Cara O. Frank, L.OM.
Several years ago, Jill Blakeway wrote an excellent article discussing how Chinese medicine understands and treats perimenopausal estrogen dominance. In it, she articulated Li Dong-yuan’s yin fire theory, which organizes seemingly opposite symptoms of dampness and yin deficiency, qi stagnation and spleen deficiency into a cohesive, practical method. I was delighted to see that she uses his version of Lǐ Shì Qīng Shŭ Yì Qì Tāng (Summerheat-Clearing Qi-Boosting Decoction) since this has long been a favorite of mine as well.
Many Chinese herbal formulas can be dated back to centuries, if not millennia, ago. They are well documented historically and endure to this day based on their efficacy. They work and surpass the test of time. Despite a wide range of doctors, currents of thought, herbs, formulas, strategies, and diseases, the core architecture of well written Chinese herbal formulas incorporates a kind of synchronous harmony of qi mechanisms: of building and clearing; of holding and moving; of ascending and descending; of expansion and contraction. Herbs are relational: they enhance one another; they control one another, and often they become more than the sum of their parts together.
So why does Jill Blakeway use Lǐ Shì Qīng Shŭ Yì Qì Tāng (Summerheat-Clearing Qi-Boosting Decoction) to treat estrogen dominant premenopausal symptoms when clearly they are not suffering from a summerheat invasion with qi deficiency? She doesn’t. She prescribes it to women because she knows that it supplements the spleen, boosts the qi, regulates the qi, clears heat, dries dampness, and nourishes the yin. In fact, this formula addresses the exact symptoms she encounters in her clinical practice when treating a majority of women. Jill’s clinical and educational experiences in Chinese herbal medicine and women’s health provides her with the competency to know that formulas can be interchanged to treat patterns, not syndromes. While Lǐ Shì Qīng Shŭ Yì Qì Tāng is discussed in older Chinese medical texts as being used to treat summerheat syndrome, when deconstructed, it can address the patterns of qi dynamics and pathologies that manifest as symptoms of estrogen dominance.
Let’s take a closer look at this formula: Formula: Lǐ Shì Qīng Shŭ Yì Qì Tāng (Summerheat-Clearing Qi-Boosting Decoction) [李氏清暑益气汤]
|黄芪 huáng qí Radix Astragali 9-12g|
|西洋参 xī yáng shēn Radix Panacis Quinquefolii 3-4.5g|
|苍术 cāng zhú Rhizoma Atractylodis 4.5-g|
|白术 bái zhú Rhizoma Atractylodis Macrocephalae 4.5-6g|
|麦门冬 mài mén dōng Radix Ophiopogonis 9-12g|
|五味子 wŭ wèi zĭ Fructus Schisandrae Chinensis 3-6g|
|葛根 gé gēn Radix Puerariae Lobatae 6-9g|
|陈皮 chén pí Pericarpium Citri Reticulatae 3-6g|
|青皮 qīng pí Pericarpium Citri Reticulatae Viride 3-6g|
|当归 dāng guī Radix Angelicae Sinensis 6-9g|
|升麻 shēng má Rhizoma Cimicifugae 3-6g|
|泽泻 zé xiè Rhizoma Alismatis 6-9g|
|黄柏 huáng băi Cortex Phellodendri Chinensis 6-9g|
|神曲 shén qū Massa Medicata Fermentata 6-9g|
|炙甘草 zhì gān căo Radix et Rhizoma Glycyrrhizae Praeparata cum Melle 2-3g|
The actions of the formula are: to clear summerheat, supplement the qi, strengthens the spleen, and dry dampness. The symptoms include fever, headaches, thirst, sweating, a sensation of heaviness, and loose stools.
- xī yáng shēn, mài mén dōng and wŭ wèi zĭ create the formula shēng mài sǎn Pulse-Engendering Powder which preserves yin, supplements qi, calms the spirit and stops excessive sweating.
- huáng qí and xī yáng shēn boost the qi and reduce fatigue.
- cāng zhú and huáng băi create the mini formula èr miào sǎn Mysterious Two Powder, which clears heat and dries dampness, especially in the lower burner. This herbal pair can be especially helpful for treating bacterial vaginosis, which frequently occurs in menopausal women as a consequence of vaginal dryness.
- Huáng băi and zé xiè are featured together in the formula zhī bǎi dì huáng wán Anemarrhena, Phellodendron, and Rehmannia Pill. While the first herb is bitter and cold and the latter is sweet and bland, they both settle ministerial fire, thus clearing deficiency heat. For severe sweating, Li also suggests that one add zhī mǔ Anemarrhenae Rhizoma, (along with wŭ wèi zĭ)” to restrain and gather in.”
- All citrus parts regulate the qi. Here, chén pí and qīng pí dry dampness and reduce stagnation. Qīng pí enters the liver channel, and is notable for scattering and lump reducing qualities, making it helpful for breast lumps and ovarian cysts
- Gé gēn along with huáng qí and shēng má, boost and lift the qi. Gé gēn is one of my favorite herbs these days. The range of its applications is broad, so I will limit my comments about how it can be helpful for brain-fog. We know that gé huā; the flower of gé gēn is used to treat alcohol toxicity. Therefore, gé gēn can be used for feeling dizzy and confused. Modern studies show that it can increase cerebral blood flow. In my practice, I include it in most of my formulas for patients with dementia and Alzheimer’s. So, within the context of this discussion, gé gēn may help alleviate brain fog. The second point of interest is that gé gēn is filled with isoflavones: mainly puerarin, methylpuerarin, daidzein, daidzin, and daidzein glucopyranoside. These are some of the same isoflavones found in soybeans. They are especially cardioprotective, but the weak effect on hormones may act as an estrogen agonist, thus balancing the estrogen dominance.
This large and complex formula is a variation of Li’s most iconic formula: Bŭ Zhōng Yì Qì Tāng (Center-Supplementing and Qi-Boosting Decoction). It includes all the hallmarks of his formula construction: Gé gēn, shēng má, and huáng qí raise the clear yang. Huáng qí, bái zhú, and zhì gān căo supplement the qi and strengthen the spleen. Huáng băi, cāng zhú, and zé xiè clear heat and dry dampness. shén qū, chén pí and qīng pí regulate the qi; xī yáng shēn, mài mén dōng and wŭ wèi zĭ nourish the yin and generate fluids.
To illustrate how wide-ranging this formula is, in my book, Case Studies: Eye, Ear, Nose and Throat Disorders, Lǐ Shì Qīng Shŭ Yì Qì Tāng is used to treat a case of Ménière’s Disease. It is interesting to consider other disorders that share similar symptoms and indications for this formula, such as chronic fatigue syndrome, gastroenteritis, environmental allergies, SIBO, and many others.
How can a formula, written initially to treat summerheat pathogen, be helpful to a perimenopausal, estrogen dominant woman? The answer is simple: when the pathomechanisms of a disorder are deconstructed, the formula is spot on. Treat the pattern.
A second perspective:
One of my favorite formulas for the mixed patterns of qi stagnation, heat, and blood deficiency and stagnation is Jīng Jiè Lián Qiào Tāng, Schizonepeta and Forsythia Decoction. This formula was first recorded in the Wondrous Lantern for Peering into the Origin and Development of Miscellaneous Diseases (Zá Bìng Yuán Liú Xī Zhú, 杂病源流犀烛) published in 1773
|荆芥 jīng jiè Herba Schizonepetae 3g|
|连翘 lián qiào Fructus Forsythiae 3g|
|防风 fáng fēng Radix Saposhnikoviae 3g|
|当归 dāng guī Radix Angelicae Sinensis 3g|
|川芎 chuān xiōng Rhizoma Chuanxiong 3g|
|白芍 bái sháo Radix Paeoniae Alba 3g|
|柴胡 chái hú Radix Bupleuri 3g|
|枳壳 zhĭ qiào Fructus Aurantii 3g|
|黄芩 huáng qín Radix Scutellariae 3g|
|栀子 zhī zĭ Fructus Gardeniae 3g|
|白芷 bái zhĭ Radix Angelicae Dahuricae 3g|
|桔梗 jié gĕng Radix Platycodonis 3g|
|甘草 gān căo Radix et Rhizoma Glycyrrhizae 1.5g|
The formula is usually grouped with formulas that dispel wind-heat pathogen. The actions of the formula are to dispel wind, clear heat, clear toxicity, and reduce stagnation.
- Jīng jiè and lián qiào are the chief medicinals that dispel wind and clear heat. You can find this pair in yin qiao san as well. Both are light and ascending. jīng jiè enters the blood, to vent heat from the blood, while lián qiào can clear wei level heat.
- Bái sháo, chái hú, zhĭ qiào, and gān căo create the formula Si Ni San- Four Frigid Extremities powder, which regulates the qi, clears constraint and spreads liver qi.
- Huáng qín and zhī zĭ clear heat. This pair is featured many formulas that clear fire.
- Dāng guī and chuān xiōng harmonize the blood.
- Bái zhĭmight be paired with lián qiào to clear toxic heat. It might also be paired with jié gĕng for this same purpose.
- Gān căo harmonizes the formulas and, along with jié gĕng, benefits the throat.
- Chái hú and jié gĕng have an ascending directional energy, while zhĭ qiào descends. Together, these three opens the chest and alleviates depression. Another formula that features these medicinals is Xuè Fǔ Zhú Yū Tāng House of Blood Stasis-Expelling Decoction.
In relation to our discussion, Jill’s list of common symptoms of perimenopausal, estrogen dominant women can include: Breast swelling and tenderness, anxiety and mood swings, “fuzzy thinking,” irritability, fatigue, loss of ambition, slow metabolism, water retention, loss of libido, PMS, weight gain, insomnia, thickening of endometrial lining, clotted menses, increased risk of uterine fibroid, increased incidence of ovarian cysts.
Lets review how Jīng Jiè Lián Qiào Tāng might address these symptoms:
- PMS, mood swings, breast swelling and tenderness, along with irritability, are easily treated with si ni san.
- Anxiety, irritability, and insomnia can be treated with lián qiào and zhī zĭ, both of which clear heat from the heart and alleviate vexation.
- Bleeding irregularities such as cramps or clotty menses can be treated with dāng guī and chuān xiōng and to a certain extent, jīng jiè and huáng qín.
- Ovarian cysts and breast lumps can be treated with bái zhĭ
- Acne is treated with jīng jiè, lián qiào, fáng fēng, jié gĕng, and bái zhĭ.
Thus, the formula addresses nearly every symptom that might be experienced in a woman presenting with estrogen dominance. In contrast to Qīng Shŭ Yì Qì Tāng, Jīng Jiè Lián Qiào Tāng is more effective for regulating the liver, harmonizing the blood and clearing heat, while Qīng Shŭ Yì Qì Tāng is more effective for spleen deficiency with retention of dampness. If we were to think about the directional energy of the formulas, Qīng Shŭ Yì Qì Tāng is uplifting, while Jīng Jiè Lián Qiào Tāng uses both ascending and descending herbs to open and regulate the qi.
What is the takeaway? The takeaway is to honor this statement: Tóng bìng yì zhìyì bìng tóng zhì. Same disease, different treatments. Different diseases, same treatment. As long as we treat the pattern, not the western diagnosis, we can nearly guarantee clinical results.
About Cara Frank, L.OM.
Cara Frank, L.OM., was raised by beatniks in a health food store in Brooklyn, NY. When she was 8, she cartwheeled 5 miles from Greenwich Village through Soho and Chinatown and across the Brooklyn Bridge. For nearly 40 years, she’s had the same crazy passion for Chinese medicine. At 17, she had her first acupuncture treatment. At 20, she enrolled in acupuncture school. In 1998 she went to China to study where she fell deeply in love with Chinese herbs. Since then, she has devoted her life to studying and teaching the topic.
Cara is the founder of Six Fishes Healing Arts in Philadelphia, where she maintains a busy acupuncture practice and acts as the head fish of warm and lively office. She is also the president of China Herb Company. You can read her full bio or schedule an appointment.