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Estrogen And Herbs (Part 3 of Menopause)

Posted on June 11, 2012 at 2:31 PM Comments comments ()
  • By John Chen, PhD, PharmD, OMD, LAc

  • Premarin (conjugated estrogen) is one of the most frequently prescribed medications in the United States. Considering that only half of the population can be prescribed this medication (females), and that only elderly patients need this medication, it is an astounding number. I am often asked by practitioners about patients of theirs who are prescribed estrogen but wish to take herbal alternatives, or patients who are prescribed herbs but wonder if the estrogenic effects of the herbs will conflict with their current therapy. I will try to address these issues in three separate parts. Part one will discuss herbs that have estrogenic effects, along with possible side-effects; part two will cover herbs that may be used to treat menopausal signs and symptoms; and part three will focus on herbs that may be used to treat osteoporosis.

  • Estrogen is commonly prescribed for numerous purposes, including (but not limited to) menopausal signs and symptoms, osteoporosis, and atrophic vaginitis. More recently, the beneficial effects of estrogen have been observed in patients with Alzheimer's disease (with improvement up to 16 weeks) and dyslipidemia.

  • In addition to drugs, there are many other alternatives for natural sources of estrogen. In traditional Chinese medicine, many herbs have estrogenic effects. Although Chinese herbs are not prescribed individually for such purposes, the addition of herbs with estrogen-like effects will definitely supplement a formula and enhance its overall therapeutic value. According to studies in mice, it has been discovered that fructus cnidii monnieri (she chuang zi), semen cassiae (jue ming zi) and radicis angelicae sinensis (dang gui) increase estradiol levels; flos carthami tinctorii (hong hua) increases FHS levels; and semen astragali complanati (sha yuan zi) increases the weight of the uterus.

  • The use of estrogen replacement therapy, despite numerous benefits, still has many potential conflicts and controversies. One of the biggest disadvantages associated with the use of estrogen is the staggering number of side-effects, including, but not limited to, increased risk of breast and uterine cancer; endometrial carcinoma; malignant neoplasm; gallbladder disease; thromboembolitic disease; and photosensitivity. Due to these adverse effects, many people opt not to take estrogen supplements; many others cannot take estrogen supplements.

  • In addition to side-effects, one contraindication of estrogen supplementation is for patients who have cancer of the breast, uterus or endometrium. Use of drugs, supplements or foods with hormonal activity may stimulate the growth of cancer cells, and must be avoided. Specifically with Chinese herbs, those that increase the secretion of female hormones or increase the weight of the sex organs should be avoided. Examples include she chuang zi, jue ming zi, dang gui, hong hua, and sha yuan zi. Furthermore, patients should be careful eating meat or animal products, as many of these have been treated with hormones to hasten growth.

  • In summary, though traditional Chinese medicine and Western medicine have vastly different diagnostic criteria and treatment approaches, the medicines used by the two systems are in fact similar in many ways. Both have similar therapeutic effects and potential conflicts. Protocols concerning how to incorporate these herbs into formulas for the treatment of menopause and osteoporosis will be discussed in parts two and three of this series.

  • References

  • Buckley B. 34th annual top 200 drugs. Pharmacy Times, April 1999.
  • Liu J, Gong H. Screening Some of the Estrogen-Like Herbs. Presented at the 5th Symposium on Research in Chinese Medicine and the 14th Symposium on Natural Products, Oct. 31-Nov. 1, 1999, Taipei, Taiwan.
  • Estrogen supplements. Drug Facts and Comparison, 1999.
  • Balch J, Balch P. Prescriptions for Nutritional Healing, 2nd edition, 1997.

Menopause: Western and Traditional Chinese Medicine Perspective Part II

Posted on April 30, 2012 at 7:50 PM Comments comments ()
By John Chen, PhD, PharmD, OMD, LAc
Traditional Chinese Medicine Perspective
According to traditional Chinese medicine, the fundamental changes that occur during menopause can be attributed to kidney deficiency. Since the kidney is the organ responsible for growth, maturation and aging, the deficiency of kidney yin is directly related to signs, symptoms and complications of menopause. In addition to kidney yin deficiency, other common conditions that occur in menopause are kidney yang deficiency; kidney essence (jing) deficiency; liver qi stagnation; blood deficiency; and uprising deficiency heat. Therefore, treatment of menopause using Chinese herbal medicine can be divided into two parts: primary diagnosis and treatment, and differential diagnosis and treatment.
Differential Diagnosis and Treatment
This section addresses the treatment of menopause based on differential diagnosis according to the theories of the traditional Chinese medicine. While all patients with menopause will have kidney yin deficiency, many will have other associated conditions that must be addressed. The differential diagnosis and treatments are as follows.
Kidney yin deficiency, one of the most common scenarios of menopause, is characterized by symptoms such as delayed menstruation (scanty in amount or ceased completely); hair loss; scanty vaginal discharge; dryness of vagina; dizziness; tinnitus; hot flashes; night sweats; five heart irritable heat (heat and irritable sensation in the chest, palms and soles); hot flashes; insomnia; increased dreams; itchy skin or formication (tactile hallucination with feeling of insects crawling on skin); and soreness and weakness of lower back and knees. The tongue is red with scanty coating, and there is a thready rapid pulse. The recommended herbal formulas are zhi bai di huang wan and qing hao bie jia tang.
Liver qi stagnation is evident with the showing of irritability; nervousness; hypochondriac distention; constipation; palpitations; insomnia; emotional instability; and generalized weakness. The tongue is red with a thin yellow coating, and the pulse is wiry. The recommended herbal formulas are chai hu jia long mu tang and jia wei xiao yao san.
Blood deficiency can be diagnosed when the clinical manifestation shows dizziness; hot flushes; sweating; insomnia; dryness of skin; sallow complexion; emotional instability; and myalgia. There is a pale tongue with a thin coating, and a thready pulse. The recommended herbal formulas are si wu tang and gui pi tang.
Uprising deficiency heat will show such symptoms and signs as severe night sweating and hot flushes; a bone-steaming sensation; irritability; dizziness; nervousness; and emaciation. The tongue is red with a thin coating, and there is a thready rapid pulse. The recommended herbal formula is qing hao bie jia tang.
Kidney yang deficiency, probably the least common of all menopause diagnosis, is characterized by heavy menstrual bleeding; metrorrhagia or complete ceasing of menstruation; soreness and weakness of the lower back and knees; edema of the face and limbs; cold limbs; cold appearance; loose stools; polyuria; and urinary incontinence. There is a pale tongue with thin coating, and a deep-thready-weak pulse. The recommended herbal formulas are you gui wan and li zhong tang.
Kidney essence (jing) deficiency can be diagnosed with such symptoms and signs as weakness and soreness of the lower back and legs; inability to stand for a prolonged period of time; and decreased bone mass density. Kidney jing deficiency is directly related to the Western diagnosis of osteoporosis. Gui lu er xian jiao is the formula of choice for the prevention and treatment of osteoporosis as it contains herbs that increase the utilization of calcium; strengthen the bones; prevent fractures; and promote healing. From the Western medicine perspective, these herbs are rich in calcium, and function to increase adsorption of calcium into bone and promote the growth and healing of bones. According to a clinical study conducted in Taiwan, the use of herbs in gui lu er xian jiao has been found to increase bone mass density by an average of 3.4% in one year. In addition to herbs, an adequate amount of calcium and vitamin D should be taken on a daily basis to ensure proper integrity of bones.
Lifestyle and Dietary Instructions
Menopause patients are encouraged to follow a diet with a high content of raw foods, fruits and vegetables to stabilize blood sugar. Some foods may promote hot flashes or aggreate mood swings and should be avoided, such as dairy products, red meats, alcohol, sugar, spicy foods, and caffeine. Cigarette smoking or exposure to second-hand smoke should be avoided as they may dry up yin and body fluid. Lastly, stress, tension and anxiety should be avoided as much as possible.
Author's Comments
Traditional Chinese medicine is extremely effective in treating menopause and related conditions. However, it is important to keep in mind that as kidney tonic herbs treat menopause, they also regulate the endocrine system. Therefore, it is not unusual for women to experience menstruation once the herbs are initiated. In addition, some herbs have estrogen-like effects and should be avoided in patients who have estrogen-dependent cancer. Examples of these herbs include fructus cnidii monnieri (she chuang zi), semen cassiae (jue ming zi), radicis angelicae sinensis (dang gui), flos carthami tinctorii (hong hua) and semen astragali complanati (sha yuan zi).
Conclusion
Though menopausal signs and symptoms are disturbing, they are self-limiting and not life-threatening. Such signs and symptoms may be prominent for a few years, but they will gradually lessen in severity and eventually disappear. Osteoporosis, on the other hand, will continue to deteriorate with age and can be life-threatening. It is a disorder that requires active intervention and treatment.
Hormone replacement therapy is considered the standard treatment for menopause and related conditions. However, there is not a consensus as to when and how to use these medications. While they may alleviate hot flashes and prevent osteoporosis, they will also increase the risk of breast, ovarian and uterine cancer, and have a number of significant side-effects. The bottom line is that synthetic hormones can never replace endogenous ones. Therefore, no matter when and how they are prescribed, the potential for adverse reactions will always be present.
Traditional Chinese medicine, on the other hand, offers a gentle yet effective way to address menopause and related conditions. Chinese herbs have demonstrated via numerous in vivo and in vitro studies to have a marked effect on the endocrine system to alleviate hot flashes, vasomotor instability, loss of bone mass, and other conditions associated with menopause. Most importantly, they are much gentler and safer on the body.
Menopause Conditions and TreatmentsDiagnosisClinical ManifestationHerbal Rx Kidney Yin Deficiency Delayed menstruation (scanty in amount of ceased completely); hair loss; scanty vaginal discharge; dryness of vagina; dizziness; tinnitus; hot flashes; night sweats; five heart irritable heat (heat and irritable sensation in the chest, palms and soles); hot flashes; insomnia; increased dreams; itchy skin or formication (tactile hallucination with feeling of insects crawling on skin); soreness and weakness of lower back and knees Anemarrhena phellodendron & rehmannia formula (zhi bai di huang wan) and artemisia & turtle shell decoction (qing hao bie jia tang) Liver Qi Stagnation Irritability; nervousness; hypochondriac distention; constipation; palpitations; insomnia; emotional instability; generalized weakness. Bupleurum & dragonbone combination (chai hu jia long mu tang) and bupleurum & peony formula (jia wei ziao yao san) Blood Deficiency Dizziness; hot flushes; sweating; insomnia; dryness of skin; sallow complexion; emotional instability; myalgia. Tang kuei four combination (si wu tang) and ginseng & longan combination (gui pi tang) Uprising Deficiency Heat Hot flushes; bone-steaming sensation; irritability; dizziness; nervousness; emaciation. Artemisia & turtle shell decoction (qing hao bie jia tang) Kidney Yang Deficiency Heavy menstrual bleeding; metrorrhagia or complete ceasing of menstruation; soreness and weakness of the lower back and knees; edema of the face and limbs; cold limbs; cold appearance; loose stools; polyuria; urinary incontinence. Eucommia & rehmannia formula (you gui wan) and ginseng & ginger combination (li zhong tang) Kidney Essence (Jing) Deficiency Weakness and soreness of the lower back and legs; inability to stand for a prolonged period of time; decreased bone mass density. Testudinis & cervi formula (gui lu er xian jiao)
References
  1. Hsu H. Effectiveness of gui lu er xian jiao on treatment of osteoporosis. Clinic Medline of Taiwan.
  2. Fauci A, et al. Harrison's Principles of Internal Medicine, 14th edition, 1996.
  3. Facts and Comparison, Jan. 2000.
  4. Liu J, Gong H. Screening some of the estrogen-like herbs. The 5th Symposium on Research in Chinese Medicine and the 14th Symposium on Natural Products, October 31-November 1, 1999, Taipei, Taiwan.

Menopause: Western and Traditional Chinese Medicine Perspective Part I

Posted on April 30, 2012 at 7:45 PM Comments comments ()
By John Chen, PhD, PharmD, OMD, LAc
Menopuase is defined as the permanent cessation of menses. While it is a normal process of aging, it creates a number of complications that require medical attention, such as vasomotor complaints (hot flashes), psychosomatic complaints, genital atrophy and osteoporosis. The issue of menopause is becoming increasing important because as most baby-boomers approach menopause at age 50, they are expected to spend more than 1/3 of their life in post-menopause since the life expectancy is now over 85 years. This update will discuss the optimal methods to address all of the changes that occur during menopause with both Western and traditional Chinese medicine.
Western Medicine Perspective
Menopause is not a disease, but a normal process of life. Still, it does create conditions and complications that may require medical intervention. Vasomotor complaints (hot flashes), psychosomatic complaints, genital atrophy and osteoporosis are the four main medical conditions associated with menopause that will be discussed in this article.
Hot flashes may occur in 80% of menopausal women, and may last for up to five years. Vasomotor flush is the objective and visible flushing of blood of the thorax, neck and face, followed by increase in body temperature and profuse sweating. Hot flashes is the subjective sensation of intense warmth in the upper body, typically lasting for four minutes. Since hot flashes occur most frequently at night, it is not uncommon for these women to experience insomnia, restlessness, irritability and emotional instability. Many women will seek professional help when these changes begin to disturb their daily activities.
Genital atrophy is also common as it may occur in approximately 20% of postmenopausal women. Since many tissues in the genitourinary region are estrogen-dependent, post-menopausal women may experience atrophy of such tissues as lower vagina, labia, urethra and bladder trigone. As a result, there may be vaginal dryness; painful coitus; diminished libido; increased vaginal ulceration; increased risk and frequency of infection; dysuria; urgency; painful urination; and stress incontinence. Once again, genital atrophy may require medical intervention by health care professionals.
Osteoporosis is a disorder characterized by a reduction in bone mass. Osteoporosis is becoming one of the more common disorders in the West as the population continues to age and life expectancy continues to increase. Osteoporosis occurs mostly in individuals between 51and 75 years of age, and is six times more common in women than men. There are numerous risk factors for osteoporosis, including (but not limited to) aging, dietary habits, lifestyle and family history. Chronic use of drugs also increases the risk of osteoporosis, with thyroid supplements, corticosteroids and heparin among those drugs implicated. Likewise, exposure to ethanol, alcohol, tobacco and drug abuse are causative or complicating factors. The clinical implications of osteoporosis include fractures of bones after minimal trauma. Injuries often result from a (relatively low-impact) fall from standing height, subsequently leading to fractures of the vertebrae, wrists, hips, humerus and tibia. In frail patients, even a child's overenthusiastic hug can cause fractures. With bone fracture, there is severe pain, discomfort, decreased mobility, risk of infection and, in osteoporotic patients, prolonged recovery. In the elderly, decreased mobility can lead to further health complications, delaying recovery even longer. Amongst the conditions associated with menopause, osteoporosis is considered by many as the most severe and the most significant.
Many drugs are available for prevention and treatment of menopause and related conditions. Listed below are some of the drugs most commonly used:
Hormone Replacement Therapy (HRT)
The purpose of hormone replacement therapy is to supply the body with an external source of hormones, including estrogen and/or progesterone. While there are numerous forms, Premarin (conjugated estrogen) and Provera (medroxyprogesterone) remain the most popular brands. In fact, Premarin is the most frequently prescribed medication in the United States. This is an astounding number considering menopausal women are the only individuals who are prescribed this medication. As a group, estrogen is commonly prescribed for numerous purposes, including (but not limited to) menopausal signs and symptoms, osteoporosis and atrophic vaginitis. In addition to menopause, some early studies have hinted that the use of estrogen may be associated with the prevention of Alzheimer's disease. However, more recent data concluded that the beneficial effects of estrogen last only up to 16 weeks, after which no difference is observed between the placebo and the control group.
Unfortunately, despite the possible benefits, estrogen replacement therapy has many potential conflicts and controversies. One of the biggest disadvantages associated with the use of estrogen is the staggering number of side-effects, including (but not limited to) an increased risk of breast cancer, uterine cancer, ovarian cancer, endometrial carcinoma, malignant neoplasm, gallbladder disease, thromboembolitic disease and photosensitivity. Progesterone is prescribed with estrogen to minimize the risk of endometrial cancer. However, it can cause side-effects such as an increase in cholesterol levels, edema, weight gain and bleeding. Due to these adverse effects, many women cannot take hormone replacement therapy, and there are many who opt not to take HRT.
Biphosphonates for Osteoporosis
Biphosphonates are a class of drugs that includes alendronate (Fosamax), etidronate (Didronel), pamidronate (Aredia), tiludronate (Skelid) and risedronate (Actonel). These substances treat osteoporosis primarily by blocking the loss of bone mass. Biphosphonates such as alendronate may increase bone density by 5-10% if taken daily, continuously, for three years. Side-effects of these drugs include nausea, diarrhea, esophageal irritation and esophagitis. Furthermore, in laboratory studies, the use of biphosphonates is associated with the development of cancer (thyroid adenoma and adrenal pheochromocytoma) and fertility impairment (inhibition of ovulation and testicular and epididymal atrophy).
SERM
SERM is the abbreviation for selective estrogen receptor modulator. Currently, Evista (raloxifene) is the only medication approved in this class. It works by facilitating the utilization of calcium for proper bone strength, and is therefore used for prevention and treatment of osteoporosis. Unfortunately, this medication is associated with an increased risk of venus thromboembolism and increased severity and incidence of hot flashes. It is also contraindicated in patients with liver problems, as it is metabolized hepatically.
Clonidine
Catapres (clonidine) is another option for the relief of hot flashes. It stabilizes the blood vessels by binding to the alpha-adrenergic receptors. It is rarely prescribed as it has significant side-effects such as postural dizziness, blurred vision, first dose syncope, and withdrawal hypertension.
Summary
There are numerous options available for the treatment of menopause and related conditions. Unfortunately, there is no consensus on how menopause should be treated with Western medicine. Despite all of the clinical and laboratory research, medical doctors cannot agree on when and under what circumstances to start the treatment of menopause. Some propose to begin treatment during perimenopausal years; others prefer to initiate treatment only after menopausal symptoms and signs have begun; and still others discourage the use of drugs since the risks outweigh the benefits. Until more information is available, the best conclusion that can be drawn at this time is that the treatment should be individualized, with the doctors and patients in complete understanding of what is at risk and what is to be accomplished.
In part two of this series, we will discuss the diagnosis and treatment of menopause from the perspective of traditional Chinese medicine.
References
  1. Beers M, Berkow R. The Merck Manual of Diagnosis and Therapy, 17th edition, 1999.
  2. Dorland's Illustrated Medical Dictionary, 28th edition, 1994.
  3. Berkow R, et al. The Merck Manual of Diagnosis and Therapy, 16th edition, 1992.
  4. Fauci A, et al. Harrison's Principles of Internal Medicine, 14th edition, 1996
  5. Buckley B. 34th annual top 200 drugs. Pharmacy Times, April 1999.
  6. Estrogen supplements. Drug Facts and Comparison, 1999.
  7. Facts and Comparison, Jan. 2000.


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