THE MENOPAUSE IN WESTERN MEDICINE
“Menopause” indicates the complete and permanent cessation of menstruation: an interval of 6-12 months is usually necessary to establish the diagnosis. “Climacteric” indicates the phase in a woman’s life during which she makes the transition from a reproductive to a non-reproductive stage: this transition is a period of declining ovarian function which usually spans 2-5 years around the menopause. Thus, when we refer to the discomfort and symptoms appearing during these years, it would be more appropriate to call them climacteric syndrome rather than menopausal syndrome.Menopause usually occurs between the ages of 48 and 55 and the median age in industrialized countries is about 51.
The very first chapter of the “Su Wen” 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. Indeed, the mean age at menopause is just over 50 and this is remarkably constant not only throughout the Western world but also 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.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.
This is very important to remember when interpreting menopausal problems from the point of view of Chinese medicine. The symptoms of hot flushes (flashes) and in particular vaginal dryness are due to a decline of oestrogen and therefore Tian Gui in Chinese medicine; Tian Gui derives from Kidney-Jing. 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 foetus, 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. This confirms that the biological basis of the menopause is determined during a woman’s lifetime, i.e. although the decline of Kidney-Jing is gradual, lifestyle and dietary habits from childhood onwards determine what kind of menopause a woman 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 more severe symptoms during the climacteric years. The main menopause-linked symptoms are three:vaginal dryness, hot flushes (flashes), night-sweating.
By far the commonest symptom is hot flushes (flashes), from which 85 per cent of menopausal women suffer; 45 per cent may experience them for 5-10 years after the menopause. Indeed, some gynaecologists say that, strictly speaking, only hot flushes and vaginal dryness are oestrogen-deficiency-related manifestations; according to their view, most of the other manifestations are due to increased stress at this time of life. Other symptoms that they may appear during the menopause are headaches, tiredness, lethargy, irritability, anxious mood, nervousness, depressed mood, insomnia, inability to concentrate.
THE MENOPAUSE IN CHINESE MEDICINE
From a Chinese perspective, menopausal symptoms are due to a decline of Kidney-Jing in its Yin or Yang aspect; however, within this basic pathology there can be many variations of patterns. I must stress that I am discussing only the “normal” menopause that occurs around age 50 and not premature menopause that may occur even in the 30s. While the “normal” menopause is due to a physiological decline of Tian Gui, premature menopause is always a pathology. Since menopausal symptoms (especially vaginal dryness, hot flushes and night-sweating) are due to the decline of oestrogen occurring at this time, from the Chinese point of view, they are due to the physiological decline of Tian Gui. Tian Gui is discussed in the very first chapter of the Su Wen which says that, in girls, it arrives when she is 14 (7×2) and it dried up when she is 49 (7×7): ”
At the age of 14 the Tian Gui arrives, the Ren Mai begins to flow, the Chong Mai is flourishing, the periods come regularly and she can conceive… At the age of 49, the Ren Mai is empty, the Chong Mai depleted, the Tian Gui dries up, the Earth Passage [uterus] is not open, so weakness and infertility set in.”The Golden Mirror of Medicine (Yi Zong Jin Jian, 1742) says: “ At 7, Kidney-Qi is abundant and the Motive Force (Dong Qi) between the kidneys is abundant. At 14, Tian Gui arrives, i.e. the Dong Qi within the Water of the pre-natal Tian Gui, and it enters the Uterus.”This is an interesting statement that makes the point that what he calls “Dong Qi”, essentially the Yuan Qi, is pre-natal and is therefore already active when a girl is 7.
By contrast, Tian Gui is post-natal and it is the transformation of Yuan Qi into Water when it enters the Uterus making the girl fertile. Although I myself think that we should be careful in making direct connections between Western and Chinese medicine, in this case I think we can definitely say that “Tian Gui” is an expression of ovarian activity and of oestrogen which is what determines puberty and menopause. As Tian Gui derives from Kidney-Jing, it follows that, during the menopause, there is a (physiological) decline of Kidney-Jing.
Finally, I would like to stress that the menopause is neither a “disease” nor a pathology: it is the natural, physiological decline of Kidney-Jing. Indeed, many women go through the menopause without marked symptoms. Of course, it may become a pathology when a woman suffers from a pre-existing deficiency of the Kidneys and other patterns which will cause distressing symptoms which require intervention.
Pathology of menopausal symptoms
I often hear that menopausal symptoms such as hot flushes are due to Kidney-Yin deficiency: not so! Half of the menopausal women I see have a Pale tongue and suffer from Kidney-Yang deficiency. That is because Kidney-Jing deficiency may manifest with a Yin or Yang deficiency; indeed, many herbs that nourish Jing are in the category of tonics of Kidney-Yang (e.g. Bu Gu Zhi, Yi Zhi Ren, Suo Yang, Jiu Zi, Sha Yuan Ji Li).
My experience is that in menopausal women, more often than not, there is an overlapping deficiency of Kidney-Yin and Kidney-Yang, albeit always with a predominance of one (i.e. it is never 50% Kidney-Yin and 50% Kidney-Yang deficiency).
1) Simultaneous Kidney-Yin and Kidney-Yang deficiency Hot flushes are easy to explain when there is Kidney-Yin deficiency as Empty Heat rising from Kidney-Yin deficiency, but how to explain them in Kidney-Yang deficiency? As mentioned above, during the menopause there is usually an overlapping Kidney-Yin and Kidney-Yang deficiency. Therefore when Kidney-Yang deficiency predominates, the tongue is Pale and the woman has many Cold symptoms such as feeling cold, cold feet and/or back, pale urine, etc. However, since Kidney-Yin is also deficient, there will be some Empty Heat rising and causing hot flushes. Figure 1 illustrates this concept; as can be observed, both Kidney-Yin and Kidney-Yang are deficient in both cases (albeit in different proportions) so that a woman suffering from Kidney-Yin deficiency may also experience cold feet and one suffering from Kidney-Yang deficiency will have hot flushes.
2) Minister Fire
There are also other aspects to the menopausal pathology that explain the hot flushes with Kidney-Yang deficiency. One aspect is the Minister Fire. The Minister Fire is the physiological Fire of the Kidneys that plays a vital role in supporting the physiological activity of all organs. The Minister Fire is a “formless” Fire that has special characteristics: crucially; it is a Fire that does not dry up Water as it even nourishes Water. When there is a deficiency of the Minister Fire there is a Kidney-Yang deficiency and, since the Minister Fire may even nourish Water, there is also a (secondary) Kidney-Yin deficiency.
3) Derangement of Qi
There is yet another aspect to the menopausal pathology that has not to do with Yin and Yang but with Qi. With the onset of the menopause and the decline of Kidney-Jing, there also develops a weakening of the Ren and Chong Mai in the Lower Burner and an “instability” of Qi in the Lower Burner. Thus, during the menopause, Qi is easily deranged and, because it is unstable in the Lower Burner, it rises above contributing to the hot flushes. Thus, in explaining hot flushes, one should not concentrate purely on the Heat aspect of them, but also on the derangement of Qi aspect. Therefore, besides clearing Heat, hot flushes should be treated also by consolidating Qi of the Ren and Chong Mai in the Lower Burner and subduing it in the upper part of the body.
4) Vaginal dryness
So far, we have concentrated on the pathology of hot flushes but the pathology of vaginal dryness is equally important and very distressful. The pathology of vaginal dryness is more directly related to Kidney-Jing than that of hot flushes is. In vaginal dryness we must obviously nourish Yin but remember that it also occurs with Kidney-Yang deficiency for the reasons explained above. What it means in treatment is that, if we are treating vaginal dryness in a woman with Kidney-Yang deficiency with herbal medicine, we must definitely modify the formula with the addition of herbs such as Sheng Di Huang Radix Rehmanniae and Nu Zhen Zi Fructus Ligustri lucidi.
5) Full patterns
Finally, the menopause obviously does not occur in a vacuum and every woman of around 55 will always have a pre-existing pathology that will aggravate the menopausal symptoms. It is important to understand that such pathology will aggravate the menopausal symptoms but is not menopausal as such. The only strictly menopausal pathology is a decline of Tian Gui and a Kidney deficiency.
Thus, in addition to a Kidney deficiency, there will also be some Full patterns such as:
Rebellious Qi of the Chong Mai
All these patterns will contribute to the development and severity of menopausal symptoms and they must be treated in addition to tonifying Kidney-Jing.
Aetiology of menopausal problems
As we discuss “aetiology” for diseases, to discuss the “aetiology” of menopausal problems seems to contradict what I stressed above, i.e. that the menopause is not a “disease”. However, the factors discussed below are factors that definitely aggravate menopausal symptoms.
1) Emotional stress
Emotional stress is an extremely important aggravating factor in menopausal problems, building up for year after year before the onset of the menopause.
Anxious, fear or guilt weaken the Kidneys and lead to Yin deficiency, especially when these emotions occur against a background of overwork as is usually the case. In the long run, as Kidney-Yin fails to nourish Heart-Yin, they also lead to Heart-Yin deficiency and Heart Empty Heat and this would aggravate hot flushes.
Worry, anger and fear may lead to Liver-Yang rising which would aggravate hot flushes.
In my experience, 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-Yin deficiency in Western women. As there is a pre-existing Kidney-Yin deficiency, this will aggravate the symptoms of vaginal dryness and hot flushes.
Tobacco smoking injures not only the Lungs but also the Kidneys. It dries up Jing and Blood and it therefore leads to Kidney-Yin deficiency which would aggravate menopausal symptoms.
Tobacco has an interesting history in Chinese society and medicine. When tobacco was first introduced in China (1575), Chinese doctors started testing it to see whether it could be used as a medicinal herb. The Zhen Nan Ben Cao (Ming dynasty) concludes that tobacco is pungent in taste, hot and toxic without any medicinal effect.
Cu Ci Shan (Qing dynasty) made the most interesting statement when he said: “Tobacco is pungent and drying, it burns Jing (Kidneys) and the Fluids, damages the throat, the sStomach and the Lungs…it enters the Heart orifice causing mental confusion as if one were drunk. It makes the tongue coating dark-yellow or black, food and drink have no taste, the medical texts have no treatment for this.” The most interesting part of the statement is the reference to tobacco burning Jing: this would therefore aggravate a Jing deficiency and aggravate menopausal symptoms.
4) Irregular diet
Eating irregularly and eating excessive amounts of dairy foods and greasy-fried foods leads to the formation of Phlegm. This often aggravates menopausal symptoms.
5) Tea/coffee and alcohol
Tea, coffee and alcohol are Yang in nature and would aggravate menopausal symptoms and hot flushes.
Based on the above aetiological factors, I now advice young women about the menopause. If I see a, say, 35-old woman who is overworking, eating a lot of dairy foods, drinking excessively and smoking, I tell her that now is the time to do something about the menopause and I list below the advice I give them.
Not to overwork
Do moderate exercise
Not to smoke
To consume only moderate amounts of alcohol
To avoid emotional stress (easy to say!)
To consume tea and coffee in moderate amounts
Not to eat dairy foods
Treatment of menopausal problems
The acupuncture treatment must be based on tonifying the Kidneys and strengthening the Ren and Chong Mai. When treating menopausal problems, I nearly always treat the Ren Mai and the three points I use every time are LU-7 (on the right), KI-6 (on the left) to open the Ren Mai and Ren-4 Guanyuan. In addition, I would also reinforce KI-3 Taixi and SP-6 Sanyinjao. In case of Kidney-Yang deficiency, I would use the same points plus BL-23 Shenshu.
In addition to points to tonify the Kidneys, I also use points to subdue Qi and clear Empty-Heat. I do this with: L.I.-4 Hegu, P-7 Daling and HE-6 Yinxi. In case of severe emotional stress and anxious mood, I add Du-24 Shenting and Ren-15 Jiuwei.
In case of rebellious Qi of the Chong Mai, I use the Chong Mai instead of the Ren Mai with these points: SP-4 Gongsun (on the right), P-6 Neiguan (on the left), plus L.I.-4 Hegu on the right, LIV-3 Taichong on the left, KI-13 Qixue (bilateral), Ren-4 Guanyuan.
2) Herbal treatment
I shall now discuss the treatment of the main patterns involved in menopausal problems.
a) KIDNEY-YIN AND KIDNEY-YANG DEFICIENCY WITH PREDOMINANCE OF KIDNEY-YIN DEFICIENCY
Dizziness, tinnitus, poor memory, hardness of hearing, night-sweating, dry mouth and throat at night, lower backache, ache in bones, tiredness, depressed mood, slight anxious mood, cold feet, abundant-pale urine.
Tongue: normal-coloured without coating or with rootless coating. The tongue will be red if there is Empty Heat.
Pulse: Floating-Empty or Weak on both Kidney positions.
Ren-4 Guanyuan, KI-3 Taixi, KI-10 Yingu, KI-9 Zhubin, SP-6 Sanyinjiao, Ren-7 Yinjiao, LU-7 Lieque and KI-6 Zhaohai in combination (opening points of the Ren Mai).
Zuo Gui Wan Restoring the Left [Kidney] Pill plus Ba Ji Tian Radix Morindae officinalis.
EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun
Sheng Di Huang
Radix Rehmanniae glutinosae 6g Shu Di Huang Radix Rehmanniae glutinosae praeparata 6g Gui Ban Plastrum Testudinis 12g Mu Li Concha Ostreae 12g Gou Teng Ramulus Uncariae 6g Suan Zao Ren Semen Ziziphi spinosae 4.5g Fu Ling Sclerotium Poriae cocos 6g Fu Shen Sclerotium Poriae cocos pararadicis 6g.
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. It also calms the Mind more.
GENG NIAN FANG Menopause Formula
Sheng Di Huang
Radix Rehmanniae glutinosae 9g Nu Zhen Zi Fructus Ligustri lucidi 6g Han Lian Cao Herba Ecliptae prostratae 4.5g Suan Zao Ren Semen Ziziphi spinosae 4.5g Long Chi Dens Draconis 12g Gou Teng Ramulus Uncariae 6g Lian Zi Xin Plumula Nelumbinis nuciferae 4.5g Fu Ling Sclerotium Poriae cocos 6g He Huan Pi Cortex Albizziae julibrissin 6g Zi Cao Radix Lithospermi seu Arnebiae 4.5g.
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.
GENG NIAN AN Peaceful Menopause
Shu Di Huang
Radix Rehmanniae glutinosae praeparata 9g Ze Xie Rhizoma Alismatis orientalis 6g Fu Ling Sclerotium Poriae cocos 6g Mu Dan Pi Cortex Moutan radicis 6g Shan Yao Radix Dioscoreae oppositae 6g Shan Zhu Yu Fructus Corni officinalis 6g Sheng Di Huang Radix Rehmanniae glutinosae 6g Shou Wu Radix Polygoni multiflori 6g Xian Mao Rhizoma Curculiginis orchioidis 6g
This formula nourishes both Kidney-Yin and Kidney-Yang, but primarily Kidney-Yin.
Modifications These modifications apply to all the above formulae.
-Itching: add Chan Tui Periostracum Cicadae, Fang Feng Radix Ledebouriellae divaricatae, Hai Tong Pi Cortex Erythrinae variegatae, Yu Zhu Rhizoma Polygonati odorati.
-Dizziness, headache: add Tian Ma Rhizoma Gastrodiae elatae, Gou Teng Ramulus Uncariae, Shi Jue Ming Concha Haliotidis, Niu Xi Radix Achyranthis bidentatae seu Cyathulae, Sang Ji Sheng Ramulus Sangjisheng.
-Liver-Yin deficiency: add Nu Zhen Zi Fructus Ligustri lucidi and Han Lian Cao Herba Ecliptae prostratae.
The list below compares and contrasts the four above formulae for menopausal problems from Kidney-Yin deficiency.
SYMPTOMS & ACTIONS:
ZUO GUI YIN
Exhaustion, dry throat, hot flushes
Peeled and slightly Red
Fine, Weak-Deep on both Rear positions
Dr MENG JING CHUN
Nourish Yin, absorb fluids, calm the Mind
Exhaustion, dry throat, night-sweating, hot flushes, mental restlessness
Red, without coating
GENG NIAN FANG
Nourish Yin, calm the Mind, subdue Liver-Yang
Exhaustion, dry throat, hot flushes, mental restlessness, anxiety, irritability, headaches
Red and Peeled
Floating-Empty, Overflowing on both Front positions and Weak-Deep on both Rear positions
GENG NIAN AN
Nourish Yin and Blood, tonify Kidney-Yang, subdue Liver-Yang
Exhaustion, dry throat, hot flushes, cold feet, headaches
Red and Peeled
ER XIAN TANG and ER ZHI WAN Two Immortals Decoction and Two Solstices Pill
Xian Mao Rhizoma Curculiginis orchioidis 6g Yin Yang Huo Herba Epimedii 9g Ba Ji Tian Radix Morindae officinalis 9g Huang Bo Cortex Phellodendri 4.5g Zhi Mu Radix Anemarrhenae asphodeloidis 4.5g Dang Gui Radix Angelicae sinensis 9g Nu Zhen Zi Fructus Ligustri lucidi 12g Han Lian Cao Herba Ecliptae prostratae 9g
The formula Er Xian Tang specifically nourishes Kidney-Yin and tonifies Kidney-Yang.
Nu Zhen Zi and Han Lian Cao (together forming Er Zhi Wan) nourish Kidney-Yin, clear Empty Heat and stop night-sweating.
EMPIRICAL PRESCRIPTION by Dr Meng Jing Chun
Yin Yang Huo Herba Epimedii 4.5g Xian Mao Rhizoma Curculiginis orchioidis 4.5g Bai Zhu Rhizoma Atractylodis macrocephalae 6g Dang Shen Radix Codonopsis pilosulae 6g Mu Xiang Radix Aucklandiae lappae 3g Gou Teng Ramulus Uncariae 6g Fu Ling Sclerotium Poriae cocos 6g Fu Shen Sclerotium Poriae cocos pararadicis 6g Sheng Di Huang Radix Rehmanniae glutinosae 6g.
This formula is better if Kidney-Yang deficiency predominates; it also addresses headaches deriving from Liver-Yang rising, itself stemming from Kidney-Yin deficiency.
GENG NIAN LE Happy Menopause Chai Hu Radix Bupleuri 6g Dang Shen Radix Codonopsis pilosulae 6g Ban Xia Rhizoma Pinelliae ternatae 6g Zhi Gan Cao Radix Glycyrrhizae uralensis praeparata 3g Huang Qin Radix Scutellariae baicalensis 4.5g Fu Xiao Mai Semen Tritici aestivi levis 6g Da Zao Fructus Ziziphi jujubae 6 dates Shan Zhi Zi Fructus Gardeniae jasminoidis 4.5g Zhen Zhu Mu Concha margaritiferae 12g Yin Yang Huo Herba Epimedii 6g.
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.
GENG NIAN FANG (Two formulae)Menopause Formulae
Sheng Di Huang Radix Rehmanniae glutinosae 9g Nu Zhen Zi Fructus Ligustri lucidi 6g Han Lian Cao Herba Ecliptae prostratae 6g Suan Zao Ren Semen Ziziphi spinosae 6g Long Chi Dens Draconis 12g Gou Teng Ramulus Uncariae 6g
Lian Zi Xin Plumula Nelumbinis nuciferae 6g Fu Ling Sclerotium Poriae cocos 6g He Huan Pi Cortex Albizziae julibrissin 6g Zi Cao Radix Lithospermi seu Arnebiae 4.5g
Yin Yang Huo Herba Epimedii 6g Xian Mao Rhizoma Curculiginis orchioidis 6g Huang Qi Radix Astragali membranacei 6g Dang Shen Radix Codonopsis pilosulae 6g Suan Zao Ren Semen Ziziphi spinosae 4.5g Fang Ji Radix Stephaniae tetrandae 4.5g Fu Ling Sclerotium Poriae cocos 6g Lian Xin Plumula Nelumbinis nuciferae 6g Xu Duan Radix Dipsaci asperi 6g He Huan Pi Cortex Albizziae julibrissin 6g
These two formulae should be alternated. They tonify both Kidney-Yin and Kidney-Yang and calm the Mind.
FU GENG YIN Woman’s Menopause Decoction
Sheng Di Huang Radix Rehmanniae glutinosae 6g Zi Cao Radix Lithospermi seu Arnebiae 4.5g Yin Yang Huo Herba Epimedii 6g Sang Ji Sheng Ramulus Sangjisheng 6g Dang Gui Radix Angelicae sinensis 6g Gou Teng Ramulus Uncariae 6g Xiang Fu Rhizoma Cyperi rotundi 4.5g Mai Ya Fructus Hordei vulgaris germinatus 6g.
This formula nourishes Yin and tonifies Yang, cools Blood and subdues Liver-Yang.
List 2 below compares and contrasts the last five formulae.
SYMPTOMS & ACTIONS:
ER XIAN TANG and ER ZHI WAN
Tonifies Kidney-Yang, nourishes Kidney-Yin, clears Empty Heat
Hot flushes, cold feet, night- sweating, frequent urination, feeling of heat in the evening
Red without coating
Floating-Empty or Rapid-Fine
Dr MENG JING CHUN
Tonifies Kidney-Yang (primarily), nourishes Kidney-Yin, tonifies Qi, subdues Liver-Yang
Hot flushes, cold feet, frequent urination, night sweating, tiredness, loose stools, headaches
Deep-Weak on both Rear positions
GENG NIAN LE
Harmonizes the Liver and the Lesser Yang, calms the Mind, stops sweating
Night- sweating, hot flushes followed by feeling cold, irritability
Red, unilateral coating
Wiry, Empty on the deep level
GENG NIAN FANG (two formulae)
Nourishes Kidney-Yin, tonifies Kidney-Yang, subdues Liver-Yang, calms the Mind, tonifies Qi, resolves Dampness
Hot flushes, night- sweating, cold feet, frequent urination, tiredness, loose stools, headaches, irritability, swollen ankles
Red or Pale (depending on predominance of Kidney-Yin or Kidney-Yang deficiency)
Floating-Empty or Fine-Rapid
FU GENG YIN
Nourishes Kidney-Yin, tonifies Kidney-Yang, nourishes Blood, subdues Liver-Yang
Hot flushes, night sweating, cold feet, frequent urination, headaches, blurred vision, poor memory
Pale or Red
Floating-Empty or Weak-Deep on both Rear positions
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 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.
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.
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 patent remedies.
The points used were selected from the following:
– LU-7 Lieque and KI-6 Zhaohai to regulate the Ren Mai, strengthen the Uterus and nourish Kidney-Yin.
-Ren-15 Jiuwei to calm the Mind and clear the Heart.
– Ren-4 Guanyuan to nourish the Kidneys and calm the Mind.
– Du-24 Shenting and G.B.-13 Benshen to calm the Mind.
– Du-20 Baihui to lift depression.
– HE-6 Yinxi and KI-7 Fuliu to stop night-sweating and clear Heart Empty Heat.
– SP-6 Sanyinjiao to nourish Yin, calm the Mind and promote sleep.
b) KIDNEY-YIN AND KIDNEY-YANG DEFICIENCY WITH PREDOMINANCE OF KIDNEY-YANG DEFICIENCY
Lower backache, cold knees, sensation of cold in the back, feeling cold in general but also occasionally hot in the face, menopausal hot flushes, night-sweating, weak legs, bright-white complexion, weak knees, decreased libido, tiredness, abundant-clear urination or scanty-clear urination, urination at night, possibly swelling of the legs, loose stools, depressed mood.
BL-23 Shenshu, LU-7 Lieque and KI-6 Zhaohai (Ren Mai), Ren-4 Guanyuan, Ren-6 Qihai, KI-3 Taixi, KI-7 Fuliu, BL-23 Shenshu, BL-52 Zhishi. Moxa is applicable is Yang deficiency is pronounced.
You Gui Wan Restoring the Right [Kidney] Pill plus Sheng Di Huang Radix Rehmanniae glutinosae and Tian Men Dong Tuber Asparagi cochinchinensis.
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.
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; the backache and hair loss indicate Kidney deficiency.
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 we have discussed, 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 hot flushes. In this patient, the brittle nails indicate some Liver-Blood deficiency.
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.
c) KIDNEY-YIN AND LIVER-YIN DEFICIENCY WITH LIVER-YANG RISING
Irritability, headaches, dizziness, tinnitus, blurred vision, dry eyes, dry skin, hot flushes, ache in joints, night-sweating, sore back.
Tongue: Red without coating possibly redder on the sides.
Pulse: Floating-Empty, Wiry on the left-Middle position.
Nourish Kidney- and Liver-Yin, subdue Liver-Yang, calm the Mind, settle the Hun.
LU-7 Lieque and KI-6 Zhaohai (Ren Mai), KI-3 Taixi, LIV-8 Ququan, SP-6 Sanyinjiao, Ren-4 Guanyuan, LIV-3 Taichong, Du-24 Shenting, G.B.-13 Benshen, G.B.-20 Fengchi, P-7 Daling. KI-3, LIV-8, SP-6 and Ren-4 with reinforcing method, the others with reducing method.
KUN BAO TANG Female Treasure Decoction
Sheng Di Huang Radix Rehmanniae glutinosae 9g Bai Shao Radix Paeoniae lactiflorae 9g Nu Zhen Zi Fructus Ligustri lucidi 6g Ju Hua Flos Chrysanthemi morifolii 6g Huang Qin Radix Scutellariae baicalensis 4.5g Suan Zao Ren Semen Ziziphi spinosae 6g Long Chi Dens Draconis 12g
This formula nourishes Liver- and Kidney-Yin, subdues Liver-Yang, calms the Mind and settles the Hun.
QI JU DI HUANG WAN Lycium-Chrysanthemum-Rehmannia Pill
Shu Di Huang Radix Rehmanniae glutinosae praeparata 24g Shan Zhu Yu Fructus Corni officinalis 12g Shan Yao Radix Dioscoreae oppositae 12g Ze Xie Rhizoma Alismatis orientalis 9g Mu Dan Pi Cortex Moutan radicis 9g Fu Ling Sclerotium Poriae cocos 9g Gou Qi Zi Fructus Lycii chinensis 9g Ju Hua Flos Chrysanthemi morifolii 6g
This formula is a variation of Liu Wei Di Huang Wan Six Ingredients Rehmannia Pill which nourishes Liver- and Kidney-Yin. The first six ingredients make up the original prescription.
QING XIN PING GAN TANG Clearing the Heart and Balancing the Liver Decoction
Huang Lian Rhizoma Coptidis 3g Mai Men Dong Tuber Ophiopogonis japonici 9g Bai Shao Radix Paeoniae lactiflorae 9g Bai Wei Radix Cynanchi baiwei 9g Dan Shen Radix Salviae miltiorrhizae 9g Long Gu Os Draconis 15g Suan Zao Ren Semen Ziziphi spinosae 9g
This formula nourishes Liver-Yin, clears Heat, absorbs fluids (to stop sweating) and settles the Hun.
List 3 below compares and contrasts the formulae for menopausal problems from Liver- and Kidney-Yin deficiency and Liver-Yang rising.
SYMPTOMS & ACTIONS:
KUN BAO TANG
Nourishes Kidney-Yin, subdues Liver-Yang, calms the Mind, settles the Ethereal Soul
Night- sweating, hot flushes, feeling of heat in the evening, mental restlessness, anxiety, insomnia, headachesRed without coating, redder tip, Floating-Empty
QI JU DI HUANG WAN
Nourishes Liver- and Kidney-Yin, subdues Liver-Yang, Night- sweating, hot flushes, feeling of heat in the evening, headaches, Red without coating, Floating-Empty
QING XIN PING GAN TANG
Clears Heart- Heat, nourishes Heart-Yin, calms the Mind, settles the Ethereal SoulMental restlessness, bitter taste, anxiety, insomnia, feeling of heat in the evening, night sweating, Peeled, red and swollen tip, Heart crack, Floating-Empty, relatively Overflowing on both Front positions
A 55-year-old woman had started suffering from menopausal symptoms a year after the stoppage of her periods. Her main problems were hot flushes, night-sweating, a “prickly feeling” over her skin, depression, tiredness, dry eyes and mouth, headaches, and irritability. Other symptoms included backache, frequent urination, constipation and cold feet. Her tongue was Red on the sides and her pulse was Weak on both Rear positions and slightly Overflowing on the left Middle and Front positions.
The main underlying pattern is that of Kidney-Yin and Liver-Yin deficiency (hot flushes, constipation, night-sweating, dry eyes and mouth). As often happens, there is also a concurrent deficiency of Kidney-Yang (tiredness, frequent urination, backache, cold feet). The depressed mood is due to the weakening of Will-Power (Zhi) consequent to the Kidney deficiency. In addition to the Kidney deficiency, there is Liver-Yang rising (from Kidney-Yin deficiency) as evidenced by the headaches, irritability, Red sides of the tongue and pulse Overflowing on the left Middle and Front positions.
The treatment principle adopted was to nourish Kidney-Yin, tonify Kidney-Yang, subdue Liver-Yang, strengthen Will-Power and calm the Mind. She was treated with acupuncture and patent remedies.
The points used were selected from the following:
– LU-7 Lieque and KI-6 Zhaohai to regulate the Ren Mai, strengthen the Uterus and nourish Kidney-Yin.
– Ren-4 Guanyuan to nourish the Kidneys.
– P-7 Daling to calm the Mind.
– LIV-2 Xingjian to subdue Liver-Yang.
– SP-6 Sanyinjiao to nourish Yin and calm the Mind.
– BL-23 Shenshu, BL-52 Zhishi and BL-47 Hunmen to tonify the Kidneys, strengthen Will-Power, pacify the Liver and settle the Hun.
d) KIDNEY-YIN AND HEART-YIN DEFICIENCY WITH HEART EMPTY HEAT
Hot flushes, palpitations, insomnia, night-sweating, blurred vision, dizziness, tinnitus, anxiety, mental restlessness, backache, a malar flush, feeling of heat in the evening, dry mouth and throat, poor memory, dry stools.
Tongue: Red body without coating with a redder tip. Pulse: Rapid-Fine, or Floating-Empty, or Weak-Deep on both Rear positions and Overflowing on both Front positions.
Nourish Kidney-Yin, calm the Mind, clear Empty Heat.
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-13 Qixue, HE-6 Yinxi, KI-7 Fuliu, HE-8 Shaofu, P-7 Daling, Ren-15 Jiuwei, Du-24 Shenting. HE-6, HE-8 and P-7 with reducing or even method; all the others with reinforcing method.
TIAN WANG BU XIN DAN Heavenly Emperor Tonifying the Heart Pill
Sheng Di Huang Radix Rehmanniae glutinosae 12g Xuan Shen Radix Scrophulariae ningpoensis 6g Mai Men Dong Tuber Ophiopogonis japonici 6g Tian Men Dong Tuber Asparagi cochinchinensis 6g Ren Shen Radix Ginseng 6g Fu Ling Sclerotium Poriae cocos 6g Wu Wei Zi Fructus Schisandrae chinensis 6g Dang Gui Radix Angelicae sinensis 6g Dan Shen Radix Salviae miltiorrhizae 6g Bai Zi Ren Semen Biotae orientalis 6g Suan Zao Ren Semen Ziziphi spinosae 6g Yuan Zhi Radix Polygalae tenuifoliae 6g Jie Geng Radix Platycodi grandiflori 3g
This formula nourishes Kidney-Yin, clears Heart Empty Heat and calms the Mind: it is ideally suited to treat menopausal problems occurring with these patterns.
LIU WEI DI HUANG WAN and HUANG LIAN E JIAO TANG Six-Ingredient Rehmannia Pill and Coptis-Gelatinum Corii Asini Decoction
Shu Di Huang Radix Rehmanniae glutinosae praeparata 24g Shan Zhu Yu Fructus Corni officinalis 12g Shan Yao Radix Dioscoreae oppositae 12g Ze Xie Rhizoma Alismatis orientalis 9g Mu Dan Pi Cortex Moutan radicis 9g Fu Ling Sclerotium Poriae cocos 9g Huang Lian Rhizoma Coptidis 3g Huang Qin Radix Scutellariae baicalensis 9g Bai Shao Radix Paeoniae lactiflorae 9g Ji Zi Huang Egg yolk 2 yolks E Jiao Gelatinum Corii Asini 9g
The formula Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill, already explained, nourishes Liver- and Kidney-Yin. The formula Huang Lian E Jiao Tang Coptis-Gelatinum Corii Asini Decoction, clears Heart-Heat and nourishes Yin.
TREATMENT OF FULL PATTERNS DURING THE MENOPAUSE
As we have discussed above, every menopausal woman is bound to suffer from patterns other than those purely related to the decline of Kidney-Jing. Therefore, every menopausal woman will suffer from a combination of Kidney deficiency and some Full patterns such as Qi stagnation, rebellious Qi of the Chong Mai, Phlegm and Blood stasis. However, remember that such Full patterns are not “menopausal” syndromes in the same way hot flushes and vaginal dryness are. Therefore, when the clinical picture is significantly complicated by some of the above Full patterns, I will tend to use a custom formula rather than a prepared remedy. If the above Full patterns are pronounced, then it might be advisable to deal with these first by using a decoction that resolves Phlegm, 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 months a formula such as Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction . Similarly, were Phlegm pronounced, one might start with a decoction to resolve Phlegm such as Er Chen Tang Two Old Decoction. However, prepared remedies may also be used in these cases combined with the menopausal remedies.
PROGNOSIS AND PREVENTION
Chinese medicine can help women to minimize their problems in the transition from a reproductive to a non-reproductive age. Herbal treatment is more effective than acupuncture because herbs are better at nourishing Jing. Acupuncture is very effective at controlling menopausal symptoms but it needs to be administered regularly, so that herbal medicine is cheaper for the patient.
Generally speaking, if menopausal problems occur against a background of Kidney-Yin deficiency, the treatment will be more difficult and one can say that the redder the tongue body and the less coating there is, the more difficult the treatment. The tongue indicating the worst prognosis would be one with a dark-Red body, completely without coating, cracked and dry.
As mentioned earlier, the severity of menopausal symptoms depends on the pre-existing condition of the Kidneys and therefore on the woman’s diet and lifestyle throughout her lifetime. Thus, it is important that the patient understands this and is willing to be patient; Chinese medicine can help a woman in this transition period only in a slow and gradual way. It is becoming more difficult to explain this to patients given the “quick results” they are offered (and sometimes experience) through hormone replacement therapy (HRT).
We should now discuss the integration of Chinese herbal medicine with HRT, is such integration is possible. In my experience, there is no problem in using Chinese herbs while the patient is taking HRT because they work in different ways and at different levels. HRT works by “tricking” the hypothalamus in thinking that the ovaries are still working so that it will stop stimulating the pituitary gland to secrete FSH. Chinese herbs work by gently nourishing Kidney-Jing to minimize the effects of the menopausal transition. However, while it is possible to combine the two in the short term, it does not make sense to combine them in the long term. In any case, menopausal women generally come to us wither because they do not want HRT or because they want to stop it.
Finally, another question that arises is: how long can a woman go on taking Chinese herbs for the menopause? In my experience, these can be taken for years without any side-effects. However, when a patient takes a remedy for the long term, I usually ask them to suspend it for about 1 month every 6-9 months.
The ovarian changes associated with the menopause have already been mentioned in the introduction. The main endocrine change is a decreased oestrogen production by the ovary which is the main source of oestrogen (in the form of oestradiol) in the reproductive years. After menopause, the ovarian oestrogen production decreases markedly and the main circulating oestrogen is oestrone rather than oestradiol. Most of the oestrogen present in menopausal women is derived from adipose tissue from the conversion of androstenedione to oestrone. The amount of oestrone produced in adipose tissue is determined by the overall amount of this tissue. Therefore thin women convert a smaller percentage of androstenedione to oestrone (1.5 per cent) compared with obese women who may convert as much as 7 per cent. The main source of androstenedione is the adrenal glands.
The time preceding the menopause is characterized by an increasing irregular menstrual cycle which may become either scanty or heavy and irregular in timing. The symptoms associated with the menopause may be classified according to the organ or tissue involved:
∙ Brain: hot flushes, depression, anxiety, insomnia, poor memory and concentration
∙ Vagina: vaginal dryness and atrophy
∙ Heart: coronary heart disease
∙ Blood vessels: arteriosclerosis
∙ Bone: osteoporosis
∙ Skin: thinning, slow healing, itching
As mentioned before, some gynaecologists consider only hot flushes and vaginal dryness as oestrogen-related menopausal symptoms. Hot flushes are the most common menopausal symptom: up to 85 per cent of menopausal women suffer from them and 45 per cent of them do so for up to ten years after the menopause. Associated with an increase in temperature, increased pulse rate, and increased blood flow in the hand, each hot flush lasts on average 2.7 minutes.
Hot flushes are a mechanism for dissipating heat through vasodilatation and perspiration in response to the thermoregulatory centres in the anterior hypothalamus. The vasomotor symptoms (hot flushes) occurring during the climaterium are probably due to fluctuating pulses of pituitary follicle-stimulating hormone (FSH) which rises to abnormal blood levels at this time in an effort to provoke ovulation from increasing unresponsive follicles. Oestrogen in the form of HRT (hormone-replacement therapy) “deceives” the pituitary that normal ovulation and oestrogen production is continuing so that the overproduction of FSH ceases and so do the hot flushes.
The Western treatment of menopausal problems is based on the administration of hormone replacement therapy (HRT or ERT) in different forms: these could be native oestrogens (oestradiol, oestrone, oestriol), conjugated equine oestrogens, and synthetic oestrogens (such as ethinyl oestradiol) in a dose ranging between 5 and 10 μg. This is a lower dose (usually about 1/7th) than the one used in the contraceptive pill and, for this reason, many gynaecologists believe that the potential side-effects of HRT have been wrongly extrapolated from those of the contraceptive pill.
Indeed, they say that some of the side-effects, far from being that, are actually indications: for example, while the contraceptive pill carries the potential adverse reaction of cardiovascular disease, HRT is, presumably, effective in “protecting” menopausal women from cardiovascular disease.1 However, this thesis is hotly debated as we shall see shortly.
In any case the potential adverse effects of HRT include endometrial hyperplasia and cancer, thromboembolism, strokes, hypertension, breast cancer, gall-bladder dysfunction, gall stones, and lesser symptoms such as nausea, vomiting, water retention, and headaches.2 As most practitioners will know, in spite of the potential adverse effects, menopausal women are increasingly being prescribed HRT almost routinely. The one adverse effect that is usually taken seriously is the potential risk of breast cancer: for this reason, HRT should never be given to a woman who has or has had breast cancer or to a woman who has a breast lump of an unknown nature. However, this view is also debated as there are doctors who think that women who have been “cured” of their breast cancer can receive HRT without risk.3
The oestrogen present in HRT is often supplemented by the administration of progestins principally to oppose the effect of oestrogen on the endometrium (hyperplasia and increased risk of endometrial cancer). There are two classes of progestins used: native progestins (progesterone and 17-hydroxyprogesterone) and synthetic progestins (19-nortestosterone derivatives and 21-carbon-atom compounds such as medroxyprogesterone and megestrol). If oestrogen is given for 25 days (with a break of 5 days), progestin is added in the last 12 days. If oestrogen is given continuously for 30 days without a break, progestin is usually administered in the last 12 days.
Vaginal bleeding usually occurs with cyclic oestrogen/progesterone therapy and is caused by the progesterone component. Progesterone therapy for menopausal women has not proved of much benefit and also has potential side-effects such as depression, breast fullness and tenderness, a distended feeling, weight gain and symptoms like those of pre-menstrual tension. However, the theoretical side-effects of progesterone rarely manifest in practice when it is combined with oestrogen for the relief of menopausal symptoms. Progesterone’s undisputed role in HRT is to neutralize oestrogen’s potentially carcinogenic effect on the endometrium and breast.
HRT therapy can be administered in the following forms:
∙ Oral (tablets)
∙ Transdermal (patches)
∙ Percutaneous (gel)
∙ Subcutaneous (implants)
∙ Vaginal (creams, pessary, tablets)
Contraindications to oestrogen treatment are:
∙ Hormone-related cancer
∙ Active liver disease
∙ A history of hormone-induced thromboembolism
∙ Vaginal bleeding of an unknown cause
∙ Untreated hypertension4
Please note that I have reported the above contraindications mostly for the practitioner’s information; it should be borne in mind, however, that new research is being carried out on the effects of HRT all the time so that new findings are reported every few months. Thus, not all gynaecologists would agree with the above list of contraindications: for example, there are some who claim that having had breast cancer is not always a contraindication for HRT. From a Western point of view, menopausal problems are almost exclusively attributed to a deficiency of oestrogen and the “cure” is therefore HRT.
In modern industrialized societies HRT is increasingly prescribed almost routinely as soon as a woman approaches the menopause, both to alleviate menopausal symptoms and because of its alleged protective effect against osteoporosis and heart disease. More and more, the menopause has been medicalized and defined as a “deficiency disease”. For example, a recent text on women’s problems in general practice says: “In the USA, Australia and Western Europe, the concept has emerged of the menopause as a deficiency disease which needs treatment by hormone replacement therapy.”5 There are many flaws in this thinking.
First of all, the menopause is not a “disease” and it needs medical intervention only if its symptoms are uncomfortable and distressing.
Secondly, the decline in oestrogen levels following the reduction in follicles is a natural, physiological process that is part of a woman’s biological rhythms. Seen from this perspective, menopause is no more a “disease” than menarche is.
Thirdly, the “protective” effect of HRT against osteoporosis and heart disease is hotly debated and not at all conclusively proven. The many studies which have been conducted are confusing and contradictory. For example, a review of English-language literature on oestrogen therapy from 1970 to 1992 concluded that oestrogen use by menopausal women reduces the risk of coronary heart disease (CHD) by about 35 per cent and the risk of hip fracture in post-menopausal women by about 25 per cent.6 Moreover, meta-analysis of epidemiological data demonstrates that women using HRT after menopause experience lower rates of heart disease.7
On the other hand, a study of 1,234 post-menopausal women observed over a period of twelve years found that women using oestrogen had over a 50 per cent elevated risk of cardiovascular morbidity and more than a twofold risk of cerebrovascular disease. The study also concluded that no benefits from oestrogen use were observed in the study group.8 Moreover, two other studies demonstrated a (small) increased risk of venous thromboembolism in users of HRT.9
Fourth, and probably most important, there are many studies showing that HRT does increase the risk of endometrial and breast cancer. The review of literature mentioned above found that since 1970 at least thirty-five epidemiological studies have shown a significantly increased risk of endometrial cancer in women who have taken oestrogen. Similarly, the same review showed that the risk of breast cancer increases with long-term use of oestrogen.10 In fact, a Swedish study of 23,000 hormone users reported that the incidence of breast cancer compared with that in non-users was increased after six years’ use.11
One of the most recent British studies of 5,000 women taking HRT showed that breast cancer mortality in these women compared with the general population rose from 0.55 per 1,000 in the earlier period of follow-up to 1984, to 1 per 1,000 between 1984 and 1988.12 In both the Swedish and British studies no protective effect was observed when progestogen was given.13 However, other studies show that the risk of breast cancer is reduced or nullified if progesterone is administered (in addition to oestrogen) continuously rather than sequentially.14
Fifth, “protecting” a woman from osteoporosis and heart disease must surely depend on very many factors such as diet and lifestyle before the onset of the menopause: thus, it is simplistic, at best, to think that oestrogen taken as soon as the menopause approaches is going to “protect” a woman from these diseases.
Although the potential impact of HRT on the risk of endometrial and breast cancer it still debated and not conclusively proven, taking all the above factors into account, it does seem that Chinese medicine, with its gentle and steady tonification of the Kidney-Jing without side-effects, can offer a safe, effective and logical alternative to HRT, even though its effects will never be as rapid as those of HRT. In any case, the treatment of menopausal problems with acupuncture and Chinese herbs should not necessarily be seen as an “alternative” to HRT as the two may also be combined because HRT and a Chinese treatment work in different ways. HRT works by “tricking” the body into thinking that it is still ovulating but it does not tonify the Kidneys.15 Chinese medicine, on the contrary, works by gently tonifying the Kidneys and the Kidney-Jing to help the woman in this transition time of life.
The interesting thing is that, as the ovaries reduce their production of oestrogen, nature has something else up her sleeve. Women are also able to produce a form of oestrogen (called oestrone) from the adrenal glands in order to compensate for the decline from the ovaries.
Women also produce oestrogen from fat cells, so being ultra-slim will not have health benefits in the long run, particularly if you are going through menopause. Of course obesity presents its own health problems, but from an oestrogen-production point of view, it is better to be slightly overweight than very thin.
WOMEN’S HEALTH INITIATIVE RANDOMIZED CONTROLLED TRIAL ON THE RISKS AND BENEFITS OF OESTROGEN PLUS PROGESTIN IN HEALTHY POSTMENOPAUSAL WOMEN
The Women’s Health Initiative in the USA conducted a trial to assess the risks and benefits of Hormone Replacement Therapy (HRT) in healthy postmenopausal women. 16,608 postmenopausal women aged 50-79 with intact uterus were given conjugated equine oestrogens 0.625 mg plus medroxyprogesterone acetate 2.5 mg or a placebo. The trial was to last 8.5 years.
The main outcomes checked were breast cancer and coronary heart disease. On May 31 2002, after 5.2 years, the trial was stopped because it showed an unacceptable increased risk of breast cancer (26%), coronary heart disease (29%) and stroke (41%) in the women who were taking HRT. The investigators concluded that the overall health risks exceeded the benefits from use of combined oestrogen and progesterone.
This study does not come as a surprise as other studies have highlighted the risks inherent in HRT. In fact, some studies show that women on HRT have an increased risk of breast cancer. A Swedish study of 23,000 hormone users reported that the incidence of breast cancer compared with that in non-users was increased after six years’ use. One of the most recent British studies of 5000 women taking HRT showed that breast cancer mortality in these women compared with the general population rose from 0.55 per 1000 in the earlier period of follow-up to 1984, to 1 per 1000 between 1984 and 1988. Thus, excessive oestrogen, as the above studies show, increases the risk of developing breast cancer.
MILLION WOMEN STUDY
Growing evidence about the risks of breast cancer and other serious illnesses posed by hormone therapy for menopause has led many women to give up the drugs, and many doctors to stop recommending them.
But there has been a lingering belief, according to some, that for younger women in the early stages of menopause, hormone risks may be negligible, at least for a while. So those who are really suffering from hot flushes, insomnia and other symptoms are often told that it is probably all right to take the drugs, as long as they use the lowest possible dose for the shortest possible time. Some researchers are even testing an idea, called the timing hypothesis, that starting hormone treatment early in menopause may help protect women from heart disease.
Now, information from a huge observational study in Britain suggests that the women thought to be at the lowest risk from hormones may actually be at the highest risk, at least when it comes to breast cancer. The study found that women with the greatest risk of breast cancer from hormones were those who took them earliest — before or soon after menopause began. These findings are not considered to be the strongest type of evidence because they do not come from a randomized trial. However, this particular observational study also has a unique strength — it included more than a million postmenopausal women, i.e. one in four British women who were aged 50 to 64 during the enrolment period, from May 1996 to December 2001.
The research, called the Million Women Study, found that in women aged 50 to 59 who had never taken hormones, 0.3 percent a year developed breast cancer. The rate was higher, 0.46 percent a year, in women who started taking the most commonly used hormones — estrogens combined with progestin — five or more years after menopause began. But it was highest of all — 0.61 percent a year — in women who started taking the drugs before or less than five years after menopause began. And the risk was increased even in women who took the drugs for less than five years.
The lead investigator of the study, Prof. Dame Valerie Beral, a professor of epidemiology at the University of Oxford, said that her research group had decided to look at the interval between the start of menopause and the start of treatment because other studies had found evidence of higher risk among women who started earlier. But in the other studies, the numbers of women who had started early were relatively small, and so the evidence was not statistically significant. In the Million Women Study, 90 percent of the women taking hormones had begun them before or within five years of the start of menopause, so there was a better chance of finding an answer.
One of the studies that had detected a possible but inconclusive link between earlier hormone use and increased cancer risk was the above-mentioned Women’s Health Initiative, the randomized trial that in 2002 found that combined hormones were causing small but significant increases in the risk of breast cancer, heart disease, strokes and blood clots in the lungs.
1. A. Govan, D. Hart and R. Callander 1993 Gynaecology Illustrated, Churchill Livingstone, Edinburgh, p. 477.
2. Gomel V. and Munro M. 1989 Gynaecology: a Practical Approach, Williams and Wilkins, Baltimore, p. 131.
3. I S Fentiman “Hormone Replacement Therapy and Breast Cancer: Proceed with Caution”, Journal of the British Menopause Society, Vol. 1, No. 2, October 1995, p. 21.
4. V. A. Ravnikar “Barries for Taking Long-term Hormone Replacement Therapy: Why Do Women not Adhere to Therapy?” in European Menopause Journal, Vol. 3, no. 2. (Suppl.), 1996, p. 93.
5. Women’s Problems in General Practice, p. 198.
6. D. Grady et al “Hormone Therapy to Prevent Disease and Prolong Life in Postmenopausal Women”, Annals of Internal Medicine, Vol. 117, No. 12, 15 December 1992, pp. 1021-3.
7. V. Mijatovic and A. Pines “Menopause-induced Changes in Cardiovascular Functions and HRT”, European Menopause Journal, Vol. 2, No.1, 1995, p. 4.
8. P. W. F. Wilson et al “Postmenopausal Oestrogen Use, Cigarette Smoking, and Cardiovascular Morbidity in Women over 50″, New England Journal of Medicine, Vol. 313, No. 17, 24 October 1985, p. 1038.
9. E. Daly et al “Risk of Venous Thromboembolism in Users of Hormone Replacement Therapy”, The Lancet, Vol. 348, No. 9033, 12 October 1996, p. 977.
H Jick et al “Risk of Hospital Admission for Idiopathic Venous Thromboembolism among Users of Postmenopausal Oestrogens”, The Lancet, Vol. 348, No. 9033, 12 October 1996, p. 981.
10. “Hormone Therapy to Prevent Disease and Prolong Life in Postmenopausal Women”, pp. 1018-20.
11. L. Bergkvist et al “The Risk of Breast Cancer after Oestrogen and Oestrogen-Progestin Replacement” in New England Journal of Medicine, Vol. 321, No. 5, 3 August 1989, pp. 293-297.
12. K Hunt et al “Mortality in a Cohort of Long-term Users of Hormone Replacement Therapy: an Updated Analysis”, British Journal of Obstetrics and Gynaecology, Vol. 97, December 1990, pp. 1080-1086.
13. Women’s Problems in General Practice, p. 216.
14. B G Wren “Hormonal Replacement Therapy and Breast Cancer”, European Menopause Journal, Vol. 2, No. 4, 1995, p. 13.
15. The relationship between HRT and Chinese treatment is similar to that between antibiotics and Chinese treatment: antibiotics kill bacteria but they do not release the Exterior, restore the descending and diffusing of Lung-Qi, clear Heat or resolve Phlegm. Thus, if a patient is already taking antibiotics, this is not a contraindication for treatment with Chinese herbs.
16. Grady D et al 1992, pp. 1018-20.
17. Bergkvist L et al 1989 The Risk of Breast Cancer after Oestrogen and Oestrogen-Progestin Replacement. New England Journal of Medicine, vol. 321, no. 5, pp. 293-7.
18. Hunt K et al 1990 Mortality in a Cohort of Long-term Users of Hormone Replacement Therapy: an Updated Analysis. British Journal of Obsetrics and Gynecology, vol. 97, pp. 1080-6.