With Hormone Replacement Therapy (HRT) no longer the magic bullet for women experiencing symptoms associated with menopause, and increasing concern on some fronts about the safety and efficacy of off-the-shelf single-herb supplements like Black Cohosh (Douaud/Daniells), Chinese herbal medicine offers a safe, customized, and time-tested alternative for the mitigation of symptoms associated with menopause.

Menopause is defined as the complete and permanent cessation of menstruation. It is part of the natural life cycle and is not a condition that needs to be treated medically unless it presents with uncomfortable symptoms. The time before cessation of menses is called the "climacteric" or "peri-menopause" and is often where women experience the most distressing symptoms. The climacteric and the symptoms associated with it can start many years before the menses actually ends. The basic mechanism of menopause from the western medical perspective is the gradual decline of viable ovarian follicles and the corresponding drop in estrogen production. Prior to birth the female fetus has about 6 million potential follicles, by menarche (the beginning of menstruation) this number has already dropped to 300,000, at menopause a mere 10,000 potential follicles remain. At a certain point the depletion of follicles corresponds to a drop in estrogen levels (estrogen in secreted by the maturing ovarian follicles). This drop in estrogen levels may precipitate a feed back loop in which the pituitary gland produces increased levels of FSH in an effort to trigger ovulation; if the remaining follicles are unable to cooperate, this increase in FSH level may generate heat (Maciocia). The classic "hot flash" is the body’s way of dissipating the excess heat to the exterior of the body by vasodilation, which is the same mechanism that makes us break into a sweat when we are trying to break a fever. Although it is uncomfortable, especially when it happens 20 times a day!, it is not pathological in itself.

The mean age for menopause is 51. About 25% of women slide through this transitional time with minimal symptoms, 50% experience symptoms that they characterize as mild to moderate, 25% are truly miserable. 85% of women going through menopause experience some degree of hot flashes, sometimes for a number of years (Weschler/Maciocia). The other menopausal symptom that is directly linked to decreased estrogen levels is vaginal dryness. Other symptoms that form part of the "menopausal syndrome" but are harder to explain as a direct result of dropping estrogen levels are: poor memory and concentration, sleep disturbances, depression/anxiety, and thinning of the skin.

HRT offered an 80% to 90% reduction in symptoms of hot flashes and vaginal dryness (Daniells/Weschler) but often needed to be combined with other therapies to address the symptoms not directly connected to estrogen levels. The long term consequences of HRT have been shown to be serious enough to curtail its wide spread use; enter Traditional Chinese Medicine (TCM). While western medicine looks at menopause, sees the falling estrogen levels, and intervenes to replace the estrogen and essentially fool the body into thinking that it is still producing estrogen and ovulating; TCM looks at menopause as a natural end to the reproductive years and works to establish a new balance in the new situation. In this model the kidney, which is home to the ancestral energy or Jing, the essence of the life force, and the ability to reproduce, is the key player. The kidney essence which incorporates both the yin and the yang has declined to the point where reproduction is no longer possible, often the decline of the yin and the yang are not equal; the dynamic balance between the two primary energies is disturbed, symptoms may result. The classic textbook situation is that the yin ( the cool, moistening, nourishing, containing, feminine aspect) has been relatively more exhausted by a lifetime of stress, lack of sleep, childbirth, and monthly blood loss. In its depleted state the yin is unable to contain and balance its partner the yang, thus the yang (the warming, moving, protective, active, male aspect) seems to flair out of control producing heat symptoms, drying the fluids, harassing the heart and disturbing sleep. The treatment for such a situation is two fold: #1 to address the symptoms that arise because of the imbalance (hot flashes, dryness, insomnia) and #2 to address the imbalance itself by tonifying the yin aspect directly thus allowing the system to re-balance. For some women this can be achieved by acupuncture alone but for many women herbal medicine offers a stronger and more effective intervention.

Prescription of Chinese herbal medicine is based on pattern differentiation, thus each prescription is tailored to the individual’s specific presentation. The average formula might contain anywhere from 6 to 20 different herbs selected to work synergisticly and to balance out any unwanted side effects. While 2 women might both present with a main complaint of menopausal symptoms each would be experiencing different symptoms with different severity depending on many factors including constitutional tendencies, lifestyle, and any other health challenges that she might have. Because each women’s menopause is different, the treatment must be individualized and must evolve as the body transitions through this phase.

Unfortunately treating menopausal symptoms with Chinese herbal medicine is not a quick fix. Even though HART produced quick relief it was also a long term medication commitment, many women who had to stop HART experienced renewed menopausal symptoms which went on for years. Tonifying any aspect of the kidney is a long term proposition and while some level of symptomatic relief may be a matter of weeks of treatment, establishing a new and sustainable balance is more likely to be a matter of months or even years (not really surprising when you consider that it took about 50 years to get to this point). The good news is that since the herbal prescriptions are based on the individual’s presentation rather then a one size fits all approach, many issues can be addressed in one prescription, and the prescription, because it treats the whole picture, is balanced within itself and thus much less likely to have unwanted side effects. Since herbal scripts are usually written for a relatively short period and are constantly being adjusted based on patient report and clinician observations the treatment is constantly evolving, decreasing the likelihood of the body becoming resistant or unresponsive to the herbs and allowing the treatment to change over time as the body achieves a more harmonious balance in its new, estrogen reduced, incarnation.

Sources
Daniells, Stephen; Questions raised over HRT alternatives; Decision News Media 4/9/2006
Douand, Clarisse; Health Canada issues black cohosh advisory; Decision News Media 8/23/06
Maciocia, Giovanni; Obstetrics & Gynecology in Chinese Medicine; Churchill Livingstone 1998
Weschler, Toni; Taking Charge of Your Fertility; 2002

- Rebekah Michaels, LicAc., MAOM, Diplomate OM