Perimenopausal syndrome refers to a constellation of symptoms occurring before, during, and after menopause. These typically include hot flashes, night sweats, insomnia, heart palpitations, emotional depression and/or anxiety, heart palpitations, fatigue, and impaired memory. Recently, some published Chinese research on the Chinese medical pattern discrimination of perimenopausal syndrome has corroborated what I have been saying for several years. I believe that this research has important implications for all Chinese medical practitioners treating perimenopausal complaints in particular and perimenopausal women in general. This research may also help lay the foundation of a truly integrated Chinese-Western medicine. This research was conducted by Ye Yan-ping. Its title is, "A Survey of the Pattern Discriminations of the Chinese Medical Disease Mechanisms in 106 Cases of Female Climacteric Syndrome," published in the October, 2000 issue of Fu Jian Zhong Yi Yao (Fujian Chinese Medicine & Medicinals) on pages 18-19.

Of the 106 women in this study, 13 were less than 45 years of age; 63 were 45-50; and 30 were 51-55. All were seen as out-patients at the Shenzhen Municipal Chinese Medical Hospital in Guangdong. Eleven of these women had experienced menopause as a result of bilateral surgical removal of their ovaries. Of the remaining 95, 50 had already ceased menstruating, while the other 56 were still menstruating. The shortest disease course was three months and the longest was 11 years. Nine cases had accompanying coronary artery disease, nine had hypertension, two had diabetes, five has cerebrovascular sclerosis, and two had osteoporosis.

Four patterns were used in this study: 1) liver depression, 2) kidney vacuity, 3) liver depression and kidney vacuity, and 4) liver depression, kidney vacuity and blood stasis. These were based on criteria found in Zhong Yi Zhen Duan Xue (A Study of Chinese Medical Diagnosis) and Zhong Yi Fu Ke Xue (A Study of Chinese Medical Gynecology).

1. Liver depression pattern: Hot flashes, emotional depression, chest oppression and a tendency to sighing, vexation and agitation, easy anger, insomnia, chest, rib-side, and breast distention and pain, A dry mouth with bitter taste, torpid intake, delayed or sometimes early, sometime late, no fixed schedule menstruation, lengthy menstrual periods, excessively profuse menstruation or flooding and leaking, a red or pale red tongue with white or yellow fur, and a bowstring or fine, rapid pulse

In actuality, Ye has collapsed two separate patterns under this single heading: simple liver depression qi stagnation and liver depression transforming heat.

2. Kidney vacuity pattern: Vexatious heat in the five hearts, night sweats, insomnia, dizziness, impaired memory, fatigue, low back and knee soreness and weakness, tinnitus, blurred vision, profuse dreams, or, cold body, chilled limbs, loose teeth, forgetfulness, a pale or fat, pale tongue with thin, white fur, and a deep, fine or fine, rapid pulse

Once again, Ye has collapsed three separate patterns under a single category. The first set of signs and symptoms are those of liver blood-kidney yin vacuity. The second set are those of kidney yang vacuity, while, in real-life clinical practice, one often sees liver blood-kidney yin and yang dual vacuity.

3. Liver depression & kidney vacuity pattern: A combination of the main signs and symptoms of liver depression and kidney vacuity occurring simultaneously

4. Liver depression & kidney vacuity mixed with blood stasis pattern: A combination of the signs and symptoms of liver depression and kidney vacuity accompanied by headache, low back pain, numbness of the four extremities, chest oppression and/or chest pain, scanty menstruation which is dark in color and may contain profuse clots or flooding and leaking with blood clots, dry, scaly skin, itching, a dark, purplish tongue and/or static macules

In this study group, the pattern of liver depression and kidney vacuity mixed with blood stasis was the most numerous pattern with 34 cases or 32.1%. The second most numerous was liver depression and kidney vacuity with 33 cases of 31.1%. Simple kidney vacuity accounted for 22 cases or 20.8%, and simple liver depression was the least numerous, with 17 cases or 16%. This means that 84% of all the women in this study had some form of kidney vacuity. In addition, serum estradiol (E2) levels progressively decreased beginning with simple liver depression and going to liver depression and kidney vacuity mixed with blood stasis, and there was a marked decrease in E2 from simple liver depression and simple kidney vacuity to liver depression and kidney vacuity and liver depression and kidney vacuity mixed with blood stasis. Of the women under 45 years of age, none displayed a simple liver depression but all displayed mainly kidney vacuity symptoms. Of eight cases in this group of 11 patients with simple kidney vacuity, seven were patients who had been thrown into menopause by surgical removal of their ovaries.

In discussing the above statistics, Ye says that kidney vacuity is the single most important factor in the cause of menopausal syndrome. Of the 50 women who had already stopped menstruating, only five women or 10% displayed simple liver depression patterns, while 90% displayed kidney vacuity either singly or in combination with liver depression and/or blood stasis. Of the 56 women who had not yet stopped menstruation, 21.4% displayed pure liver depression patterns. Thus Ye repeats the traditional assertion that kidney vacuity is the cause of the exhaustion of the tian gui. However, he goes on to equate decline in E2 with kidney vacuity. If further research bears out this relationship between decline of E2 and kidney vacuity signs and symptoms, such decline in serum E2 may be added to the defining signs and symptoms of this pattern in women. This would be a big step forward in the integration of Chinese-Western medicine, and I for one look forward to the day that Chinese patterns can be either established or corroborated by such objective findings as serum analysis.

Secondly, Ye places great importance on liver depression as a disease mechanism in menopausal syndrome. This is somewhat unusual since most Chinese gynecology texts do not include a liver depression pattern under menopausal syndrome (viz. A Handbook of Traditional Chinese Gynecology, Zhejiang College of Chinese Medicine, Blue Poppy Press, 1995). Ye correctly argues that the liver can only carry out its proper functions of coursing and discharging if it receives blood to fill and nourish it, and it should be remembered that, "blood and essence share a common source," and, "the liver and kidneys share a common source." While Ye blames lack of the liver's coursing and discharging for the emotional depression and agitation of menopausal syndrome, I believe the relationship of liver depression to menopausal syndrome goes deeper than that. Based on my own 20 plus years clinical experience, I would say that liver depression is the single most important predictor of the severity and recalcitrance of menopausal syndrome. Menopause is a change in life, and all changes and transformations in the body can only occur if the qi mechanism is freely flowing. Menopause is itself the solution to perimenopausal kidney vacuity due to decline in acquired essence in turn due to aging. Once the menses are cut off and there is no further blood loss or consumption by pregnancy and lactation, kidney vacuity can and usually does recuperate itself. However, if liver depression inhibits the free flow of the qi mechanism, this change cannot be brought to successful conclusion and the kidneys cannot recuperate themselves. As Ye notes, fully 79.2% of the patients in this study did have either simple liver depression or liver depression mixed with kidney vacuity (and possible blood stasis). Therefore, I agree with Ye that one's emotional and psychological state can either lengthen or shorten the course of menopausal syndrome.

Further, Ye also recognizes the importance of blood stasis in the disease mechanisms of this disorder. In my experience, only a few contemporary Chinese gynecology textbooks list blood stasis as a potential pattern associated with menopausal syndrome. However, 31% of the women in this study exhibited symptoms of blood stasis. Since blood stasis may be the result of liver depression, liver blood-kidney yin vacuity, or kidney yang vacuity with vacuity cold, it is easy to see why liver depression and kidney vacuity is so commonly complicated by blood stasis. However, once one has static blood, it is difficult to engender fresh blood, and it is blood which is ultimately transformed into essence. Therefore, it should also be easy to see how static blood may impede the curing of liver depression and/or kidney vacuity. Interestingly, the rate of developing high cholesterol, hypertension, coronary artery disease, and other diseases with a high degree of association with blood stasis rises postmenopausally. Therefore, in clinical practice, due consideration should be given to quickening the blood and transforming or dispelling stasis, both remedially for menopausal syndrome and preventively for these other conditions.

While Ye's study does, I think, point out some interesting facts in terms of menopausal syndrome and Chinese medical pattern discrimination, I am surprised that he did not include any pattern including the spleen. Most contemporary Chinese gynecology texts include two spleen patterns under perimenopausal syndrome: spleen-kidney yang vacuity and heart-spleen dual vacuity. In my experience, it is spleen vacuity in the mid 30s which leads to the kidney vacuity of the mid and late 40s, and one rarely sees kidney yang vacuity in perimenopausal women without concomitant spleen vacuity. Likewise, it is difficult to find liver depression without spleen vacuity due to the close reciprocal relationship between these two viscera. If one adds in spleen vacuity and all its ramifications into the mix of complicated, multipattern presentations described above, then I believe one will have a truer, more accurate picture of the majority of perimenopausal patients. Therefore, I would have started with a liver-spleen disharmony pattern (i.e., liver depression and spleen vacuity) as my first pattern and worked from there.