Interview: Comparison of 3 Cases of Menopausal Problems

Introduction

An Interview with Jeremy Ross by Bob Quinn & Doug Ly

On September 19th, 1999 Jeremy Ross met in Seattle with Bob Quinn and Doug Ly, two of the students from his course Combining Western Herbs and Chinese Medicine. The topic was menopause and the approach was to discuss three cases that illustrate the wide range of possible presentations.

The importance of tailor-made prescriptions

JR: Before I go into the cases I'd like to make a brief comment about products on the market aimed at addressing menopausal complaints. If you are lucky, you can get favorable results for a time with a ready-made pill. The problem is that you can have many different kinds of menopausal syndromes. If you don't make a tailor-made herbal combination for the client, you aren't going to be able to address their unique and changing presentation.

You may have somebody whose main problem is heat, with hot flashes, or you may have somebody whose main problem is cold. You also might have, and we're going to discuss this possibility in one of the cases today, patients who can easily swing between hot and cold.

So, if you just have a mass-market formula to address heat you can get problems. The patient might start off hot and then go into too much cold because your formula was too cold, or vice versa; if you then try and warm them, you might make them too hot. So they're swinging like a pendulum backwards and forwards as you give them the herbs that are too extreme. So you really do have to be careful and evaluate each case separately and also be prepared to be flexible and adapt your strategy to meet the changing needs of the patient.

BQ: That's a good point to make here at the outset: every woman experiences menopause differently.

A checklist for menopausal problems

JR: It's almost like you need a mental checklist in menopause, and this is equally true with other conditions, before we could mix a formula. You need to mentally go through your checklist. Do we have a hot situation here that we need to cool? Do we have a cold situation that we need to warm? Have we got one that easily oscillates from hot to cold, so that we need to stabilize the middle, if you like, to create fewer oscillations?

Then you're going to ask yourself if you're dealing with somebody who's anxious, depressed, or has very weak energy so that they're frequently getting colds. Do they have poor circulation? Do they have edema? Do they have rheumatic or other aches and pains, which can be common with menopause? Are they exhausted so that they need tonifying?

DL: So this mental checklist idea is your way of deciding which herbs will go into the formula. It tells you what you have to address with the herbs.

JR: Yes, with this sort of approach, you're less likely to make mistakes and make a patient worse. So, the first thing is this concept of a checklist for a particular disease, which you can then adapt to a particular person. You're looking for herbs that treat a specific syndrome or specific symptom. You've got to treat both the effect and the causes of the effect. For example, it might be the case that a hormonal imbalance is the cause, and the end results of that are the hot flashes and the sweats.

First Case

BQ: Let's start with the first case.

JR: Sallie, our first patient, was perhaps the most classic menopausal situation. She was having severe hot flashes and night sweats, and this is what most people think menopause is all about. This was complicated by the fact that she had considerable muscle pain. Also, it bears mentioning that the hot flashes were linked to some degree with stress, and she had anxiety as well. So you see, even in this supposed classic case there are complicating factors.

Sallie's combination

The herbs were prescribed as 5 ml of 1:5 tincture 3 times per day in a little water.

In Western herbal medicine, herbs that regulate the female reproductive system are called emmenagogues, or in Chinese medicine you might call them herbs that regulate the Uterus. In this combination for Sallie, the herbs work in different pairs and trios. Leonurus (motherwort), Cimicifuga (black cohosh), and Salvia officinalis (sage) can act as emmenagogues; Anemone (pulsatilla) combined with Salvia can treat hot flashes and regulate the sweating; and Leonurus paired with Anemone is a specific pair to stabilize mood changes and to calm anxiety in menopause.

The Cimicifuga will also combine with the Salvia to treat Sallie's rheumatic pains.

DL: What were you thinking of with the Schisandra and Angelica sinensis?

JR: The Schisandra is in there in combination with the Crataegus and Leonurus to calm the Heart. The Angelica sinensis is partly in there because it regulates the Uterus and menstruation and is generally helpful in menopause, but also because this patient is Deficient, easily tired, and in Chinese medicine terms, has Deficient Blood. Angelica sinensis is a good herb for tonifying the Blood. So, as a general principle you can say that you're picking herbs not just because of one function, but they need to have two or even three functions that fit the patient.

DL: Could I back us up a bit and ask you to briefly run through those herbs that you consider generally useful for menopause?

JR: Yes, the herbs generally used for menopause in this formula are Leonurus, Cimicifuga, Anemone and Salvia. Leonurus not only regulates menstruation, but it also is calming to the Heart and a good heart tonic, and it's specific for the anxiety and palpitations which many women have in menopause. It's interesting that quite a few menopausal women, and I think all three women we will be discussing, have Deficient Heart energy in Chinese terms. Either they have palpitations or they have poor circulation or something of this nature.

BQ: Talk about the Anemone a bit if you would. It's not that commonly prescribed by herbalists in this country.

JR: Sure. Anemone is used specifically for hot flashes due to tension. You wouldn't use it for a menopausal person with depression. There would be a good chance of making them worse. It specifically is for feelings of fearfulness, jumpiness or pressurized stress, even to the point of desperation. In Chinese terms, I would call it Kidney fear invading or affecting the Heart.

DL: Salvia is often prescribed to stop sweating, and you mentioned it helps with the rheumatic pains. Does it have other functions you're interested in here?

JR: Salvia is a generally useful herb for menopause because it regulates menstruation, and it can tonify the blood. It is, as you said, especially important for regulating sweating. In hot infusion it can make you sweat, but if taken cold it can regulate excessive sweating. Now if that sweating is due to stress, then the combination with Salvia would be Anemone, which would cut the stress down. If in that situation the sweating is also due to Deficiency, then Salvia is going to combine with Schisandra, which is an herb that will help to stop sweating, but especially in cases when there is Deficiency of Kidney and Heart. The Schisandra does more to stabilize the Heart Qi than to tonify it.

BQ: Of course you have Crataegus there as well.

JR: Yes, Crataegus is there to stabilize the Heart. I've found that Crataegus, which is normally used for heart pain or high blood pressure, is an extremely useful herb in menopause when the patient swings from hot to cold, or has fluctuations of energy. When that is the case the patient is basically Deficient, and Crataegus seems to stabilize the Heart Qi and by doing so, helps to buffer some of these swings of mood or swings of temperature. Qi is the thing that helps you adapt, and helps keep you stable, so that you can resist external changes of temperature more easily. When your Qi drops, you can more easily feel upset by cold or heat, and interestingly Crataegus, by helping the Heart, seems to help this.

DL: Do you use Crataegus in other diseases where there are significant Deficiencies?

JR: Yes, I do. I use it often in chronic fatigue and fibromyalgia cases where, again, there's considerable weakness, but the people are emotionally labile. It can be very helpful in these situations.

Second Case

BQ: Shall we move on to the second case?

JR: Sure. Tammy is an interesting case because she had at the time of the intake very severe bleeding with the menopausal situation. She had reported definite hormone imbalances, and in addition, she was very Deficient, especially of Heart energy, in that she could have mood swings, and she could feel cold. Sometimes she did have hot flashes, but the main thing was the Deficiency. She had palpitations, her general energy was down, and the Heart pulse was quite weak.

The principle of treatment is first to reduce the bleeding, then to regulate the hormone balance, and treat the Deficiency. Tammy was given 3 separate prescriptions, one for each of the principles of treatment.

Stop bleeding combination

The herbs were prescribed as 5 ml of 1:5 tincture 3 times per day in a little water.

Hormonal regulation prescription

Tammy was advised to take 2.5 ml (half a teaspoon) of 1:5 tincture of Vitex agnus-castus (Chaste tree berries) every morning in a little water, at least for the next two months. Vitex was given as a separate herb, since it specifically regulates hormone balance in menopause, as it does in menstruation.

Constitutional combination

This combination was only to be taken once the bleeding was reduced, and was to treat the underlying Deficiency.

The herbs were prescribed as 5 ml of 1:5 tincture 3 times per day in a little water.

DL: This case is really quite different from Sallie then.

JR: Right, very different. Which just illustrates the initial point I was making: There is no one picture for menopause; each woman has her own experience and unique symptom picture. With the constitutional combination for Tammy we had to do something to stabilize the Heart and to give energy. There was also a bit of a tendency to experience some depression and digestive problems.

The main formula contained Crataegus (hawthorn), Convallaria (lily of the valley), and Sarothamnus (broom tops): a combination that can strengthen and stabilize the heart. Convallaria can stabilize heart arrhythmias and irregular heartbeats, amd Sarothamnus can tonify Heart Qi, but is contra-indicated in high blood pressure. Schisandra was also given to stabilize the Heart, and Schisandra and Panax ginseng combine to firm and tonify Kidney Qi. Schisandra and Salvia combine to regulate any perspiration.

So this formula is quite different from the one for Sallie. Since heat is not a major problem, we can use the rosemary, which is a warm herb.

BQ: I have a question about the formula to stop the bleeding if you don't mind going back. The Quercus and Capsella are herbs commonly used to stop bleeding, but the periwinkle is something that it would be helpful if you talk a bit about.

JR: Sure. The other herb very similar in its effects to Vinca is Trillium (beth root). The only problem is that Trillium is an endangered species, and therefore I don't recommend it anymore and we use Vinca instead. Both these herbs have the specific function of not only stopping or reducing bleeding in menopause or in menstruation, but regulating, in Chinese terms, the Uterus as well. You can use Vinca for dysmenorrhea or irregular menstruation as well; it's not just a "stop bleeding" herb, like Quercus and Capsella. Vinca is also specific for menorrhagia, and it combines well with Vitex; they are both regulatory.

DL: So the Quercus and Capsella you use just to stop the bleeding, and you're not looking for any other function from them. Is that right?

JR: Right. Quercus and Capsella are herbs for any kind of bleeding or diarrhea; they are general astringents.

BQ: What do you see in Chinese terms as the reason she is bleeding so heavily?

JR: The Qi's not strong enough to hold in the blood. You might use Astragalus to address that if she weren't so dry.

DL: In my TCM education we were taught that menopause was most typically a problem of Yin Deficiency, particularly Kidney Yin Deficiency. With these two cases we're seeing a lot more things like Heart Deficiency. Can you just speak a bit about menopause in terms of general Chinese principles?

JR: Basically in menopause, from the Chinese medicine point of view, you've got either an Excess condition or a Deficiency condition. A pure Excess condition is relatively rare, but you can get it. It's almost like the caricature of a menopausal person: they're rushing around with a bright red face, completely hot, dripping with sweat, can't sleep at night, maybe anxious, but definately hyperactive, and maybe with mood swings. That's the picture people think of first. And that could be based on deficiency of Yin.

Some of the Japanese schools say that wherever you think you've got an Excess, there's always an underlying Deficiency, which I think is very wise. People don't tend to think about this, but in fact the majority of people with menopausal problems either have overt or under-the-surface Deficiency that can be quite strong. They can have Deficient Blood so severe that their tongues are really pale, their lips are pale, they feel emotionally fragile, they've got floaters, they've got scanty menstruation, blurred vision, poor memory, and can't concentrate.

Or on the other hand they can actually have Deficient Yang. They can be so Deficient that most of the time they're exhausted, depressed, cold, they've got arthritis worse with cold and damp, they've got watery edema, their skin's quite pale, and so on. Now that's the other extreme from the hot and fiery one, and it isn't so common.

Another classic one is the alternation between what you call Deficient Yin and Deficient Yang. Under some circumstances, like a cold climate, a damp climate, not enough food or, just simple exhaustion, they might show more Deficient Yang symptoms, like the depression and the feeling cold, no energy, that sort of thing. If, however, they go to a hotter climate, it may swing the other way, and they then become more Yin Deficient. They get more night sweats and hot flashes. They still feel tired, but now they're more restless with insomnia, whereas before they were apathetic, dull, depressed and so on. And that's a big category, the people who swing from one to the other.

BQ: Now I think you said your general strategy with those women who swing from one extreme to the other was to treat the middle, to solidify there. Can you talk a bit in Chinese terms about what is typically going on there?

JR: What's very often the problem is that the Kidney is Deficient and the Heart is Deficient, which leads these two rather labile organ systems to wide swings of hot to cold and excitement to depression. That's why it's important if you are treating menopause, to not necessarily cool heat or warm the cold, but treat the middle, strengthen the middle of the road, emphasize the Ômiddle way' and avoid extremes. I already mentioned herbs that strengthen the heart's ability to adapt, like Crataegus, and herbs like Angelica sinensis, which tonifies the Blood and therefore gives a kind of buffering.

The Chinese herb Pseudostellaria is also very good because it tonifies the Qi of the Spleen and Stomach, providing the grounding, stabilizing energy of the Earth element, which helps to stabilize the Heart. This helps to keep energy and behavior in the middle of the range, and reduces extremes.

BQ: I'm glad we touched on all that because as Doug said the first thing we were taught to look for in menopause was Kidney Yin Deficiency. It was really emphasized. Now, I don't hear you saying that doesn't play a role, but this notion of creating stability by treating the "middle" is really a great idea.

JR: Yes, it's a fascinating topic. The one thing I would say is that with menopausal situations, look at tonifying the Spleen and by strengthening the Spleen, create the stability and solidity of the Earth element. These people are going through a major life change, and a major change in self-image; it may be a loss of self-respect, they may have feelings of low self-esteem; they're bodies are changing, they're aging. So if you tonify the Spleen, this is going to help. That's why nutrition is so important because you have to help them nourish themselves. I know it seems a simple thing, but if they learn to nourish themselves, it's like caring for themselves, and it helps their self-esteem. It can be a vicious circle: The more your self esteem goes down, the less likely you are to look after yourself and eat well.

BQ: Well, Fire is the mother of Earth, which brings us back to the Heart, and I have a question there. You've already mentioned a few things about Leonurus, Convallaria, Schisandra and Crataegus. Could you discuss rosemary in connection with the Heart?

JR: The use of rosemary is very important in treating depression. It's a warm and expansive herb. Culpepper said, "It eases the melancholy vapors of the heart." The camphor, the borneol, and some of the other volatile oils are slightly excitatory to the central nervous system and to the circulatory system. These aromatic oils can make the patient less depressed initially, but then they may become more anxious and then they may have more hot sweats.

So rosemary very often has to be used in small amounts. If it is not enough, then increase it; if it is too much, reduce it. You may come to a point in the treatment where the rosemary has done its job. The person is less depressed, but now their hot flashes come back. So you would have to take the rosemary out. You do have to be careful with some of these herbs.

Third Case

BQ: Should we look at the third case?

JR: Right. The third patient's name is Christine. Although Christine occasionally at that time had some sweats, she was predominately Deficient and Cold: she was having repeated influenzas and colds, very poor circulation and felt cold much of the time. It was a major problem. She did also have, in Chinese terms, Deficient Blood, with floaters, dizziness, scanty and delayed menstruation and poor concentration. Finally, she also had some side pain near the gallbladder area, and she did have poor digestion whereby, for whatever reason, probably sort of a mixture of deficiency and stagnation, she would feel sort of heavy in the middle of her stomach after eating. So, as usual we've got a complex case.

I think it is very useful to look at Christine as a prime example of somebody who, because they are so Deficient, can, in different situations, swing from cold to hot. We have to follow these extremes by modifying the combination. So first of all, the initial combination was given when she was feeling quite cold.

Christine's initial combination

The herbs were prescribed as 5 ml of 1:5 tincture 3 times per day in a little water, and 5-20 drops of Capsicum (Cayenne pepper) 1:5 tincture were to be added to each dose of the main herb combination.

BQ: I think Christine couldn't even take a shower without considerable discomfort because of the chill she experienced drying off.

JR: That shows the severity of her cold. Although we have an occasional hot flash situation here, it's not a major one like Sallie, and cold predominates. This is a case where the vital fire and the energy in general is low. We have to raise energy, but specifically we need to warm.

BQ: I think she took it for a month with very good results. She was much warmer, and she also got her menses. At the time of this first formula she had not had a period in quite some time. Taking this formula regulated her cycle again. Could you just sort of think out loud for us to help us see what you were thinking here, because this formula is much more warming than I would have had the nerve to give someone with sweats?

JR: Okay, so I think the first thing is that what we have here is a cold person in need of warming herbs. We try not to go over the top, but in this case, the warm herbs, especially the threesome of Zanthoxylum (prickly ash bark), Cinnamomum (cinnamon bark) and Capsicum, are very important. These are herbs to warm, not only the Interior of the body, which is more the cinnamon and the Capsicum, but especially to take it out to the periphery, which is the prickly ash bark. Not only that but we need to take the warmth into the flesh and muscles; that is the job of the Angelica archangelica. Angelica is an warm, anti-rheumatic and a circulatory stimulant. Rosmarinus (rosemary) was put in to raise the energy and to warm Heart and Spleen. In combination with the Angelica, the rosemary will help to warm the digestion as well as warming the circulation.

The other thing that the rosemary does in this formula, because it is not only aromatic, it's also quite bitter, is to move stagnant energy in the Liver, Gallbladder, Spleen and Stomach, and to stimulate and tonify the digestion. Artemisia (mugwort) is another bitter and aromatic herb for the Liver and Spleen, which can regulate menstruation and also stimulate digestion. This was another part of the success of the formula that her digestion definitely improved, and she didn't have so much of a stuffed sensation in the middle of her abdomen after eating. Also, she didn't have any more colds.

DL: Is there something in the formula that specifically treats the surface of the body, and bolsters the Wei Qi to account for the fewer colds?

JR: That's probably due to the mixture of the warming herbs, also the Angelica and Zanthoxylum specifically bringing energy out to the periphery to protect the surface of the body. This is also partly why she feels warmer.

DL: I have a general question about all three of these cases. We are talking about the fact that situations change quite a bit. All three patients tend to be Deficient and so therefore, they tend to go off in many different directions. That kind of made me wonder about sweet tonics and the Spleen connection. I was wondering when it would be appropriate to give these women sweet tonics because most of these herbs here are pretty bitter. Are you trying to treat the immediate symptoms first, and then you would add the sweet tonics later?

JR: Absolutely. I think this is an excellent question because in the case of Sallie, the Angelica sinensis was the sweet herb in there as that sort of nourishment for the Spleen, Heart, Blood and Qi and so on, to stabilize the center. But, I think that once you could get her symptoms under control, then would be the time to put in, in her case, probably Ophiopogon. This would then help the Schisandra and Salvia deal with the sweats. Ophiopogon would be a sweet, stabilizing tonic for the Heart, and it would add to the Angelica sinensis to give you probably as much sweet as youÔd want in that particular combination.

The reason I didn't put it in in the beginning was because she does have muscle pain. I was worried about too much Damp going into the situation in the early stages. If we can get the muscle pain down, then I would be very happy to add another sweet herb. Tammy is another person who actually does have a problem with digestion. She tends to have a very easy tendency to heaviness in the body after eating, and her Spleen pulse is usually always in Excess even though the rest of her pulses are normally Deficient. It's flooding, it's slippery, and she does tend, like many in Northwest America, to too much Damp. That's why we've got less sweet herbs in her constitutional combination. But you could add Angelica sinensis later, to help to tonify the Blood.

BQ: Although the formula you wrote for her did have some Blood tonifying action.

JR: Yes. We had Rosmarinus and Salvia officinalis, a pair of aromatic, bitter herbs that can tonify and move the Blood. Rosmarinus and Salvia can be used to tonify Blood for example, in cases of graying hair and hair loss. They do it partly by calming the Spleen and all the worry that makes you lose hair, and partly because of their bitter effects to stimulate the digestion. Culpepper would say that these two herbs stimulate the spleen and the liver to breed blood.

Changing a combination to meet changing needs

JR: Now Christine went on a trip to a different climate, and stopped the herbs, and some of her problems reestablished themselves. Is that correct?

BQ: In fairness to you, the formula worked wonderfully for a month. What else can you expect? People, especially in menopause, are changing, and the formula needed to be adjusted and she was out of your treatment at that point.

JR: Yes, she was far away. I think the other thing to mention, which is very interesting, is why it's so important not just to give an unvarying formula, even if you make a combination especially for a patient, you must be prepared to vary it with the changing environmental requirements. She went away, I think it was to Arizona, where the weather outside was extremely hot and dry. She had gone from Seattle, where the weather is not known for it's blazing heat. She was traveling, I understand, for about one week in a car where the other person in the car had the air conditioning on. So she was alternating, backwards and forwards, from a very hot and dry, to a very cold and dry environment. Since she's very Deficient, this unfortunately had the result to start the destabilization mechanism going again. She started alternating between feeling very cold and having up to twenty sweaty, hot flashes a day. If I understand correctly, what she did then after the trip was she stopped the original formula and moved to another formula.

BQ: Right. On the trip she didn't take herbs at all I believe. When she returned to Seattle, then she tried something else that you discussed in class.

JR: Right. She tried something we had been talking about in class, which wasn't made specifically for her, it was a general combination for menopausal sweating.

Christine's new combination

The herbs were prescribed as 2.5-5 ml of 1:5 tincture 3 times per day in a little water, and to stop other herbs during this time.

This is like a mini-formula which isn't really meant to be used by itself, it should be tailored to individual needs. The Ophiopogon and Salvia combination tonifies Yin and Wei Qi and stabilizes the sweating. Ophiopogon tonifies the Heart Yin, it tonifies the Yin in general and helps Deficient Yin sweating with Deficiency Heat. Salvia is a slightly calming herb that helps menopause, as does the Ophiopogon, but the Salvia is specifically an astringent herb that regulates sweating. Anemone, as I mentioned earlier, is specific for menopausal hot flashes and is particularly calming. The problem with giving Anemone for someone like Christine long term is that it is too Cold. But in this situation something was needed temporarily to reduce the sweating, and the combination worked extremely well.

The sweats were reduced from twenty per day to three. The Glycyrrhiza (liquorice root) is exactly what you were talking about, Doug. It is a sweet herb in there to make a sort of center balancing point in a formula, to give stability. With the two sweet herbs, Glycyrrhiza and Ophiopogon, we're trying, by tonifying the Spleen, to make a sort of anchor to hold the person stable. If you imagine a boat on the sea left without an anchor, it would be blown about all over the place. If you let the anchor drop, it holds the boat more or less in place.

Anemone, to continue the analogy, would be rather like trying to drop your sails, so you don't get blown about so much by the gale. But the problem with dropping your sails is that when the gale has gone and you want the wind to move the ship- you won't move. So you can't use Anemone by itself for a long period of time. The Ophiopogon and the Glycyrrhiza are more like heavy anchors that hold the boat down. The Salvia, if you like, is like closing the hatches to stop the gale from getting in or you being effected by those wind changes. That was the second formula for Christine and it was for a time successful.

DL: It seems like Christine is a good example where you have to treat the branches first and then after that you have a clearer picture of what you need to work with.

JR: That's an excellent point. This second combination was taken without a consultation, but sometimes even if you do a full consultation you can't always see all the ramifications and different facets of the person. Once you clear some of the branches out of the way like Tammy's severe bleeding or Sallie's muscle aches or Christine's cold, you get a more accurate picture.

BQ: It did show me though how quickly a formula can work because in less than a week Christine said she was enjoying her showers. She said she hadn't really connected in her mind why she had such a difficult time. It seems so obvious in retrospect to see: "I'm cold is why I'm not enjoying my shower." But with hot flashes going on at the same time, it was not really so obvious. In any event the formula worked very quickly to bring more vitality, better digestion and a more regulated body temperature and menstruation.

JR: I think this emphasizes what Doug was saying. Now we've seen we can control some of the main symptoms. That's great, but what's happened in the meantime is that she's gone through these environmental extremes and stresses, extreme oscillations between heat and cold. It's interesting to know that that affects her so much.

Now we know that the next job we have with her is to strengthen the center. She can easily go to the hot and sweaty side, and can easily go to the cold side. So the strategy would be to strengthen the middle and to be prepared for whatever other oscillations she might have due to whatever life stresses she gets.

The other thing to mention here is that Christine was given the Capsicum separately. I always do that and tell people to determine how many drops they need. She only needed two to three drops per dose. Partly because that's all she needed to warm her up but partly also because people who are deficient can experience too much of a shock from Capsicum, and it will send them oscillating back and forth.

BQ: Jeremy, we are unfortunately out of time. I think you've done a great job of thinking out loud for us, so to speak, so that we can see how it is you are constructing your formulas. It was a great educational experience. Thanks for your time.

DL: Thanks, Jeremy.

JR: You're both welcome.

Bob Quinn is the manager of People's Herbs, Inc. in Clackamas, OR and has an acupuncture and bodywork practice in Sandy, OR. Doug Ly is an acupuncturist in Seattle and also a sales representative for NF Formulas.