to phytoestrogen therapy. Both naturopathic medicine and TCM recommend against long-term conjugated HRT. Studies suggest that sustained postmenopausal HRT substantially increases the risk of breast cancer.[39] Clinically, some women find all forms of HRT disruptive to their sense of well being, moods, and sleep patterns. These women present as allergic to exogenous hormones and should not take these medications.

Conclusions

All three systems of medicine (Western, TCM, and naturopathic) are in agreement that some form of hormone replacement or enhancement is necessary for the postmenopausal woman: to reduce symptoms of hormonal decline, to slow down the aging process, and to prevent osteoporosis and cardiovascular disease. In evaluating each system, it appears that the integrated approach utilizing low dose NHRT combined with herbal medicine, diet, and life style changes provides the greatest results with the least risk. Conjugated and higher dose hormone therapy should be limited to women with severe symptoms and used for a short duration. Acupuncture can be useful to manage patients who are unable to tolerate hormone or phytoestrogen preparations. Calcium and supportive vitamin and mineral supplementation should be suggested to all patients.

James E. Williams, Doctor of Oriental Medicine, Licensed Acupuncturist (California), Acupuncture Physician (Florida), Diplomate of Chinese Herbology, and Board Certified Naturopathic Physician: is the former Director of Alternative and Complementary Medicine at The Center for Women’s Medicine in San Diego, senior faculty at the Pacific College of Oriental Medicine, and founder of The Institute for Asian Medicine and Philosophy.

References

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[1] Lobo AR. Treatment of the Postmenopausal Woman: Basic and Clinical Aspects. Raven Press, New York, 1994; 1-8.

[2] Hill K. The demographics of menopause. Maturitas 1996; 23:113.

[3] McKinlay SM, Brambilla DJ, Posner JG. The normal menopausal transition. Maturitas 1992; 14:102.

[4] Hulka BS, Meirik O. Research on menopause. Maturitas 1996; 23:109-110.

[5] Schiff I, et al. Achieving long-term continuance of menopausal ERT/HRT: consensus opinion of the north American menopausal society. Menopause 1998; 5:69-72.

[6] Berman FS, Epstein RS, Lydick EG. Compliance of women in taking estrogen replacement therapy. J Women’s Health 1996; 5:213-20.

[7] Ettinger B, Li DK, Klein R. Continuation of postmenopausal hormone replacement therapy: comparison of cyclic versus continuous combined schedules. Menopause 1996; 3:185-9.

[8] Lobo, RA. Treatment of the Postmenopausal Women: Basic and Clinical Aspects. Raven Press, New York, 1994; 415-18.

[9] Seidl MM, Stewart DE. Alternative treatments for menopausal symptoms. Systematic review of scientific and lay literature. Can Fam Physician 1998; 44:1299-308.

[10] ibid

[11] Brown D, Gaby A, Riechert R, Kelly G. Clinical Applications of Natural Medicine: Menopause. Natural Product Research Consultants, Seattle, 1997.

[12] Chen YLD, Voda AM, Mansfield PK. Chinese mid-life women’s perceptions and attitudes about menopause. Menopause 1998; 5:28-34.

[13] Veith, I. The Yellow Emperor’s Classic of Internal Medicine. University of California Press, Berkeley, 1949.

[14] Ming O. Chinese-English Dictionary of Traditional Chinese Medicine. Joint Publishing, Hong Kong, 1988.

[15] Guillaume, G. Postmenopausal Osteoporosis and Chinese Medicine. American Journal of Acupuncture 1992; 20:2.

[16] Jin Y. Handbook of Obstetrics & Gynecology in Chinese Medicine, An Integrated Approach. Eastland Press, Seattle, 1998.

[17] Lobo RA. Treatment of the Postmenopausal Woman: Basic and Clinical Aspects. Raven Press, New York, 1994.

[18] Lobo RA. The role of progestins in hormone replacement therapy. Am J Obstet Gynecol 1992; 166:1997-2004.

[19] Wright JV, Morgenthaler J. Natural Hormone Replacement. Smart Publications 1997.

[20] Head KA. Estriol: safety and efficacy. Alternative Medicine Review 1998; 3:101-113.

[21] Laux M, Conrad C. Natural Woman, Natural Menopause. Harper Collins, New York, 1997.

[22] Murray MT. Menopause: is estrogen necessary. Am J Natural Medicine 1995; 2:2-15.

[23] Reichert, R.G. Phyto-estrogens. Quarterly Review of Natural Medicine (spring) 1994.

[24] Cassidy A, Bingham S, Setchell KDR. Biological effects of a diet of soy protein rich in isoflavones on the menstrual cycle of premenopausal women. Am J Clinical Nutrition 1994; 60:333-340.

[25] Gennari C. et al. Effect of ipriflavone, a synthetic derivative of natural isoflavones, on bone mass loss in the early years after menopause. Menopause 1998; 5:9-15.

[26] Baird DD, Umbach DM, Lansdell L, et al. Dietary intervention study to assess estrogenicity of dietary soy among postmenopausal women. J Clin Endocrinol Metab 1995; 80:1685-90.

[27] Brzezinski A, et al. Short-term effects of phytoestrogen-rich diet on postmenopausal women. Menopause 1997; 4:89-94.

[28] Whitten PT, Naftolin F. Effects of a phytoestrogen diet on estrogen dependent reproductive process in immature female rats. Steroids 1992; 57:6.

[29] Murray MT. HRT vs. Remifemin. Am J Natural Medicine 1996; 3:7-10.

[30] Duker EM, et al. Effects of extracts from Cimicifuga racemosa on gonadotropin release in menopausal women and ovariectomized rats. Planta Med 1991; 57:420-24.

[31] Gruenwald J. Standardized black cohosh (Cimicifuga) extract clincial monograph. Quarterly Rev Nat Med 1998; Summer:117-125.

[32] Luo YK. et al. Menopause syndrome as treated by traditional Chinese medicine. J Am College TCM 1989; 7:55-64.

[33] Lyttleton, J. Topics in gynaecology: menopause. J Chinese Medicine 1990; 33.

[34] Dharmananda S. The Endocrine Impact Of Chinese Medicine. Institute of Traditional Medicine, Portland 1994.

[35] Hirata JD, Swiersz LM, et al. Does dong quai have estrogenic effects in postmenopausal women? A double-blind placebo-controlled trial. Fertility & Sterility 1997; 68:981-986.

[36] Bensky D, Barolet R. Chinese Herbal Medicine, Formulas & Strategies. Eastland Press, Seattle 1990.

[37] Wyon Y, Lindren R, Lundeberg T, Hammar M. Effects of acupuncture on climacteric vasomotor symptoms, quality of life, and urinary excretion of neuropeptides among postmenopause women. Menopause 1995; 2:3-12.

[38] Brinton LA, et al. Breast cancer risk among women under 55 years of age by joint effects of usage of oral contraceptives and hormone replacement therapy. Menopause 1998; 5:145-171.

[39] Ettinger B, et al. Long-term postmenopausal estrogen therapy may be associated with increased risk of breast cancer: a cohort study. Menopause 1997; 4:125-129.