Keywords: Chinese medicine, Chinese herbal medicine, gynecology, perimenopausal depression, Xiao Yao San

In Shi Yong Zhong Yi Nei Ke Za Zhi (Journal of Practical Chinese Medicine Internal Medicine), #12, 2009, p. 57-58, Dong Feng published an article titled, “The Treatment of 45 Cases of Climacteric Depression with Modified Xiao Yao San.” A summary of this article is presented below.

Cohort description:

All 45 cases were seen as outpatients at the An Yang Chinese Medical Hospital in Henan province, all were female, and all were 45-56 years of age. Their course of disease had lasted from three months to three years. Most of the cases presented a depressed affect, tension, agitation, irritability, chest and rib-side distention and pain, a bitter taste in the mouth, a dry throat, headache, red eyes, tinnitus, possible clamoring stomach and/or acid eructation, fatigue, lack of strength, sluggishness, torpid, stagnant movement and activity, difficulty thinking, slowed responsiveness, changes in libido, worry, depression, sorrow, a bitter, oppressed psyche, lots of thinking, lots of worrying, constipation, a red tongue with yellow fur, and a bowstring, rapid pulse. In some cases, there were accompanying menstrual abnormalities.

Treatment method:

All cases were administered the following version of Xiao Yao San (Rambling Powder):

Dang Gui (Radix Angelicae Sinensis), 10g
Bai Shao (Radix Alba Paeoniae), 10g
Chai Hu (Radix Bupleuri), 10g
Fu Ling (Poria), 10g
Bai Zhu (Rhizoma Atractylodis Macrocephalae), 10g
Sheng Jiang (uncooked Rhizoma Zingiberis), 3g, added at the end
Bo He (Herba Menthae Haplocalycis), 3g, added at the end
Zhi Ke (Fructus Aurantii), 15g
Xiang Fu (Rhizoma Cyperi), 10g
Chuan Xiong (Rhizoma Chuanxiong), 10g
Yu Jin (Tuber Curcumae), 10g
Hu Po (Succinum), 3g, added at the end
Gan Cao (Radix Glycyrrhizae), 6g

One packet of these medicinals was decocted and administered per day in two divided doses, once at noon and once in the evening before going to bed. Ten days administration equaled one course of treatment.

If there was heart fire exuberance, 10 grams each of Huang Lian (Rhizoma Coptidis) and Zhi Zi (Fructus Gardeniae) were added to clear the heart and drain fire.

If there was liver fire exuberance, 10 grams each of Ju Hua (Flos Chrysanthemi Morifolii), Gou Teng (Ramulus Uncariae Cum Uncis), and Ci Ji Li (Fructus Tribuli Terrestris) were added to clear the liver and level or calm the liver.

If there was liver depression, 15 grams of He Huan Hua (Flos Albiziae) was added to quiet the spirit and resolve depression.

If there was phlegm heat, 10 grams each of Ban Xia (Rhizoma Pinelliae), Chen Pi (Pericarpium Citri Reticulatae), and Dan Nan Xing (bile-processed Rhizoma Arisaematis) were added to clear heat and dispel phlegm.

If there was heart-spleen dual vacuity, modified Gui Pi Tang (Restore the Spleen Decoction) was added.

If there was yin vacuity, 10 grams each of Mai Men Dong (Tuber Ophiopogonis), Bai He (Bulbus Lilii), and Wu Wei Zi (Fructus Schisandrae) were added.

If there was heart vexation and easy fright, 15 grams each of Long Gu (Os Draconis) and Mu Li (Concha Ostreae) were added.

If there was a predilection to sorrow, easy crying, and no sleeping day or night, 15 grams each of He Huan Hua (Flos Albiziae) and stir-fried Suan Zao Ren (Semen Zizyphi Spinosae) were added.

Study outcomes:

Reduction in Hamilton Depression Rating Scale, the American Psychiatric Association’s Diagnostic & Symptom Manual (DSM), and the Chinese counterpart to the DSM were used as outcomes criteria for this study. Based on these criteria, 35 out of 45 cases were judged cured, nine improved, and four experienced no effect, for a total effectiveness rate of 91.67%.

Discussion:

At the climacteric, it is very easy for there to appear yin and blood depletion and vacuity with liver blood insufficiency. If, on top of that, there is an unfulfilled (unsatisfied, discontented) psyche, the liver may lose its reaching and spreading which then produces repression and depression. If liver depression transforms heat, this produces tension, agitation, and irritability, a bitter taste in the mouth, a dry, throat, etc. Although the Chinese author does not spell out the following, liver depression may counterflow horizontally to attack the spleen. The spleen qi becomes vacuous and weak, and thus there are fatigue, lack of strength, sluggishness, etc. The spleen is the latter heaven root of the engenderment and transformation of the qi and blood and rules upbearing of the clear. Therefore, the heart spirit above may fail to be adequately constructed and nourished, thus giving rise to a disquieted spirit. Further, depressive heat ascending and floating may harass the heart spirit. The spleen also governs the movement and transformation of water fluids. So if the spleen qi is vacuous, fluids may collect and transform into phlegm which may follow the qi upward and also harass the spirit and confound the clear orifices. Since blood and essence share a common source, blood vacuity may give rise to or worsen yin vacuity. If yin is too vacuous to control yang, than yang becomes hyperactive and tends to float upward.

The interesting thing to me about this study is that, unlike so many other Chinese studies on peri- and menopausal complaints, Dr. Zheng does not emphasize yin vacuity as the main disease mechanism. Although she starts by saying that at this stage in a woman’s life, yin and blood vacuity are common, she then goes on to emphasize the role of liver depression in the disease mechanisms and treatment of this condition. Certainly it is my own clinical experience that the duration, severity, and recalcitrance of peri- and menopausal complaints are directly proportional to a woman’s liver depression and not to any yin vacuity. If the liver was not depressed, the qi mechanism would not be inhibited and the spleen would make more blood. Therefore, latter heaven essence would be produced to bolster and support former heaven essence. It is the qi mechanism that governs all changes and transformations in the body, and menopause is such a transformation. Peri- and menopausal complaints are mostly symptoms of the qi mechanism being inhibited during the process of this change. Once the woman is able to go through the change successfully, menopausal symptoms disappear automatically because clinical yin and blood vacuities have automatically righted themselves because of 1) the cessation of menstruation and, therefore, periodic loss of yin-blood, and 2) the spleen’s ability to engender and transform qi and blood and, hence, latter heaven essence.

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