By Steve Clavey
Interested in this topic? Read our other blog post on menopause
This article first appeared in The Lantern, a Chinese medicine journal with a focus on Chinese herbal medicine. While the intended audience is Chinese medicine practitioners the article provides an insight into an interesting menopausal symptom as well as the way Chinese medicine practitioners analyse, diagnose and treat conditions.
There is a menopausal pattern that occurs quite frequently, at least in Australia and I suspect in most Western countries, but has not as yet appeared in the literature—as far as I know.
The woman presents with hot flushes; they can be frequent or rare, mild or intense, but the one thing that these flushes have in common is that they are focused primarily in the head. This is not to say that there is no heat in the back or legs, but the head is the hottest. She complains of going red in the face and, if she sweats, it is mainly or even exclusively on the head.
In fact, this peculiarity of the sweating was the characteristic that led me to start to
notice this particular pattern. These women often do not sweat on the body, but do sweat profusely from the head. In trying to figure out why this occurred, I came to realise that the cause was subsurface fluid retention: fluid or dampness in the tissues and flesh. Because heat can not reach the surface to dissipate, the woman becomes, in effect, a chimney.
All the heat is being funneled upward to the only place that does not have much flesh: the head.
What is interesting is that the internal heat need not be excessive. Simply by being unable to vent itself in the normal way through the pores all over the surface of the body, even just normal heat created by the usual activity will be concentrated into the much smaller area of the head, and therefore experienced as excessive. In such women, the tongue will not necessarily be red, because the heat itself is normal heat, and the tongue will often just be a normal light pink, or even pale if yang deficiency is a contributing factor to the creation of the fluid metabolism disruption.
The pulse, too, while usually slippery, will not only not be rapid, it could well be languid (huán).
Of course, if there is too much heat being produced internally, the symptoms of redness in the face, sweating from the head and disturbing hot flushes will feel even worse. In this case the pulse will feel slippery and slightly rapid (the speed being somewhat slowed by the dampness) and the tongue will be red.
Another characteristic of the pattern is that when the weather is cold, or in cold rooms, these women will be slow to warm up. Once they do warm up, however, they often suddenly become too hot and have to throw everything off again. All of this can be explained by the subsurface fluid retention, which prevents normal warming circulation from reaching the tissues. Once it does reach the tissues, however, it can quickly become too much, since the normal avenue of regulation—through the surface tissues and pores—is obstructed by the retained fluids.
Whether the fluid is pathogenic water, or the fog-like dampness, can be seen from
the tongue and the tongue coat. If the tongue is slightly swollen with tooth marks, pathogenic water is likely to be the culprit, whereas if the tongue coat is slightly thicker than normal it is probably dampness. The treatment for both are the same (at least at this stage of my appreciation for the pattern) so differentiation of the two is not crucial.
The treatment approach
The treatment is to leach dampness and fluids away from the tissues. Here is where
Chinese medicine theory is very helpful. Su Wen chapter five says:
In the heavens it is dampness, in the world it is earth, in the body it is flesh, among organs it is Spleen, in colour it is yellow, in tone it is 'do', in sound it is singing, in movement it is reflux, in orifice it is the mouth, in flavour it is sweetness, in mind it is thinking.
Thinking injures Spleen, fury overcomes thinking; dampness injures the flesh, wind
overcomes dampness; sweets injure flesh, sourness overcomes sweetness.
To leach dampness (earth) away from the tissues of flesh (earth), the flavours should
be bland and sweet (ie. the earth flavours), which cover both Spleen and Stomach. As the Ling Shu chapter 78 says: Of the five (sic) flavours, sour enters the Liver, acrid enters the Lungs, bitter enters the Heart, sweet enters the Spleen, salty enters the Kidneys, and bland enters the Stomach.
While guided by the general principle of using bland flavours to leach dampness away from the surface tissues in order to allow heat to dissipate normally out through the pores, in practice the actual herbs used will vary to match the peculiarities of the individual patient. That said, a typical prescription would look something like this:
Discussion of herbs
Fu Ling Pi (Poriae Cutis) aims at the surface tissues and is better at leaching damp than Fu Ling (Poria), although it is less Spleen tonifying. The follow-up treatment should aim more at tonifying Spleen but the present goal is to clear the pathogenic fluids from the surface tissues. Chi Fu Ling (Poria rubra), because of its redness, has an affinity with the blood and so can remove dampness from the blood level, but the primary reason for using it here is that the smaller blood vessels travel in the flesh, which is our target tissue; also Chi Fu Ling is better than Fu Ling at separating dampness from heat.
Tong Cao (Tetrapanacis Medulla) is sweet, bland and cold and enters the Lungs and Stomach; it promotes the movement of the fluid pathways so that heat is carried down and out through the urine. Notably, however, the effects of Tong Cao can both ascend and descend, and thus it helps restore normal rising and falling throughout the San Jiao as well as the in-and-out (chü rù) action through the pores and surface tissues.
Che Qian Cao (Plantaginis Herba) operates more generally through the body and is
thus my first choice when damp is widely distributed. Che Qian Zi (Plantaginis Semen) is more focused on promoting urination, but this may be the preferred herb if urination is scanty or difficult. Ze Xie (Alismatis Rhizoma) is sweet and cold with its primary action in the lower Jiao where it opens urination to drain away the damp that has been leached from above.
Hua Shi (Talcum) is sweet, bland and cold; the sweet flavour protects and harmonises earth, the bland flavour leaches out pathogenic dampness, and the cold cools heat. It is also slippery and promotes dispersal of obstructions through the orifices.
Yi Yi Ren (Coicis Semen) specifically expels damp pathogens from the flesh.
Several herbs in the formula are not bland. Yin Chen Hao (Artemisiae scopariae Herba) is cold, slightly bitter, and fragrant so that it disperses pathogenic damp and leads heat downwards and out through the body. Shan Zhi Zi (Gardeniae Fructus) is lightly bitter in flavour, which drains and parches damp; it is cold in nature, so it cools; overall it drains heat down through the San Jiao. It is used here to give a rapid cooling effect so that the patient is comfortable while the slower process of leaching the pathogenic dampness is taking place. After the dampness has been leached away, of course, the surface tissues and the pores will work so that heat will be vented normally.
Chen Pi (Citri reticulatae Pericarpium) and Shi Chang Pu (Acori tatarinowii Rhizoma)
are both pungent, warm and fragrant, andharmoniously enter the middle Jiao (ie. the earth) to lightly disperse turbid-damp and assist the ascent of clear yang.
When one is encouraging downward movement to drain dampness through the
urination, it is important to also remember the effect this may have on Spleen qi, which should be ascending. The fragrant warmth of Chen Pi (Citri reticulatae Pericarpium) and Shi Chang Pu (Acori tatarinowii Rhizoma) helps to keep the rising clear yang from being dragged downward, and thus preserve this ascending function of Spleen qi intact.
Some Variations
When the patient is hotter, more directly cooling herbs could be used, even up to Shi Gao (Gypsum fibrosum) which itself is pungent and disperses the surface. When patients are addicted to coffee I find Shi Gao is particularly useful as it counters the intensely fiery effect of the coffee on the Stomach channel. A minimum dose is 30g in any case, and I am quite comfortable using up to 90g when needed.
If the patient does not have excess heat, and instead has hot flushes only because the heat is being channeled upward via the action of the obstructing pathogenic damp in the surface tissues, they may have a pale-red or even distinctly pale tongue. In the latter case, one might even consider using Wu Ling San (Five Ingredient Powder with Poria), as the Gui Zhi (Cinnamomi Ramulus) will assist
the qi-transformation function not only of the Bladder but also of the protective qi that governs the functioning of the pores.
Additional Notes
- The pattern for Zhu Ling Tang (Polyporus Decoction) is close, however, and I have used it often in menopausal situations. The pathology described in this article puts the prohibition against using Zhu Ling Tang in cases of profuse sweating in a new light: if the sweating – even if profuse – is only on the head, then the danger of severe damage to the fluids is reduced, and the formula can probably be used safely.
- When talking about tones in the Su Wen, the five tones are gōng, shāng, jué, zhi and yŭ, which are generally equivalent to do, re, mi, so, la.
- When referring to “Movement” in the Su Wen the meaning is biàn dòng, meaning an action that indicates a change. Each of the five elements and their organs has an indication, eg. for the Lungs it is cough (kài), for Liver it is grasping (wò), for Kidneys it is trembling (lì), and for Heart it is melancholy (yōu).
- Further discussion of how Tong Cao can both ascend and descend: The Ben Cao Gang Mu (Grand Materia Medica) explains: “Its nature is cold, so it descends; its flavour is bland, and so it ascends.”
- If the tongue is slightly swollen with tooth marks, pathogenic water is likely to be the culprit, whereas if the tongue coat is slightly thicker than normal it is probably dampness.
- When patients are addicted to coffee I find Shi Gao is particularly useful as it counters the intensely fiery effect of the coffee on the Stomach channel.
Interested in this topic? Read our other blog post on menopause
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