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Vol.2 Issue 1
Menopause
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We asked three clinicians with diverse approaches to patient care to discuss the
management of a patient who is experiencing symptoms associated with the
menopausal transition. The participating clinicians were:
Charles Lo, MD - Dr. Lo completed medical school and an internal medicine residency in the United States. Subsequently, he studied Traditional Chinese Medicine (TCM) in China. He has a private practice in Chicago where he specializes in TCM.
Cliff Kearns, DC - Dr. Kearns is a chiropractor with expertise in homeopathic medicine and nutraceuticals.
Shirley Moore, CNM, RN - Ms. Moore is a certified nurse midwife who integrates complementary therapies into the care of menopausal women.
CASE STUDY
JS is a 48-year old Caucasian female who presents with complaints of "hot flashes" and "irritability" of six months duration.
Past Medical History
G3, P3
LMP four months ago, menstrual cycles have been "irregular" for the past two years
Lifestyle History
Drinks ~1 glass of wine daily
Denies current or previous drug or tobacco use
Walks one mile daily
Family History
Mother: died at age 63 of breast cancer
Father: 83, alive & well
Siblings: 1 brother aged 52, alive & well
Medications
Daily calcium supplement (500 mg) with vitamin D (100 IU)
Daily multivitamin
Physical Assessment Data
Height: 61 inches
Weight: 120 lbs.
Pulse: 65
BP: 118/60
Review of systems all WNL
Moderator: Dr. Lo, as a practitioner of Traditional Chinese Medicine, how would you manage this patient's symptoms?
Dr. Lo: The patient is a 48 year old female who complains of hot flashes and irritability for 6 months. Her LMP was 4 months ago and her menstrual cycle has been irregular for 2 years. From a Traditional Chinese Medicine (TCM) viewpoint, the patient has imbalances of the Kidney and Liver.
To understand the TCM interpretation of menopause, one must consult The Yellow Emperor's Classic of Internal Medicine which was written around 250 B.C. Chapter One, titled "The Universal Truth," states: "In general, the reproductive physiology of woman is such that at seven
years of age her kidney becomes full, her permanent teeth come in, and her hair grows long. At fourteen years, the tian kui, or fertility essence, matures, the ren/conception and chong/vital channels responsible for conception open, menstruation begins, and conception is possible. At twenty one years, the kidney energy is strong and healthy, the wisdom teeth appear, and the body is vital and flourishing. At twenty eight 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 thirty five years, the yangming stomach and large intestine channels that govern the major facial muscles begin to deplete, the muscles atrophy, facial wrinkles appear, and the hair begins to thin. At forty two, all three yang channels, taiyang, shaoyang, and yangming, are exhausted, the entire face is wrinkled, and the hair begins to turn gray. At forty nine years, the ren and chong are completely empty, and the tian kui has dried up. Hence, the flow of menses ceases and the woman is no longer able to conceive."
Based on this medical model, a normal woman's menstrual cycle ceases at age 49 when the tian kui, or heavenly water, dries up and the chong channel, or sea of blood, is empty. The Kidney is the principle source of blood production, along with the Spleen and Heart. The other TCM Kidney functions include hot and cold regulation, water metabolism, bone and calcium metabolism, fertility, sexuality, and control of head hair and teeth. The Kidney is the main organ that becomes deficient at the menopausal transition, and the manifestations are hot flashes, night sweats, coldness, osteoporosis, low libido, head hair graying and loss, dryness, lower back and leg pain, and bladder dysfunction.
The irritability and irregular cycles are symptoms of Liver imbalance or stagnation of Qi. The TCM Liver regulates the menstrual cycle because it stores the menstrual blood and controls the timing of the release of the blood. When Liver Blood is deficient, the mood becomes irritable, thus PMS symptoms of depression, breast tenderness, bloating, irritable bowel, migraine headaches, and cramping are manifestations of Liver Qi stagnation.
From a TCM perspective, my recommendations would include:
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Dietary modifications, including the elimination of alcohol, coffee, and refined sugars, all of which intensify irritability and hot flashes. She should eat more cooked green vegetables, less meat, and more fish. Also, she should drink green tea for its cooling effects.
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The use of herbal medications. Traditional formulas for Liver Qi stagnation with Heat would be Jia Wei Xiao Yao Wan (modified Bupleurum and Peony formula). This formula would decrease her irritability and make her cycles more regular, as well as cool her. Another useful formula for hot flashes would be Zhi Bai Di Huang Wan (Rehmannia Six formula with Anemarrhena and Phellodendron).
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I would also encourage lifestyle changes. She should begin weight-bearing exercises, such as walking or aerobics. She should also begin Tai Qi or yoga.
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Acupuncture therapy would also be useful including needling of Acupoints: Pericardium 6, Spleen 4 and 6, Kidney 6, Lung 7, Liver 3, Large intestine 4.
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Spiritual balancing is also an important aspect that should be addressed.
Dr. Kearns: Our patient has entered menopause. There are insufficient data here to determine a specific homeopathic remedy for this case however, there is still plenty to offer her.
First, for the hot flashes and irritability I would begin a trial of black cohosh extract standardized to 2.5% triterpene glycosides (0.5 mg) 1 tablet b.i.d. Black cohosh brings relief from menopausal symptoms including hot flashes, night sweats, and mood swings. It has been clinically studied for more than 40 years for its ability to reduce menopausal discomfort in women. I would also begin soy supplementation either by soymilk (fortified with calcium) 1-2 cups per day or soy bean extract standardized to contain 15% isoflavones 1-3 100mg tablets per day.
JS is taking calcium 500mg/day but she is probably unaware that upon starting menopause, her calcium requirement has jumped to 1500mg/day. She should keep track of her calcium consumption through food and adjust her supplementation accordingly. I would also suspect that JS is lacking in magnesium, a mineral that aids in energy production, nerve and muscle functions, and calcium assimilation. Magnesium is harder to get from foods than calcium and should be taken in a 2:1 ratio (Ca:Mg) prior to menopause and a 3:1 ratio (Ca:Mg) after the onset. According to recent USDA surveys, the average intake of magnesium by women 19 to 50 years of age was about 74 percent of the RDA. About 50 percent of women had intakes below 70 percent of their RDA.
Ms. Moore: JS is presenting with classic symptoms of menopause, though menopause may not be the only cause of these symptoms. For example, mood and temperature changes may be related to thyroid disease, which is not uncommon in women around the menopause. Additional laboratory work-up is necessary. I would obtain an FSH, TSH, and/or salivary hormone panel. Once it has been established that these symptoms are not occurring from some other pathology, one can assume that JS is either menopausal or perimenopausal. If we define menopause as no menses for one full year and an FSH above 30, then we can't be certain at this time that she's menopausal, so we need to address her contraceptive needs along with her need for symptom relief.
Given her family history of breast cancer, JS may be unwilling to use hormone replacement therapy for her symptoms. If she had any desire to use a hormone, I would try an over-the-counter 2% progesterone cream, 1/4 to 1/2 tsp 3 weeks per month.
I agree with Dr. Kearns' recommendations, and would offer a few additional lifestyle recommendations to help decrease her symptoms, improve her heart, breast, bone, mental and colon health.
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I recommend a diet that is high in fiber, low in fat, using complex carbohydrates, and many fresh fruits and vegetables. Protein is important but should include a variety of vegetable, as well as animal, proteins. Fish should be encouraged at least once a week. The association between certain foods and "hot flashes" should be examined. Caffeine, spicy foods, chocolate, and alcohol are known to increase hot flashes and these should be avoided. Excessive intake of phosphorous, caffeine, alcohol, and protein can cause calcium loss from bone and should be avoided.
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A complex multivitamin should be taken daily. I prefer one that is a powdered capsule or liquid as these are more readily absorbed and less is excreted. Vitamin B5 can help to decrease hot flashes. I agree with Dr. Kearns that her calcium intake needs to increase to 1500 mg daily with 400 IU of vitamin D, and needs to be balanced with her magnesium intake. I usually recommend supplementation of both.
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Some dietary supplements may be helpful with hot flashes. A daily intake of 25 gms of soy may help with hot flashes. I would discuss with JS sources of soy such as soy milk, dried soy nuts, edamame, soy bars, tofu, tempeh and ways to include these in her diet. Some soy supplements have also been helpful to relieve hot flashes. Two examples of these are Phytosoya® by Archopharma and Total Woman® by Ortho.
Another dietary supplement that I strongly encourage and find helpful for hot flashes and irritability is milled flax seed. It is best to get whole golden flax seeds and mill them in a coffee grinder fresh daily. The recommended supplement is 2 to 4 tablespoons daily taken with at least 8 oz. of water. I find this not only helps hot flashes and irritability, but it is also helpful to the bone, lowers cholesterol, improves joint pain, and is a fiber source that promotes colon health. Flax seed is an excellent source of omega 3 fatty acids and lignans which have selective estrogen properties.
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I agree with Dr. Kearns regarding the benefits of black cohosh. Black cohosh has been used in Germany as a first line therapy for hot flashes during menopause. It is believed to bind to estrogen receptors. Black cohosh should be taken at 40 mg twice daily. When using herbs it is important to take them in divided doses and to start with the lowest dose and increase gradually. It's also best to use a German-imported herb or herb that's labeled "guaranteed potency" as the herbal market in the US is not controlled as our pharmaceutical market is. A commercially-prepared product called Remifemin® has been shown to be effective for 60% of women. However, it's important to understand that just because herbs are natural does not mean that they are universally safe. For example, women who take hormone replacement therapy, oral contraceptives, sedatives, blood pressure medication, tamoxifen, or have a history of breast cancer should not use black cohosh. Herbs are best used in an intermittent fashion. Some studies have shown that the therapeutic effects of black cohosh are limited to 6 months. If after six months hot flashes return, I would recommend stopping for a month and using alternatives such as vitamin B5 and/or soy isoflavones and then resume black cohosh in one month.
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Exercise is an important component of good health after menopause. Much research supports the importance of exercise in maintaining good mood and avoiding depression. In addition to walking one mile daily, I would recommend that JS do weight resistance 2-3 times per week, and some form of stretching and relaxation exercise such as yoga, pilates, or Tai Chi.
Remember that when using alternative therapies a minimum of three months therapy should be used before complete relief should be expected.
Dr. Lo: I agree that black cohosh may relieve hot flashes and I support the use of supplemental soy and magnesium. Unfortunately, these measures only treat the presenting symptoms and do not really address the underlying root problems of the Kidney and Liver Deficiencies. I agree with Ms. Moore's comprehensive and holistic approach to the patient's problems. The multivitamin suggestion is good, although I would remind practitioners to recommend a non-iron-containing multivitamin to postmenopausal women or to adult men. Iron overload is not uncommon and can damage the heart, liver, pancreas and other organs. The flax seed supplementation is also excellent. The exercise recommendations are crucial for prevention of osteoporosis/osteopenia in postmenopausal women. In fact, supplements are probably overemphasized compared to regular weight-bearing exercise. Tai Qi has been shown in clinical trials performed by the NIH to improve balance and to reduce the number of significant falls in elderly patients. Yoga is an excellent alternative or addition to a comprehensive plan. Exercise is also crucial for emotional stress management, prevention of insomnia, prevention of obesity and type II diabetes mellitus, and reducing the risk of Alzheimer's disease, besides addressing the bone density issue.
Most practitioners who "treat" postmenopausal women are quick to prescribe HRT, Fosamax®, and other drugs and supplements, but ignore the truly important lifestyle management issues that are crucial to a woman's future health: diet, exercise, stress management, spiritual
balance.
REFERENCES
NEIJING SUWEN ( The Yellow Emperor's Classic of Internal Medicine), Chapter 1.
Bensky and Barolet, Chinese Herbal Formulas: Formulas and Strategies, Eastland Press, 1990.
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