Menopause: natural process or disease?

Menopause: natural process or disease? What the classics say You will search the classics in vain for terms like 1 climacteric (geng nian qi phase of old age) or menopause (jue jing qi cessation of menstrual period). By Dagmar Hemm THE Zhong Yi Fu Ke Xue Jiang Yi (1964) contains for the first time a complete chapter dedicated to menopause. 2 Up until then any symptoms older females suffered were included in the relevant chapters of medical books: hot flushes were discussed under yin deficiency, depression under Liver qi stagnation without any regard for age or gender. No chapter dealt with specific problems afflicting older women. If they were discussed at all, they may appear in the gynaecology chapter under a section on amenorrhea (jing bi ) or miscellaneous diseases (za zheng ) with titles such as the following: Lao nian jing duan fu xing (menstrual bleeding returning in old age) Lao nian xing yin dao yan (vaginal inflammation at old age) Lao nian nu yin gan se (vaginal dryness in older women) Lao nian xue beng (hemorrhage in old age) Lao nian pi fu sao yang zheng (itchy skin diseases in old age) Jue jing huo gu zhi shu song zheng (reduced bone density after menopause, i.e. osteoporosis) Bai he bing Zang zao (lily disease) and (dry organ disease, hysteria). The inclusion of menopause/climacteric in textbooks after 1964 was taken directly from Western medicine. The Western medical definition of menopause as a decrease in oestrogen and progesterone was translated into the TCM terminology shen xu (Kidney deficiency). 3 At this point we should note that the Traditional Chinese Medicine to which we reverently attribute a 2000-year history is a construction of the Chinese Republic with the consequence that it has lost most of its true traditional values. In the middle of the 20 th century Chinese medicine was cleansed of its feudalistic, shamanistic and religious elements. What remained were zang-fu syndromes, often based on Western disease categories, including the category of the climacteric, for which, as we will see below, we can find no reference in the classical texts, because it did not have any clinical relevance. Menopause in the classics Huang Di Nei Jing The first mention of menopause, the end of the female reproductive life, can be found in the first chapter of the Huang Di Nei Jing Su Wen: Su Wen, chapter 1: Huang Di asked, When one grows old, one cannot bear children. Is this due to heredity or to the loss of one s procreative energy? Qi Bo answered, In general, the reproductive physiology of woman is such that at seven years of age her Kidney energy becomes full, 14

Part 1 her permanent teeth come in, and her hair grows long. At 14 years the Tian Kui, or fertility essence, matures, the Ren and Chong channels responsible for conception open, menstruation begins, and conception is possible. At 21 years the Kidney energy is strong and healthy, the wisdom teeth appear, and the body is vital and flourishing. At 28 years the bones and tendons are well developed and the hair and secondary sex characteristics are complete. This is the height of female development. At 35 years the Yang Ming/Stomach and Large Intestine channels that govern the major facial muscles begin to deplete, the muscles begin to atrophy, facial wrinkles appear, and the hair begins to thin. At 42 all three yang channels Tai Yang, Shao Yang, and Yang Ming are exhausted, the entire face is wrinkled, and the hair begins to turn grey. At 49 years the Ren and Chong channels are completely empty, and the Tian Kui has dried up. Hence, the flow of the menses ceases and the woman is no longer able to conceive. 4 This quote describes the seven-year cycle of women, with the cessation of the fertile age at 7x7 years, 5 when menstruation stops due to empty Ren Mai and a weakening Chong Mai that is all. Associated problems are not necessarily seen in this context, but rather as diseases that can occur any time. Interestingly, there is also no mention of Kidney deficiency, which modern TCM regards as the root of menopausal problems. Instead, Kidney energy is associated with teeth, the change from milk teeth to second teeth at seven years of age, and then the development of wisdom teeth at the age of 21. Apart from that, hair growth is linked with the Kidneys (at seven years), and bone development (at 21 years, when the woman is fully developed). But in terms of menopause as discussed in this place, the Kidneys do not play any specific role. Jin Gui Yao Lue Fang Lun by Zhang Zhong-Jing The term zang zao dry zang is especially interesting: it is often translated as hysteria or internal turmoil/palpitations of the Heart. This term is first used by Zhang Zhong-Jing (c.150-219 AD) in his Jin Gui Yao Lue Fang Lun. In his Shang Han Lun (On Cold Disorders) he refers to the earlier text Tai Lu Yao Lü (Treatise on Herbs for Obstetrics). Unfortunately, this text has been lost, but it shows that specific treatises on gynaecology existed before the Han dynasty. The Jin Gui Yao Lue Fang Lun (Prescriptions from the Golden Chamber) 6 still exists, containing three chapters (chapter 20-22) on gynaecological problems: Gynopathy during pregnancy, Postpartum diseases and Miscellaneous female diseases. In the last chapter we can find for the first time (based on our current state of knowledge) 7 written testament to menopausal disorders: Clause 22-6: The patient suffers hysteria and tends to weep constantly as if she were haunted. She frequently stretches and yawns repeatedly. Decoction Radix Glycyrrhizae, Fructus Tritici and Fructus Ziziphi Jujubae (Gan Mai Da Zao Tang) can be adopted to calm the patient. Stew the drugs in six sheng 8 of water until three sheng remain. Serve the lukewarm decoction in three doses. This decoction is also a tonic for the Spleen. Explanation: This formula is effective in treating syndromes of zang zao (hysteria), which results from emotional depression and excessive worry. Symptoms and signs may include restlessness and irritability, insomnia and constipation. To strengthen the action of the prescription, the following can be added: Dang Gui (Angelicae Sinensis Radix), Bai Shao (Paeoniae Alba Radix), Fu Ling (Poria), Suan Zao Ren (Ziziphi Semen), Bai Zi Ren (Biotae Semen), Long Chi (Dens Draconis), Mu Li (Concha Ostreae) etc. 9 The use of the term zang zao (dry zang) leaves no doubt that this prescription is designed for the menopausal woman the woman does not menstruate anymore, her uterus is dry, she cannot bear any more children. Zang zao/hysteria could be included in the modern day category of depression: The patient tends to weep constantly as if she were haunted. The term haunted is an insinuation of malicious ghosts or souls of deceased, implying the influence of the hereafter on the wellbeing of the living. But the symptoms are not associated with any particular age. This means that younger women could also suffer from dry zang, and this sadness and apathy may not be associated only with the climacteric. The following case 22-9 refers to a 50-year -old woman, definitely beyond the reproductive age, which has ended with 7x7 years: Question: A 50-year-old woman patient suffers vaginal bleeding for several dozen days. She also has tidal fever in the evening, with contractions and distention in the abdomen, restlessness, heat on palms and parched mouth and lips. Can master explain this? Master: This is a gynaecological disease. The patient once had a miscarriage with blood stasis remaining in the abdomen. How is this diagnosed? A parched mouth and lips are the relevant symptoms. Wen Jing Tang can be given as a treatment. n Dagmar Hemm studied sinology, ethnology and economics in Munich, Taibei and Beijing, completing a PhD in 1995. She has been practising Chinese medicine and naturopathy since 1999, and travels yearly to China for further study. She is the author of several Chinese medical and philosophical publications The Lantern 15

Generally speaking, if the menstruation is disrupted or irregular, the main concern is this: is the woman pregnant or has she reached the end of her reproductive age? Wen Jing Tang (Warm the Channels Decoction) Wu Zhu Yu (Evodiae Fructus) 3 liang Dang Gui (Angelicae Sinensis Radix) 2 liang Chuan Xiong (Ligustici Chuanxiong Rhizoma) 2 liang Bai Shao (Paeoniae Radix) 2 liang Ren Shen (Ginseng Radix) 2 liang Gui Zhi (Cinnamomi Ramulus) 2 liang E Jiao (Asini Corii Colla) 2 liang Mu Dan Pi (Moutan Cortex) 2 liang Sheng Jiang (Zingiberis Recens Rhizoma) 2 liang Gan Cao (Glycyrrhizae Radix) 2 liang Ban Xia (Pinelliae Rhizoma) 0.5 sheng Mai Men Dong (Ophiopogonis Radix) 1 sheng Stew the drugs in one dou of water until three sheng remain. Serve the decoction lukewarm in three doses. This prescription is also effective in syndromes of coldness in the abdomen and chronic infertility. It is also effective for sudden profuse uterine bleeding and menstrual disorders such as menorrhagia and late menstruation. Explanation: This is a case caused by the prevalence of cold and deficiency over the Chong and Ren channels as well as blood stasis. Removal of the stasis is not sufficient for treating the disease. Although such symptoms and signs as restlessness, heat in the palms, parched mouth and dry lips are observed, diagnosis of the tongue and pulse finds no heat syndrome. Thus therapy of warming the channels should be adopted. ( Wen Jing Tang means literally a decoction that can warm the channels). Blood stasis will be removed when the channels are warmed. Wu Zhu Yu (Evodiae Fructus), Sheng Jiang (Zingiberis Recens Rhizoma) and Gui Zhi (Cinnamomi Ramulus) warm the channels and the blood and disperse the cold. E Jiao (Asini Corii Colla), Dang Gui (Radix Angelicae Sinensis), Chuan Xiong (Chuanxiong Rhizoma), Bai Shao (Paeoniae Radix) and Mu Dan Pi (Moutan Cortex) nourish the blood, harmonise the nutrient essence and remove the stasis. Mai Men Dong (Ophiopogonis Radix) and Ban Xia (Pinelliae Rhizoma) moisten the dryness and reverse the adversity. Gan Cao (Glycyrrhizae Radix) and Ren Shen (Radix Ginseng) tonify the interior vital energy. When the above ingredients are used in combination, they can warm and tonify the Chong and Ren channels, disperse the pathogenic factors and reinforce body resistance. It is also effective in treating the syndrome of coldness in the abdomen, infertility and menstrual disorders. 10 These are the only two cases that relate to older women. Clause 22-4 initially looks like a case of hot flushes, but there is the following commentary by Wu Qian 11 : Greater Yang syndrome with delirium and bleeding indicates that pathogenic heat has invaded the blood chamber. When sweat appears on the head only, puncture Qi Men (LV-14) to release the excess. Following this, heavy perspiration will lead to recovery. (Wu Qian has a further comment on this): Female patients will experience the syndrome of heat invading the blood chamber during menstruation. Male patients also experience the syndrome of heat invading the blood chamber, which is manifested by delirium and gastrointestinal bleeding. 12 Pulse Classic (Mai Jing ) The Pulse Classic (Mai Jing) written in the third century by Wang Shu-He is the oldest text on pulse diagnosis. It often refers to older texts, but also offers progress in the area of gynaecology. For example, it describes that if pregnancy is present, which pulses are physiological or pathological during pregnancy, when labour will start and how to determine the gender of the unborn child. Volume nine contains patterns of women s diseases and their differentiation by means of pulse diagnosis. There are also a few cases of older women with irregular menstruation: The master explained: There is a woman aged 60 or so who often menstruates. Suppose she is taken with an enduring disease of diarrhea. If there is lower abdominal tightness and fullness, she is difficult to treat. 13 [The Yellow Emperor] asked: There is a woman aged 50 or so who complains of a tormenting pain in the back all the time, abdominal pain from time to time, low food intake, constantly feeling fed up, and frequent abdominal distention. Her pulse is faint in the yang (i.e. the cun position) and small and tight in the guan and chi positions. There is thus incongruity between the form and the pulse. I would like to hear what you would say about this. The master answered: It is necessary [first] to inquire about what the sick person feels about food and drink. If the sick person says, I have no desire for food and drink and have a foul smell of grain qi, the disease lies in the upper burner. If the sick person says, I have more or less a desire for food and drink, but it is also all right if I do not eat then the disease lies in the middle burner. If the sick person says, I have normal food intake as before, then the disease lies in the lower burner. The (last) disease belongs to the category of dai xia (below the belt) and should be treated as such. 14 16

(The Yellow Emperor) asked: Suppose a woman of 50 years or so suffers from the disease of diarrhea [hemafecia is suspected instead] which has persisted for tens of days without a break. She has fever in the evening, lower abdominal urgency and pain, abdominal fullness, heat in the palms, and a dry mouth and lips. Then what kind of disease is this? The master answered: This disease falls within the category of dai xia (i.e. gynecological disease). What is its cause? There has been miscarriage and [consequently] blood stasis is lingering in the lower abdomen. Then what is the indication (of this stasis)? The sign of dry mouth and lips is its revelation. [To treat this case] it is necessary to administer Wen Jing Tang (Warm the Channels Decoction). 15 [The Yellow Emperor] asked: Suppose a woman aged 50 years or so one day suddenly begins to pass blood and [the uterine bleeding] runs for two or three days on end. Then how can one treat her? The master answered: This woman is infertile and has had no menstruation [for a certain period of time]. Now blood is contrarily cleared. This is respited menses. It does not need treatment. It will come to a stop of itself. If she usually had a menstrual period of five days, then she will recover in five days. 16 Once a woman came for examination. Her pulse was faint and choppy. By reason, she should have been suffering from vomiting or diarrhea. However, she said not. Subsequently, [I] asked the lady her age. The lady was seven times seven (or, in other words) 49. [By this age] the menses should have stopped but they continued up to then. It was this that accounted for her vacuity. 17 For visceral agitation in women characterised by susceptibility to sorrow, desire to cry, acting as if possessed by a spirit or ghost, and frequent yawning, Gan Cao Xiao Mai Tang (Licorice & Wheat Decoction) is the ruling formula. 18 These cases are similar to those from the Jin Gui Yao Lue described above. Generally speaking, if the menstruation is disrupted or irregular, the main concern is this: is the woman pregnant or has she reached the end of her reproductive age? Delayed menopause Unless there are other complaints, delayed menopause is usually not treated. However, if bleeding occurs significantly after the onset of menopause, this should be investigated: At the age of 49 the heavenly water has dried up, if it continues to flow this is not a disease but an excess of blood. But if [the menstruation] has already stopped and then starts again, one should look for the causes and treat the disease factors accordingly. 19 The Golden Mirror of Medicine Yi Zong Jin Jian lists the following conditions and their appropriate formulas: I. Menstruation that recurs after menopause can be due to excessive blood heat. [If it is] swallow Qin Xin Wan (Scutellaria and Vinegar Pill) with warm wine, and use Yi Yin Jian (Supplement Yin Decoction). Qin Xin Wan (Scutellaria Heartwood and Vinegar Pill) Huang Qin Xin 60g (Scutellariae Radix heartwood) Soak in vinegar for one week, roast dry; repeat seven times. Finally powder then make small pills from the powder. Take 70 pills with warm wine on an empty stomach, morning and night. Yi Yin Jian (Supplement Yin Decoction) Zhi Mu (Anemarrhenae Rhizoma) Huang Bai (Phellodendri Cortex) Gui Ban (Testudinis Plastrum) Sheng Di (Rehmanniae Radix) Shou Di (Rehmanniae Radix Preparata) Sha Ren (Amomi Fructus) Gan Cao (Glycyrrhizae Radix) Da Zao (Jujubae Fructus) Sheng Jiang (Zingiberis Rhizoma Recens) II. If there is profuse bleeding which drains out the heat, [this can result in] damage to the Chong and Ren Mai. Give Shi Quan Da Bu Wan (All-Inclusive Great Tonifying Pill) and Ba Zhen Wan (Eight Treasure Pill). III. If sudden violent anger, anxiety or excessive thinking has injured Liver and Spleen [and thus affected their functioning in relation to controlling the blood], consider Xiao Yao San (Rambling Powder) and Gui Pi Tang (Restore the Spleen Decoction). 20 For many centuries the medical literature concerning infertility and gynaecology considered medical, religious and supernatural influences as disease causes. But this started to change in the Song dynasty (12 th century) and had changed completely by the time of the Ming dynasty (14 th century): the texts took on a moralising tone, disease was often considered as punishment for immoral behaviour. Sometimes the medical part of the text was even overshadowed by a larger, moral and philosophical component. Here is an example from the Principles on Increasing One s Descendants Guang Si Ji Yao, written by Wan Quan in 1572, in which he considers the wrong moral behaviour of the woman as the cause for a self-inflicted disease: The gentleman asked: How can you regulate menstruation, if one time it comes early and another time it comes late? I answered: This is a disease of the mind and thought, which can hardly be treated with standard methods. The gentleman asked: Why? I said: If you give a lot of caresses but the love is not reciprocated, if the desire is strong but happiness does not arrive, this is so because the mind and the thoughts cannot expand. [The] woman serves [you] with her body, but she is proud by nature. She uses her beguiling charm to please [you], but in her heart she is obstinate. This is therefore difficult to treat with medicines. 21 The position of women had worsened substantially around this time. While women enjoyed a certain degree of emancipation and freedom during the Tang dynasty, these vanished quickly during the 11 th and 12 th century with the rise of Neo-Confucianism. Women s activities were reduced to the household and to bear and educate children. They were physically restricted by their bound feet, and morally pushed by the strict Confucian behavioural codes into the role of the virtuous house wife. Disease or childlessness were often considered punishment for the woman s indecent behaviour. This did not only include pre-marital or extra- marital intercourse or remarriage of a widow, but simply being touched by an unrelated man. Even a doctor could not feel the pulse of a genteel woman as this meant the loss of honour for her. In general doctors often lament that women are much harder to treat than men, and not only for anatomical reasons. Here, for an example, is the complaint of Kou Zong-Shi, the author of the Ben Cao Yan Yi (Extension of the Materia Medica, 1116): The Lantern 17

When one cannot perform three of the four examinations (inspection, smelling-listening, inquiry, and palpation), even a superb doctor cannot fully utilise his skill. This has been the problem from ancient times until now. This explains why they say that treating women is not easy. Is it not true? Kou Zong-Shi said that he would rather treat 10 men than one woman, meaning that women s disorders are usually not easy to treat. Because women are sequestered they are melancholic, anxious, indignant, suspicious, and confused about their preferences. They do not get what they want, and they are stubborn and obstinate. Even during consultation, physicians are not allowed to observe a woman's physical appearance, inspect her complexion, listen to her voice, or inquire of her illness. In an affluent family, a woman stays behind a curtain in her private room and covers her hands with a handkerchief. Not only is inspecting the complexion impossible, but a thorough pulse examination technique is also impossible. If a doctor must ask about the details of the illness, the patient will feel the questions are overly complicated, suspect him of not being an expert in medicine, and then will not trust him enough to take the prescribed medicine. People do not understand that inquiry is not an easy matter. A doctor who is not expert in medicine cannot conduct the inquiry properly. When one cannot perform three of the four examinations (inspection, smelling-listening, inquiry, and palpation), even a superb doctor cannot fully utilise his skill. This has been the problem from ancient times until now. This explains why they say that treating women is not easy. Is it not true? 22 References Luo, Xi-Wen (Übersetzer) (1987). Synopsis of Prescriptions of the Golden Chamber (Jin Gui Yao Lue Fang Lun). Beijing: New World Press. Ni, Maoshing (1995). The Yellow Emperor s Classic of Medicine. A New Translation of the Neijing Suwen with Commentary. Boston and London: Shambala. Scheid, Volker (2006). Not Very Traditional, Not Exactly Chinese, So What Kind of Medicine is It? TCM s Discourse on Menopause and its Implications for Practice, Teaching, and Research. Journal of Chinese Medicine 82: pp. 5-20. Shen Yu (Transl.) (2005). A Heart Approach to Gynecology: Essential in Verse, Taos: Paradigm. Volkmar, Barbara (2007). Die Fallgeschichten des Arztes Wan Quan. Medizinisches Denken und Handeln in der Ming-Zeit. München: Elsevier. Yang, Shou-Zhong (Übersetzer) (1997). The Pulse Classic. A Translation of the Mai Jing by Wang Shu- He. Boulder: Blue Poppy Press. n Translation by Bettina Brill n The second part of this article will appear in The Lantern, Vol 5.1 Endnotes 1. In the West menopause also did not appear as a condition until the end of the 19 th century. The term climacteric (the German klimakterium) was created to define the period of menopause. The German term turned into the Japanese term konenki, which in turn arrived in China as geng nian qi (Scheid, 2006, p. 9) 2. It is interesting to note that the first edition of 1960 did not yet contain any chapter on menopause; this was added in the second edition in 1964 (Scheid 8). Zhong Yi Fu Ke Xue Jiang Yi,1964. 3. The idea to equal Western hormones with the Chinese understanding of Kidney function originated from the Shanghai physician Chen Zi-Yin (1928 -). He demonstrated that patients with Kidney yang deficiency had low urine concentrations of 17-Hydroxycorticosteroid. He concluded that there was a relationship between Kidney yang deficiency and the adrenal gland, in other words the hormones. Thus the connection between hormones and (Chinese) Kidney function was established. This perception has lasted until this day, even though 40 years of research have not been able to support this theory. (See Scheid 8) 4. Ni (1995): p. 2 5. The translation of seven sui with seven years is not quite correct. According to Chinese counting a newborn is already one year old. Independent of an individual birthdate everyone turns one year older at Chinese New Year. A newborn can thus turn two shortly after birth, if it falls close to the Chinese New Year. Puberty starts for girls at 14 sui, corresponding to the Western age of 12 14 years. 6. The first 10 of a total of 16 volumes (fascicles) of Zhang Zhong-Jing were published by Wang Shu-He, ordered by the Imperial medical academy during the Jin dynasty (265-420) as Shang Han Lun. The remaining six volumes were not published until the Song dynasty during the reign of emperor Ren Zhong (1023-1063) as Jin Gui Yao Lue Fang Lun. (Luo, 1987 ) 7. Based on the enormous amount of medical treasures that were unearthed in 1976 from the Mawangdui graves, we can only hope that we might find more medical literature in the many unopened graves still remaining. 8. During the Han dynasty: 1 liang = 3 g 1 liang = 4 fen, 1 fen = 0.75 g 1 jin = 16 liang, 48 g 1 sheng = 18-30 g, 60-80 ml 1 dou = 10 sheng, 600-800 ml (cf.luo (1987): p. 24, 27, 41) 9. Luo (1987): p. 309 10. Luo (1987): p. 313 11. Wu Qian is the author of the Golden Mirror of Medicine Yi Zong Jin Jian. 12. Luo (1987): p. 308 13. Yang (1997): p. 330 14. Yang (1997): p. 336 15. Yang(1997): p. 338 16. Yang(1997): p. 340 17. Yang(1997): p. 343 18. Yang (1997): p. 344 19. From the Yi Zong Jin Jian (The Golden Mirror of Medicine). Cf. Shen Yu (2005): p.38 20. Shen Yu (2005): p. 45 21. Volkmar (2007): p. 380 22. Shen Yu (2005): p.49 18