Hot flashes, acupuncture and Traditional Chinese Medicine
Acupuncture continues to top the list of ‘go to’ alternatives for hot flashes. And despite confusion, researchers remain focused on trying to explain (and perhaps overcome) conflicting study findings. That, my dear readers, is a very good thing, as this non-invasive, gentle treatment modality, while not the end all to be all, may one day become as accepted among Western practitioners as pharmaceutical agents are.
The goal of Traditional Chinese Medicine (TCM) and acupuncture as they relate to menopausal symptoms like flashes is to reinforce the kidneys, which according to TCM philosophy, result due to a decline in kidney yin and yang (think: out of balance). As I wrote a few years ago:
TCM and other similar philosophies emphasizes various body systems that together, form a network or grid connected by a meridien, if you will, as well as the relationship of the body to its social and natural environment. Its primary focus on maintaining health and enhancing the body’s ability to fight off disease. TCM will not focus, for example, on treating specific pathogens but rather, on addressing non-specific factors that create disturbances or imbalances within a certain network. TCM also examines how these imbalances may occur in unique parts of a specific system, such as the heart and blood vessels and small intestine (all of which are part of the heart system) and how they change over time. Western medicine, on the other hand, focuses primarily on treating morbidities, or symptoms related to various conditions and diseases. You can read more rabout TCM in this post from September, 2010.
In TCM, menopausal symptoms are believed to be related to a decline in yin or yang in the kidneys. One of the oldest prescriptions in TCM to reinforce kidney energy is known as ‘Qing E Fang’ (QEF) and the first record of its use dates back to the year 960. The preparation is a combination of four key ingredients that are mediated through estrogen receptors and expression, hence, its potential usefulness in menopause. (These ingredients, in case you are interested, are Cortex Eucommiae (whose bark and leaf have an antioxidant effect) Fructus Psoraleae (commonly used for bone health and to treat estrogen associated diseases), Semen Juglandis and Rhizoma Garlic.)
From a Western perspective, there is evidence (albeit preliminary) that suggests that acupuncture actually inhibits the thermoregulatory action of the hypothalmic-pituitary gland that works to create a hot flash. (You can read more about how a hot flash comes about here.) And when study trials are designed with TCM and acupuncture philosophy in mind, they tend to yield positive results – such as a small study that appears online in Menopause journal.
This time, researchers took four groups of women who experienced 20 or more hot flashes a week and assigned them to one of four groups: real acupuncture, sham acupuncture (needles inserted superficially), a 14 herb chinese formulation known as Zhi Mu 14 or a placebo version of the same. Women in all four groups were exposed to licensed practitioners and received TCM diagnoses. An important distinction in this research was that not only did the researchers predetermine 8 standard sites for needle insertion, BUT they also allowed the clinician to use an additional, individual points. In the sham acupuncture group, the acupuncture points corresponded to those used regularly in large clinical trials. Women using the Zhi Mu or the placebo took three capsules daily. And, all women maintained a hot flash and menopause symptom diary.
The findings are intriguing. While Zhi Mu did not appear to have much impact on hot flashes, acupuncture did, resulting in significant improvements in both hot flash frequency and severity as well as in other symptoms. Over the long term, acupuncture also appeared to attenuate bladder and sexual problems as well as joint and muscle aches and pains. Moreover, the findings also suggested that real acupuncture is superior to sham acupuncture in reducing severity and frequency of menopausal symptoms, much more so than other clinical trials. Importantly, the researchers believe that their results, albeit preliminary, are due to standardized plus individualized treatment performed by highly experienced acupuncturists.
Where are the holes? Well, this was a small group of women and Zhi Mu doses were not modified according to individual needs (as they might have been in the real world). They also did not test liver values at the end of the study (evidently Zhi Mu has been linked to liver toxicity in some women) so safety of this particular preparation was not properly assessed. Still, scientific jargon aside, this is what you need to take away from this information:
A very small study that was designed by Western practitioners within the parameters of TCM philosophies once again demonstrated the beneficial effect of acupuncture on hot flashes in particular. When acupuncture is conducted appropriately and by a highly skilled practitioner, positive benefits may be realized.
Before we jump to any future conclusions, it’s time to revisit and consider the value of alternatives for menopausal symptoms. Sometimes a spade simply is not a spade and there is more than meets the eye when you start digging through the details.
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Hot flashes, Traditional Chinese Medicine & JQF – it is time for an Rx change?
I am a huge fan of Traditional Chinese Medicine (TCM), having used various preparations over the past 20 years for numerous ailments. These preparations have been prescribed by a practitioner who is licensed and degreed in TCM and my experience, albeit anecdotal, has been nothing but positive. In fact, I have been using a TCM formulation for several years now to help battle numerous symptoms and in combination with other prescribed herbs, I’ve mostly won. That’s one of the main reasons that I am always intrigued when I stumble upon well-designed studies that demonstrate benefit, like this one in the journal Menopause.
A bit of context
TCM and other similar philosophies emphasizes various body systems that together, form a network or grid connected by a meridien, if you will, as well as the relationship of the body to its social and natural environment. Its primary focus on maintaining health and enhancing the body’s ability to fight off disease. TCM will not focus, for example, on treating specific pathogens but rather, on addressing non-specific factors that create disturbances or imbalances within a certain network. TCM also examines how these imbalances may occur in unique parts of a specific system, such as the heart and blood vessels and small intestine (all of which are part of the heart system) and how they change over time. Western medicine, on the other hand, focuses primarily on treating morbidities, or symptoms related to various conditions and diseases. You can read morerabout TCM in this post from last September.
In TCM, menopausal symptoms are believed to be related to a decline in yin or yang in the kidneys. One of the oldest prescriptions in TCM to reinforce kidney energy is known as ‘Qing E Fang’ (QEF) and the first record of its use dates back to the year 960. The preparation is a combination of four key ingredients that are mediated through estrogen receptors and expression, hence, its potential usefulness in menopause. (These ingredients, in case you are interested, are Cortex Eucommiae (whose bark and leaf have an antioxidant effect) Fructus Psoraleae (commonly used for bone health and to treat estrogen associated diseases), Semen Juglandis and Rhizoma Garlic.)
About the research
For this study, researchers used a formulation based on QEF known as Jiawei Qing’s Fang or, JQF, which used two of the four herbs (Cortex Eucommiae, Fructus Psoraleae) mentioned above. In JQF, they are combined with the herb, Salviae Miltiorrhizae, that has been used specifically to treat gynecological disorders and has properties that are similar to SERMs, drugs that mimic estrogen but are theoretically safer. The 72 women participating in the study were all perimenopausal and had severe and frequent hot flashes; they were randomly instructed to take JQF or placebo daily over 8 weeks. For a month thereafter, symptoms were evaluated using a menopause measure that looks at vasomotor, physical, psychosocial and sexual health). The women also kept daily diaries to record the frequency and severity of their flashes.
Notably, this is one of the first times that perimenopausal women have been the focus of a study that involves TCM. Moreover, in this study, researchers selected a formulation that worked on the kidney and also contained an herb that not only mimics SERMS but also improves blood circulation. And the findings? Women who randomly took JQF not only experienced significant improvements in their hot flashes, but also reported improvements in quality of life in terms of the impact of vasomotor and physical symptoms. Moreover, because Salviae Miltiorrhizae works on blood circulation, they also had reductions in the blood fats (triglyerides) which means that the formulation might also be beneficial in terms of heart disease prevention in menopausal women.
Is it time for a change of Rx for the change? Should you be seeking out a practitioner who can prescribe JQF and advise you on its best use for you? Or is it too early? JQF was well tolerated, although two women were found to have liver measures negatively affected in ways that did not require any medical intervention but did raise a few red flags and calls for more study. JQF represents a seemingly scientifically proven alternatives to hormone therapy. It’s refreshing to watch TCM come out of Asia and be increasingly incorporated into Western philosophy.
Wednesday Bubble: Time to debunk the hype about traditional Chinese Medicine
This week is dedicated to the debunk – debunking the absolute need for anti-anxiety medications (it may be your flashes, not your mood), debunking the myth underlying the lack of published data supporting the use of traditional Chinese Medicine (TCM, e.g. acupuncture and herbal medicine) and debunking the one-sided, endless loop about hormone replacement therapy.
Because Wednesday falls in the middle of the week, I want to focus on traditional Chinese medicine, which is considered part of the offerings that fall under the umbrella of “complimentary and alternative medicine.” As a practice, TCM was created roughly two thousand years ago and refined in the centuries that followed. And yet, Western practitioners continue to question its value because they claim that there is no real evidence supporting its therapeutic effectiveness. No evidence? A quick search on Google yields countless databases, with one example housing over 400,000 studies and abstracts, many of which have been published in reputable Chinese biomedical journals over the past several decades.
The challenge and the solution
Unquestionably, the evidence doesn’t look quite as strong when strict Western methodology is applied to Eastern philosophies without addressing their distinctions. In fact, a prime example of what happens when the paradigm shifts is the ACUFLASH study, which as I reported earlier this year and late last, demonstrated the benefits of acupuncture when the investigator practitioners were allowed to incorporate some invidualized therapy into the mix.
So what exactly does that mean – to incorporate individualized therapy into the mix?
A unique aspect of the ACUFLASH study was the ability of the practitioners to work within a defined framework but with the addition of directing therapy to each participant’s specific needs. In other words, the practitioners met before treatment and agreed on the specific symptoms or conditions they would include in the study as well as the specific acupuncture treatment points they could work on. This organized system meets some of the strict criteria of Western scientific study. However, they could then choose which of the the treatment points would most benefit a given participant’s system imbalance as well as provide possible diagnoses and self care recommendations (e.g. soy, herbs, physical activity and relaxation techniques) which participants were free to add at their own discretion. This ability to work within the confines of both Western and Eastern practice resulted in significantly beneficial results.
TCM versus Western Medicine
TCM and other similar philosophies emphasizes various body systems that together, form a network or grid connected by a meridien, if you will, as well as the relationship of the body to its social and natural environment. Its primary focus on maintaining health and enhancing the body’s ability to fight off disease. TCM will not focus, for example, on treating specific pathogens but rather, on addressing non-specific factors that create disturbances or imbalances within a certain network. TCM also examines how these imbalances may occur in unique parts of a specific system, such as the heart and blood vessels and small intestine (all of which are part of the heart system) and how they change over time. Western medicine, on the other hand, focuses primarily on treating morbidities, or symptoms related to various conditions and diseases.
Another point of distinction is that while Western practice is geared towards treating specific causes and symptoms of a disease, it doesn’t do so well when the causes or influences are less specific or more importantly varied. Sexual desire, or lack thereof, is a perfect example. It’s been demonstrated time and again that certain aspects of menopause or aging, for example, sexual desire, are not only related to physiology but also to environmental factors. And while the addition of estrogen can certainly help to keep vaginal juices flowing, so to speak, it can’t address social, psychological or behavioral factors that might also be influencing that desire.
I have said it before and I’ll say it again: my dream will be fulfilled when East meets West. I’d like to see greater integration of of the two philosophies and less push back from the Western Medical Establishment against TCM. Calling it a ‘sham,’ because it doesn’t fit into the traditional mold, calling it snake medicine because it isn’t based on medical school learnings, and refusing to examine published scientific papers that have been translated, however roughly, into English, does a disservice to the patients who might benefit from the integration of the two.
Since when are hot flashes and mood swings ‘pathologies,’ symptoms of a disease that requires drug treatment?
Isn’t it time to separate fact from fiction, hype from hope and myth from truth. TCM isn’t a sham. And menopause? It can truly be addressed without drug therapy.
Read MoreAlternative medicine and the ‘pause: what your gynecologist is thinking
Women rank among the highest consumers of complementary and alternative medicine for their healthcare, and according to the National Center for Complementary and Alternative Medicine, age matters. In fact, the largest percentage of adults reporting that they use alternative medicine strategies are 50 to 59 years old, and as many as 42% discuss their use with their doctors. However, what does your gynecologist think about complementary and alternative medicine use? Is she or he supportive and what modalities tend to rank highest in terms of recommendations or endorsements? Moreover, how do gynecologists differ in their opinions?
In the U.S., most ob/gyns appear to believe that convention medicine practices for reproductive issues might benefit by the integration of complementary strategies. However, most of the positive beliefs focus on biofeedback, chiropractic, acupuncture or meditation. Conversely, the doctors report that they would not recommend dietary changes or Traditional Chinese Medicine and a majority were not strong supporters of herbal medicine. This is in direct conflict with German gynecologists. But why should we care about the Germans and what they think!!!?
To digress, I don’t know how many of you are familiar with the Commission E Monographs but, they comprise the world’s leading scientific summaries on the use of medicinal herbs in health and disease. In the late 1970s, the German Ministry of Health established Commission E, a panel of experts charged with evaluating the safety and efficacy of the herbs available in pharmacies for general use. In all, the group published 380 herbal monographs that are considered “the most accurate information available in the entire world on the safety and efficacy of herbs and phytomedicines.” Hence, the Germans definitely have a leg up when it comes to alternative medicine, at least when it comes to the use of herbal alternatives.
So, let’s take a look at a similar survey experience newly published in Complementary Therapies in Medicine, in which over 2,500 respondents indicated a familiarity with the use of alternative medicine specifically for menopausal symptoms. Almost all of the gynecologists had some experience with black cohosh, chaste tree berry and St. John’s Wort and believed them to be effective. And the modality that they felt was most effective? Lifestyle changes and alteration (think: change in dietary habits, physical activity, reduction of stress, etc). The least effective strategies, at least in the eyes of German doctors, were yoga, acupuncture and homeopathy.
The researchers point out that the viewpoint of German doctors is important because these practitioners play an important and consistent role counseling women who complain of menopausal symptoms. The same is true for their U.S. counterparts. And yet, despite the wealth of data in the Commission E monographs, many doctors still continue to question effectiveness and scientific evidence supporting the use of alternatives.
Will this make a difference with regard to the choices that women are making? Probably not, because as I’ve been writing for years, one size does not fit all, especially when it comes to weighing the benefits versus the risks of hormone replacement.
The next time you have your annual with your gynecologist, find out what she or he thinks of complementary and alternative and strategies and most of all, ask why. What she or he is thinking might not be aligned with what you find works best for you.
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Hot flashes and Japanese herbal medicine: the lowdown on TU-025
Women who choose to go the alternative route for menopausal hot flashes have few evidenced-based options. Although acupuncture and standardized black cohosh have been shown to be effective in ameliorating hot flashes, others, including red clover and even soy, have been less successful. Consequently, herbal practitioners often turn to Traditional Chinese medicine (TCM) herbal formulations or the lesser known (in the U.S.) Japanese multiherb medicinal formulations known as Kampo. Interestingly, the term Kampo refers to ‘the way of China” and the practice which is several thousand years old is based on TCM.
Kampo is prescribed by over 90% of Japanese gynecologists and is regulated by the Japanese Ministry of Health to insure manufacturing standards and product stability. One of the most popular Kampo agents for perimenopausal hot flash management is an 1,800 year old formulaton known as “keishibukuryogan” or in the US, as TU-025. Comprised of a combination of cinnamon bark, peony root, peach kernal and mountain bark, it active ingredient remains unknown. Japanese data from both the government and the manufacturer demonstrate a very low incidence of side effects and no estrogenic activity, which means that theoretically, it could be safely used by women who have had breast or gynecologic cancers. Nevertheless, its utility in American women has not been known, at least until now.
In a study published in the August issue of Menopause, 178 postmenopausal women were randomly assigned placebo, 7.5 g/daily TU-025 or 12.5 g/daily TU-025 for 12 weeks. All participants reported 28 or more hot flashes a week, had been in menopause for at least a year, had stopped using hormones for at least 8 weeks if they were already using them, smoked less than 10 cigarettes a day and most were slightly overweight or obese (based on body mass index). None were using antidepressants (which studies have shown may help alleviate hot flashes), nor did they have a history of breast or uterine cancer. While the 7.5 gram daily is the dose taken most often by Japanese women, the researchers upped the dose to 12.5 gm daily to account for a larger sized American woman.
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