Case Studies: Perimenopause

Different herbal treatments work for two women with periomenopausal symptoms.


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As a man, I don’t completely know what subtle changes of estrogen and progesterone can do to a woman’s mood, temperature regulation, energy level, and especially to the regularity of her menstrual cycle. But I hear what women have reported to me in my clinical practice; I keep up on current research; and I have observed the changes in testosterone and probably other hormones in myself over the years. The effects of sexual hormones are profound. Studies show they can influence our behavior, learning ability, and sexual drive.

Over the years, a number of women have come into my clinic for help with what they thought were symptoms related to perimenopause. Perimenopause is the time before the cessation of ovulation and menses that can last for a few months to a year and, rarely, for up to ten or fifteen years. My experience and research tell me that if a woman experiences symptoms common to perimenopause for two or more years, she is more likely experiencing the effects of other health imbalances and not necessarily a drop in estrogen and progesterone due to primary loss of ovarian power.

Perimenopause and hormonal balance

The timing for perimenopause is different for each woman. Some women enter perimenopause in their thirties, but the average age is in one’s late forties or early fifties.

The process of menopause is not like flipping a switch—it’s often a gradual process that takes months or even years. Marked fluctuations in estrogen levels can occur and progesterone levels also decline as ovulation gradually ceases.

The tricky part for a woman and her herbalist is that hormonal balance is affected by a number of other factors besides age, including liver health and bile production, stress, diet, exercise, and overall health. The changes are often vague and inconsistent, so it may be difficult for a woman to identify what exactly is wrong. Such symptoms as reduced energy and sex drive, depression, and forgetfulness can come from a variety of causes, including poor nutrition or from sitting and staring at a computer screen all day. One recent study from Harvard Medical School found that perimenopausal women were twice as likely to experience depression than premenopausal women and four times more likely to be depressed if they also experience hot flashes.

Two different cases

I remember two patients who clearly illustrate why it is difficult to make quick decisions about perimenopause and its effects.

Harriet was fifty-one and had come into the clinic to see if herbal medicine could help her with symptoms her doctor said were related to perimenopause. She described her increasing feelings of irritability, sleeplessness, hot flashes, vaginal dryness, forgetfulness, and loss of interest in sex. According to Traditional Chinese Medicine (TCM), menopause and the time period leading up to it can be related to deficiency syndromes of the kidney, heart, or blood, and might include stagnation of blood and vital energy. Kidney yin deficiency (basically hormonal deficiency) is common. TCM can identify imbalances of other systems, such as the liver system, that can make symptoms of hormonal imbalance worse.

Harriet had a very “wiry” liver pulse, and she reported headaches. Her tongue had a definite purple cast to the sides. These signs and symptoms clearly indicated a stagnant liver condition, and so herbs to reduce stagnation could help her overall condition, along with hormone-regulating herbs.

Claudia was forty-three, and she came into the clinic for the same symptoms as Harriet. She sat quietly as she described her irregular periods, irritability, and hot flashes. I had to listen closely be-cause her voice was low, almost without energy. Her tongue was extremely red with no normal thin white coating, and her pulses were weak and thready.

In Claudia’s case, I wondered if her hormone changes were due to perimenopause or from a simple case of kidney yin deficiency, which is similar to “adrenal burnout.” This is a common syndrome in TCM, often caused by years of overwork, worry, use of stimulants and other recreational drugs, lack of refreshing sleep, and poor nutrition. Unfortunately, hormone tests don’t always provide the answers because during perimenopause, many women will have subtle changes in hormone levels that fluctuate during the month, and these are difficult to measure in the laboratory. Another way to determine the cause of these symptoms is to work with a complete health program and herbs for a period of three months to see if the symptoms clear up. Especially important is the regularity of the menstrual flow and cycle. If the cycle normalizes for an extended time, then symptoms are more likely to be due to a kidney imbalance or other causes rather than weakening ovarian function.

Harriet was more likely experiencing symptoms related to a reduction in ovarian function than Claudia because of her age. And although Claudia could have had ovarian dysfunction, leading to a reduction in progesterone or estrogen, this might have been temporary. One way to find out was the use of the reliable hormone-regulating herb vitex (Vitex agnus-castus). Vitex can increase progesterone levels and gently encourage normal ovarian function. In a woman with ovarian dysfunction, vitex should help her periods normalize and continue. The herb may also help women who have irregular periods due to approaching menopause. Vitex can help make a smooth and more painless transition.

The herbal programs

For Harriet, I recommended vitex and black cohosh (Cimicifuga racemosa) liquid, 2 droppersful with a little water, first thing in the morning, and in the evening, an hour or so after dinner. The black cohosh can reduce hot flashes and works with vitex as a hormone regulator. For depression, the pharmacy blended a tincture for her consisting of St. John’s wort (Hypericum perforatum), lavender (Lavandula angustifolia), and ginkgo (Ginkgo biloba). Because Harriet also experienced periods of anxiousness and sleeplessness, I added California poppy (Eschscholzia californica), 2 to 3 droppersful in a little water, three or four times daily, away from meals. The vitex and black cohosh can help with vaginal dryness, but I also gave Harriet a bottle of “Dong Quai Gin,” a traditional formula containing dong quai root (Angelica sinensis). She agreed to take 1 teaspoonful of the liquid before meals.

For Claudia, I gave a pure vitex liquid. Her herbal program also consisted of a complete tonic for her kidneys, which included rehmannia (Rehmannia glutinosa), American ginseng (Panax quinquefolius), reishi (Ganoderma lucidum), ligustrum (Ligustrum spp.), and white peony root (Paeonia lactiflora). Because Claudia seemed to lack pizzazz, she may have been suffering from some yang deficiency as well. So I had her drink a tea of gingerroot (Zingiber officinale) with some added American ginseng when she could.

The results

The results were surprising. Because Harriet’s periods stabilized, her symptoms declined over the next six months, and as of this writing, her periods were still going eighteen months later! Whereas Claudia’s symptoms improved, especially her energy level and mood, her periods stayed irregular and have nearly stopped. A saliva hormone test indicated that her estrogen and progesterone levels were low. She might have been moving into early menopause. I wanted to keep working with her to help bring more balance and strength to all her internal organs, especially her hormonal system. We needed a little more time to determine if she really was approaching menopause. Her periods actually stopped altogether after about six months. Her doctor didn’t know whether she had entered menopause or not, but thought it likely. She had no hot flashes or any other symptoms, except her menstrual cessation.

Christopher Hobbs’s case studies are gleaned from his thirty years of studying and practicing herbalism. Hobbs, a fourth-generation botanist and herbalist, is an Herbs for Health editorial adviser and licensed acupuncturist. He is the coauthor of Vitamins for Dummies (IDG, 1999) and the author of many other books.

“Case studies” is not intended to replace the advice of your health-care provider.