Questioning Menopause Part Two

Originally published Nov. 5, 2019

MENOPAUSE PART TWO: WHAT’S IN THE TEXTS?

In the first part of this discussion of menopause, I hopefully established the unique nature of the modern biomedical notion of a female-specific “menopause.” In particular, what I wanted to emphasize was the uniqueness of the biomedical and increasingly popular attitude worldwide of MEDICALIZING and PATHOLOGIZING the naturally occurring cessation of women’s monthly bleeding cycle. In other words, I want to encourage you to think critically about the basic premise of the concept of menopause as a pathology, as a condition in need of medical intervention, rather than a naturally occurring process. From this perspective, the biomedical concept stands out as an exception among other medical paradigms, rather than representative.

In this context, we can finally attempt to answer the innocuous-sounding question posed at the beginning of this discussion: How do the Chinese classics talk about menopause? To be meaningful, our inquiry has to be expanded a little beyond the obvious and technically correct answer:

Since the concept of “menopause” does not even exist in traditional Chinese medicine or language, the medical classics do not talk about it at all.

That may be the case, strictly speaking, if we define “it” narrowly as the “pathology of age-related cessation of monthly bleeding.” As contemporary practitioners of Chinese medicine in our modern biomedicalized society, however, we still need answers for our friends, family members, and patients who come to us with conditions that they experience as pathological. So how do the classical texts discuss the aging process of women, especially in contrast to that of men? And how might these descriptions be used in the contemporary context?

The obvious place to look for answer is the “Treatise on Heavenly Perfection in the Ancient Past,” better known as The Yellow Emperor’s Inner Classic, Sùwèn Chapter One:

The Yellow Emperor asked: “Concerning the reason why people age over the years and lose the ability to bear children, is it because their raw material and strength are used up? Or is it a matter of heavenly calculations?”

Qí Bó replied: “When girls are in their seventh year of life, their kidney qi begins to flourish, their teeth change, and the hair on their head grows long. In their fourteenth year, the tiānguǐ arrives, the flow in the Rènmài penetrates, the great Chōngmài is exuberant, and the menses descend in a timely manner. Therefore they can have children. In their twenty-first year, the kidney qi is balanced and even. Therefore the true [i.e., wisdom] teeth are born and growth reaches its limit. In their twenty-eighth year, the sinews and bones are firm, the growth of head hair has reached its limit, and the body is exuberant and strong. In their thirty-fifth year, the Yángmíng vessel weakens, the face becomes scorched, and the hair begins to fall out. In their forty-second year, the three yang vessels weaken above, the face is scorched all over, and the head hair begins to turn white. In their forty-ninth year, the Rènmài is empty (xū), the great Chōngmài is weakened and reduced, the tiānguǐ is exhausted, and the pathways of the earth are impenetrable. Therefore their physical body becomes decrepit and they can no longer [bear] children.

In their husbands, in the eighth year of life, the kidney qi is full (shí), the hair on the head grows long, and the teeth change. In their sixteenth year, the kidney qi is exuberant, the tiānguǐ arrives, essence qi spills over and drains out, and yin and yang harmonize [most likely: sexual intercourse takes place]. Therefore they are able to have children. In their twenty-fourth year, the kidney qi is balanced and even, and the sinews and bones are robust and strong. Therefore the true teeth are born and growth reaches its limit. In their thirty-second year, the sinews and bones are abundant and exuberant and the flesh is full and strong. In their fortieth year, the kidney qi weakens, the head hair falls out, and the teeth wither. In their forty-eighth year, the yang qi is weakened and exhausted above, the face becomes scorched, and the hair on the head and temples turns grey and white. In their fifty-sixth year, the liver qi weakens, the sinews are no longer able to move [freely], the tiānguǐ is exhausted, essence is reduced, the kidney is weakened, and the body is all used up. In their sixty-fourth year, they lose their teeth and head hair.

Now the kidney! It governs water and receives the essence (jīng) from the five zang and six fu organs and stores it. For this reason, when the five zang organs are exuberant, [the essence] can pour out. In the present case, the five zang organs are all decrepit, the sinews and bones dissolve and drop, and the tiānguǐ is all used up! Therefore the hair on the head and on the temples turns white, the body feels heavy, the gait is no longer straight, and the person is no longer able to procreate.”

帝曰：人年老而無子者，材力盡耶？將天數然也？

岐伯曰：女子七歲腎氣盛，齒更髮長；二七而天癸至，任脈通，太衝脈盛，月事以時下，故有子；三七腎氣平均，故真牙生而長極；四七筋骨堅，髮長極，身體盛壯；五七陽明脈衰，面始焦，髮始墮；六七三陽脈衰於上，面皆焦，髮始白；七七任脈虛，太衝脈衰少，天癸竭，地道不通，故形壞而無子也。

丈夫八歲腎氣實，髮長齒更；二八腎氣盛，天癸至，精氣溢寫，陰陽和，故能有子；三八腎氣平均，筋骨勁強，故真牙生而長極；四八筋骨隆盛，肌肉滿壯；五八腎氣衰，髮墮齒槁；六八陽氣衰竭於上，面焦，髮鬢頒白；七八肝氣衰，筋不能動，天癸竭，精少，腎藏衰，形體皆極；八八則齒髮去。

腎者主水，受五藏六府之精而藏之，故五藏盛，乃能寫。今五藏皆衰，筋骨解墮，天癸盡矣。故髮鬢白，身體重，行步不正，而無子耳。

The first notable point here is perhaps that the big change that indicates the end of natural fertility in both male and female bodies is expressed identically as “the tiānguǐ is exhausted” 天癸竭. Too many Western practitioners still follow the sharp dichotomy between male and female bodies posited by biomedicine and define tiānguǐ only as “female reproductive essence” or something along those lines, or simply equate it with menstruation. In fact, however, it is a concept that equally defines male and female bodies, the only difference being that its arrival and departure occur in multiples of 7 in women and multiples of 8 in men. While the specific manifestations of the gradual exhaustion of the tiānguǐ differ, it is associated with jīng essence and the kidneys in all human bodies. As a side note, the potential of this “androgynous” model of the human body in classical Chinese medicine, as Charlotte Furth has famously called it, for a contemporary clinical reality of diagnosing and treating bodies that are more sexually fluid in their anatomy and physiology than ever before in human history is a huge, mostly still untapped resource.

Another difference to the biomedical concept of menopause is that in the classical Chinese view, aging is a gradual process of physical substances (Yáng Qì, kidney essence, tiānguǐ, or the flow in the vessels) being weakened, reduced, and eventually used up, starting in the fifth seven- or eight-year cycle, not a drastic change associated with the abrupt cessation of a physiological process as implied by the Latin “meno-pause.” In this gradual decline, the cessation of female bleeding is not even significant enough to be mentioned specifically. Instead, the Rènmài channel becomes “empty” 虛 and the Chōngmài reduced 衰少. And then there is this mysterious lack of flow-through, of penetration, in the “pathways of the earth” 地道不通, whatever that phrase may mean. Many later scholars follow Wáng Bīng 王冰 in equating “pathways of the earth” 地道 here with 坤道, or in other words the pathways specific to the female body or even more narrowly the reproductive tracts specific to female anatomy like the biomedical fallopian tubes. Zhāng Zhìcōng 張志聰, explains this term differently and in a way that does not limit it to the female body per se:

The pathways of the earth are the vessel paths in the lower body. The “Treatise on the Three Sections and Nine Indicators” (Suwen 20) states that “the lower body is earth, is the Foot Shàoyīn.” The Guǐ Water is stored in the kidney and when the Tiānguǐ is exhausted, this means that the Foot Shàoyīn vessel in the lower body is no longer penetrable.

地道、下部之脈道也。三部九候論曰：下部地，足少陰也。癸水藏於腎，天癸竭，是足少陰下部之脈道不通。

As we can see, the description of aging is a slow and gradual process that occurs in both male and female bodies over a range of years and culminates in the eventual loss of the ability to produce children, with no dramatic pathological effects specific to women. In other words, there is no such thing as a pathology around the age-related cessation of female bleeding.

This same attitude is also expressed, perhaps even more strongly so, in gynecology texts like Qí Zhòngfǔ’s 齊仲甫 “Hundred Questions on Gynecology” 女科百問 from 1220 CE (see my book Channeling the Moon Part One, for a translation and discussion of the basic gynecological theories and menstrual conditions). It is worth contemplating why the only question that addresses the natural physiological cessation of menstruation is concerned with “The Reason that in Women of an Age When the Predestined Numbers Have Run Out the Menstrual Fluids Should Have Stopped but Are Flowing Again” (Channeling the Moon, Question 11, pp. 210-229)! This makes perfect sense from the standpoint of traditional Chinese gynecology, where the gradual decline and eventual cessation of menstruation due to aging is seen as a physiological rather than a pathological process. As such, the pathology is not the fact that the menses stop flowing but rather that they CONTINUE to flow in women past their proper age. After quoting the above-cited account of physiological aging from Sùwèn 1, Qí Zhòngfǔ offers this answer for why the menses might continue flowing:

Perhaps there was an excessive measure of taxation damage or the random experience of joy or anger. Something was left-over in the channels due to vacuity and debilitation, and furthermore there was an attack of evil Qì and a surge. Because of this, [the menstrual fluids] should have stopped but did not.

或勞傷過度，喜怒不時，經脈虛衰之餘，又為邪氣攻沖，所以當止而不止也。

Regarding the pathological absence of menstruation at any age, Question Nine on the “Reasons for an Interruption of Menstruation and Lack of Throughflow” (Channeling the Moon, pp. 174-191) begins its answer with this summary:

Menstruation failing to flow through is caused by wind-cold intruding into the uterine network vessels; by entering the bedroom in a state of drunkenness; by the occurrence of blood withering, blood conglomerations, or blood concretions; or by the experience of panic and fear from falling down. All of these conditions prevent the menstrual fluids from flowing through.

夫月水不通，因風冷客於胞絡，或醉後入房，或為血枯血瘕血癥，或因墮墜驚恐，皆令月水不通也。

While not directly spelled out but implied in the context of the text here as another major cause for a lack of abundant menstrual flow, the factor of vacuity taxation (虛勞 xūláo) is discussed in the next question. I offer the brief summary at the beginning of that answer here since it is well-known in traditional Chinese medicine and thus would have been obvious to Qí Zhòngfǔ’s readers, that vacuity taxation resulted in exhaustion of Qì and kidney essence, which would cause an abnormal lack or absence of menstrual flow. As we shall see, this pathology may prove helpful in addressing the suffering of contemporary women in the context of menopause that I will discuss in the third, and final, installment, of my discussion on menopause in Chinese medicine.

There is taxation from forced labor and then there is taxation from taxation damage. Taxation from forced labor means that [the woman] was used too excessively, [as a result of which] the Qì in the zàng and fǔ organs has lost its healthy measure. This was the cause for her disease. Vacuity means that she already has a deficit of some sort. Taxation means that the condition because of some sort of detriment has been piling up gradually and matured over many days. How could this be something that comes about all of a sudden in a single day or night! As Master Cháo [Yuánfāng] says, “The five taxations, six extremes, and seven damages, this is what we refer to as vacuity taxation.”

夫有勞役之勞，有勞傷之勞。役之勞，所用太過，臟腑之氣失其常度，所以致疾。虛則已有所虧，勞則因有所損，其積之有漸成之有日，豈一朝一夕而驟致哉。巢氏云：五勞六極七傷，謂之虛勞也。

To conclude this second part of my discussion on menopause in Chinese medicine, let me repeat the following points:

• Menopause as an age-related pathology of stopped menstrual flow does not exist in Chinese medicine. There are no pathologies traditionally associated with the gradual physiological reduction and eventual cessation of menstruation due to old age.

• Consequently, the classical literature does not offer formulas or other treatments to address this condition.

• The age-related cessation of women’s menstrual flow is discussed as a gradual physiological process of weakening and reduction of substances, eventually leading to a lack of through-flow in women and a reduction of essence in men, in the seventh cycle of seven or eight years, respectively.

• In all human bodies, this end of reproductive capacity is expressed as the “exhaustion of tiānguǐ.”

• Other than as the effect of age, the blockage and interruption of menstruation is associated with pathological factors like wind or cold, sexual intercourse while intoxicated, blood disorders like withering or concretions, and emotional trauma.

• As an important factor for the exhaustion of Qi and kidney essence, vacuity taxation is a key pathology that affects the reproductive functions.

Please stay tuned for Part Three of my discussion on menopause in Chinese medicine.