TCM for Postmenopause

In Western culture, the symptoms of postmenopause are often discussed as if they were dysfunctions. Your patients are not dysfunctional. In Chinese Medicine, we talk about changes in terms of Yin and Yang and how to balance them. Some of those changes include bone and hair loss, skin changes, dryness, and sexual health. None of that is wrong, it’s just change.

These changes often happen after menopausal hot flashes and night sweats have subsided, but not always. Postmenopause is defined as the phase of life that starts after the cessation of menstrual periods for 12 consecutive months. We learn in the Su Wen that there are 7-year cycles for women and menopause happens at about the end of the 7th cycle, at age 49: “the Directing Vessel becomes deficient, the Penetrating Vessel depleted, the Heavenly Gui dries up, menstruation stops, and she can no longer conceive.”

That age varies today, and there are many factors that affect the timing of menopause. Family genetics are the biggest influence: “if a mother goes through menopause at the age of forty-five or younger than [sic] her daughter has a greater chance of experiencing menopause at that earlier age. The same holds true if a mother’s age of menopause is fifty-four or older.” 

Cigarette smoking and exposure to other harmful chemicals such as PFAS (per- and poly-fluoroalkyl substances) may lead to early menopause. PFAS are persistent organic pollutants, sometimes called ‘forever chemicals’ which bioaccumulate in the environment including the air, water, animals, and humans. There is regulation of some PFAS in the US, but many are still made here, and may still be in some of our everyday objects because it doesn’t degrade. “PFAS are used in nonstick cookware, water-repellent clothing, microwave popping corn bags and other food wrapping, and even some cosmetics” 

Alcohol consumption can lead to earlier menopause, but this connection is not well understood. There is no known link between cannabis use and menopause.  

Autoimmune conditions and HIV can lead to earlier menopause. Being underweight can lead to earlier menopause but there is not a link between being overweight and earlier menopause.

“Studies on diet and menopause are hard to digest. For example, diets high in fat, carbohydrates, fiber, and vegetarian diets have all been linked with an earlier age of menopause, but an increased intake of vegetables, legumes, and meat have also been associated with a lower age.”

Surgeries such as hysterectomy, oophorectomy (removing the ovaries), and uterine artery ablation to treat fibroids cause surgical menopause. Some medications like tamoxifen, which is used to treat breast cancer, can lead to earlier menopause. Taking birth control pills can possibly lead to a later menopause because they “work by suppressing the hormones that trigger recruitment of follicles, thus possibly delaying the loss of ovarian follicles that occurs each month with ovulation.”

Giving birth can lead to later menopause and is a reflection of ovarian health.

 In Western medical terms, the “The final menstrual period (FMP) marks menopause—at this point there are one hundred to one thousand primordial follicles remaining and they’re incapable of ovulation. Women don’t know their menopause birthday until twelve months after their final menstrual period, which can be annoying, but medically it only matters when evaluating abnormal bleeding or need for contraception. Postmenopause is the phase after the final menstrual period, but it’s common to also say one is in menopause.” In Chinese medicine terms, postmenopause is called Second Spring. During this time, women’s focus transitions from caring for and raising others to nourishing and caring for themselves:

“When the body begins to undergo the changes that take her through perimenopause, menopause, and beyond, in the Chinese perspective this is a time for celebration in a woman’s life, when she is possessed of wisdom and graceful beauty. This positive outlook on aging stands in stark contrast to the Western stigma against growing old. Second Spring describes an important opportunity for self-discovery and renewal in women’s lives.”

 In this article, we’ll discuss postmenopausal changes in terms of Chinese medicine patterns and some herbal formulas and acupuncture points to address them. We’ll also discuss complementary lifestyle recommendations.

According to Chinese medicine, Kidney Jing (Essence) declines as women age. Jing has both Yin and Yang parts. As Jing declines, Kidney Yin and Yang also decline.

Jing and Blood nourish each other: It is said that “Blood, as a form of Post-Natal Qi, integrates and replenishes Essence; on the other hand, the Essence contributes to making Blood by facilitating the transformation of Gathering Qi (Zhong Qi) into True Qu (Zhen Qi) and by and by being the origin of Bone Marrow which also makes Blood.” Blood becomes deficient when Jing declines and vice versa. Jing also is the source of Heavenly Gui (Menstrual Blood) and when that dries up, vaginal tissues can become dry and sometimes painful. 

According to Traditional Chinese Medicine, blood and Body Fluids (Jin Ye) together make up Yin. When Yin declines, so do blood and body fluids. This can manifest as dry eyes, skin, brittle nails, cough, and hair loss. In TCM terms, Blood Deficiency can sometimes lead to Blood Stagnation, which may turn into Heat.

A pattern of Damp-Heat can cause pain in the vaginal tissues or vulva. Damp-Heat has a few origins. It is said that “External Dampness easily invades the leg channels to settle in the genital system . . . Dampness often mixes with Heat and gives rise to Damp-Heat.”  It can also come from eating too much hot, spicy, and greasy foods. Emotions like anger, frustration and resentment can also cause Liver Qi to stagnate, which can become Liver Fire, and mix with Damp-Heat.

TCM Patterns with Corresponding Herbal Formulas and Acupuncture

Kidney Yin Deficiency

This pattern may include dry skin, dry eyes, vaginal dryness, dry cough, possibly with deficiency heat signs such as malar flush, five palm heat, and afternoon fever. There may be urinary frequency or incontinence because the urethra has a “decline of estrogen in much the same way the vagina does, that is, becomes thinner and drier and prone to irritation. This can cause frequent urges to urinate even when the bladder is not full. If the tissue thins and loses elasticity too much, incontinence of urine can result.” 

The tongue may be red with geographic coating, or no coat and the pulse may be thin and rapid. Acupuncture points to consider are Lung 7 and Kidney 6 (confluent points for the Ren channel, regulates water passages), Spleen 6 (meeting point of the Yin channels, regulates urination and the genitals), Ren 4 (meeting point of Ren and Yin channels, strengthens Yuan Qi, Jing, nourishes the Kidneys), Kidney 3 (Source point of the Kidney channel, nourishes the Kidneys and clears deficiency Heat), and Kidney 2 (Fire point of the Kidney channel, clears deficiency Heat). 

Some TCM formulas to consider are:

• Gu Ben Tang, which nourishes Kidney, Lung, and Stomach Yin 
• Yu Quan Tang to nourish Yin, generate body fluids, and clear Heat 
• Zhi Bai Di Huang Tang nourishes Kidney Yin, quells deficiency Fire, and clears Damp-Heat from the lower jiao.       

There are some modifications of Zhi Bai Di Huang Wan that address specific symptoms:

• Qi Ju Di Huang Tang nourishes Liver and Kidney Yin and Liver Blood and benefits the eyes. The signs may include blurry vision and dry irritated eyes. 
• Ming Mu Di Huang Tang also nourishes Liver and Kidney Yin, clears Heat, extinguishes Wind, sedates Liver Yang and benefits the vision. Being a more complex blood nourishing formula than Qi Ju Di Huang Wan, the signs may also include headaches and tinnitus.   

Kidney Yin and Yang Deficiency  

Signs may include hot flashes alternating with cold, night sweats, heat rising to the head, frequent urination, and low back pain. Acupuncture points may include: Kidney 3 (nourishes Kidney Yang and Yin), Lung 7 and Kidney 6 (confluent points of the Ren channel), Ren 4 (nourishes the Kidneys, regulates the lower jiao), Spleen 6 (meeting point of the Yin channels, regulates urination and benefits the genitals), Bladder 23 (Back shu point of the Kidneys, regulates water passages, strengthens lower back) and Bladder 52 (Nourishes the Kidneys and Jing, strengthens lower back).

• Er Xian Wan (Two Immortals) - nourishes Kidney Yin & Yang and nourishes Jing. Signs for this formula may include vaginal dryness, decreased libido, and frequent urination. In his article about Osteoporosis and TCM, Skye Sturgeon writes “This formula has been proven to have anti-osteoporotic actions comparable to estrogens and has attributed enormously to the prophylaxis or therapy of bone loss caused by ovariectomy.”  

Kidney Yang Deficiency 

Signs may include feeling cold alternating with hot flashes, pale face, back pain, and ankle swelling. There may be a pale, swollen tongue with a wet white coat and a deep, weak pulse. Acupuncture points may include: Lung 7 and Kidney 6 (confluent points of the Ren channel), Kidney 3 (Source point of the Kidney channel), Ren 4 (meeting point of Ren and Yin channels). Use moxibustion to warm the lower jiao), Kidney 7 (Jing-River point of the Kidney, Strengthens lower back, for cold and hot bones), Bladder 23 (Back shu point of the Kidneys) and Bladder 52 (Nourishes the Kidneys and Jing, strengthens lower back).

• Jin Gui Shen Qi Tang warms and nourishes Kidney Yang. Signs may include cold sensations, low back and knee pain, frequent urination, and low libido. 
• Jin Suo Gu Jing Tang addresses low libido and frequent urination or urinary incontinence.
• Wu Zi Yan Zong Tang can be used for the same signs with blurry vision, and possibly visual floaters from Kidney and Liver Blood & Yin Deficiency  

Kidney Deficiency and Jing Deficiency   

Signs may include Joint pain, low back pain and bone loss are some of the signs of Kidney Yang and Jing deficiency. Acupuncture points are similar to those for Kidney Yang deficiency plus Bladder 11 (Hui Meeting point of Bones, benefits bones and joints) and Du 14 (meeting point of the Du and Yang channels, benefits the spine), and Bladder 47 (for bone and joint pain). Spleen 21 can be used for whole body pain and Gallbladder 31 can be used for lower body pain. 

• Ge Jie Da Bu Tang (Gecko Tonic Teapills) nourishes Yang, Qi, Blood and Jing.
• Yao Tong Tang nourishes Kidney Yang, Qi, and Blood and strengthens tendons and bones.

Skye Sturgeon discusses some of the herbs in these formulas in depth in his article on Osteoporosis and TCM.

Blood Deficiency  

Signs for this pattern may include dry skin, hair, eyes, brittle nails. There may be a pale tongue and a thready or weak pulse. Acupuncture points may include: Liver 8 (He-Sea point of the Liver channel, Nourishes Blood and Yin), Stomach 36 (He-Sea point of the Stomach channel, nourishes Qi, Blood, and Yin), Bladder 17 (Hui Meeting point of Blood, nourishes Blood), Bladder 18 (Back Shu point of the Liver, nourishes Liver Blood), and Spleen 6 (meeting point of the Yin channels, Harmonizes the Liver, Tonifies the Kidneys and the Spleen). If there is itching, add Large Intestine 11 (eliminates Wind and alleviates itching), Du 14 (expels Wind and clears Heat), and Gallbladder 31 (eliminates Wind and itching).

• Shou Wu Pian nourishes Blood, Liver and Kidney Yin and Jing. This contains just He shou wu. Signs may include dry, greying hair and hair loss, dry skin, and brittle nails. 
• Qi Bao Mei Ran Dan Wan also contains He shou wu plus more herbs to nourish Liver and Kidney Yin such as Niu xi, Gou qi zi and Tu si zi
• Dang Gui Yin Zi Tang nourishes and cools the Blood and stops itching. Signs may include chronic dry, itchy skin.

Damp-Heat in Lower Jiao 

Signs for this pattern may include genital soreness, redness, and swelling. There may be a red tongue with red sides, a greasy or dry yellow coat and a slippery, rapid, or wiry pulse. Acupuncture points may include Ren 3 (meeting point of the Ren and Yin channels, drains Damp-Heat in the lower jiao), Ren 2 (meeting point of the Ren and Liver channels, regulates the lower jiao), Gallbladder 34 (Clears Damp-Heat), Liver 4 (moves Liver Qi in the lower jiao, clears Heat), Spleen 9 (clears Damp) and Spleen 6 (clears Damp and harmonizes the lower jiao). 

• Long Dan Xie Gan Tang clears Damp Heat from the Lower Jiao, and cools Liver Fire. 

Vulvodynia is an umbrella term for chronic pain or discomfort in the vulva usually caused by hypersensitivity of the vulval nerve fibers with symptoms that include burning, soreness, or irritation. In her practice, acupuncturist Jennifer Dubowsky sees this in women in their teens up to their 50’s and 60’s. About 16-17% of women experience it. Jennifer says a combination of acupuncture, herbs and topicals is most effective to treat vulvodynia. When using topicals, Jennifer says to make sure they don’t have propylene glycol, which is a vulva irritant. There are topical vulva balms, lubricants, and washes available that may relieve pain. 

Don’t Forget the Shen

When treating women who are in postmenopause, please remember their Shen. Regular acupuncture treatments that support their underlying patterns are important and so is the connection with their practitioner. Don’t underestimate the value of hands-on treatments and spending time with patients.

If your patient asks about her Chinese Medicine diagnosis, explaining the idea of balancing Yin and Yang may be more useful than saying they are ‘deficient’ in Yin, Yang, Blood, or Jing. Clinical words about postmenopause symptoms like ‘atrophy’ and ‘dysfunction’ may not be the most comforting to our patients.

There is body shame, ageism, othering, and mystery in our culture surrounding menopause and postmenopause. For example, women may be frustrated and embarrassed by frequent urination or incontinence. Insomnia, either trouble falling asleep or staying asleep, can lead to fatigue.  Pelvic pain and vaginal dryness can affect a woman’s sex life and may lead to stress or fear of sex.  Cultural perceptions around aging are reflected by our culture’s “anti-aging” bias and may be stressful for our patients.

Essential oils can be used in a Traditional Chinese Medicine context like Chinese herbs. For example, Mei Gui Hua (Rose) Nourishes Yin and clears empty fire; clears heat in the blood; and establishes Heart and Kidney communication. Aromatherapy also helps access healing on an emotional and spirit level. 

TCM Nutrition: More than just bone broth

At menopause, when estrogen production decreases, bone building does too. Osteoporosis happens when “the cells that remove bone matter do so at a disproportionately faster rate than the cells that build it, leaving empty space in the bones, which become brittle and prone to fracture.”  

 Bone broth, which is very popular right now, is a great way to get calcium in your diet to strengthen bones and protect against osteoporosis. If patients want to make their own bone broth, I recommend the recipe in Nishanga Bliss’ book Real Food All Year. What are the options for vegetarians? There are two vegetarian calcium soups mentioned in Paul Pitchford’s Healing With Whole Foods. One is a soup made with barley and kale. The other is a tonic for the Kidneys and includes beans and seaweed. Consider making a raw herb formula customized to your patient's constitution that they cook with the above soups.  

It is also important for patients to add foods to their diet to support the TCM patterns discussed earlier.  

Foods that nourish Kidney Yin include:

Millet, barley, wheat germ, tofu, string bean, black bean, black soybean, mung bean and its sprouts, kidney bean, kudzu root, potato, water chestnut, black sesame seed, watermelon and other melons, blackberry, mulberry, blueberry, huckleberry, sardine, clam, crab, eggs, pork.  

Foods that nourish Kidney Yang include:  

Basil, chive seed, dill seed, garlic, lamb, sage, star anise, cinnamon bark, fennel seed, dried ginger, raspberry, chestnut, clove, fenugreek seed, nutmeg, rosemary, walnut, savory, and thyme.  

Foods that nourish Blood include:  

Apples, egg (chicken and duck), honey, pineapple, rabbit, tomato, asparagus, duck, kidney bean, mango, pomegranate, watermelon, lemon, pear, pork, yam, dark leafy greens, watercress, apricot, dandelion, date, spinach, fig, nettle, parsley. 

Foods that drain Damp include:  

Adzuki beans, green tea, lemon, buckwheat tea, daikon, mustard leaf, pumpkin, scallion, celery garlic, onion, radish, turnip, daikon, horseradish, kelp, oats, pear, turnip greens, apples.  

Foods that clear excess Heat include:  

Asparagus, banana, elderflower, lettuce, mung bean and its sprout, eggplant, chicken egg white, grapefruit, millet, peppermint, tofu, bamboo shoot, lemon, potato, watermelon.

Emphasizing foods to add to the diet can be a more positive, less punitive way of approaching nutrition with patients than what to avoid, although I also recommend that patients reduce the four whites (sugar, salt, white flour, and dairy, especially cow dairy) to reduce general inflammation  and mitigate the symptoms of postmenopause.  

Lifestyle Recommendations 

Exercise: Support through movement for mind, body, and spirit.   

According to physician and yoga expert Mary Schatz, M.D., “...yoga can stimulate the bones to retain calcium, provided the body gets enough calcium in the first place. It does this through weight-bearing poses (like arm balances, inversions, and standing poses) that affect the whole spine, arms, shoulders, elbows, legs, knees, ankles, and feet, while encouraging full range of motion.”   

Other weight-bearing exercises include walking, running, Tai Chi and Qi Gong for 20 minutes, at least three to four times a week. It’s important to note that herbs and calcium supplements “...alone will not prevent bone loss. You must pound the calcium into your bones with walking and other exercises that put weight on your bones.”  

Pelvic floor physical therapy may be helpful for women experiencing discomfort during sex. As Jennifer Dubowsky says, “Kegels don’t always help.” A trained pelvic floor physical therapist can assess if muscles are tight, weak, or a combination of both.   

Gender-Affirming Care  

Not everyone who experiences menopause and postmenopause identifies as a woman. It’s important to respect our patients’ gender identity. Lasara Firefox Allen is a Genderqueer Menopause coach. They write that gender-affirming care “requires healthcare providers to recognize and respect the diverse identities and experiences of genderqueer individuals. By prioritizing inclusivity, cultural competency, and collaboration, medical professionals can support genderqueer folx through this significant life transition with empathy, dignity, and respect. Together, we can create healthcare environments that affirm and empower all individuals, and honor gender diversity.” 

There is more information on working with Transgender patients from a TCM perspective in Katrina Hanson’s Integrating Yin Yang Theory in Transgender Care article and in her online courses.   

Conclusion

How can we support our postmenopausal patients to age well and with ease? We can start by diagnosis in terms of the TCM patterns we see. We balance Yin, Yang, Qi, Blood, and Jing. We offer them lifestyle advice that may include nutrition, exercise, and complementary therapies. We find language that affirms who our patients are as individuals. We sit with our patients, listen to them, address their concerns compassionately, and we help them to celebrate this time in their life.

Resources:

• https://www.pacificcollege.edu/news/blog/2014/11/29/tcm-solutions-for-osteoporosis
• https://www.yogajournal.com/lifestyle/health/womens-health/bone-up/
• https://my.clevelandclinic.org/health/diseases/21837-postmenopause
• https://jenniferdubowsky.com/lets-talk-about-vulvas-and-vulvodynia/
• https://jenniferdubowsky.com/vulvodynia-acupuncture-and-chinese-medicine/
• https://jenniferdubowsky.com/my-book/adventures-in-chinese-medicine/
• https://longwhitecloudqigong.com/how-qigong-helps-with-osteoporosis/
• https://www.mayway.com/articles/integrating-yin-yang-theory-in-transgender-care
• 7 Times a Woman, Dr. Lia Andrews, 2013.
  
• The Woman’s Book of Yoga & Health, Linda Sparrowe and Patricia Walden, 2002.  
• Chinese Herbal Medicine Formulas & Strategies, Dan Bensky & Randall Barolet, 2009.   
• Obstetrics and Gynecology in Chinese Medicine, Giovanni Maciocia, 1998.
  
• The Foundations of Chinese Medicine, Giovanni Maciocia, 1989.
  
• A Manual of Acupuncture, Peter Deadman, Mazin Al-Khafaji, Kevin Baker, 1998.  
• Healing with Whole Foods, Paul Pitchford, 1993.
  
• Helping Ourselves: A Guide to Traditional Chinese Food Energetics, Daverick Leggett,1995.
  
• 1 The Menopause Manifesto, Dr. Jen Gunter, 2021.
  
• Second Spring: Dr. Mao’s hundreds of natural secrets for women to revitalize and regenerate at any age, Dr. Maoshing Ni, 2009.
  
• Chinese Medicine Essential Oils: A Materia Medica and Practical Guide to Their Use, Evelyn Robert, L.Ac. and Jefferey Yuen, 2022.
  
• Real Food All Year, Nishanga Bliss, 2012.