Menopause: A Perspective of East vs West

Abstract
This paper reviews menopause and describes how this condition is understood in both Western medicine (WM) and traditional Chinese medicine (TCM). It further identifies the key diagnostic indicators for menopause in both medical systems and explains how these indicators reflect the disease pathogenesis. Furthermore, it will compare WM and TCM treatment protocols and outcomes for the menopausal syndrome (MPS).

Introduction
Menopause is arguably not a disorder, rather it is a natural process every woman’s body goes through during her late 40’s or early/mid 50’s (Kwee, Tan, Marsman, & Wauters, 2007; Maciocia, 1998, pp. 741-742). This fits the TCM theory of the 7-year cycles in Women, according to which Menopause occurs at the age of 49 (Maciocia, 1998).

World-wide, in 1998, there were over 470 million menopausal women (Sze, et al., 2009) and it is estimated that in 2010, 171 million women, in Western countries alone, will suffer from MPS (Tan, et al., 2008). Menopausal symptoms can vary in variety and severity, and may last for several years. Menopause usually begins with the perimenopausal phase and ends following the postmenopausal phase (Avis, et al., 2001).

However, in the biomedical model there are considerable gaps in the knowledge and understanding of perimenopause and menopause related pathophysiology as well as treatment approaches, and little scientific investigation has focused on menopausal transition and early post-menopause (Kang, Ansbacher, & Hammoud, 2002; Sherman, Miller, Nerurkar, & Schiff, 2005; Woods & Mitchell, 2005).

WM utilises hormone replacement therapy (HRT) as the primary treatment for MPS, by replacing the naturally declining hormones with HRT. However, increasingly, women are moving away form HRT (Borud & White, 2009), as it is associated with increased risks of heart disease, breast cancer and other health problems (Borud, Alraek, White, Fonnebo, & Grimsgaard, 2007; Chiou, Tai, & Chien, 2006; Kang, et al., 2002; Sze, et al., 2009; Zhang, Wang, Zhang, Chen, & Liang, 2005).

TCM on the other hand, has a well-developed, individualised diagnostic approach to symptoms associated (in WM) with menopause. It does not focus on the hormonal changes that occur; rather its focus is on assessing the individual according to classic diagnostic principles and once a diagnosis is made, treatment principles are developed from which a treatment regime is derived and implemented (Kaptchuk, 1983, pp. 6-7; Scheid, 2007).

Menopause from a TCM Perspective

Aetiology:
According to Maciocia (1998) symptoms associated with Menopause are due to a decline of the Kidney Essence, and the primary TCM patterns associated with Menopause involve the Kidneys, Liver, Heart and Stagnation of Blood. This is reiterated by Lyttleton (2004, p. 339), who states: “…every menstrual cycle in which an ovulation occurs requires contribution from the Jing (Kidney Essence). It is when no more Jing contributions can be made (i.e. there are no more viable eggs) that menstrual cycles cease and menopause has arrived”. Thus, as Kidney Jing weakens, Kidney Yin and/or Yang may become deficient. This in turn may lead to more complex TCM patterns involving either the Liver (e.g., Kidney- and Liver-Yin deficiency with Liver-Yang rising) or Heart (e.g., Kidneys and Heart not harmonising). Alternatively, Kidney deficiencies may lead to stagnation of Qi and/or Blood, or accumulation of Phlegm and stagnation of Qi.

Typical pattern differentiation and their respective treatments are outlined by Maciocia (1998, pp. 743-759) and are presented below. However, there is at least one commonly seen pattern that is not frequently outlined or discussed. Liver & Heart Xue Xu.

In the author’s experience, problems associated with menopause begin during a difficult birth, where there is an excessive loss of blood followed by an inadequate recovery period. The birthing process is draining enough without the excessive loss of blood. Both Kidney Yin and Yang energies are lost during the birthing process not to mention the Kidney Essence (Jing).

In today’s western society, there is typically little time for a mother to recover from the trauma and energy expenditure of birth. The family structure of yesteryear, where grandmothers, sisters and other family members where close at hand to help the new mother with her baby, is no longer common place. Instead, most new mothers have to continue their duties plus look after the newborn baby. This is draining her of further energies, which will lead to potential problems at the time of menopause.

Patients usually present with anxiety, palpitations, floaters before the eyes and blurring of vision, especially when tired, and other typically xue deficient signs and symptoms. In addition, they also present with mild night sweats, or a sensation of getting hot then cold at night, they tend to have a malar flush, however, the otherwise typical yin xu symptoms are not present or if present are only mild in nature (Blood nourishes Yin). The Liv/Ht. Xue Deficiency is characterised in menopause by pale tongue, malar flush, insomnia – usually problems with falling asleep (Ht Xue Xu) but may also wake up during the night (Ht Yin Xu), poor memory or forgetfulness, but may also have symptoms such as brittle nails, lusterless hair, etc.

Kidney-Yin Xu
Dizziness, tinnitus, malar flush, night sweats, hot flushes, 5-hearts hot, sore back; dry mouth, hair &or skin; itching, constipation. Tongue: Red without coating. Pulse: Floating-empty, or Fine-Rapid, or very Deep-weak on both Rear positions
Possible TCM Prescriptions
Zuo Gui Wan
Geng Nian Fang
Geng Nian An
Qi Ju Di Huang Wan
Possible Acupuncture Points
Lu.7 (R/S) and Kid.6 (L/S); Kid.3; Kid.10; CV.4; Sp.6; Ht.6; Kid.7.

Kid. Yang-Xu
Hot flushes but cold hands and feet, night sweats in the early morning, pale face, depression, chilliness, backache, oedema of ankles. Tongue: Pale. Pulse: Fine, Deep.
Possible TCM Prescriptions
You Gui Wan & Li Zhong Wan
Women’s Treatsure Remedy
Possible Acupuncture Points
Bl.23; Bl.52; Kid.3; Lu.7 (R/S) and Kid.6 (L/S); CV.4, CV.15, Kid.7.

Kid.-Yin and Kid. Yang Xu
Hot flushes but cold hands & feet, night sweats, frequent-pale urination, flushed around the neck when talking, slightly agitated, chilliness, dry throat, dizziness, tinnitus, backache. Tongue: may be Pale or Red, depending on which deficiency predominates. Pulse: may be Floating-Empty or Fine-Rapid if deficiency of Yin predominates or Weak-Deep if deficiency of Yang predominates.
Possible TCM Prescriptions
Er Xiang Tang and Er Zhi Wan
Empirical Prescrition of Dr Meng Jing Chun
Geng Nian Le
Geng Nian Fang (two formulae)
Fu Geng Yin
Possible Acupuncture Points
Kid.3, Lu.7 and Kid.6; CV.4; Bl.23, Bl.52, Sp.6.

Kidney- and Liver-Yin Xu with Liv. Yang rising
Irritability, dizziness, tinnitus, blurred vision, dry eyes, dry skin, hot flushes, ache in joints, night sweats, sore back, headaches. Tongue: Red without coating. Pulse: Floating-Empty, Wiry on the left-Middle position.
Possible TCM Prescriptions
Qi Ju Di Huang Wan
Kun Bao Tang
Qing Xin Ping Gan Tang
Possible Acupuncture Points
Kid.3, Liv.8; CV.4; Lu.7 and Kid.6; Liv3; GV.24; G.B.13; Pc.7.

Kidneys and Heart not harmonised
Hot flushes, palpitations, insomnia, night sweats, blurred vision, dizziness, tinnitus, anxiety, mental restlessness, backache, 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.
Possible TCM Prescriptions
Tian Wang Bu Xin Dan
Liu Wei Di Huang Wan & Huang Lian E Juao Tang
Women’s Treasure remedy.
Possible Acupuncture Points
Lu.7 (R/S) and Kid.6 (L/S); Kid.3; CV.4; Sp.6; Kid.13; Ht.6; Kid.7; Ht.8; Pc.7; CV.15; GV.24.

Accumulation of Phlegm & Stagnation of Qi
Obesity, a feeling of oppression of the chest, sputum in the chest, a feeling of fullness of the epigastrium, a feeling of distension of the breasts, irritability, belching, nausea, no appetite, moodiness, depression. Tongue: slightly Red sides, sticky coating. Pulse: Wiry.
Possible TCM Prescriptions
Yue Ju Wan
Tree Treasures remedy
Possible Acupuncture Points
CV.17; Pc.6; Lu.7; CV.6; CV.10; T.B.6; St.40; Sp.6; Sp.9; St.28; CV.4.

Stasis of Blood
Hot flushes, mental restlessness, menopause preceded by a period when menses are very irregular stopping for a long time then starting again, dark-clotted blood, insomnia, high blood pressure, abdominal pain. Tongue: Purple. Pulse: Wiry or Choppy.
Possible TCM Prescriptions
Ge Xia Zhu Yu Tang
Wen Jing Tang
Wu Jun Wan
Women’s Treasure remedy
Possible Acupuncture Points
Sp.4 (R/S) and Pc.6 (L/S); Kid.14; Sp.10; Bl.17; CV.4; CV.6; Liv.3; Pc.7.

WM Perspective

In order to understand the biomedical approach to Menopause, it is necessary to understand the normal ebb and flow of hormones in a healthy woman’s menstrual cycle. Fig. 1 provides an overview of the key hormones involved in a normal menstrual cycle.

Ebb and Flow of Hormones during a normal 28-day menstrual cycle

Fig. 1 shows hormone levels during the normal menstrual cycle (Hendrix, 2007).

From Fig.1, it is clear that during the follicular phase the Pituitary hormones FSH and LH are at low levels. At the same time the maturation of follicle occurs and the Endometrium is regenerating (beginning following cessation of menses). Oestrogen is present at relatively higher levels than progesterone. At around day 14, ovulation occurs and LH and FSH rise sharply; Progesterone begins to increase, while Oestrogen levels decrease. During the Luteal phase LH and FSH drop off to approximately pre-ovulation levels; Progesterone remains relatively high until around day 19 after which it beings to decline. If fertilisation does not take place and thus implantation of a fertilised egg in the Endometrium does not occur, the Endometrium begins to breakdown and by day 28 the cycle starts again.

These processes begin to change with the onset of perimenopause. The following is an abbreviated, simplified account of the steps a woman’s body undergoes as menopause progresses into Postmenopause. [Summarised from (Maas, van der Graaf, van der Schouw, & Grobbee, 2004)]:

Loss of ovarian follicles results in a number of endocrine changes
(1) decline in ovarian production of estradiol,
(2) increased circulating concentrations of follicle-stimulating hormone (FSH) and
(3) decreased concentrations of inhibin, which normally inhibits the release of FSH.

As circulating oestrogen concentrations decline, variations in the timing of menstrual bleeding and in the nature of bleeding may occur. Such cycles may be associated with insufficient FSH in the follicular phase, in turn resulting in lower Luteal phase oestrogen and progesterone secretion.

Extraovarian sources, such as adipose tissue, convert androstenedione to testosterone and estrone postmenopausally.
In the perimenopause, FSH concentrations increase without a concomitant increase in luteinizing hormone (LH).
Reduced concentrations of oestrogen and progesterone and increases in FSH affect the central nervous system, resulting in vasomotor instability, and this may lead to the characteristic hot flashes or flushes in many perimenopausal and postmenopausal women.

Perimenopause

Perimenopause starts long before cessation of menstruation. Periods may become irregular, scant or heavy, and there may be symptoms of anxiety and depression, as well as many others (Avis, et al., 2001; Gyllstrom, Schreiner, & Harlow, 2007; Woods & Mitchell, 2005).

Menopause

Menopause starts after a naturally occurring absence of any menstrual period for at least 12 months (Gyllstrom, et al., 2007). There is much debate in the literature, however, over which symptoms are associated with Menopause (Kaufert & Syrotuik, 1981) and lists ranging from one to over thirty symptoms have been constructed. Symptoms are categorised as either physical or psychological and most commonly include both, such as hot flushes, night sweats, anxiety, depression and others (Gyllstrom, et al., 2007; Kaufert & Syrotuik, 1981; Malacara, et al., 2002).

Postmenopause

Postmenopause is a transition from menopause to post-menopause during which some symptoms decrease in severity while other such as libido, vaginal dryness, urinary symptoms and others increase (Woods & Mitchell, 2005).

Menopause (a.k.a. Climacteric Syndrome) from the biomedical viewpoint is a result of declining hormones. Management is by use of hormone replacement in one form or another, to ‘re-establish’ the hormonal balance in the patient (Maciocia, 1998). The Merck Manual (Hendrix, 2007) lists four primary categories considered in WM:
Vasomotor, e.g.: Hot flushes and sweating,
Neuropsychiatric, e.g.: Depression and anxiety,
Genital: e.g.: Vaginal dryness and dysuria;
Other: e.g.: reduced quality of life.
Each of these categories is addressed with either HRT, or other types of medication to address the symptoms.

Range and Depth of Research into Menopause and the Treatment thereof by TCM

Chinese herbal medicine is effective in treating menopause (Chen, et al., 2003; Huazhang & Chunyan, 2008; Kwee, et al., 2007; Liu, et al., 2009). Chen et al., (2003) investigated the effectiveness of Jia Wei Xiao Yao San on various menopausal symptoms and found that it may offer a safe and effective alternative to Premelle® (HRT medication). Another study by Venzke et al., (in press) showed that Acupuncture is an effective treatment of post-menopausal vasomotor symptoms. Similarly, Borud and White (in press) report on a RCT, which investigated the effect of Acupuncture on Hot Flushes and demonstrated that Acupuncture was able to reduce the daily number of Hot Flushes experienced by the treatment group by 50%. Frisk, et al., (2008) investigated the effect of electro-acupuncture on Hot Flushes in women with Breast Cancer and found a significant reduction in Hot flushes, thus providing a safer alternative to HRT. Several other studies (Cohen, Rousseau, & Carey, 2003; Huazhang & Chunyan, 2008; Kronenberg & Fugh-Berman, 2002) showed Acupuncture to significantly improve a range of symptoms associated with Menopause.

Research currently undertaken in biomedical science is more difficult to summarise, as focus is not simply on the effectiveness of drugs or other therapies on Menopause; rather research is diverse, focusing on the safety of HRT (Stevenson, 2009), effectiveness of particular hormones/drugs on osteoporosis (Stanosz, Zochowska, Safranow, Sieja, & Stanosz, 2009), Breast cancer (Campagnoli, Biglia, Cantamessa, Lesca, & Sismondi, 1999; Kenemans, Verstraeten, & Verheijen, 2005), bone density (Stanosz, et al., 2009), heart disease (Rees & Stevenson, 2008; Stevenson, 2009), etc., and results are contradictory and in many cases less than conclusive (Maas, et al., 2004; Maciocia, 1998, p. 761; Modena, et al., 2005; Palacios, 2008; Rees & Stevenson, 2008; Stevenson, 2009).

Cultural difference in the perception of symptoms associated with menopause have recently also been of research interest (Gold & Greendale, 2007). Studies reported by Gold & Greendale (2007) indicate that experience of menopausal symptoms in women from different cultural backgrounds appears to be related to both age at menopause and symptom reporting. They state that: “African-American and Latina women have an earlier menopause than Caucasian or some Asian women. Women in less developed countries also experience menopause earlier. Additionally, Mayan and Asian women report fewer hot flashes, whereas African-American and Hispanic women have a higher prevalence of vaginal dryness than Caucasian women”.

Demonstrate Critical Analysis

From a clinical application perspective, the studies referred to above and others indicate the value of using both Acupuncture and Chinese herbal medicine in the treatment of symptom complexes associated with menopause. None of the above studies recommend the combination of TCM and WM as an approach to treating menopause, however, this does not mean they cannot be used simultaneously. Nevertheless, it has been my experience that while a TCM treatment approach can be implemented along side a patient receiving HRT, the patient can reduce and ultimately stop taking HRT and will continue to have her symptoms reduced as the Chinese herbs begin to rebalance the underlying deficiencies.

When reviewing the above studies as to the safety and effectiveness of HRT there seems to be little consensus as to its safety, dosage or duration of use, which is also pointed out by Maas, et al., (2004) with respect to coronary heart- and atherosclerotic disease. It is for this reason that the TCM approach to Menopause is, in my opinion, preferable and associated with less risk, than the stereotypical HRT approach used all too frequently in WM.

Menopause is a natural process and both the presence and severity of symptoms depend on pre-existing underlying conditions (Maciocia, 1998, p. 759). Further, from clinical observations and discussions with patients, I propose, that post-menopause, there are still subtle symptoms that can be identified, from a TCM perspective, and fall into the various stages of the menstrual cycle. For example, mood swings can occur in a cyclic time frame over the lunar month; libido also tends to fluctuate. I propose that despite cessation of menstruation as such, the energetic cycle, as described by Lyttleton (2004, p. 100) during normal menses, continues at least for many years.

It would be interesting to survey postmenopausal women asking them to complete a questionnaire/diary over 4-6 months where they record mood swings, libido, vaginal dryness/mucous and possibly other parameters. This might show that a quasi-menstrual cycle is still operating on an energetic level.

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