January 4, 2012

A Menopausal case


When I think back of my undergraduate studies in Traditional Chinese medicine just under ten years ago, I remember a time where the possibilities of treatments were endless. I felt that when thrown into the real world of practice I would be invincible. We were taught hundreds of formulas for hundreds of conditions, and were led to believe that we would achieve excellent outcomes if we were only to memorize these specific formulas and apply them to these conditions. Once in practice we quickly learn that this is in fact not reality! One that specifically comes to mind is the treatment of menopausal conditions (更年期综合症).

In many English language textbooks (and even standard mainland texts), menopause is most commonly associated with a yīn deficiency pattern, and is treated with formulas such as Liù Wèi Dì Huáng Wán, Dāng Guī Liù Huáng Wán, etc.  However, once in clinical practice when encountering these kinds of patients, these formulas tend to exert only minimal effects. Now I’m not saying that these kinds of yīn deficiency patients do not exist, they do, albeit in much smaller numbers than we may have been taught.

In my experience practicing in the cold and wet pacific north west, the majority of menopausal woman I treat rarely suffer from a yīn deficiency pattern, but in fact manifest with various patterns, with a strong majority showing signs of yáng deficiency. Yáng deficiency? When I discuss cases with colleagues and talk about treating hot flashes, night sweats, and other menopausal complaints with high doses of herbs like Fù Zǐ or Ròu Guì, they think I’m nuts. However, the proof is in the pudding. The way I see it is that as a culture we are eating poorly, are under an enormous amount of stress, take far too many pharmaceutical drugs, get inadequate amounts of sleep, lack exercise, are far too over stimulated, and consume various vitamins, supplements, and undertake random fasts and cleanses. These are all practices that inevitably deplete our yáng reserves. The essential mechanism that I recognize in many of the woman I see, is a deficiency of yáng that is unrooted in the lower body and floats upwards causing symptoms such as insomnia, hot flashes, night sweats, etc. I feel that it is these ‘heat like’ symptoms that confuse many practitioners, who prescribe various heat clearing, yīn nourishing medicinals all to no avail.

When a patient presents with these seemingly signs of heat, how are we to distinguish between a yīn or yáng deficiency? In his well-written article in the Lantern entitled ‘Playing with Fire’, Gunter Neeb quotes Xú Dà-Chūn from his ‘On the Origins and Development of Medicine’, outlining a very basic diagnostic approach to patients with excessive sweating which can be applied to the excess sweating seen in menopausal conditions:

“Sweating due to loss of yin manifests with aversion to heat, warm hands and feet and skin that is warm to the touch and with warm sweat. The patient is thirsty for cool drinks. His breath is agitated, his pulse overflowing (hong). Sweating due to loss of yang is exactly the opposite: the patient fears cold, the extremities and skin are cool with a cold sweat. He favours bland or slightly sweet foods and is not very thirsty, but has desire for warm drinks. His breath is feeble and the pulse is rapid, superficial and empty”.

This diagnostic guideline above is essentially the same that I have been using when faced with cases of night sweating and have found the results to be extremely gratifying both for me, and my clients. When dealing with hot flashes, I simply inquire how the patient feels following the flush. If they feel very cold afterwards, and also have a lack of thirst, no major dry symptoms, and possible lumbar pain, I will diagnose the pattern as a yáng deficiency.

I would like to illustrate this further with a case from my own practice.

On June 22, 2011 a 48-year-old female presented at the clinic complaining of general menopausal symptoms. These included; irritability, low libido, night sweats, weight gain, occasional hot flashes, poor sleep, light-headedness, a history of low back pain, slight thirst, a strong aversion to cold, and some pretty intense stress recently. Her tongue was essentially unremarkable, and her pulse was deep, and slightly weak. Her bowel movements and urination were normal, and she experienced no digestive issues. Her last menstrual period was in November 2010.

When asked how she felt after either the sweating or hot flashes, she mentioned that she felt very cold, and needed to really bundle up to stay warm. In addition, she had given birth to two boys three and a half years prior, after several rounds of intensive in vitro fertilization treatments.

I saw her pattern as a yáng deficiency, with the yáng being un-rooted in the lower burner, and floating upwards. She was also manifesting very mild yīn deficiency symptoms.

She was administered a formula in granule form, at two teaspoon (6g), twice daily.

Fù Zǐ 20g
Ròu Guī 10g
Bái Sháo 10g
Hé Huān Pí 10g
Fú Xiǎo Mài 12g
Nǔ Zhēn Zǐ 12g
Hàn Lián Cǎo 12g
Mǔ Lì 12g
Lóng Gǔ 12g
Zhì Gān Cǎo 10g
Fú Shén 10g

Results: On follow up one week later, she reported that all her symptoms had improved, and she was feeling “wonderful”. She was given another two weeks of the same formula. On follow up five months later, she informed me that since taking the formula, all her symptoms disappeared, and have yet to return.

6 comments:

Sharon Weizenbaum said...

Hi Eran! Great case study and discussion. It is good to have these examples and quotes that illustrate the concept that hot flashes and night sweats can be due to Yang deficiency. I think you are becoming a fire god with that dose of Fu Zi.
Best to you!
Sharon

Z'ev Rosenberg said...

Eran,
A few years back Volker Scheid published research he had done (in the Journal of Chinese Medicine) on treatment of menopausal patients in Asian countries. It turns out that in mainland China, the TCM hospital clinics were trying to emulate the effects of hormone replacement therapy, which they saw as zhi yin/nourishing yin, so they based treatment around liu wei di huang wan. In the mainland textbooks, menopausal syndrome was a new disease pattern, and its treatment was highly influenced by biomedical ideas. My experience is the same as yours, little success with yin supplementing formulas (although I have some cases that have responded well to dang gui liu huang tang). After all, liu wei di huang wan was a pediatric formula developed by Qian Yi in the 12th century! I do much better with variations of wen jing tang, shen qi wan, zhen wu tang, si ni tang or even dang gui si ni tang! Thanks for posting this. .

Eran Even said...

Sharon- thanks. If I was a fire god, I would have used 100g of fu zi, à la fan zhong-lin :)
Hugs!!

Z'ev- I haven't seen Volker's research, but am definitely intrigued. I'll look out for it. I think anytime we try to emulate western medications/treatments we are getting further from the real deal, are diluting the practice, and inevitably our overall effectiveness decreases. It is really so rare for me to see a menopausal woman manifesting primarily yin-xu signs/symptoms, and it's usually only secondary to the main pathomechanism. Maybe this has something to do with our weather? I wonder if many woman in places like Arizona, or inland from you guys display more yin-xu signs. thoughts?

giusi said...

Hi Eran,

you can read one of Volker's papers on the topic here:

http://easts.dukejournals.org/content/2/4/485.full

Giusi

Eran Even said...

Cool, thanks for the link Giusi!!

Anonymous said...

That was a very interesting article. I am currently traversing menopause myself but more interestingly am trying to make inroads into my sons congenital health woes via TCM. My son, now almost 16, was born without a thyroid gland and is severely and multiply disabled as a result. Using standard TCM formulas does not work. Perhaps at the bottom of the confusion with Chinese medicine and western people as you rightly have said is dietary and lifestyle issues but also under par thyroid function ?

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