by Harriet Beinfield, L.Ac. and Efrem Korngold, L.Ac., OMD

Most gynecologists have a knee-jerk reaction: if it's menopause, it's time for Premarin. While this may be all right for some women some of the time, it is not for all women all of the time. Most women want to heed their doctors - some seek to be educated about alternative points of view. Although hormone supplementation may be useful and warranted, conventional pharmaceuticals (like Premarin, Provera, Estraderm, Estrace) are not the only or necessarily best choice. When combined, acupuncture, herbal formulas, and natural hormone creams can be of enormous benefit.

Western and Chinese medical paradigms are quite parallel in the way they describe the menopausal process. One speaks through the language of hormones and their interaction with the reproductive organs and the other uses the vocabulary of Essence and its relationship with the Kidney. Understanding hormone supplementation within the context of Chinese medical thinking will maximize our ability to treat menopausal women effectively. Translating from West to East, steroid hormones can be regarded as Essence (jing) tonics.

The Western Vocabulary of Hormones
Derived from the Greek word hormon, meaning to urge on, excite, or stimulate, hormones are chemical messengers disseminated via the bloodstream to regulate cell physiology. They interact with and counterbalance each other. In the follicular phase, the ovaries secrete estradiol to produce eggs. After ovulation, the space once occupied by the egg becomes the corpus luteum which produces progesterone, about 20 mg/day. During pregnancy the uterus and placenta produce up to 400 mg/day of progesterone (pro-gestation). Progesterone can be considered a precursor hormone, meaning that it occupies the headwaters from which flow a stream of steroid hormones including cortisol, androstenedione, testosterone, and the estrogens (estrone, estradiol, estriol). The ovaries, along with the thyroid and adrenals, form an integral part of the hypothalamic-pituitary axis responsible for the fundamental regulatory processes of reproduction, growth, maturation, metabolism, maintenance of temperature and pressure, red blood cell production, and adaptation to stressors like infection, trauma, and other environmental influences.

In spite of the recognized complexities of hormonal dynamics, disturbances that occur in menopausal women are simplistically attributed to the decline of ovarian function and the consequent cessation of estradiol secretion. A complex chronological, biological, and cultural event has been reduced to a single problem estrogen deficiency with an apparently uncomplicated and obvious solution estrogen replacement.

The current medical wisdom is the product of an industrially manufactured consciousness. In 1966 Searle, Upjohn, and Wyeth-Ayerst pathologized the perception of menopause, transforming it from a transitional life stage into a chronic disease process by hiring a Brooklyn physician named Robert A. Wilson to write a book called Feminine Forever, proclaiming that estrogen would protect a woman's youth and save her from living decay. The book injected fear by insisting that without estrogen replacement therapy (ERT), bones would dissolve, hearts clog, vaginas shrivel, breasts sag, skin crinkle, and minds deteriorate.

Estrogen became perceived to be the miracle antidote to loss. The marketing campaign worked. Menopause is now universally and virtually unanimously treated with estrogen. Estrogen sales jumped from $17 million in 1966 to $83 million in 1976, and in 1990 sales swelled to $460 million. This in spite of the NIH Consensus Conference on Estrogen Use and Postmenopausal Women that concluded: Given the current state of knowledge, no general recommendation, applicable to all postmenopausal women, can be made...[HRT is a] promising but unproven approach to prevention.

The Chinese Vocabulary of Essence
While Western doctors define the problems associated with menopause as stemming solely from estrogen deficiency, in Chinese medicine estrogen, along with other hormones, is subsumed within the larger category of internal secretions known as Essence (jing). Estrogen is a kind of Essence, just like carrots are a kind of vegetable; but just as all vegetables are not carrots, not all Essence is estrogen.

In John Lee, M.D.'s descriptive definition, it is striking how easily the term Essence (jing) can be substituted for steroid: Steroid [hormones] stabilize, energize, nurture our cells and tissues, ensure repair and replication of vital tissue, protect us against damage, and foster the genesis and development of a new life to carry on our species. The same functions performed by the hypothalamic-pituitary axis--the capacity to grow, mature, reproduce, maintain stability, generate blood and marrow, adapt to stress, repair body tissues are governed by the Kidney. Inherited and acquired Essence, pooled within the reservoir of the Kidney, are stored and dispensed as needed. All other organ systems live downstream from this inland sea, dependent on its supply.

When Essence is plentiful, our ability to resist disease and adapt to change is optimal. With age, fundamental resources ebb, and these capacities decline. In youth it is possible to compensate for spending more biological cash than is returned to our reserve Essence account, but as this principal diminishes over time, we become less able to push ourselves without receiving notice of insufficient funds. If throughout our lives we run the body economy at a deficit, the dearth of resources eventually catches up with us. Menopausal complaints are the outcome of deficit spending: the debt can no longer be rolled over, because there's no longer a cushion of funds from which to draw. Menopausal problems result from the diminution of Essence and a consequent deficiency of Qi and Blood.

Stored by the Kidney, Essence is the origin of all Yin (Blood and Moisture) and Yang (Qi and Warmth). Loss of libido, stamina, hearing, vision, lower back pain, sore hips or knees, apathy, despair, dull mindedness, memory problems, vaginal dryness and atrophy, thinning of bones, deterioration of teeth and gums are all symptoms of deficient Essence.

When Essence becomes depleted, so do Blood and Qi, Yin and Yang. Lack of Qi produces fatigue, weakness, dull thinking, melancholy, and decreased motivation. Deficiency of Blood leads to weak vision, dizziness, night sweats, irritability, and restless sleep. Lack of Blood deprives muscles, tendons, and ligaments of sufficient nourishment and suppleness, so they become tight and inflamed, leading to muscle cramps, joint pain, and neck tension. The organism responds to this state of scarcity with anxiety and lability, for lack of Blood disrupts the smooth flow that preserves elasticity of tissue and emotional flexibility. As Kidney Essence declines, a domino effect engenders down line deficiencies that eventually impact the Liver, Heart, Spleen, and Lung.

Hot flashes are a consequence of the inability of Yin to restrain Yang, so heat flares upward uncontrollably. Yin deficiency of the Liver and Heart can trigger hyperactivity that leads to rising Heat. But hot flashes may also be a consequence of Kidney Yang deficiency, or weakened Life Gate Fire. When Kidney Yang is weak, the Spleen becomes unable to extract the necessary nutrients to generate adequate Moisture and Blood. This results in Dryness (dry eyes, skin, hair, and vagina, brittle nails, constipation, even cystitis). This in turn undermines shen-jing, the unified relationship between Heart and Kidney, Mind and Essence. Kidney Yang deficiency engenders Spleen weakness, causing symptoms such as lethargy, weakness, easy bruising, poor concentration, fluid retention, indigestion and bloating. It also leads to a weakening of the Kidney's capacity to anchor the Qi, permitting True Yang to leave its proper place in the Lower Burner and surge upward, producing agitation, flushing and perspiration, followed by chilliness, weakness, and fatigue.

In sum, labile emotions and unpredictable surges and lapses of physical and mental energies result from the attrition of Yin and Yang Essences of the Kidney, causing the Qi of the Liver, Heart and Spleen to become erratic and insufficient. Many women have signs of both Kidney Yin and Yang depletion. But because hot flashes, sweating, agitation, and dryness (Kidney Yin Deficient symptoms) are more attention-getting, herbs that treat Kidney Yin deficiency are often overemphasized at the expense of those that restore the true Yang of the Life Gate, an equally important goal.

Diet and Menopause
Dietary changes can be profoundly helpful. Many menopausal women become lactose intolerant and eliminating milk products can dramatically reduce symptoms of indigestion like bloating and gas. In general, high carbohydrate consumption can be problematic. Carbohydrates are broken down into glucose, which triggers insulin production. Excessive carbohydrates lead to excessive levels of insulin which reduces the cell's ability to respond to hormone stimulation. While foods with a sweet flavor tonify Qi and Blood and strengthen the Spleen, excess sweetness will produce dampness and stagnation. This results in feelings of heaviness, lethargy, distension, constipation, diarrhea, muscle soreness, and puffiness. Spleen Qi stagnation leads to Liver Qi stagnation, resulting in irritability, frustration, hypersensitivity, cramps, swollen breasts, mood swings, and headaches.

By reducing carbohydrate intake, one reduces the level of circulating insulin, enabling the cells to respond normally to thyroxin, progesterone, estrogen, testosterone, cortisol, and other hormones. This disturbed carbohydrate-insulin dynamic interferes with the liver's ability to detoxify excess estrogen: women with symptoms of Liver Qi and Blood stagnation are likely to be estrogen dominant. These women will benefit by restricting carbohydrate consumption (grains, cereal, bread, potatoes, pasta, fruit or fruit juice) to one meal a day, preferably dinner. Digestive aids such as pancreatin and plant-based enzymes as well as friendly intestinal microflora (probiotics) will also help to normalize the function of the Stomach and Spleen.

The Yin and Yang of Estrogen and Progesterone
The life process demands the capacity for proliferation and restraint, growth and its regulation - both are necessary for conception, gestation, birth, and development. Ordinarily estrogen is considered to be a Yin-promoting agent because it relieves conditions of Yin deficiency (hot flashes, dryness) as well as producing conditions of Yin excess (Dampness, Blood stasis). Progesterone could easily be considered a Yang agent because of its ability to enhance fat metabolism and thyroid function, as well as improving circulation of Blood and distribution of fluids.

However, in the context of developmental cycles, estrogen acts like a Yang agent because it promotes cell division and rapid growth, whereas progesterone acts like a Yin agent because it moderates growth by promoting cell differentiation and maturation. Pregnancy requires cell proliferation, differentiation, and maturation - both Yin and Yang functions. The dynamic of estrogen and progesterone can be compared to that of the sheng (engendering) and ke (controlling) sequence. In later life we are not supposed to continue to proliferate tissue at a rapid rate, grow, and accumulate mass, but rather to mature.

Because of Western medical education and research, we are aware of the benefits of estrogen and uninformed about the value of progesterone. Whereas estrogen levels decline by 50 per cent at menopause, progesterone levels can drop nearly to zero. Even though the ovaries cease producing estradiol, estriol continues to be made by the adrenal glands and in fat cells. Canadian endocrinologist Jerilynn Prior has found that athletes with low progesterone levels but high estrogen showed signs of osteoporosis, provoking her to speculate that it is perhaps progesterone deficiency, not estrogen depletion, that is the true culprit. It is also not widely known that lifelong exposure to xenoestrogens (estrogen-like compounds found in petrochemicals) destroys follicular function, preventing the development of the corpus luteum, resulting in massive estrogen dominance and profound progesterone deficiency. Excess estrogen, whether endogenous (produced by the body) or exogenous (from outside the body), creates Qi and Blood stagnation, particularly affecting the Liver and Spleen.

Phytosterols
There is no direct evidence that plants contain compounds that are the same as estrogens. Norman Farnsworth, an internationally renowned pharmacognosist, states that because plants have been used successfully to induce ovulation and increase fertility, it's logical but not necessarily correct to infer that it must be because they contain substances that are equivalent to human and animal hormones. Yet a great variety of plant constituents are similar in their molecular structure to human steroid hormones. The implications of this are still under investigation in an attempt to explain the mechanism by which herbs affect hormones. It is speculated that herbal agents: stimulate endogenous hormone production; sensitize and/or increase hormone receptors; inhibit steroid degradation by altering the rate of catabolism in the liver (producing the net effect of more circulating hormones in the blood stream). Also, we now know that compounds such as genistein in soy and red clover occupy estrogen receptor sites, compounds in licorice can occupy receptors for cortisol, and dang gui appears to contain compounds that occupy progesterone receptors.

Herbs are complex biological substances with incompletely understood mechanisms of action, sometimes producing paradoxical, normalizing effects. Genistein simultaneously acts as a weak estrogen, anti-estrogen, angiogenesis inhibitor, and anti-oxidant. Perhaps Japanese women do not complain of hot flashes because their soy-based diet contains high levels of genestein, which buffers the loss of estrogen by binding to the same receptor sites on cells, easing the panic of the hypothalamus in response to declining estrogen. It is curious that Asian women have lower levels of estrogen and a lower incidence of estrogen-deficiency symptoms. According to Subhuti Dharmananda, Ph.D., licorice not only mimics cortisol, but also acts as a modulator of estrogen activity, inhibiting or enhancing its effects. Many herbs are adaptogenic, enhancing the body's self-regulatory capacities. They can affect not only the quantity of hormones circulating in the blood, but also the body's ability to respond to those hormones. A term for describing how estrogen receptors respond to exogenous and endogenous compounds is selective estrogen receptor modulator (SERM).

Natural Progesterone Cream
Natural progesterone differs significantly from Provera (medroxyprogesterone acetate), properly referred to as a progestin, not progesterone. What is meant by a natural hormone is a substance that precisely matches in molecular configuration what the body itself produces. Natural has less to do with where it comes from, and everything to do with its biochemical structure. The naturally occurring plant sterol diosgenin from Mexican yams can be converted through a simple laboratory process called hydrolyzation into a steroid compound molecularly identical to human progesterone. Transdermal (topically applied) natural progesterone creams, gels, and patches do not have the side effects associated with Provera and other progestins. Possible side effects of Provera include fluid retention, weight gain, depression, fatigue, nausea, acne, migraine, breast tenderness, spotting between periods. Unusual but possible side effects include: liver toxicity, thrombophlebitis, pulmonary embolism, stroke, or retinal thrombosis.

Hormones taken orally enter the bloodstream from the small intestine, and go directly to the liver. Because the liver is not accustomed to receiving large amounts of hormones, it begins to break them down, leaving only a small percentage of the ingested hormone available to cells. Transdermal delivery circumvents the digestive system--cells absorb hormones more efficiently, rapidly dispersing them into the blood via capillary beds in skin and muscle. Martha Howard, M.D. says, oral pharmaceuticals can be harmful to the liver and gall bladder. Oral administration is outmoded. Plant-derived creams fit better in the body's receptors. I prefer transdermal delivery systems - it's safer and more natural.

Progesterone has a broad spectrum of action, relieving symptoms of Qi, Blood, and Essence deficiency - normalizing estrogen levels (Yin) and thyroid function (Yang)--without causing stagnation. When progesterone supplementation is inadequate in relieving hot flashes, sweating, and vaginal dryness, herbs that tonify Yin, dispell Heat, and astringe Moisture should be used. Another option is to use a transdermal preparation marketed as a phytoestrogen cream (containing extracts of ginseng, dang gui, chaste tree berry, red clover, black cohosh, pomegranate, black walnut, borage and grape seed) that may help to relieve hot flashes and vaginal dryness.

Women concerned about or diagnosed with breast cancer wonder whether they should use natural progesterone cream. A Johns Hopkins study published in 1981 found that women with low progesterone levels had a 5.4 times greater incidence of breast cancer and a 10 times greater incidence of general malignancy. This makes sense since progesterone encourages cell differentiation and malignancy is a phenomenon in which undifferentiated cells multiply. One study showed that transdermal progesterone reduced the risk of breast cancer by decreasing the rate of division of breast epithial cells, and inhibited the estrogen-induced proliferative response in cancerous cell lines. It has also been reported that women whose breast tumor surgeries were performed in the early luteal phase (the early part of the last half of the cycle) had better outcomes. This is when progesterone is dominant, and estrogen levels are relatively lower.

If hormones and Essence are virtual synonyms, then hormones can be used in the same manner as Essence-replenishing herbs. In the spirit of integrative medicine, Chinese medicine can expand its thinking and practice to include natural hormone therapy as a complementary modality.

 

Harriet Beinfield, L.Ac., and Efrem Korngold, L.Ac., OMD are co-authors of Between Heaven and Earth: A Guide to Chinese Medicine, the Chinese Modular Solutions Handbook for Health Professionals, the pamphlet Chinese Medicine: How It Works, and many articles. For 25 years, they have been engaged in the active practice of acupuncture and Chinese herbal medicine and were among the first to become licensed by the State of California in 1976. Currently on the faculty of the American College of Traditional Chinese Medicine, they have taught and lectured at medical schools, hospitals, acupuncture colleges and conferences.