“In Celtic cultures, the young maiden was seen as the flower; the mother, the fruit; the older woman, the seed. The role of the post- menopausal woman is to go forth and reseed the community with her concentrated kernel of truth and wisdom”.1
Traditional Chinese Medicine describes menopause as part of the natural aging process and a sign of depletion of Jing or Essence. Cessation of monthly bleeding is our body’s mechanism for redirecting this essence when the body can no longer afford to use it for reproduction.
According to Western physiology, perimenopause is the transition period leading up to menopause and can last for 1 to 5 years. Menopause, the cessation of menstrual bleeding, occurs when there is significant decrease in the ovarian production. Simultaneously, there is an increase in FSH and LH levels, which is the attempt by the hypothalamus to stimulate the ovaries to produce more estrogen. This causes hot flashes, night sweats and palpitations. During the perimenopausal phase, a woman’s levels of progesterone and estrogen are dropping, (although estrogen levels begin to fluctuate the closer she gets to menopause). Often there are missed cycles and irregular cycles. Some symptoms that may appear during these years include irregular menses, memory loss, insomnia, hot flashes, night sweats, emotional fragility, palpitations, vaginal dryness, dry skin, back pain, headaches, PMS and excessive bleeding. At menopause, some of these symptoms can be intensified. Most symptoms will diminish after menopause, as the body re-establishes a new order of things. After menopause, bone loss accelerates for 3 – 5 years, at a rate of from 1.5% to 5% per year, after which it continues at a lower level of around 1% to 1.5% loss per year, on the average.2Many American women continue to have problems with vaginal thinning and begin to develop osteoporosis.
Our bodies have a back-up system. Estrogen and progesterone continue to be produced by the adrenals and fat cells (and to a much lesser degree by the ovaries) following menopause. When this back-up system is working properly, women have few or no side effects. Why are we seeing so many problems for American women? I see several important factors:
1. Often there is chronic depletion of energy during the perimenopausal years, due to poor nutrition, stress (women are expected to juggle families and careers) and sedentary lifestyles. Chinese medicine believes that persistent overstimulation of the body leads to burnout and damages kidney essence. (This is also known as “adrenal exhaustion”).
2. Our collective cultural belief is that aging brings illness and infirmity, along with a loss of status for women. We need more vibrant models of older women, as well as spiritual renewal.
3. In the US we have the “medicalization of menopause”. Most doctors believe that all women should go on Hormone Replacement Therapy (HRT) in order to avoid osteoporosis and heart disease, and now women are afraid to age without it.
4. We get excessive amounts of synthetic hormones from animal foods in our diets, (a common practice in the US, which is banned in some parts of Europe.) We also have many chemical pollutants in our foods (in much higher concentrations in animal products), water and air, as well as depletion of the trace minerals in our soil.
5. Other factors include anovulatory cycles dues to over-exercising and the loss of body fat; anorexia and bulimia (an epidemic in our culture, causing trauma to the body and spirit, malnutrition and loss of periods, which can lead to early menopause and osteoporosis); hysterectomy (the #1 surgical procedure in the US); tubal ligation; abortions; and drug therapies that can interfere with hormone levels.
Let us look at how women from other cultures fare. Women in non-Western cultures manage to escape our high rate of menopausal symptoms, cancer and hip fractures, even though they have much lower calcium intake. They eat less animal protein, (an excess of which causes our bodies to excrete calcium, as well as suppress sex hormone production). They also eat more potassium rich foods, (fresh fruit, vegetables, grains and legumes), and have more physically active lives. Japanese women have much fewer menopausal complaints and have 1/5 our breast cancer rate. This is attributed to their high intake of soy products (which are naturally high in estrogen) and low use of animal fats. Here in the US, Seventh Day Adventists who eat no meat, lose bone at 1/2 the rate of regular meat eaters. According to Dr. John Lee, vegetarians need 1/2 as much supplementation of calcium in their diet as regular meat eaters.
HRT and the Biochemistry of Hormones
Estrogen and progesterone are steroid hormones. Before menopause they are produced from the ovaries, and to a lesser degree from the adrenals and fat cells. After menopause, as the ovaries dramatically reduce their output of hormones, the back-up system of the adrenals and fat cells takes over. The biosynthesis of steroid hormones begins with cholesterol which is converted into pregnenelone and then into progesterone. From progesterone, all the other hormones are derived – (corticosteroids, adrenal steroids, testosterone and the three types of estrogen: estrone, estriol, and estradiol). Of the three types of estrogen, most women in the US are given synthetic estradiol, which is proven to increase the size of estrogen-dependent tumors and is contraindicated for women who have had cancer. Estriol is a type used more commonly in Europe. It cannot be patented, so is not pushed commercially. It is a weaker and safer source which is reported to help shrink estrogen dependent tumors and protect against cancer.
Synthetic hormones have serious side effects. Hormones work like keys in lock. The slightest variation in the key can prevent it from performing its intended functions. Synthetic hormones are less safe and effective than the natural and cheaper hormones, which can be exact replicas of human hormones. Plant substances make precursors of human sex hormones that can be converted in the body.
Premarin, the most commonly prescribed synthetic estrogen in the US, is made from pregnant mare’s urine. It has many potential side effects, including breast and endometrial cancer, blood clots, damage to the liver and the gall bladder, growth of uterine fibroids, hypertension, fluid retention, weight gain, fibrocystic breasts, depression, nausea and migraines. Provera (a synthetic progesterone or “progestin”) is prescribed along with estrogen to reduce the risk of endometrial cancer. Estrogen causes a thickening of the endometrium and progestin sloughs it off every month, bringing back monthly periods for many women.
A great many women use these drugs, even though studies show many potential problems. A 1989 study by Bergkvist et al, reported in the New England Journal of Medicine, showed that supplemental estrogen combined with progestin caused an increased risk of breast cancer, which was not prevented, but rather increased by the addition of progestin.6 A 1992 study from Canada of 699 women compared women with breast cancer with a control group. This study showed that users of estrogen were 40% more likely to get breast cancer that non-users.7 The PDR says that “provera causes breast malignancies in beagle dogs.”8
The message seems to be – “Don’t take powerful drugs indefinitely and avoid them if possible”. Many doctors are recommending women stay on HRT for life, because the benefit to bone density and protection from heart disease go away when a women stops taking the drugs. Some doctors are prescribing the estrogen patch or vaginal estrogen creme for vaginal dryness, both of which have milder effect and fewer side effects. Many women prefer these options. However, a much safer and equally effective option is the use of natural “human identical” hormones. These will be discussed in the next section.
Natural Sources of Hormone Replacement
There are many natural sources of hormone. They are not widely publicized, even though research studies and clinical experience shows that they are safe and effective. Since natural substances cannot be patented by drug companies and guaranteed a monopoly of the market, our doctors only know about drugs which are aggressively promoted by the drug companies. The average cost for a single drug to be tested and the results to be submitted to the FDA is $112 million. Research is not done on healthy women to understand what makes us well. Rather it is done by scientists who view menopause as a disease, so the studies are geared toward proving that women need drug therapy.
Diet is an extremely important factor in having a healthy menopause. The list of foods and herbs that contain hormone precursors is very long. These substances reduce the impact on the body of lowered estrogen and progesterone production by the ovaries. However, when we highly process our food (adding salt and losing potassium content), when we eat a diet rich in animal protein and fat, it reduces our body’s supply of sex hormones. Other factors to be aware of in order optimize our health and the strength of our bones include the following: avoid cigarettes, avoid losing too much body fat, reduce alcohol, caffeine, red meat and soft drinks, increase intake of leafy green vegetables, low fat yogurt, whole grains, vegetables, fruits and legumes, avoid the use of cortisone, diuretics, anti-convulsant drugs and anti-acids., engage in weight-bearing exercise, at least 30 minutes 4 times per week, and supplement your diet with calcium/magnesium complex, vitamin/mineral complex, Vitamins E,B,C,A and Evening Primrose, flax seed or fish oil for their essential fatty acids.
Natural “human identical” hormones differ from medical hormone replacement because they are molecularly identical to our own estrogen and progesterone that we produce in our bodies. They are produced from wild yam and soybean. What happens when we take drugs that are not human identical? We often experience side effects because of metabolites which are formed in our bodies when we ingest them. When taking the natural hormones we need to adjust dosages, so that we are taking the least amount of hormone to do the job. We know we are taking too much when we get side effects such as bloating, breast tenderness, or breakthrough bleeding.
There are natural sources of progesterone and estrogen, which are on the market now. They are available as a pill, transdermal cream and vaginal cream. For many women, natural human identical progesterone alone (made from Mexican wild yam root) can help with all menopausal type symptoms, including PMS, insomnia, fibrocystic breasts and osteoporosis. Natural human identical estrogen (made from soy, wild yam root and licorice) can be prescribed for women who don’t get enough improvement with the progesterone alone, especially for hot flashes and vaginal thinning or atrophy. Some women are trying pregnenalone and DHEA as adjunct therapies, for such symptoms as memory loss, arthritis, fatigue, weight gain, low sex drive and bone loss. A blood or saliva test can be done to determine if you are low in any of these important hormones. Many of these products are available in health food stores or you can get them from your alternative medicine provider.
Stronger dosages of estrogen and progesterone need to be prescribed by your doctor or nurse practitioner. Estriol is the mildest type of estrogen produced by the body and is used more commonly in Europe. It is made from wild yam root and cannot be patented, so is not marketed commercially to doctors here in the U.S. It is a weaker and safer source of estrogen than estradiol, and is reported to help shrink estrogen dependent tumors and protect against cancer. It is an option that should be considered for women who have had cancer and want to avoid estrogen, but are having severe symptoms of estrogen depletion. Estriol can help maintain your current bone levels and has a mild protective effect for the heart. Another variation on this theme, and somewhat stronger, is a formula called Bi-estrogen. This contains 80% estriol, and 20% estradiol. (Tri-estrogen is a very similar formula, which contains 80% estriol, 10% estrone, and 10% estradiol). Because of the added estradiol, it is a better choice for women who have more menopausal symptoms and need to build up their bone density. Testosterone cream can be taken in addition for low sex drive, weak bones and muscles. A blood or saliva test will indicate hormone levels, and help you decide if supplementation is necessary. Your doctor or nurse practitioner can order these products for you from a compounding pharmacy in your local area.
Chinese Herbal Therapy
Chinese herbs have been used for centuries for menopausal symptoms and to protect the bones. The basic goal of treatment is to tonify the Kidney Jing, Yin and Yang. The traditional Chinese herbal formulas, which have been used in some cases for centuries, have many subtle, but powerfully strengthening effects upon the whole endocrine system. At the present time, Western science has discovered much about how our hormones work. Scientists can synthesize more and more powerful drugs. However, the subtleties of how the body works are still a mystery. I am sure that, with time and more research, we will come to understand more about the genius and elegance of Chinese herbal therapy for regulating hormones.
HRT is given in doses several hundred times that used in Chinese herbal therapy!10 (even though the amount used today is significantly smaller than 10 to 20 years ago.) According to Subhuti Dharmananda, in his paper, “The Endocrine Effect of Chinese Medicine”, “Chinese herbs act by stimulating the production of hormones, altering the condition of hormone receptors or changing the rate of catabolism of hormones, rather than by providing the hormones or hormone analogs that function the same as hormones.”11 Many of the ingredients in formulas may have little or no hormonal effects, although the effect of the whole formula will substantially increase hormone levels. Chinese herbs work by improving the function of aging organs and glands.
It is remarkable to observe that the use of herbs, which are appropriate to a person’s normal condition, will usually have a balancing effect on their hormones as well. Japanese studies show that herbal formulas work differently, depending upon the pre-existing condition of the patients using the herbs. For example, Cinnamon and Hoelen Formula, when used in a study with women for uterine fibroids, showed no significant hormonal changes in the women. But using the same formula with a group of anovulatory women, (infertility due to luteal dysfunction), caused an increase in FSH and estradiol, and effectively re-established ovulation. This attests to the subtlety, effectiveness and safety of Chinese Herbal Therapy.
The Chinese Journal of Traditional and Western Medicine, 1991, reported a study of 2 months administration of Rehmannia 6 Formula to relieve menopausal symptoms in early post-menopausal women. The study showed an increase of 20% in estrogen, a decrease by 1/2 in FSH, and a decrease in LH to pre-menopausal levels; the number of estrogen receptors in leukocytes more than doubled. The Chinese Journal of China Materia Medica, 1993, reported a study of aged rats, in which Rehmannia 8 Formula increased estradiol in females and testosterone in males. The Journal of Traditional Chinese Medicine, 1992, reported a study of 58 patients with osteoporosis, using Chinese herbs for 10 to 12 weeks. Bone density improved an average from 4.0 to 0.9 (0=normal). A three month course of treatment for osteoporosis can be successful in increasing bone density back to near normal levels, and as long as the patient is following a good diet, exercises daily, and avoids harmful practices (smoking, etc.), they probably will not need further treatment, unless they become sedentary from illness or injury. If that occurs, then he or she might need a follow-up course of treatment. In many cases, the patients are instructed to continue herbal therapy at a much lower dose in pill form for long-term tonification, (for example, Rehmannia 6 or 8 Formula).
It is significant that high levels of herbs are being prescribed in these studies, equivalent to 25 to 75 grams of raw herbs or 18 to 27 grams of freeze-dried herbs per day. It is more common for American patients to have difficulty digesting large amounts of herbs. Sometimes it is necessary to work on improving the digestion first, and to start off with a lower dose of herbs and work up to a higher dose.
Differential Diagnosis
Formulas that are commonly used during menopause are prescribed according to how the symptoms present. The following is a list of formulas that can be useful:
1. LIVER QI DEPRESSION WITH OR WITHOUT HEAT – Symptoms could include: irregular or short cycles, clots, fatigue, anger, frustration, depression, mood swings, cold extremities, PMS, breast tenderness or lumps. When there is stagnation (liver qi or blood stagnation), it is very important to treat the stagnation before or along with the tonic formulas for the kidney. The classic base formulas are Xiao Yao San and Jia Wei Xiao Yao San.
2. KIDNEY AND LIVER YIN DEFICIENCY – Symptoms could include hot flashes, night sweats, palpitations, thirst, weak knees and low back, chronic vaginal infections or cystitis. The classic base formulas I use are Rehmannia 6 (You can add phellodendron and anemarrhena for heat) or Left Restoring Decoction (Zuo Gui Wan).
3. KIDNEY YANG DEFICIENCY – With floating yang due to deficiency. Symptoms could include heat, dryness, upper body distress, severe hot flashes, insomnia, severe fatigue, teeth or bone problems. These women really need hormonal support and are frequently already on HRT. The classic base formula I use is Two Immortal Decoction (Er Xian Tang), to which I often add placenta and tortoise shell.
4. QI AND BLOOD DEFICIENCY – Symptoms could include dry skin, vaginal dryness, dizziness, insomnia, fatigue, digestive symptoms, muscle weakness, dry eyes or poor vision, scanty menses or excessive bleeding. The classic base formulas I use are Tang Quei and Peony (Dang Gui Xiao Yao San) or Ginseng and Longan Formula (Gui Pi Tang).
5. HEART FIRE -Symptoms could include forgetfulness, fear, anxiety, nightmares, hot flashes, palpitations and irregular periods. The classic formulas I use are Zizyphus Combination (you can add polygala, oyster shell, semen biota or albizziae.), Rehmannia 6 plus anemarrhena and phellodendron (Zhi Bai Di Huang Wan), or Heavenly Emperor’s formula (Tian Wang Bu Xin Tang).
To these formulas, you can add sedating or cooling herbs to improve the treatment.
Herbs to calm the heart and sedate the spirit and for uprising qi include: oyster shell, dragon bone, magnetite, tortoise shell, fu shen, polygala, zizyphus spinoza, uncaria and schizandra. Heat clearing herbs include: phellodendrom, anemarrhena, coptis, moutan, raw rehmannia and tortoise shell.
Substances which can be added which have a stronger hormonal effect include: placenta (the strongest effect), ginseng, deer antler, lithosperum, epimideum, psoralea, centipede and astragalus seed. (These herbs should be avoided when treating someone with cancer, an estrogen-dependent tumor or endometriosis.) Other herbs in the category of strong hormonal effect include cynamorium, schizandra, lycium fruit, rehmannia, licorice and cyperus.17
I have found in my practice that these formulas can be very effective. They can take the place of using the natural or synthetic hormone replacement. Even if a women is already using hormones, she can benefit from using Chinese herbs for the symptoms which don’t respond to HRT, to treat the underlying imbalance, or to help her get off of HRT. The synthetic hormones have side effects, especially liver qi stagnation and blood stagnation. I generally use freeze-dried herbs, at least 9 grams per day. Sometimes I use more if I decide to use two formulas at the same time, rather than adding or subtracting to the base formula for each patient’s special needs. I treat with acupuncture once a week, emphasize a good diet with mineral rich leafy greens and seaweed, exercise, stress reduction and supplementing with vitamins, minerals and essential fatty acids.
Conclusion
The natural “human identical” forms of progesterone and estrogen, used separately or together, work very well, and can be used along with or in place of herbs. I will often prescribe these products. Sometimes it is necessary for a woman to go back to her doctor or nurse practitioner for a stronger prescription of progesterone, estrogen, or for testosterone, DHEA, or pregnenalone. In that case, I usually recommend getting a blood test or saliva test for hormone levels before determining which hormones need replacement. A bone density test is also recommended for women around age 50. When bone density levels are low, that is another factor which must be taken into consideration when creating a treatment plan.
In conclusion, it is important to remember that each woman is unique and has special needs. I try to listen carefully to each person in order to hear what she is asking for. This transition can be upsetting, confusing and exhausting. Books which I recommend for further reading include: Women’s Bodies, Women’s Wisdom, by Christiane Northrup, MD; Wise Women’s Guide to the Menopausal Years, by Susan Weed; Breezing Through the Change, by Ellen Brown and Lynne Walker; and Natural Hormone Replacement, by Jonathan Wright, MD.
Footnotes:
1. C. Northrup MD, Women’s Bodies, Women’s Wisdom (New York: Bantam Books, 1994) p.430.
2. J. Lee MD, Natural Progesterone (Sebastapol, Ca.: BLL Publishing, 1994), p.53.
3. Northrup, Women’s, p.465 (see note 1).
4. E. Brown and L. Walker, Breezing Through the Change (Berkeley, Ca.: Frog Ltd, 1994) p.116.
5. Lee, Natural, p.60 (see note 2).
6. Bergkvist L, Adami H-O, Persson I, Hoover RT, Schairer C, The risk of breast cancer after estrogen and estrogen-progestin replacement. (New England Journal Of Medicine, 1989); 321: p.293-297.
7. Brown, Breezing, p.238 (see note 4).
8. Physician’s Desk Reference, (Oradell, New Jersey: Medical Economics Co., 1989),p.2180.
9. Brown, Breezing, p.x1.(see note 4).
10. S. Dharmananda,The Endocrine Impact of Chinese Medicine, Start Group Manuscripts, Portland, Oregon: Institute for Traditional Medicine, 1994), p.8.
11. Dharmananda, Endocrine, p.7 (see note 12).
12. Hsu HY, Application and Research of Chinese Herbal Formulas and Scientific Research: Cinnamon and Hoelen Formula, (Oriental Healing Arts Institute Bulletin 1986) 11(3): 139-147.
13. Zhang Jiaquig and Zhou Dajing, Changes of leucocyte estrogen receptor levels in patients with climacteric syndrome and therapeutic effect of Liuwei Dihuang Wan, (Chinese Journal of Traditional and Western Medicine 1991)11(9): p.521-523.
14. Chen Jiayi, Zhang Yuyana, and Wu Qiang, Effect of Jinjui Shengi Pills on sex hormones in aged rats, (China Journal of Chinese Materica Medica, 1993) 18 (10): p.619-620.
15. S. Dharmananda, Clinical Tips -#35, Osteoporosis, The Suscriber Series, (Portland, Oregon: Institute for Traditional Medicine.)
16. Dharmananda, Endocrine, p.18.
17. Dharmananda, Endocrine, p.5 and 8.