bubble_chart Concept

Women of childbearing age, due to the degeneration of ovarian function, can no longer bear children. This transitional period from being able to bear children to being unable to do so is called "menopause." Perimenopausal syndrome refers to a series of symptoms and signs that occur during this transitional period when menstruation is about to cease but has not yet completely stopped, and kidney qi is gradually declining.

Women generally stop menstruating around the age of 49. The Neijing states: "At the age of 49, the Ren meridian becomes deficient, the Tai Chong meridian weakens, and the reproduction-stimulating essence is exhausted." During this stage, menstruation often becomes irregular, with periods that may be delayed or shortened, and the flow may vary in amount. This is a normal physiological phenomenon, and most women can adapt to these changes without experiencing other systemic symptoms. However, a small number of women may experience some symptoms during menopause, such as dysphoria, irritability, tidal fever, sweating, dizziness, blurred vision, palpitations, insomnia, dry mouth and throat, loss of appetite, feverish sensations in the palms and soles, back and waist pain, mental fatigue, emotional agitation, tinnitus, forgetfulness, or abnormal skin sensations, or slightly elevated blood pressure. This is referred to as perimenopausal syndrome. This condition can sometimes persist for several months, or even 1 to 2 years, and can have a certain impact on women's physical and mental well-being.

During the period before and after menopause, as kidney qi gradually declines, the Chong and Ren meridians become deficient, and the essence and blood are insufficient, the functions of the zang - fu organs become imbalanced. This may be due to the deficiency of kidney yin, leading to hyperactivity of liver yang, or the simultaneous deficiency of both kidney yin and kidney yang, resulting in symptoms of yin deficiency with yang hyperactivity and deficiency of both yin and yang. Clinically, it is more common to see cases where kidney yin is insufficient and liver fire is excessively active.

bubble_chart Modern Research

Menopausal Hormonal Metabolic Changes

1. Progressive disappearance of estrogen: Around the age of forty, the frequency of ovulation decreases, marking the onset of the ovarian function's depletion phase, known as menopause, which can last up to twenty years. This period is characterized by reduced fertility, cessation of menstruation, progressive tissue atrophy, and aging. The primary cause of this developmental process may be the reduced production of estrogen.

The decrease in estrogen is not linear but gradual, leading to the successive loss of related functions, including ovulation and menstruation, as well as the strength of vaginal and labial tissues, ultimately resulting in the atrophy of all dependent tissues. By the ages of forty to fifty, as the number of follicles decreases, the production of estrogen also diminishes. When the follicles are depleted, the source of estrogen becomes almost entirely indirect, derived from the conversion of ovarian stroma and adrenal precursors in non-endocrine tissues. When the gonadal source disappears, the ovaries atrophy and become fibrotic. At this stage, estrogen is maintained at a critical level, sourced from food and adrenal activity products. However, as surrounding tissues age further (60-80 years), these sources also become depleted.

2. Menopausal symptoms are the result of the interaction of the following three factors:

• Estrogen depletion.
• Physiological responses to aging.
• Psychological impacts of aging.

3. Symptoms related to menopause and estrogen disappearance:

• Menstrual disorders: Including anovulation and reduced fertility, decreased menstrual flow, hypermenorrhea, and irregular menstruation.
• Vasomotor instability (hot flashes, sweating): The cause of hot flashes is unknown, possibly due to estrogen decline leading to instability in the pituitary and autonomic nervous systems. Hot flashes are characterized by a wave-like sensation of heat rising from the chest to the head, often accompanied by profuse sweating, lasting from a few seconds to thirty minutes, or even an hour, and are particularly prone at night.
• Psychological symptoms: Including anxiety, tension, depression, dysphoria, etc.
• Atrophic degeneration: Atrophy of the vaginal epithelium and urethral caruncle, dyspareunia and pruritus (due to labial, vaginal orifice, and vaginal atrophy), general skin atrophy, urgency, cystitis, and other disorders.
• Numerous complaints: Such as headache, insomnia, myalgia, changes in libido, palpitations, etc. Lower back pain may be a symptom of osteoporosis (seen in about 25% of menopausal women).

4. Early menopause (perimenopause)

Early reduction in estrogen levels, with symptoms depending on the rate of reduction. Most middle-aged women experience a moderate rate of estrogen depletion, hence experiencing grade I cyclic hot flashes at menopause. Clearly, the factors influencing the rate of estrogen disappearance are unknown. However, the sensitivity to gonadotropins, the number of follicles, the extent of peripheral estrogen production, the amount of remaining ovarian stroma, and the patient's physical and mental health are certainly related.

If caused by surgery or radiation therapy, the sudden loss of estrogen makes symptoms more pronounced. The most severe signs, such as vasomotor hot flashes and sweating, globus hystericus, palpitations, etc., will appear.

If estrogen disappears slowly, vasomotor reactions are fewer, and prolonged abnormal uterine bleeding should be considered for possible malignant diseases, often requiring surgery for confirmation.

5. Advanced stage menopause

The impact of advanced stage menopause (very low estrogen production) depends on various factors, including the general resistance of target tissues to aging, overall health, diet quality, and activity level. Additionally, estrogen produced via peripheral non-endocrine pathways is also important.

Due to the extremely low production of estrogen, which is insufficient to maintain the basic functions of dependent tissues, it may lead to skin itching, vaginitis, dyspareunia, urinary symptoms (dysuria, urgency, incontinence, urethritis), and osteoporosis. If the function is somewhat better, it can maintain a basic state. It is not uncommon for women who have been menopausal for 10 to 15 years to still have ovarian hormone-induced cervical fluid and vaginal epithelium.

The estrogen surge caused by chronic stress is also sufficient to affect the activity of the membrane within the uterus, leading to bleeding. Clinical experience shows that advanced-stage menopausal bleeding can occur after physical and emotional stress (such as the loss of a loved one, anniversaries, or emotional upheavals).

6. Menopause and Postmenopause

The most noticeable change in menopausal women is the decrease in estrogen, especially the reduction of active estradiol (E2) in the blood to one-fifth of its previous level. At this time, the inactive estrone (E1) becomes the primary estrogen in menopausal women. The precursor of estrogen, androstenedione, decreases by half after menopause. During the reproductive period, about 60% of its secretion comes from the adrenal glands and 40% from ovarian follicles; after menopause, ovarian secretion accounts for only 15%, while adrenal secretion accounts for 95%. Androstenedione is the main product that compensates for ovarian function after menopause. It is metabolized into estrogen in the skin, and this estrogen may contain a catechol group (catechole group), which can bind to dopamine receptors and compete with dopamine, causing instability in the autonomic nervous system and leading to a series of changes. The secretion of gonadotropins increases significantly during menopause due to the lack of negative feedback regulation by estrogen, and the elevated levels of FSH and LH in the blood serve as definitive evidence of menopause.

bubble_chart Pattern Analysis

1. Liver Hyperactivity Due to Kidney Deficiency︰Menstrual cycle disorder, scanty flow, bright or dark purple color, dizziness, dizzy vision, tinnitus, difficulty sleeping, dysphoria, irritability, tidal fever, profuse sweating, flushed cheeks with a burning sensation, red tongue texture, and fine rapid pulse. As kidney qi gradually declines, which is the precursor stage described in the Neijing as "at the age of seven times seven, the Conception Vessel becomes deficient, the Thoroughfare Vessel declines, and the reproduction-stimulating essence is exhausted," the menstrual cycle begins to disorder, with scanty flow and bright or dark purple color. Kidney yin deficiency leads to the liver losing its nourishment, causing rising deficient fire, hence symptoms such as dizziness, dizzy vision, tinnitus, difficulty sleeping, dysphoria, irritability, tidal fever, profuse sweating, flushed cheeks with a burning sensation, red tongue texture, and fine rapid pulse—all manifestations of yin deficiency with effulgent fire. The treatment should focus on nourishing the kidneys and calming the liver, using the Anemarrhena and Phellodendron Rehmannia Decoction (Yizong Jinjian): Anemarrhena 3 qian, Phellodendron Bark 3 qian, Moutan Bark 2 qian, Poria 3 qian, Chinese Yam 4 qian, Cornus Fruit 3 qian, Alisma 3 qian, Unprocessed Rehmannia Root 8 qian. This formula is suitable for kidney yin deficiency, hyperactive liver yang, and insufficiency of the Thoroughfare and Conception Vessels, aiming to tonify the kidneys, calm the liver, and regulate the Thoroughfare and Conception Vessels.
2. Deficiency of Both Kidney Yin and Yang︰The manifestations of kidney yin and kidney yang deficiency are intermingled. The menstrual cycle has become irregular, accompanied by dizziness, tinnitus, soreness and weakness in the lower back, cold feet, occasional chills, sudden hot flashes, a pale tongue texture, and a deep, thin pulse. Both kidney yin and kidney yang are deficient. Yang deficiency leads to chills and cold feet, while yin deficiency causes hot flashes. Deficient yang rising results in dizziness and tinnitus. Insufficiency in the Chong and Ren meridians leads to an unstable menstrual cycle. Kidney qi deficiency causes soreness and weakness in the lower back, a pale tongue texture, and a deep, thin pulse. The treatment should focus on warming and tonifying kidney yang, nourishing the kidneys to purge fire, and regulating and replenishing the Chong and Ren meridians. The prescription is Curculigo and Epimedium Decoction: Common Curculigo Rhizome (3 qian), Epimedium Herb (3 qian), Chinese Angelica (3 qian), Morinda (3 qian), Phellodendron Bark (1.5 qian), and Anemarrhena (1.5 qian). This formula uses Common Curculigo Rhizome, Epimedium Herb, and Morinda to warm and tonify kidney yang; Phellodendron Bark and Anemarrhena to nourish the kidneys and purge fire; and Chinese Angelica to nourish blood and regulate menstruation.

bubble_chart Documentation

• 《Annotation of Furen Liangfang‧Treatise on Overdue Formulas for Women's Reproduction-Stimulating Essence》: "Scholar Xu said, if a woman's Jingmai does not stop after the due date, with pain in the waist and abdomen, or if menstruation occurs after the age of forty-nine, Angelica Powder should be used."
• Xue Ji stated: "For the aforementioned symptoms, if there is liver and kidney deficiency heat, use Angelica Powder; if there is liver blood deficiency heat, use Four Substances Decoction with Bupleurum, Gardenia, and Moutan; if there is internal movement of liver fire, use Minor Bupleurum Decoction with Gardenia and Moutan; if there is liver fire and blood dryness, use Modified Free Wanderer Powder; if there is stagnant fire in the spleen meridian, use Modified Returning to Spleen Decoction; if there is stagnant fire in the liver and spleen, use both Free Wanderer Powder and Returning to Spleen Decoction; if there is liver-kidney depletion, use both Free Wanderer Powder and Six-Ingredient Pill with Rehmannia."
• 《Golden Mirror of the Medical Tradition》: "After a woman reaches the age of forty-nine, if the reproduction-stimulating essence does not flow, and if it stops and then returns without other symptoms, it is due to excess blood and should not be stopped with medication; if it is due to blood heat, Scutellaria Heart Pill or Yiyin Decoction should be used; if there is excessive blood loss and heat follows the blood, leading to deficiency and damage of the Chong and Ren meridians and unstable blood, Ten Major Tonics Decoction or Eight Precious Ingredients Decoction should be used; if it is due to anger damaging the liver, causing the liver to not store blood, or worry damaging the spleen, causing the spleen to not control blood, Peripatetic Powder and Returning to Spleen Decoction should be used as appropriate."