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Does the Standard TCM Diagnosis for Menopause Accord With That of the University of Westminster Polyclinic

Introduction Eighty per cent of women in the UK experience menopausal symptoms and 45% find the symptoms distressing[1]. Because of the potential seri-ous adverse effects of the long-term use of hormone replacement ther-apy (HRT) its use has declined dramatically, and more women are in-creasingly turning to complementary and alternative medicines (CAM)[2]. Traditional Chinese medicine (TCM) is just one alternative with its claim to have successfully treated menopause for over 2000 years. However, good quality TCM clinical trials to validate its efficacy are sparse, and the collective unwillingness among practitioners and researchers to critically examine the myth of tradition that underpins TCM and CAM invalidates much of the research that is currently carried out to evaluate the TCM treatment of menopausal syndrome[3].Until the 1960s menopausal problems did not constitute part of classi-cal Chinese medical literature and treatment. It is identified simply as an event in the life passage, similar in character if not in timing for males and females alike. Just as females cease to menstruate, males’ ‘semen be-comes scanty’, and these changes are not seen as a ‘pathology’ but ‘part and parcel of the ungendered feebleness of old age’ and as the natural phase of a woman’s and man’s life[4].

Menopausal experience has been shown to vary significantly with culture and location. Vasomotor symptoms (hot flushes) is emblematic of meno-pause in the West whereas women in East Asian cultures and India, for example, report muscle and joint pains as well as depressed mood as the most common complaint. In these cultures the majority do not consider menopause a problem requiring medical intervention, and as a result, there has been a relatively low uptake of HRT[3,5].

Aims, Objectives and RationaleThis research aims to define and compare the standard TCM diagnosis (TCM pattern classification) of menopause with that of the University of Westminster Polyclinic and to evaluate the herbal formulae that are pre-scribed accordingly. This is conducted with reference to the historical and political context of the development of TCM treatment strategies for menopausal syndrome in Maoist Communist China of the early 1960s, with the goal to systematize Chinese medicine[6].

The specific objectives will be to examine:

• TCM textbook diagnosis (Table 1) and treatment of menopausal syn-drome in China and the West• University of Westminster Polyclinic patient case studies and the ap-proach to the treatment of menopause• Plurality of approaches to the treatment of menopause within the Chinese medical tradition

MethodologyTo achieve this we looked at patient files of 63 females that visited West-minster Polyclinic in the year 2012 from January until end of November; 41 years being the youngest woman and 78 years being the oldest. We were looking for patients that showed menopausal symptoms (some but not all were listed in the Kupperman Index), or were diagnosed with as-sociated patterns or syndromes.

These included hot flushes, menstrual irregularity, night sweats and mood swings (including irritability). We did not limit our analysis to only women with hot flushes because of the small sample size and in order to establish whether all women going through the menopause experience hot flushes, and patients were eligible for inclusion even if their main presenting condition was not discomfort due to menopause. However, hot flushes is read as “empty heat” and is a key sign supporting the Kid-ney deficiency model in TCM[8] and therefore important for this analy-sis. This search produced 18 patients that had pre-, peri-, and postmeno-pausal status. After an initial amount of 3 articles that were provided by Alan Treharne (clinical supervisor at WP) an online search was conducted that was looking for articles and literature using following key words: menopause, menopause syndrome, CHM, TCM. This search was conducted to compare our findings and articles and was performed with Medline, Elsevier and Amed. After manually screening the findings, 18 articles seemed relevant to this subject; of which 2 had already been part of the initial ones.

Limitations and factor analysisThe small sample size limited the conducted research and its validity, be-cause the amount of different formulas almost met the total amount of pa-tients. Because some patients might have presented for non-menopause conditions, it made the data inaccessible for quantitative analysis, as the recorded symptoms were too heterogeneous. A factor analysis was con-ducted using SPSS 21 (IBM corporation 2012) that didn’t produce valid outcomes within factors that were used in a similar but bigger study in the UK by Volker Scheid[8]. This was due, first, to the small sample size, and secondly, to the big variety of symptoms within the patient group. This caused the Measure of Sampling Adequacy (MSA) to be < .50 and thus inapplicable for a factor analysis[9].

Irregular periods, hot flushes, red face, sweating, burning heat, agitated or disordered moods, abnormal sensation in the skinCore Pattern Symptoms of PatternLiver and Kidney yin deficiency

Shorter cycle, profuse bleeding of red blood, or inces-sant spotting; hot flushes, sweating, heat in the palms and soles, dry mouth, difficult bowel movements, ach-ing and weakness of back and knees, dizziness, tinni-tus, red tongue with little coating, thin and rapid pulse

Kidney yangdeficiency

Longer cycle, or increased volume of bleeding, amen-orrhea, tiredness, cold extremities, pale complexion, vertigo, aching and weakness of back, increased uri-nation, pale tongue with thin coating, deep, thin and forceless pulse

Table 1: TCM patterns related with menopause[3,8]

“A second important factor are essential differences in how TCM and Kampo practitioners match formulas to presenting complaints. In TCM treatment protocols are formulated on the basis of theories that physicians hold regarding the pathophysi-ology of a given condition. Kampo physicians,on the other hand, utilize a phenomenological approach that directly matches a pa-tient’s symptoms and signs to the manifestation patterns defined for specific herbal formulas. A Kampo physician thus would simply determine a womanas exhibiting a ‘‘Cinnamon Twig and Poria Pill manifestation pattern’’ (Guizhifuling tang zheng ) with the diagnosis specifying thetreatment[3].”

Figure 1: Pattern differentiation in a different light

Karen Ingman & Johannes Nigsch

ResultsOf the 18 patients selected 16 had been treated with Chinese herbal med-icine and two with acupuncture. Eleven had been diagnosed with Liver and/or Kidney yin deficiency; of which three were also diagnosed with Kidney yang deficiency. Ten showed the most typical symptom of hot flushes. The formulas used and the corresponding diagnoses can be seen in Table 2. It is noticeable that at Westminster Polyclinic a huge variety of formulas were used, although 61% of the patients (11) showed Liver and/or Kidney yin deficiency within their diagnosis. This indicates that Westminster Polyclinic often uses pattern differentiation and not solely syndrome differentiationdifferentiation (Figure 1).Some of the formulas prescribed were Tao Hong Si Wu Tang, Zhi Bai di Huang Tang, Erxian-Tang, Qing Ying Tang, Xiao Xian Xiong Tang and Shen Ling Bai Zhu Tang (See Table 3 for all formulas).

Critical DiscussionThe invention and recent addition of menopausal syndrome as a medical problem requiring intervention was politically motivated by the Maoist state to prove TCM’s validity in treating biomedical diseases. In fact, the modern construction of “menopause” that is found in TCM, is a product of nineteenth century bioscience that was transported to Asia[4].Chinese medicine physicians were recruited to write TCM medical textbooks with lightening speed, that included a provisional medical gynaecology text-book in 1960, and which was rewritten four years later as a 2nd edition by the Chengdu School, to include another 10 diseases including menopaus-al syndrome. As a result of misinterpretation and deletion of the classical literature, many Western and Chinese TCM textbooks offer a simplified emphasis on Kidney deficiency as the root cause with secondary condi-tions (see Table 1).Gynecological conditions are first mentioned in the Qing dynasty and related to the Chong and Ren mai due to their connec-tion to the uterus. Their regulation,together with the Yang brightness, which are both associated with the Stomach and Spleen, are emphasized in clinical practice by other Chinese medicine practitioners, during this

phase of decline of the Kidney qi around 49 years, rather than the Kid-neys, which are more related to the menarche[3].In the Westminster Polyclinic study only three formulas were used more than once, i.e. twice, namely Zhi Bai di Huang Tang, Tao Hong Si Wu Tang and Er Xian Tang (in one case with modifications, in one case additional to another formula, see Table 2). Also patients with a similar diagnosis were given different formulas, which shows an approach that views these patients in their entirety. For example, one patient that had been pre-scribed with Xue Fu Zhu Yu Tang showed a similar diagnosis to another patient that was given Tao Hong Si Wu Tang, both for blood stasis, heat in the Chong mai and blood xu. Another patient in our group on the other

Formulas prescribed at Westminster Polyclinic

Diagnosis in our cases

Zhi Bai di Huang Tang Kid yin xu, xue xu, Kid yang xu, empty heatZhi Bai di Huang San + modified Er Xian San

Kid yin xu, xue xu, Kid yang xu, yang rising

Qi Ju di Huang Tang Yin xu, Ht qi xuTao Hong Si Wu Tang Xuexu, blood stasis, Lu&St yin xu, Sp qi xu,

Liv qi stagBu Fei Tang Lu, Kid, Spxu, xue xuShao Yao Tang + Shen Ling Bai Zhu Tang

Liv/Sp disharmony, damp-heat in LJ, Sp qi xu

Jin Gui Shen Qi Tang Kid&Sp qi xu, Kid yin&yang xuLiu Wei di Huang Tang Liv&Kid yin xu, phlegm in MJ, Liv yang ris-

ingTian Wan Bu Xin Dan + Chai Hu

Liv qi stag, Kid yin xu

Er Xian Tang + dang shen, Huang Lian, He Huan Pi

Liv&Kid yin xu, Liv yang rising, damp heat in MJ

Xue Fu Zhu Yu Tang Blood stasis, heat in the Chong, xue xuXiao Xian Xiong Tang Phlegm, damp-heat in MJ, qi&xue xuGui Pi Tang Sp qi xu, Livxuexu, kid yin xuQing Ying Tang Heat in the blood, Lu yin xu, damp-heat in StDang Gui di Huang Yin Damp-heat, Liv qi stag, yin&xuexuTao Hong Si Wu Tang Liv& Kid yin def, Livxuexu, St heat

Table 2

TCM Textbooks WestminsterPolyclinic

Reviewed Literature:

The Zhejiang College of TCM[12], Flaws[13]

Kampo[3] S. Korea[10] Taiwan[11] London[3] Maciocia[14] Bensky[15]

Zhi Bai Di Huang Tang

Kidney yin xu, xu heatTao Hong

Si Wu Tang

Blood xu+stag

Ban Xia Hou Po Tang

qi stag+phlegm

Ban Xia Hou Po Tang qi stag+phlegm

Dan Zhi Xiao Yao San

Qi stag, heat+xu

Chai Hu Jia Long Gu Mu Li Tan

Qidef, qi+bl stag, +phlegm damp-nessFactor 1

Zuo Gui Yin

Kid yin defXue Fu Zhu Yu Tang Xue stag, Liv qi stag

Tian Wang Bu Xin Dan

Heart blood xuKid+Liv yin xu

Zhi Bai Di Huang Tang

Kidney yin xu, xu heat/DH LJ

Jia Wei Xiao Yao San

Liver blood xu, qi stag, heat

Jia Wei Xiao Yao San

Liver blood xu,qi stag, heat

Zhi Bai Di Huang Wan

Kidney yin xu, xu heat/DH LJ

Bu Zhong Yi Qi Tang

Kid yang xu with floating fireFactor 2

Er Xian Tang + Er Zhi Wan

Kid yin+yan gxu

Xiao Yao San

Xiao Yao San pat-tern, Liv qi stag

Er Xian Tang

Kid yin& yang defEr Xian Tang + Additions

yin+yang xu with xu heat

Nu Shen San

Qi stagnation Nu Shen SanQi stagnation

Qi Ju di Huang Wan

Liv+Kid yin xu affect eyes

Jia Wei Xiao Yao San

Liv qi stag trans-forming into fireFactor 3

You Gui Wan +Li Zhong Wan Kid yang def

Er Xian Tang

Kid yin&yang def

ZuoGui Wan

Kid&Liv yin defLiu Wei Di Huang Tang

Kidney/Liver yin xu

GuiZhi Fu Ling Wan

Blood stag. with damp cold

GuiZhi Fu Ling Wan

Blood stag. with damp cold

Gan Mai Da Zao Tang

Heart blood xu. Liver qi stagnation

Liu Wei di Huang Wan

Blood +/or yin def with yang or qi deficiencyFactor 4

Kun Bao Tang Kid&Liv yin xu+Liv yang rising

Chai Hu Jia Long Gu Mu Ling Tang, stag of the 3 yang stages

You Gui Wan

Kid yang defQing Ying Tang

Heat in ying level +blood

Chai Hu jia Long Gu Mu Li Tang

Disorder of 3 yang warps

Si Wu Tang + Addi-tions

Blood xu

Tian Wang Bu Xin Dan

Heart blood xu, Kid+Liv yin xu

Gui Zhi Fu Ling Wan

Xu cold with blood stag.Factor 5

Yue Ju Wan accumu-lation of phlegm and stagnation of qi

Tian Wan Bu Xin Tang

Yin def, xue xu, Heart qi xu

YueJu Wan

Phlegm+qi stagnationShen Ling Bai Zhu Tang

Spleen qi xu with damp

Dang Gui Shao Yao San

blood+qi xu with dampness

Qing XinLianZiYin Heart fire excess, qi xu

Liu Wei di Huang Tang

Kid+Liv yin xu

Jin Gui Shen Qi Tang

Yang xu with floating heat

Tian Wang Bu Xin Tang

Kid +ht not harmonized

Wen Jing Tang

Cold in the uterus, xue xu, xue stagna-tion

Table 3: Popular formulas prescribed for Menopause (from TCM Textbooks, Westminster Polyclinic and reviewed Literature)

hand, was administered Tao Hong Si Wu Tang for a different diagnosis including Liver & Kidney yin xu, Liver xue xu and Stomach heat which is not specifically a yin tonifying formula, and the patient’s primary pre-senting condition was hot flushes and restless legs. This choice by the (student) practitioner resembles a point of view that is different from the TCM textbook opinion. The most common formula prescribed (41.7 %) in Taiwan’s 2002 nationwide database for menopause is Dan Zhi Shao Yao San[10], which is the same formula as Jia Wei Xiao Yao San, with the

addition of Bo He and Wei Jiang, and which is a very popular formula used in the Kampo[3], S. Korea[3], Taiwan[11] studies, and Scheid[8] suggests it for a deficiency pattern with qi and blood stagnation turning into heat with factor 2 (See Table 3), which we found prescribed for only one patient in our study. Zhi Bai Di Huang Tang(with Dan Zhi Shao Yao San) is the sec-ond most used formula (11.6%) in Taiwan’s 2002 nationwide prescrip-tion database[10] and Scheid[8] proposes it in his London clinical trial for

Women’s Seven Year Life Cycle“Yellow Emperor’s Canon of Internal Medicine”

Menopause (gengnian qi) is recognized as a natural physiological cy-cle or change, a process that naturally occurs in the lives of all women. This transition occurs in the life cycle of both men and women.

The spirit of the ChineseTiangui (reproductive capacities) called atten-tion to the Heavenly North, the source of the Water of creation in Chi-nese cosmography. These generative waters of the body were conven-tionally believed to be exhausted in women at age 49 (7 times 7) and in men at age 64 (8 times 8).

(Gustav Klimt, The 3 ages of a woman; Vienna, 1905)

7 year old – a young girl’s Kidney energy is growing strong and she is developing14 year old – menstruation starts - menarche21 year old – fertility energy is full28 year old – fertility energy reaches the peak, the best time to have children35 year old – fertility peak condition declines gradually – yangming meridian declines42 year old – physical energy and fertility energy declines and difficult to conceive49 year old – Ren and Chong merdians vital energy declines, menstruation dries up, conception no longer possible

factor 5 (See Table 3) but it is notused in the Kampo nor in the S.Korea studies. Three of our patients had extreme hot flushes (one patient had more than 20 a day) in combination with other symptoms such as cold sweats, night sweats and sweating on the chest, which indicate that this group can be compared with Scheid’s factor 5, where he proposed Zhi Bai di Huang Tang, which was also used in our two cases. This formula is for Kidney and Liver yin xu with empty heat, and inter-estingly, this is also the standard TCM diagnosis and matching formula. This formula shares most herbs with another standard TCM formula for Kidney yin xu, Liu Wei di Huang Tang, but with the addition of Zhi Mu and Huang Bai, two herbs to clear damp heat in the lower jiao, which was also prescribed at Westminster Polyclinic. Two other patients with hot flushes, persistent cough, headaches and joint pains would have met Scheid’s factor 1, (See Table 3), but were giv-en different formulas than those proposed by Scheid, namely Qing Ying Tang and Bu Fei Tang. Scheid[8] mentions Gui Zhi Fu Ling Tang and Wu Ling Tang as possible formulas. These two formulas are from two differ-ent categories (one dispels blood stasis and the other leaches dampness). This again shows that the approach of pattern differentiation gives the practitioner the possibility to treat the individual rather than the disease and is much more complex than in TCM. All the reviewed studies and the Polyclinic study reveal that menopause is caused by both excess and deficiency patterns ranging from qi, blood and yin deficiency, to phlegm, damp, blood stagnation and excess heat.

ConclusionThe University of Westminster Polyclinic does not diagnose menopause simply as Kidney deficiency, although Kidney and Liver yin deficiency are often part of the diagnosis. The Polyclinic’s approach is more in depth and uses pattern differentiation that is specific to the presenting signs and symptoms of each patient and matches them to a variety of different formulas rather than simply matching menopausal syndrome to formu-las. The study highlights tensions between the tendency to simplify and standardize (thereby disregarding locality and culture), which is typical of the TCM depiction of menopause, and the wider Chinese medical lit-erature and actual clinical practice, including the Westminster Polyclinic, that uses a range of patterns which include Chong and Ren mai dishar-mony, Stomach and Spleen deficiency and Heart/Spleen deficiency, with related formulas.

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