Traditional Chinese medicine: perspectives on and treatment of menopausal symptoms

Globally, menopause occurs at approximately 50 years of age. Menopause results from the dynamic recession of ovarian function, including declining ovarian reserves and fluctuating levels of reproductive hormones manifest as changes in menstrual regularity, decline in fecundity, the gradual appearance of menopausal symptoms, and increased risk of various chronic diseases¹. Menopausal symptoms are most common in women of 40–60 years of age, with 84.2% of women experiencing menopausal symptoms during this period. Menopausal symptoms arise as a consequence of reduced estrogen secretion from the ovaries, leading to autonomic nervous system dysfunction, including hot flushes and sweats, emotional disorders, insomnia, fatigue, headache, dizziness, palpitations, formication, musculoskeletal pain and genitourinary symptoms². Although the age of menopause differs between regional and cultural contexts, the types and severity of menopausal symptoms are generally similar.

No specific reference on menopausal symptoms is found in Traditional Chinese medicine (TCM). However, according to their etiology and characteristics, menopausal symptoms can be categorized into ‘visceral agitation’, ‘lily disease’, ‘metrorrhagia and metrostaxis’, ‘depression syndrome’, ‘palpitation’, and ‘insomnia’, which are altogether referred to as ‘perimenopausal syndrome’³.

In TCM, the female life is divided into cycles, with one cycle occurring every 7 years. This is termed ‘Tiangui’, or ‘heavenly tenth’, which generally conforms to the stages of a woman’s life in modern medicine. With the onset of mental and physical exhaustion by the seventh cycle (49 years), the human body normally ages and the functions of various organs decline, particularly the kidney. From a TCM perspective, menopause is associated with ‘kidney deficiency or dysfunction’, since, in TCM, the kidney is conceptualized as a system rather than an organ that is responsible for temperature, fertility and sterility, and fluid balance regulation. Qi is also a TCM concept that refers to the maintenance of activities of daily life, visceral function, and metabolism. Yin and Yang, two opposite, complementary, and inter-related components of matters in nature, ensure that every system functions smoothly through the balance of Qi and blood. During perimenopause, women experience a gradual reduction in kidney Qi, essence, and blood, thereby leading to an imbalance between Qi and blood, kidney Yin–Yang disharmony with subsequent visceral organ dysfunction. TCM treatment for menopausal symptoms requires the identification of holistic disruptions in physiological patterns and the subsequent application of various TCM treatments, such as herbal medicine, acupuncture, meridians, auricular point therapy, and moxibustion. Additionally, these treatments can be combined with other pharmaceutical or non-pharmaceutical treatments, such as massage and psychological counseling⁴.

TCM on menopausal symptoms: theory and practice

The recession in kidney Qi, exhaustion of heavenly tenth, and deficiency in the conception vessel, which regulates menstruation and promotes female reproduction, and the thoroughfare vessel, which is intimately associated with fertility and sterility, result in physiological amenorrhea, thereby indicating that a woman has reached menopause. According to TCM theory, the root cause of menopausal symptoms is the kidney, which subsequently impacts the heart, liver and spleen. Clinically, emotional lesions are considered the main symptoms of menopausal symptoms in China. Notably, in TCM, the liver has a central role in regulating emotions and Qi function. According to this TCM model of human health, women during the menopausal period exhibit kidney deficiency and liver depression. Moreover, in TCM theory, due to heart–kidney interactions, pathological changes in the kidney subsequently impact the heart, which dominates blood circulation and mental activities that result in Yin–Yang imbalance and lack of coordination. Additionally, since the kidney is innate and the spleen is an acquired constitution that is responsible for maintaining physiological processes and synthesizing nutrients, kidney deficiency in Yang debilitation necessarily results in Yang deficiency in the kidney and spleen. Collectively, the TCM model of health posits that the main etiology of menopausal symptoms is kidney deficiency, which results in heart dysregulation, spleen deficiency, and liver depression⁵.

TCM treatment for hot flushes

Approximately 60–80% of menopausal women experience hot flushes and sweating and the peak stage of onset occurs during the late menopausal transition and early menopause⁶. It is believed in TCM that hot flushes are mainly caused by kidney Yin deficiency, resulting in excessive kidney fire and Yin deficiency in the liver and kidney, and ascendant hyperactivity of liver Yang. Hence, TCM methods for menopausal hot flushes mainly consist of nourishing Yin and clearing heat in order to regulate neuroendocrine functions⁷.

The Chinese-patented medicine, Heyan Kuntai capsule (HYKT), is widely used to treat menopausal syndrome. A dual-center, randomized, double-blind, double-dummy, parallel-controlled study was conducted for 3 months in which 147 women were enrolled and 123 completed the trial. Menopausal women were randomly divided into groups receiving either the Kuntai capsule or estradiol valerate. The modified Kupperman index, serum estradiol, and vaginal epithelial cell index were assessed as primary outcomes for evaluating treatment efficacy, and adverse events, such as vaginal bleeding and mastalgia, were also recorded. After treatment, both drugs reduced hot flushes in 92.3% and 96.5% of women, respectively, which was not significantly different (p > 0.05), suggesting that both HYKT and estradiol valerate were effective in alleviating hot flushes⁸.

Another randomized, double-blind, placebo-controlled study was conducted on 31 postmenopausal women in the Netherlands, in which the Chinese medicine Zhibai Dihuang was administered for 12 weeks followed by 4 weeks of treatment discontinuation. At follow-up, researchers evaluated the effect of this treatment on vasomotor symptoms, including hot flushes and night sweating, and found that Zhibai Dihuang significantly improved symptoms compared to a placebo (p < 0.01)⁹.

The efficacy of acupuncture in the treatment of hot flushes has been verified by extensive data provided by Chinese and international studies. A prospective and multicenter cohort study using acupuncture to treat 175 patients with hot flushes found that, within 24 h, more than 62% of subjects in the acupuncture group reported improvements in symptoms, whereas only 27% of subjects in the control group reported an improvement¹⁰.

TCM treatment for emotional disorders during menopause

Among menopausal symptoms, depression and anxiety are the main characteristics of non-specific psychological syndrome and are considered menopausal mood disorders. The morbidity of mood disorders is higher in menopausal women than in their healthy counterparts in whom regular menstruation occurs during the childbearing age. Modern medicine posits that the cause of mood disorders may be related to a decline in ovarian function and a subsequent reduction in serum estradiol levels, which result in the elevation of serum monoamine oxidase levels. This can further cause increased degradation and metabolic inactivation of dopamine, norepinephrine, and serotonin, as well as the down-regulation of monoamine neurotransmitter activity. Currently, treatment mainly involves antidepressants; however, many studies have reported that hormonal replacement therapy improves mood and cognitive function in women^11–14.

Menopausal mood disorders belong to the TCM disease categories of ‘Lily disease’, ‘hysteria’, and ‘depression’. TCM believes that the pathogenesis of this disease is due to the gradual decline in kidney Qi, thereby resulting in kidney Yin deficiency and liver depression that progresses into liver fire, thus further excessive burning Yin fluid. Together, these conditions manifest as hot flushes, sweating, chest tightness, irritability, and insomnia. Moreover, heart Yin is damaged over time and reduces interactions between the kidney and heart, which aggravates depression and anxiety¹⁵.

Saikosaponin, the active ingredient of the radix bupleuri in Xiangshao granules, has anti-inflammatory and anti-convulsion effects and can extend sleep duration. It has demonstrated good therapeutic efficacy against anxiety and depression, possibly by affecting serotonin activity in the central nervous system. Wang observed that Xiangshao granules regulated serum neurotransmitter levels, including serotonin, norepinephrine, and epinephrine, thereby indicating that Xiangshao granules may improve menopausal depression through balancing the neuroendocrine system¹⁶.

A study observing the effects of bilateral acupuncture at the Feishu, Xinshu, Ganshu, Pishu, Shenshu and Geshu points on patients with menopausal depression found that the Hamilton Depression Scale scores at the 6th week of treatment were comparable between the acupuncture group and the fluoxetine hydrochloride group¹⁷. Notably, acupuncture exhibited better outcomes (p < 0.05) at weeks 2 and 4.

TCM treatment for sleep disorders during menopause

TCM posits that the pathogenesis of sleep disorders in women during menopause is mainly due to kidney deficiency; reduced interaction between the kidney and heart; lack of Qi, blood and Yin essence; and disharmony of Yin–Yang. Accordingly, treatments, such as enriching the kidney, nourishing Yin, and soothing the mind have an improved therapeutic efficacy¹⁸.

A systematic review¹⁹ consisting of six randomized, controlled studies with a total of 510 patients comparing the efficacy and safety of JiaWeiSuanZaoRen soup and sleeping pills in the treatment of menopausal insomnia showed that JiaWeiSuanZaoRen soup showed comparable effects to diazepam and alprazolam tablets, whereas JiaWeiSuanZaoRen soup treatment showed better efficacy than estazolam (p < 0.05). Additionally, JiaWeiSuanZaoRen soup improved the quality of sleep, as indicated by the Pittsburgh Sleep Quality Index, when compared with alprazolam (p < 0.05). More adverse events were reported in the group receiving sleeping pills than in the JiaWeiSuanZaoRen soup group (p < 0.05, χ² = 4.9246). In addition, a randomized, double-blind, placebo-controlled, small-sample study²⁰ found that the sleep quality index was improved significantly after menopausal women (n = 18) received acupuncture therapy, and polysomnography indicated that the duration of deep sleep increased after treatment.

Conclusion

Recently, research on menopausal syndrome has attracted attention across the fields of gynecology, endocrinology, and neurology. Currently, hormone replacement therapy is widely used in the context of modern medicine to treat menopausal syndrome, while the reconstruction of Yin–Yang balance and the restoration of kidney Qi are fundamental in the TCM context since TCM posits that the Yin–Yang balance is disrupted during menopause. At its core, menopause treatment in TCM involves syndrome differentiation, indicating which therapies should be used – these may include TCM pharmaceuticals, acupuncture, moxibustion, Tuina (massage), auricular point application therapy, emotional therapy, and diet therapy. Studies have showed that TCM can significantly alleviate symptoms, improve quality of life, and is economical and safe. In the future, multicenter, randomized, double-blinded, controlled studies with large sample sizes are needed to identify how TCM can be applied holistically to improve syndrome differentiation. In doing so, it will be possible to develop reliable and repeatable clinical guidelines that can be used to treat menopausal symptoms.

Conflict of interest

The author reports no conflict of interest.

Additional information

Funding

Nil.