Journal of Chinese Medicine | Issue 128 | February 2022

Myths of Menopause in Chinese Medicine Practice

Myths of Menopause in Chinese

Medicine Practice
Caroline Radice

Abstract

Despite nearly a century of its medicalisation as a disease, menopause is still

poorly understood and rarely discussed outside the circle of those suffering
as they transition from their reproductive to their non-reproductive years. This
article discusses some of the common myths of the menopause, both from
the biomedical as well as the Chinese medical perspective, and presents
information that can contribute to the improvement of women’s physical and
emotional health as they age. Four case studies are included that illustrate
common misconceptions about the treatment of menopausal symptoms using
Chinese medicine.

Keywords
Chinese medicine, acupuncture, TCM, menopause, hot flashes, vasomotor symptoms, HRT

Introduction

Having worked with the perimenopausal population 1821, and by the 1930s menopause was already considered
for almost three decades in my clinical practice of a ‘deficiency disease’ (i.e. oestrogen deficiency).2
acupuncture and herbal medicine, I spend a considerable
amount of time educating patients as well as other Myth 1: Menopause is an event
practitioners about some of the persistent myths that
surround this under-discussed and misunderstood time of FACT: Although finally hitting the marker of 12 months
a woman’s life. of no periods might be thought of as an event of sorts, the
The term ‘menopause’ came late to the vernacular in experience of the transition can precede this date by many
both the East and West although women worldwide have years and symptoms can persist for many years afterwards.
experienced symptoms associated with the transition Menopause is a transitional process. The average age
from reproductive to non-reproductive years since of the final menstrual period (FMP) is about 51 years in
life expectancy allowed them to survive long enough. the US, with minor variations in other countries; most
Menopause, from the Greek meaning ‘monthly stop’ is women complete this transition sometime between 45
defined as one calendar year of no menstrual periods. and 55 years.3 For many, the years that predate the FMP
In China, according to historian Charlotte Furth in present an array of symptoms of varying levels of distress.
A Flourishing Yin: Gender in China’s Medical History, In my experience, many of the symptoms experienced by
960-1665,1 there was no term for menopause until the 19th women in their 40s and 50s with perimenopausal syndrome
century (it was simply considered another of the seven- are similar to those experienced by women in their 20s
year stages of life as defined by the Nei Jing [Inner Classic]), and 30s with premenstrual syndrome (PMS), with added
when it was imported with biosciences from the West. The vasomotor and cognitive issues.
term was introduced in the West by a French physician in The transition to menopause is consistent with declining

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Myths of Menopause in Chinese Medicine Practice

Figure 1: STRAW summary of the phases of menopause 4

levels of oestrogen and progesterone, that reset at new cycle intervals, with periods arriving a week or more early
levels once the process is completed. Only in recent years or late than typical for that person. Although inconvenient,
has there been any official effort to assess and evaluate this is not a problem that needs to be treated in most cases
the reproductive stages based on hormone and symptom unless it is accompanied by a bleeding disorder. However,
profiles in order that a common understanding of the perimenopausal bleeding disorders can be extreme and in
transition might be shared by all interested parties. Using such cases should be addressed urgently to avoid adversely
population-based data, a group was established in 2001 affecting the health, vitality and quality of life of the woman;
sponsored by the National Institutes of Health, National this was graphically discussed in a recent article in The
Institute of Aging, Office of Research on Women’s Health, Guardian entitled, ‘There will be blood: women on the
North American Menopause Society, American Society shocking truth about periods and perimenopause.’ 5
for Reproductive Medicine, International Menopause The intervals between periods usually continue to
Society and Endocrine Society. Known as STRAW (Stages increase in the one to three years prior to the FMP, with
of Reproductive Aging Workshop), this group established some women going 10 or 11 months without a period, only
criteria that are considered the standard by which stages to be surprised - and often disappointed - by another bleed.
of reproduction and its cessation are measured using No matter how scant this bleed, it starts the twelve-month
hormonal and symptom markers. These criteria divide countdown clock all over again. Uterine bleeding after the
female reproductive life into three broad categories: twelve-month timeframe is complete requires immediate
reproductive, menopausal transition and post-menopause referral to a physician for cancer evaluation.
(see Figure 1). The identified stages countdown to FMP, Many who are in ‘early transition’ according to the
or Stage 0, and then up again post FMP. These data have STRAW criteria may not realise this is the case until they
been refined and reassessed since and represent a long- attempt to conceive unsuccessfully and then learn that
overdue attempt to standardise language and understand their hormone levels are indicative of perimenopause,
symptomology of this complex process.4 with follicle stimulating hormone (FSH) levels raised in
The symptoms associated with the perimenopausal response to poor ovarian reserve. This often leads to less
stage are divided into early and late transition, with frequent ovulation and lower progesterone levels, and thus
symptoms increasing along the trajectory toward FMP. fewer menstrual periods. As menopause represents the
Early transition usually begins with some erratic timing of end of fertility, it is often a very emotional experience for

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Myths of Menopause in Chinese Medicine Practice

patients, even those who have previously conceived, and weight, metabolism, energy levels and immune function.
often coincides with other stressful life events such as caring However, if overall body function is well maintained, then
for ageing parents or ‘empty nest syndrome’ when grown the risk of such disorders can be minimised. Educating
children leave home . Practitioners of Chinese medicine women that proper diet, hydration, exercise and rest
have an exceptional ability to assist patients to process these are essential to being able to thrive post-menopause is
challenges, and such emotional stress - in combination with important. Life expectancy of women can be into the early
the myriad physical symptoms - is often what brings them 80s in most developed countries, so they are likely to spend
to my clinic. about a third of their life post-menopause. These can be
Although widely considered a ‘deficiency disease’, very productive and healthy years if they take good care of
menopause is not just about oestrogen decline. In fact, themselves along the way.
perimenopausal women are initially often oestrogen
dominant due to the lack of ovulation and resulting lower Myth 3: All menopausal transitions are the same
progesterone levels. This can present with symptoms
of worsening mood, heavy bleeding and weight-gain FACT: Although 95 per cent of women report symptoms
amongst others. In post-menopausal patients, the primary associated with menopause,8 worldwide many transition
circulating oestrogen (oestrone) is minimally produced by uneventfully with a minimum of discomfort. While main
the ovaries, adipose tissue and the adrenal glands.6 Once complaints during the menopausal transition vary, sleep
the transition is complete and the hormones are reset at disorders, sexual dysfunction and emotional upheaval
their new levels, for most women bothersome symptoms are common and approximately 85 per cent of women
decline. For some, however, post-menopausal symptoms report some degree of hot flashes.9 Public health professor
can persist for years. and medical anthropologist C.M. Obermeyer reports
For some women that the association
menopause does not occur between menopausal
gradually and naturally, but When the reproductive system is hormonal changes
rather suddenly, due to
surgical removal or damage
abruptly thrown into menopause, and symptomology is
complex and mediated by
to the ovaries (due perhaps symptoms can be severe and sociocultural factors, and
to radiotherapy or other
cancer treatment), as well
challenging to treat. that ‘the evidence does
not support the notion
as in the small percent of that women in developing
patients who experience primary ovarian insufficiency countries report fewer symptoms than in industrialised
(POI, also known as premature ovarian failure), who countries’,10 despite common myths that diets high in soy
stop ovulating and menstrual cycles prior to the age of 40. or increased cultural respect for elders might be associated
When the reproductive system is abruptly thrown into with a decrease in symptoms. In Speaking Menopause:
menopause, symptoms can be severe and challenging to Intersections Between Asian and Western Medical Discourses,
treat. To paraphrase one of my teachers, ‘When you pluck Emeritus Professor of Women’s Studies at Adelaide
from a tree fruit that is not ready to fall on its own, you also University Chilla Bulbeck writes,
damage the tree’.
The silence surrounding discussions of the menopause in
Myth 2: Menopause is a disease China does not necessarily reflect an absence of symptoms,
as suggested by some of the anthropological literature and
FACT: Although many symptoms and discomforts may advocates of traditional medicine. Taboos concerning the
present, menopause is not itself a disease. It is a normal discussion of sexual issues, including menstruation; fears
transition to the next stage of life that, if managed with of being criticized for failure of self-discipline or expressing
care, can progress smoothly and relatively easily. However, 'menopausal madness'; or lack of information concerning
by the age of 65, the protective effects of oestrogen on how to name symptoms and, possibly more often, lack of
the heart are diminished such that it brings women’s risk access to treatment: all these are among the reasons Asian
of cardiac events equal to that of men. Bone health can women maintain their midlife silence. 11
also be adversely affected: a 50-year-old woman has a 50
percent lifetime risk of fragility fracture to the femoral The SWAN Study (Study of Women’s Health Across the
neck, vertebra or distal forearm.7 Mental and emotional Nation), co-sponsored by the National Institute on Aging,
health can also be adversely affected, as well as digestion, National Institute of Nursing Research, National Institutes

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Journal of Chinese Medicine | Issue 128 | February 2022
Myths of Menopause in Chinese Medicine Practice

of Health, Office of Research on Women’s Health, and Because such an array of signs and symptoms can present
National Center for Complementary and Alternative in different women, treatment of menopause with Chinese
Medicine, is an ongoing study of ‘the physical, biological, medicine is a perfect example of how the physician does
psychological and social changes during this transitional not treat diseases but rather patterns. There can therefore
period [with] the goal of helping scientists, health care be no single menopause acupuncture protocol or herbal
providers and women learn how mid-life experiences formula as it would be unsuccessful in treating patterns
affect health and quality of life during aging.’12 This includes that vary from that presentation. Women may experience
observations about attitude, symptoms and behaviours any combination of the symptoms listed and the presenting
that contribute to quality of life during the ageing process patterns can vary greatly - thus so should treatment.
and provides a great teaching and information resource
regarding all aspects of the transition. Myth 5: Sex ends at menopause

Myth 4: Hot flashes are the only symptom FACT: Vaginal and other tissues change during menopause,
but this does not have to mean the end of sexual intimacy.
FACT: While perhaps the most visible or classic symptom Decreasing oestrogen can lead to vaginal atrophy: the
of the perimenopausal transition, hot flashes and other drying and thinning of the tissues of the vagina and urethra.
vasomotor symptoms (VMS) are not the only issues This can lead to pain during sex, as well as vaginitis and
by far. As Professor Obermeyer states, ‘there is a great cystitis (grouped under the diagnostic label ‘genitourinary
diversity in symptom frequencies … a number of symptoms syndrome of menopause’).14 There are many herbal
thought to be part of menopause are in fact not specific to formulations, both internal and topical, that can assist the
it’; the core specific symptoms are vasomotor and vaginal body to maintain moisture and the patency of the vaginal
symptoms.13 Many patients are unaware that many of their tissues so that their deterioration does not interfere with
other complaints can also be attributed to the transition. sexual activity post-menopause.
These can include:
Myth 6: Gynae exams are no longer needed
• irregular menstrual cycles
• excessive menstrual bleeding FACT: Gynaecological examinations are more important
• insomnia than ever when hormones decline, and should be
• headaches maintained yearly to stay ahead of potential problems.
• dizziness Because the protective effects of oestrogen are no longer
• joint pains present, women should remember that the risk of cancer
• fatigue and other diseases increases with age and therefore they
• irritability should continue regular pap smears, mammograms, bone
• moodiness density evaluations and colonoscopies.15
• depression
• memory loss/mental fog Myth 7: Hormone therapy is dangerous
• hot flashes/heat intolerance
• excessive sweating FACT: Although controversial, for women under 60
• dry skin, eyes, mouth, vaginal tissues hormone therapy (HT) may provide protective benefits
• body odour changes in terms of cardiac and bone loss risks, especially in patients
• gastrointestinal issues with POI whose FMP occurs prior to age 40. Menopausal
• acne symptoms have been treated as an oestrogen deficiency
• hair loss/thinning on head/growth on face using hormone replacement therapies, first from animal
• urinary incontinence ovaries, and from 1938 using synthetic forms of oestrogen.
• frequent urinary tract Infections The dose required for vasomotor symptom relief is almost
• painful intercourse six times lower than the oestrogen content in the lowest
• poor libido oral contraceptive pill. Given for less than five years in
• skin sensitivity such small doses, HT is reportedly not associated with
• thyroid, adrenal & immune changes measurable increased risk of illness such as breast cancer
or heart problems. Hormone therapy is very effective for
reducing hot flashes and sweats, heart disease, osteoporosis,
vaginal dryness and Alzheimer’s disease.16

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Myths of Menopause in Chinese Medicine Practice

Myth 8: Hormone therapy is safe Myth 9: Menopause = Kidney yin deficiency

FACT: Hormone therapy, especially long term and in FACT: This is an important myth for practitioners of
women with an intact uterus, is associated with increased Chinese medicine, who may erroneously link diseases to
risk of breast and other cancers, stroke and cardiac formulaic diagnoses and treatment protocols. Simply put,
events.17 By the mid 1970s, studies showed that unopposed limiting a complex syndrome like menopausal syndrome
oestrogen therapy was associated with an increased risk of to a single diagnostic pattern will significantly limit results
endometrial cancer,18 and in 2002 a large-scale National in the clinic. Certainly, the waning power of the Kidneys
Institute of Health trial, the Women’s Health Initiative, is part of the ageing process, but it is far from the only
which set out to ‘assess the major health benefits and risks of aspect that should be treated. There is no ‘menopause’
the commonly used combined hormone preparation in the formula, and it is not always about tonifying the Kidneys.
US’, was stopped early due to evidence of increased risk of This simplification is unfortunate and can lead both patients
stroke, heart disease and breast cancer in HT users.19,20 Later and practitioners to believe that acupuncture and herbal
follow up studies have found the results ‘discordant’21 and medicine do not work.
conclude that among women with an intact uterus, although Perimenopausal bleeding or mood changes should be
there was increased incidence, ‘there was no significance treated as normal in Chinese medicine practice. Once
in breast cancer mortality’.22 However, according to early menopause starts progressing toward the FMP, it is
Breastcancer.org, combination HT increases breast cancer appropriate to assess signs and symptoms as they manifest.
risk by about 75 per cent, even when used for only a short Heat rising, presenting possibly as hot flashes or anxiety,
time; it also increases the likelihood that the cancer may is a branch phenomenon so our job is to look for the root.
be found at a more advanced stage, and that a woman Either there is a blockage causing our normal physiological
diagnosed with breast cancer will die from the disease heat to become pathological, in which case we will see
whether pharmaceutical or excess symptoms and
bioidentical hormones are treatment needs to remove
used.23 Without HT there is There is no ‘menopause’ formula, the blockage, or else there
a 12 per cent or one in eight and it is not always about tonifying is a yang storage problem,
absolute lifetime risk and a for which we must assist
50 year old woman has a 1 the Kidneys. the Shaoyin (Heart-Kidney
in 43 (two per cent) risk of axis) so it can better root
developing invasive breast cancer in 10 years.24 the fire/yang to stop it from flaming out of right relationship
Therefore, Myths 7 and 8 are both true (and false). with water/yin. Both pathomechanisms are aggravated by
Hormone therapy is not risky used short term in certain the hectic and stress-filled lifestyles of many women today,
populations, but with older women and with long-term use which easily bring the Liver wood phase out of balance.
the risks increase. A woman must therefore measure her Below are a few short cases from my clinic where I chose
relative personal risk when making the decision to use HT something other than the classic go-to Kidney yin vacuity
for any amount of time. This is often not an easy decision. A formula Zhi Bai Di Huang Wan (Rehmannia pill with
single treatment approach is likely to be insufficient because Anemarrhena and Phellodendron).
the syndrome can be complex and debilitating. To quote
an author in a New York Times Magazine article discussing Case 1: Yangming block (excess)
her struggle with the decision whether to use HT to treat A 52 year-old female complained of feeling hot and sweaty
perimenopausal mood swings: ‘I’m sorry, but only someone all the time. She had a red complexion and tongue, and
who has never experienced one could describe a day of tended toward constipation and fullness in the middle.
“I would stab everyone I know with a fork if only I could She was thirsty for cold drinks, and complained of feeling
stop weeping long enough to get out of this car’ as a ‘mood irritable and having several years of irregular menses. Her
swing’”’25 Using multiple approaches is likely to have better pulse was excess. I prescribed Bai Hu Jia Ren Shen Tang
outcomes, as discussed in the 2021 JCM article Acupuncture (White Tiger plus Ginseng Decoction) to clear heat from
for Menopause: Evidence Summary, which advocates for the Yangming and replenish fluids (as even an excess patient
more research into combined approaches to give women can have some fluid damage from constant sweating). Note
greater options for assistance during the transition.26 the absence of vacuity signs or symptoms in this patient.
Once the blockage in Yangming was cleared, her symptoms
reduced quickly.

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Myths of Menopause in Chinese Medicine Practice

Case 2: Shaoyang block (excess) Decoction). She was well served by this formula of mixed
A 53 year-old woman reported hot flashes that woke her at warm and cool and blood-moving ingredients.
night, along with anxiety that was much worse with stress.
She had experienced irregular menses for the last seven As we see from these cases, there can be a variety of
years, with brain fog and poor focus, which were also worse presentations in the perimenopausal patient that cannot
with stress. She reported sluggish digestion and slow bowels all be treated with the same formula.
and was generally very restless day and night. Her tongue
showed red edges and tip, and her pulse was wiry and Conclusion
strong. I diagnosed her with a Shaoyang pivot blockage and
prescribed Chai Hu Jia Long Gu Mu Li Tang (Bupleurum There are many common myths of menopause. As
with Oyster Shell and Dragon Bone Decoction). This is one practitioners of Chinese medicine we have a wealth of tools
of my favourite formulas for any kind of heat and agitation at our disposal to treat the ailments associated with the
above, especially when it affects the spirit and there is menopausal transition, and by combining this with patient
blockage in the middle. This patient felt immediately calmer education we can ease the transition and help women enjoy
on this formula, and her heat symptoms diminished. good health into their later years.

Case 3: Mingmen fire not stored (deficiency)

A 48 year-old woman complained of hot flashes and sweats Dr. Caroline Radice, DACM, LAc, has been practising
and feeling intermittently ‘steamy’ day and night, although and teaching on women’s healthcare since 1995 with an
she felt cold after each flash. Her symptoms were worse with emphasis on Chinese herbal medicine. She is on the faculty
fatigue. Her face and tongue were pale, she was generally of the Pacific College of Health Sciences department of
fatigued and reported a poor appetite and soft bowel herbal medicine in New York and an adjunct at several
movements daily. Her urination was frequent and she also doctoral programmes in the US. She is also a co-founder
complained of diminished libido. Her pulse was empty on of the Shen Nong Society, a professional organisation for
both proximal (chi) positions and weak overall. For her I herbalists that has been hosting an annual conference
prescribed Jin Gui Shen Qi Wan (Kidney Qi pill from the since 2017 (www.shennongsociety.org), and a frequent
Golden Cabinet) combined with Li Zhong Wan (Regulate presenter and mentor for the White Pine Circle
the Middle Pill). The inclusion of Fu Zi (Aconiti lateralis (www.whitepinecircle.org). Dr. Radice maintains a private
Radix) and Rou Gui (Cinnamomi Cortex) in Shen Qi Wan practice in New Jersey. Email: [email protected]
focuses on warming mingmen. This patient manifested
with cold and weakness of the Spleen and Kidney Yang; References
fortifying these organs contained the mingmen fire which 1. Furth, C. (1999). A Flourishing Yin: Gender in China’s Medical History,
was floating upward. Because of the deficiency this patient 960-1665. University of California Press: Berkely, 45-46.
2. Singh, A., Kaur, S. & Walia, I. (2002). A historical perspective on
needed long-term treatment. menopause and menopausal age, Bulletin of the Indian Institute of
History of Medicine (Hyderabad), 32(2), 121-35.
Case 4: Heat above/cold below (deficiency) 3. Gold, E. (2011). The Timing of the Age When Natural Menopause
Occurs, Obstet Gynecol Clin North Am, 38(3), 425-440.
A 54 year-old patient complained of what she called 4. Harlow, S., Gass, M., Hall, J.E. et al. (2012). Executive Summary
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5. Hinsliff, G. (2021). There will be Blood: Women on the shocking
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Myths of Menopause in Chinese Medicine Practice

ycx5n2vx> [accessed 22/01/22].

12. Swan: Investigating Health for Mid-Life and Older Women. See
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16. Women’s Health Concern (2020). HRT: Benefits and Risks, available
Did you enjoy an article,
at <https://tinyurl.com/yc6rnn9y> [accessed 22/01/22] and disagree with something,
Pinkerton, J.A.V, Sanchez Aguirre, F., Blake, J. et al. (2017), The
2017 hormone therapy position statement of the North American want to raise a question,
Menopause Society, Menopause: The Journal of the North American
Menopause Society, 24(7), 728-753. start a discussion or
17. Ibid.
18. Constantine, G. et al. (2019). Increased Incidence of Endometrial
offer feedback?
Cancer Following the Women’s Health Initiative: An Assessment
of Risk Factors, Journal of Women’s Health, 28(2), doi 10.1089/ Journal subscribers can now
jwh.2018.6956.
19. US Department of Health and Human Services, Office on comment online on any article
Women’s Health (2019). Largest women’s health prevention study published in the JCM. Simply log in,
ever – Women’s Health Initiative, available at <https://tinyurl. locate the article on ww.jcm.co.uk
com/2p8tcfwb> [accessed 22/01/22].
20. Rossouw, J. et al. (2002). Risks and benefits of estrogen plus and submit your comment
progestin in healthy postmenopausal women: principal results From
the Women’s Health Initiative randomized controlled trial, JAMA, We will invite our authors to take part
288(3), 321-33. See also <www.whi.org> (and remember they also love to be told
21. Cheblowski, R. et al. (2020). Association of Menopausal Hormone
Therapy With Breast Cancer Incidence and Mortality During Long-
if you simply valued their work)
term Follow-up of the Women’s Health Initiative Randomized Clinical
Trials, JAMA, 324(4), 369-380.
22. Ibid.
23. See <https://www.breastcancer.org/risk/factors/hrt>
[accessed 22/01/22].
24. Ibid.
25. Gorney, C. (2010). The Estrogen Dilemma, The New York Times
Magazine, available at https://tinyurl.com/5bmc8n2b>
[accessed 22/01/22].
26. Saunders, N. & Berry, K. (2021). Acupuncture for Menopause:
Evidence Summary, Journal of Chinese Medicine, 125, 56-61.

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