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Article originally published May 20, 2021

The Journey of Menopause

Menopause is a normal part of aging that comes at the end of a woman’s reproductive years and is defined as the complete and permanent cessation of menstruation for at least 12 consecutive months. Menopause usually occurs between the ages of 48 and 55, and the median age in industrialized countries is about 51 years old.

Perimenopause is defined as the transition phase during which the body slowly produces less and less estrogen over a period of years until the ovaries stop releasing eggs and the menstrual cycle stops. This slow hormonal shift that occurs as the body moves from active menstruation to the complete end of menstruation is a process, possibly as short as a few months but often lasting as long as 8-10 years. This shift to menopause when the menses cease is a natural phase of every woman’s life, not an illness or a disease, and some women experience it as a smooth transition with minimal discomfort. However, during these hormonal shifts, particularly as the circulating estrogen decreases more rapidly in the last few years preceding menopause, many women experience discomfort as their bodies try to adapt. It can come as a big surprise to women in their 40s who don’t expect to have any symptoms until their menses actually cease in their late 40s to mid 50s, that it is during perimenopause that many “menopausal symptoms” actually occur. Perimenopausal women frequently experience a constellation of symptoms, including hot flashes, night sweats, insomnia, irregular menstruation and fluctuating amounts of bleeding, emotional changes, genitourinary symptoms, symptoms of dryness, headaches and joint & muscle pain. Some women continue to experience discomfort after menopause, which is known as the postmenopausal phase.

The most famous symptom of perimenopause is of course, hot flashes. Body temperature regulation issues can run from irritating to debilitating, with an estimated 35%–50% of perimenopausal women suffering from sudden waves of body heat with sweating and flushing that usually last 1–10 minutes, often at night as well as during the day. Women report experiencing hot flashes from 1-2 a day to upwards of 20 times a day. Hot flashes often lead to daytime or night sweats, which can quickly turn into cold sweats as cold air flows across the skin. As can well be imagined, sleep disturbances are also very common, with sleep disorders affecting 39-47% of perimenopausal women and 35-60% of postmenopausal women. Whether due to being awakened by a hot flash or cold sweats, by joint and muscle pain, or simply by the inability to sleep deeply during the hormonal transition, women tend to have a hard time sleeping during the whole period from perimenopause through postmenopause. Challenges with mental focus and memory are also a big concern for perimenopausal women. Not only due to fluctuating levels of estrogen, the stress and sleep difficulties of perimenopause also interfere with concentration and memory. Studies show that some 60% of women in perimenopause and menopause report that their memory is not as good as it used to be. Pauline Maki, PhD, a professor of psychiatry and psychology and director of women’s health research at the University of Illinois in Chicago says that some women with perimenopause-related brain fog become frightened, believing they are developing dementia. However, in 2009, researchers at UCLA studied over 2,000 women entering menopause over a period of four years, and they found that memory and learning ability tends to return after menopause is complete.

The Chinese Medicine View of Menopause

Traditional Chinese medicine views menopause as a completely natural part of a woman’s life. As we know, according to Chapter 1 of the Huang Di Nei Jing/Yellow Emperor’s Cannon of Internal Medicine, a women’s development, physical growth and reproductive maturation evolves in seven-year cycles, driven by her Kidney Qi and Jing. According to the Nei Jing, at 42 years old (the 6th cycle of 7) it is said that “a woman’s three Yang channels [Taiyang, Shaoyang & Yangming] begin to decline; her complexion wanes and her hair begins to turn white.” These signs of the Kidney Qi and Jing decline describe the perimenopausal transition as the hormone production decreases and the woman is less and less able to conceive. At 49 years old (the 7th cycle of 7) it is said that “the Ren is vacuous, the Tai Chong Mai is debilitated and scanty, the Tian Gui is exhausted, [and] the passageways of the earth are no [longer] freely flowing. Therefore, the form [or body] has gone bad and [women can] no [longer have] children.” This final reproductive cycle obviously indicates menopause, when the menses have stopped, and a woman is no longer able to conceive.

The discomfort that many women experience during the shift into menopause was not a classically defined disease category in the medical classics, although there are many perimenstrual symptoms, such as 5 palm fever, night sweats, insomnia, and irregular menstruation, which are classical Chinese medicine disease categories. The constellation of perimenopausal complaints have only been recognized as a syndrome in Chinese medicine for a little over 50 years. During the 1960s, TCM practitioners in China decided that perimenopausal symptoms could be diagnosed and treated as a whole, and that they were almost exclusively due to the decline of Kidney Jing-essence, which can take the form of Kidney Yin deficiency, Kidney Yang deficiency, or dual Kidney Yin and Yang deficiency. However, it was also understood that this Kidney deficiency is often combined with excess patterns, such as Dampness, Phlegm, and stagnation of Qi or Blood. In fact, the common clinical picture is rarely simple Kidney Jing deficiency, but rather a complicated picture with a mix of excess and deficiency. The traditional Japanese Kampo formulas for perimenopausal women tend to focus on eliminating excess, not tonifying deficiency.

TCM Etiology and Pathogenesis

As some women experience minimal or no perimenopausal discomfort, what causes the symptoms that can be so debilitating to others? According to TCM, the main causes for discomfort all the way from perimenopause through menopause and post menopause include overwork, excessive sexual activity or too many childbirths, chronic illness, irregular diet, and excessive worrying or other emotional stress.

According to traditional Chinese medicine there are three large categories of issues that can result in difficulty with the perimenopausal hormonal shift:

Constitutional weakness and weakness due to overwork/overextending

Constitutional weakness or lifestyle-induced weakness of the Kidney Jing-essence is an important cause of perimenopausal discomforts. Constitutional Jing deficiency may be due to the woman’s inherited deficiencies from either or both parents, such as her parents having been too old when conceiving her, her parents’ poor health at the time of conception, her mother’s health and diet not being good during pregnancy, etc. In addition to constitutional weaknesses, many months or years of overworking or overextending the body is an important cause of lifestyle induced deficiency. A combination of the traditional Chinese medical thoughts on overextending with a few modern additions include:

1. working long hours without adequate rest or standing for long periods of time
2. chronic long-term illnesses
3. excessive sexual activity, especially excessive sexual activity during puberty
4. too many childbirths, particularly childbirths in quick succession or with advanced maternal age
5. long-term lack of adequate rest and sleep
6. long-term consumption of birth control pills
7. excessive consumption of alcohol or recreational drugs

Any of these types of overworking or overextending may initially consume Spleen Qi and Liver Blood. If more extensive or over longer periods of time, it may consume Kidney Yin, Yang and Jing-essence.

Physical over-exertion with irregular diet, and/or excessive worrying

Overexertion, particularly excessive physical work, along with a diet lacking in adequate nourishment or irregular dietary habits, as well as excessive thinking and worrying, or chronic illness, can weaken the Spleen, and eventually weaken the Kidney. A female is especially vulnerable to excessive physical work during puberty, particularly excessive training for sports such as swimming, long-distance running, excessive ballet dancing, etc. A weakened Spleen may fail to create enough Qi and Blood resulting in Qi and Blood deficiency in the Chong and Ren. It may also fail to properly transform and transport fluids properly, leading to the formation of dampness, which can easily form phlegm.

Emotional stress

“Disturbance of the seven emotions” are all considered to affect the Heart, initially by directly blocking the Heart Qi and disturbing the Shen. Emotional disturbance due to worry, anxiety and fear specifically weakens the Spleen and Kidneys. These emotions can particularly deplete the Yin, especially when these emotions occur against a background of overwork. Over time, deficient Kidney Yin may fail to adequately nourish Heart Yin, which leads to Heart Yin deficiency and deficient heat. Emotional disturbance due to excessive anger, repressed anger, resentment, frustration, depression, guilt or hatred tends to result in the stagnation of Liver Qi. Qi can also become stagnated due to excessive worry, anxiety, and fear. Once the Liver Qi is stagnated, the Liver may overact on the Spleen, impairing its ability to transform and transport fluids, resulting in dampness. Or conversely, Spleen Qi deficiency can lead to dampness, and this can cause Liver Qi stagnation. Over time, Qi stagnation may more significantly slow or completely impede the transformation and transportation of fluids, until accumulations of fluids eventually form phlegm. Long term Qi stagnation also slows and blocks the flow of Blood, leading to Blood stagnation.

Sedentary Lifestyle

In addition to the classically observed causes of constitutional weakness and Qi stagnation in Chinese medicine, we can observe in our patients that a sedentary lifestyle and a lack of exercise can deplete the Spleen Qi and Liver Blood, and cause Liver Qi stagnation. Eventually long-term lack of movement and exercise can both consume Kidney Yin, Yang and Jing-essence and lead to Blood stagnation.

TCM Diagnosis and Treatment

Treatment of Early Perimenopause

In the initial stages of perimenopause about a decade before menopause, most women begin to notice subtle changes in their menstrual cycle (shortened, lengthened or irregular cycles), changes or fluctuations in how much they bleed, or possibly emotional changes such as increased irritability or depression, anxiety, or an increase or decrease in PMS. They may also have changes in libido, memory, energy, and symptoms of dryness. For women who are noticing some of these changes but without too many symptoms, it is a good idea to administer herbal formulas to support the reservoirs of the Chong and Ren Mai, nourish Qi and Blood, invigorate the flow of Liver Qi, and possibly herbs to gently nourish Yin, Yang or clear heat due to Qi stagnation. Appropriate formulas to consider include Nu Ke Ba Zhen Wan, Wu Ji Bai Feng Wan, Si Wu Tang Wan, Liu Wei Di Huang Wan, Zuo Gui Wan, You Gui Wan, Xiao Yao Wan, and Jia Wei Xiao Yao Wan.

Treatment of perimenopausal/menopausal symptoms

If a patient presents with more severe symptoms or the symptoms increase as she approaches menopause, then a stronger more targeted approach is needed. Here are the presentations and treatment of some of the most common syndrome patterns encountered in clinic.

Kidney Yin & Jing deficiency with deficiency heat

Etiology: Usually due to constitutional Jing Xu, or years of overworking and overextending, protracted illness, excessive sexual activity, or too many childbirths, which consumes Kidney Yin, Yang and Jing-essence.

Presentation: Symptoms include hot flashes, night sweats, malar flush, 5-palm fever, dizziness, tinnitus, poor memory and concentration, weakness and soreness in the low back and knees, dry mouth, hair and skin, itching, constipation, increased (with deficiency fire) or decreased sex drive, vaginal dryness, probable history of short cycles, large (with deficiency fire) or small amount of bright scarlet blood, possibly thick and sticky, possibly sudden onset of excessive bleeding or prolonged spotting.

Tongue: red, tender or dry and cracked, scanty coat or no coat
Pulse: thin and rapid or floating and empty

Treatment Principles:

1. Tonify Kidney Yin
2. Clear Deficient Heat
3. Calm the Shen

Herbal Treatment - from Least to Greatest Heat:

1. Zuo Gui Yin (Shu di huang, Shan yao, Shan zhu yu, Gou qi zi, Tu si zi, Huai niu xi) for Yin deficiency and deficient heat that is not too pronounced, plus either a small amount of Da Bu Yin Wan (Shu di huang, Gui ban, Zhi mu, Huang bai) or 1-3g/day of Gui ban/Mauremys reevesii shell extract powder is recommended for the deep Yin-nourishing quality of the turtle shell. Zuo Gui Wan is the classic Liver and Kidney Yin deficiency formula that eliminates the herbs that drain and balance (Mu dan pi, Fu ling, Ze xie) from Liu Wei Di Huang Wan, in favor of three herbs that more deeply nourish and tonify the Kidney, including the Jing-essence, as well as Liver Blood (Gou qi zi, Tu si zi, Huai niu xi).
2. Zhi Bai Di Huang Wan (Shu di huang, Shan zhu yu, Shan yao, Ze xie, Mu dan pi, Fu ling, Huang bai, Zhi mu) is indicated if the Yin deficiency heat is more pronounced heading towards upflaring fire with more frequent or longer lasting hot flashes and a significantly red tongue with a scanty coat or no coat. Zhi Bai Di Huang Wan is the classic Liver and Kidney Yin deficiency formula Liu Wei Di Huang Wan along with two herbs (Huang bai & Zhi mu) added to clear deficiency heat.
3. If the night sweats are pronounced, then add 1-3g of Mu li/Ostrea gigas shell extract powder.
4. Switch to Da Bu Yin Wan (Shu di huang, Gui ban, Zhi mu, Huang bai) if upflaring fire is stronger with increased heat signs such as worse and more frequent hot flashes and night sweats, restlessness and irritability, chronic throat pain due to deficiency heat that is worse in the afternoon, evening, or when fatigued, a red, dry tongue, little or no coat, and a small, thready and rapid pulse that may be forceful in the chi position due to the fire. Da Bu Yin Wan is a very strong compact formula split between Shu di huang & Gui Ban to very strongly tonify Yin and Zhi mu & Huang bai to strongly clear upflaring deficiency fire.
5. Switch to Qing Gu Wan (Yin chai hu, Zhi mu, Hu huang lian, Di gu pi, Qing hao, Qin jiao, Bie jia, Gan cao), a formula that does very little to nourish Yin deficiency and focuses almost exclusively on clearing the deficiency fire, if the patient presents with steaming bone syndrome - a sensation of heat in the bones while the skin is a normal temperature on palpation, afternoon tidal fever or unremitting chronic low-grade fever, severe night sweats and dark red cheeks. Once the deficiency fire has been cleared sufficiently, switch to Da Bu Yin Wan.

Kidney Yang & Jing Deficiency

Etiology: Usually due to constitutional Jing Xu, or years of overworking and overextending, protracted illness, after an injury to the body by cold, excessive sexual activity, or too many childbirths, long-term Yin deficiency or Qi deficiency, any of which may consume Kidney Yang and Jing-essence.

Presentation: Hot flashes but cold hands and feet, cold night sweats in the early morning, pale face, depression, poor memory and concentration, poor digestion, loose stools or cock’s crow diarrhea, weakness and soreness in the low back and knees, cold limbs and aversion to cold, edema at the ankles, decreased sex drive, probable history of long menstrual cycles, scanty, light red, watery blood, few or no clots, dull lower abdominal pain which comes and goes, possibly the gradual onset of profuse continuous white and dilute vaginal discharge resembling water or egg white, or prolonged pale spotting.

Tongue: pale and possibly tender tongue, thin white and possibly wet coat
Pulse: deep and weak

Treatment Principles:

1. Warm & Tonify Kidney Yang
2. Warm the Center, Strengthen the Spleen
3. Calm the Shen

Herbal Treatment:

1. You Gui Wan (Shu di huang, Shan yao, Shan zhu yu, Gou qi zi, Du zhong, Tu si zi, Dang gui, Rou gui) with a small amount of Fu Zi Li Zhong Wan (Dang shen, Bai zhu, Gan jiang, Gan cao, Fu zi) to be adjusted up if the digestive symptoms and cold are worse or down if the hot flashes increase. Although rare in clinic, women can present with a relatively pure Kidney Yang deficiency and they respond well to treatment aimed at warming and building the Kidney Yang, regardless of the seemingly “hot” symptom of hot flashes.
2. If low back pain is more pronounced, add a half dose of Yao Tong Pian (Dang gui, Du zhong, Xu duan, Bai zhu, Bu gu zhi, Huai niu xi, Gu sui bu, Du huo) to tonify the Kidneys, strengthen the lower back, and benefit the tendons & bones.

Kidney Yin and Yang dual deficiency

Etiology: Usually due to constitutional Jing Xu, or years of overworking and overextending, protracted illness, excessive sexual activity, or too many childbirths, which consumes Kidney Yin, Yang and Jing-essence.

Presentation: Hot flashes but cold hands and feet, night sweats, tendency to feel cold in between hot flashes and particularly in the early morning hours, cold limbs and aversion to cold, flushed around the neck when talking, slightly agitated, dry throat, dizziness, tinnitus, frequent pale urination, weakness and soreness in the low back and knees, decreased sex drive, vaginal dryness, probable history of irregular cycles, scanty and/or thin, light red menstrual blood, possibly episodes of excessive bleeding or prolonged spotting.

Tongue: normal to red, scanty coat
Pulse: thin and rapid or floating and empty

Treatment Principles:

1. Tonify Kidneys
2. Nourish Yin
3. Gently Warm Yang
4. Calm the Shen

Herbal Treatment:

1. A modified Zuo Gui San extract powder formula with Lu jiao jiao and Gui ban jiao to strongly nourish and consolidate Yin, Yang and Jing-essence (Shu di huang, Shan yao, Shan zhu yu, Gou qi zi, Chuan niu xi, Tu si zi, Lu jiao jiao, Gui ban jiao).
2. A combination of Yin tonic Zuo Gui Wan teapills and Yang tonic You Gui Wan teapills can be used instead and adjusted according to the patient’s needs for stronger Yin or Yang tonification.
3. If the symptoms of upflaring fire and hot flashes are stronger, add or switch to Er Xian Wan (Xian mao, Yin yang huo, Ba ji tian, Huang bai, Zhi mu, Dang gui), a small potent formula that warms and tonifies Kidney Yang, tonifies Yin, nourishes Jing, nourishes Liver Blood, drains Kidney fire, and regulates the Chong and Ren Channels.

Kidney and Liver Yin Deficiency with Liver Yang Rising

Etiology: Usually due constitutional Liver & Kidney deficiency, long-term overworking, protracted illness, excessive sexual activity, or too many childbirths, which consume Liver and Kidney Yin, Blood and Jing-essence. High emotions such as stress, frustration, overwhelm or anger cause the Liver Yang to rise, possibly stirring internal wind.

Presentation: Hot flashes, facial and neck flushing, sensation of heat rushing to the head, night sweats, irritability, insomnia, poor memory and concentration, dizziness, tinnitus, blurred vision, dry eyes and skin, aching in the joints, weakness and soreness in the low back and knees, calf cramps, headaches or migraines at the temples or behind the eyes, mild trembling, decreased sex drive, vaginal dryness, possible history of mild menstrual cramping at the end or after the period, empty and weak sensation in lower back and abdomen, scanty amount of thin blood.

Tongue: red, scanty coat or thin yellow coat
Pulse: thin, rapid and wiry

Treatment Principles:

1. Strengthen Liver and Kidney Yin
2. Subdue Liver Yang
3. Calm the Shen and Hun

Herbal Treatment - from Mild to Severe Symptoms:

1. Qi Ju Di Huang San extract powder (Shu di huang, Shan zhu yu, Shan yao, Mu dan pi, Fu ling, Ze xie, Gou qi zi, Ju hua) is indicated when the Liver & Kidney Yin deficiency is not too pronounced, particularly when eye symptoms are prominent such as blurred vision, floaters, visual weakness, dry, irritated or painful eyes, and no signs or minimal signs of Liver Yang rising, possibly just recurrent headaches.
2. Tian Ma Wan (Shu di huang, Dang gui, Qiang huo, Du zhong, Tian ma, Xuan shen, Huai niu xi, Bi xie, Du huo, Fu zi) treats a mixed pattern of Liver and Kidney deficiency (Yin, Blood, possibly slight Yang Xu) and some combination of wind-damp Bi Zheng, episodes of Liver Yang rising, and possibly the stirring of internal wind to the head. Large dosages of Shu Di Huang and Dang Gui strongly tonify Liver and Kidney Yin & Blood. Du zhong, Xuan shen and Huai niu xi further strengthen the root by tonifying and nourishing the Liver and Kidney, strengthening sinews and bones, and benefiting the joints. Tian ma calms and moistens the Liver, anchors the Yang, and strongly controls the internal stirring of Liver wind to treat headache and dizziness, resolve stiff neck and upper back, calm mild trembling, and works with the other herbs to clear wind-damp obstruction. Xuan shen strongly nourishes Yin and directs deficient fire downwards, to treat the facial and neck flushing and sensation of heat rushing to the head. Dang gui, Du zhong & Huai niu xi invigorate the Blood send it down and away from the head. A small bit of Fu zi aids Qiang huo, Du zhong, Tian ma, Huai niu xi, Bi xie and Du huo to treat the joint pain, low back pain, headaches & migraines.
3. Tian Ma Gou Teng Yin (Shi jue ming, Sang ji sheng, Gou teng, Ye jiao teng, Fu ling, Yi mu cao, Tian ma, Zhi zi, Huang qin, Du zhong, Chuan niu xi) focuses primarily on the branch treatment of sedating Liver Yang rising and possibly Liver fire, quelling internal wind and invigorating the Blood, while secondarily tonifying the root cause Liver and Kidney Yin and Blood. It contains a large dosage of Shi jue ming, a heavy shell to strongly sedate the Liver Yang rising. Shi jue ming pairs with Gou teng and Tian ma to pacify the Liver, sedate the Liver Yang and extinguish wind. Zhi zi and Huang qin clear heat and drain fire. Tian ma, Yi mu cao and Chuan niu xi quell internal wind and guide Blood stagnation down and away from the head. Sang ji sheng, Du zhong, Ye jiao teng and Chuan niu xi tonify the Liver and Kidney to strengthen the root and anchor the Liver Yang.
4. If insomnia is pronounced or is not sufficiently addressed by any of the primary formulas, then add An Mien Pian (Suan zao ren, Yuan zhi, Fu ling, Zhi zi, Shen qu, Gan cao) from 3-8 tablets before bed and possibly 3-6 tablets on the bedside table to take if she wakes during the night.

Heart and Kidney Not Communicating

Etiology: Usually due to constitutional Heart & Kidney deficiency, excessive sexual activity, or emotional disturbance from worry, anxiety and fear, which specifically weakens the Spleen and Kidney. These emotions can particularly deplete the Yin, especially when these emotions occur against a background of overwork. Over time, deficient Kidney Yin may fail to adequately nourish Heart Yin, resulting in Heart Yin deficiency and deficient heat, also known as Water failing to control Fire, so the Heart fire blazes.

Presentation: Hot flashes, insomnia, restless sleep, frequent waking, excessive and vivid dreaming, waking with anxiety, palpitations, night sweats, blurred vision, dizziness, tinnitus, malar flush, sensation of heat in afternoon or evening, low grade fever, dry mouth and throat, dry stool, mouth or tongue sores, chronic throat pain that is worse in the afternoon, evening or when fatigued, general anxiety and mental restlessness, fatigue, poor memory, forgetfulness, poor concentration with inability to concentrate for even short periods of time, weak and sore lower back and knees, probable history of short or irregular cycles, with scanty menstrual blood.

Tongue: red or very red tip with a dry, scanty coat or no coat
Pulse: some combination of thin, rapid and wiry

Treatment Principles:

1. Strengthen Heart and Kidney Yin
2. Nourish the Blood
3. Calm the Shen

Herbal Treatment:

1. Tian Wang Bu Xin Dan (Sheng di huang, Dang gui, Wu wei zi, Suan zao ren, Bai zi ren, Tian men dong, Mai men dong, Xuan shen, Dan shen, Dang shen, Fu ling, Jie geng, Yuan zhi) is the classic formula to treat Kidney and Heart Not Communicating. It works on both the root deficiency of Kidney and Heart Yin and Blood and the branch of Shen disturbance.
2. If anxiety and insomnia or are not sufficiently addressed by the main formula, add a half dose of An Shen Bu Xin Wan (Zhen zhu mu, Ye jiao teng, Nu zhen zi, Dan shen, Han lian cao, Tu si zi, He huan pi, Sheng di huang, Wu wei zi, Shi chang pu), a formula designed to rapidly calm and anchor the severely disturbed Shen and Hun with the heavy down-bearing herb Zhen Zhu Mu/Margaritifera concha which makes up almost half of the formula at 44%. The rest of the herbs work in concert to strengthen the Heart and Liver Yin and Blood and subdue the hyperactivity of Heart fire, which in turn helps reestablish the communication between the Kidney and Heart.
3. If the palpitations and night sweats are more pronounced, add a bit more Bai zi ren/Platycladus orientalis seed, and1-3g each of Ye jiao teng/Polygonum multiflorum stem and Mu li/Ostrea gigas shell extract powders. Or add a half dose of Bai Zi Yang Xin teapills (Bai zi ren, Gou qi zi, Xuan shen, Shu Di huang, Mai men dong, Dang gui, Fu ling, Shi chang pu, Gan cao) and1-3g of Mu li/ extract powder.
4. For a very dry mouth and throat, 1-3g each of Shi hu/Dendrobium nobile stem and Yu zhu/Polygonatum odoratum rhizome extract powders.

Phlegm and Qi Stagnation

Etiology: Usually due to a combination of Liver Qi stagnation and Spleen Qi deficiency which combine to create phlegm. The Liver Qi stagnation may be due to various reasons, but commonly due to emotional stress, anger, resentment, frustration, depression, guilt or hatred causing the Qi to stagnate. Either the Spleen Qi is already deficient due to overwork, irregular dietary habits & excessive worrying, or the Liver overacts on the Spleen, either of which impairs the Spleen’s ability to transform and transport fluids, resulting in dampness. Over time, Qi stagnation may more significantly slow the transformation and transportation of fluids, until accumulations of fluids eventually congeal and form phlegm.

Presentation: Hot flashes, tendency to be overweight, a sensation of oppression in the chest, sputum in the chest, breast distention or pain, a sensation of fullness in the epigastrium, irritability, moodiness, depression, belching, frequent sighing, heartburn, acid regurgitation, bitter taste in the mouth, poor appetite, indigestion, nausea, feeling of heaviness, possible history of fibroids, cysts, adhesions, mid-cycle pain, yeast infections, and lots of sticky or thick vaginal mucus, irregular menstrual cycles with uneven blood flow, possible amenorrhea due to blockage, moderate cramping, possibly sticky or thick blood or blood mixed with some mucus.

Tongue: pale or dusky, possibly slightly red sides, and/or a greasy or sticky coat
Pulse: wiry and possibly slippery

Treatment Principles:

1. Resolve Phlegm
2. Invigorate the flow of Liver Qi
3. Pacify the Liver
4. Eliminate Stagnation

Herbal Treatment:

1. Yue Ju San extract powder (Xiang fu, Cang zhu, Shen qu, Chuan xiong, Zhi zi) is a potent formula to unblock stagnation of all sorts – with Xiang fu to unblock the flow of Qi, Chuan xiong to invigorate the Blood, Cang zhu to eliminate dampness and phlegm, Shen qu to resolve food stagnation and Zhi zi to clear heat. Add 1-3g each of Tian nan xing/Arisaema erubescens rhizome and Gua lou/Trichosanthes kirilowii fruit extract powders to increase the ability to treat phlegm. It is also an excellent formula to treat the depression, which can be either a cause of or result from the Qi and phlegm stagnation.
2. For irregular menses or amenorrhea, add 1-3g of a few single herb extract powders to invigorate the Blood, such as Dang gui/Angelica sinensis root, Yi mu cao/Leonurus japonicus herb, Dan shen/Salvia miltiorrhiza root, Tao ren/Prunus persica seed, Hong hua/Carthamus tinctorius flower, Ze lan/Lycopus lucidus herb.
3. If there is strong breast distention or pain, add 1-3g of Qing pi/Citrus reticulata peel-immature extract powder.
4. If there is a lot of belching, sighing and general indigestion, add 1-3g each of Mu xiang/Aucklandia lappa root and Zhi ke/Citrus aurantium fruit extract powder, or a half dose of Shu Gan Wan teapills.
5. If there is a lot of mucus, add 1-3g each of Fu ling/Poria cocos sclerotium and Ze xie/Alisma orientalis rhizome extract powder or a half dose of Er Chen Wan teapills.
6. If there are stronger heat signs, add 1-3g each of Chuan lian zi/Melia toosendan fruit and Huang lian/Coptis chinensis rhizome extract powder.

Blood Stagnation

Etiology: Usually due to long-term Qi stagnation leading to Blood stagnation. Emotional disturbance due to excessive stress, anger, repressed anger, resentment, frustration, depression, guilt or hatred tends to result in the stagnation of Liver Qi. Qi can also become stagnated as a result of excessive worry, anxiety, and fear. A sedentary lifestyle and lack of movement or exercise can also lead to Qi stagnation. Less commonly, Qi stagnation may be caused by cold, heat, phlegm, accumulation of fluids or water, or from food stagnation. Blood stagnation can also occur directly due to surgery or physical trauma.

Presentation: Hot flashes, mental restlessness, insomnia, distending or stabbing localized lower abdominal and lower back pain, possible history of fibroids, cysts, adhesions, very irregular menstrual cycles, even amenorrhea due to blockage or skipping several months before the menses start again, with uneven blood flow and lots of starting and stopping bleeding, menstrual cramps which are sharp, cramping or piercing, fixed in location, worse with pressure and a tendency to be worse at night, dark or purplish blood with lots of clots, potentially very large clots, and the cramping pain improves after clots are expelled.

Tongue: purple tongue body, and/or dark or purple spots on the tongue, distended, thick purple sublingual veins
Pulse: choppy or wiry, possibly deep

Treatment Principles:

1. Invigorate the Blood
2. Dispel Blood Stasis
3. Invigorate the flow of Liver Qi
4. Calm the Shen

Herbal Treatment:

1. Ge Xia Zhu Yu San extract powder (Dang gui, Tao ren, Hong hua, Wu yao, Chuan xiong, Mu dan pi, Chi shao, Xiang fu, Zhi ke, Ru xiang, Mo yao, Yan hu suo, Gan cao) is a modification of the classical Blood stagnation formula Xue Fu Zhu Yu Tang designed for chronic Blood stasis and Liver Qi stagnation below the diaphragm presenting with abdominal pain or severe menstrual cramps.
2. If there are more pronounced signs of Qi stagnation with breast distention and/or pain, chest oppression, add 1-3g of Qing pi/Citrus reticulata peel-immature extract powder or a half dose of Shu Gan Wan teapills.
3. If the Blood stagnation is creating heat, add 1-3g each of Zhi zi/Gardenia jasminoides fruit, Xia ku cao/Prunella vulgaris spike and Yi mu cao/Leonurus japonicus herb extract powders.
4. If the mental restlessness and insomnia are pronounced or not sufficiently addressed by the primary formula, then add An Mien Pian (Suan zao ren, Yuan zhi, Fu ling, Zhi zi, Shen qu, Gan cao) at 3-8 tablets before bed and possibly 3-6 tablets on the bedside table to take if she wakes during the night. Or add Chai Hu Long Gu Mu Li Wan (Chai hu, Ban xia, Fu ling, Gui zhi, Huang qin, Da zao, Dang shen, Duan long gu, Duan mu li, Sheng jiang, Da huang) at 8-12 teapills before bed and possibly 4-8 teapills on the bedside table to take if she wakes during the night.

Single Herbs Frequently Added to Perimenopausal Formulas:

• Qing hao and Gui ban for unremitting hot flashes
• Mu li and Nuo dao gen for night sweats
• She chuang zi and Tu fu ling for sore, dry vagina
• Dang gui in larger doses for hot flashes, dry skin, dry vagina, vaginal atrophy
• Shu di huang to nourish Yin & Jing-essence for night sweats, irregular menses, dizziness, premature graying of the hair
• Bai shao yao, He shou wu and Sang shen zi for thinning hair
• Chi shao yao and Di fu zi for dry, itchy skin (crawling or tingling skin sensations)
• He shou wu is used as an endocrine system tonic, to rejuvenate, strengthen, and energize, nourish Yin & Jing-essence. Used to treat premature aging & weakness, vaginal discharge.
• Ren shen is used as an adaptogen to improve resistance to mental-emotional stress resulting in fatigue, poor memory and concentration, depression and anxiety, provided that Qi and Yang tonification is needed.

Chinese medicine food therapy to nourish the Yin fluids

Chinese medicine food therapy recommendations include increasing foods that nourish the Yin cooling fluids of the body, such as oysters and clams, duck, pork, eggs (especially the yolk), cow or goat’s milk (especially yogurt), millet, barley, wheat germ, wheat, pears, mango, watermelon (and all melons), blackberries, raspberries, bananas, apples, tomatoes, avocados, asparagus, artichokes, yams, adzuki and kidney beans (and most other beans), seaweeds, kelp, & micro-algae (especially spirulina, chlorella and blue-green algae), honey, coconut milk. Soups, stews and steamed or lightly sauteed foods are considered the best way to prepare foods to benefit the Yin. It is also recommended to limit foods that create excess heat in the body, such as alcohol, red meats, white sugar, spicy foods, fried and greasy foods, and crustaceans such as crab, shrimp and lobster.

References

• Maclean, William. et al., The Clinical Handbook of Internal Medicine, the Treatment of Disease with Traditional Chinese Medicine, 2nd Edition, Eastland Press, 2019.
• Maciocia, Giovanni., Obstetrics & Gynecology in Chinese Medicine, Churchill Livingstone, 1999.
• Bensky, D. et al., Chinese Herbal Medicine - Formulas and Strategies, 2nd ed., Eastland Press: 2009.
• Bensky, D. et al., Chinese Herbal Medicine Materia Medica, 3rd ed., Eastland Press: 2004.
• Chen, J. & Chen, T., Chinese Herbal Formulas and Applications - Pharmacological Effects & Clinical Research, Art of Medicine Press, 2009.
• Chen, J. & Chen, T., Chinese Medical Herbology and Pharmacology, Art of Medicine Press: 2004.