THE TREATMENT OF MENOPAUSAL SYNDROME WITH CHINESE HERBS

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Menopausal syndrome varies markedly among women. The most common symptoms include hot flushes (often called hot flashes, but the disorder involves red "flushing" of the skin), dryness and thinning of skin and vaginal wall, mood swings and depression, and insomnia. In addition, there is often a gradual weakening of the bones (reduction of bone density) known as osteoporosis that eventually leads to easy fracture. All of these symptoms are the result of declining levels of sex hormones, especially estrogens.

In seeking information about potential Chinese herbal therapies for menopause, one is directed to the modern rather than the traditional practices. This is because there is limited reference to this problem in older Chinese medical literature. As an example, in the highly respected 14th century book Danxi Zhifa Xinyao (1), there are chapters on gynecology and childbearing, but just a single mention of menopause, with reference to a problem of abdominal pain said to be the result of menopause.

It is unclear to what extent the various menopausal symptoms had been experienced by women in the Orient prior to the modern era. Several factors could have contributed to a low level of concern for menopausal symptoms. There are significant differences between Chinese women in past centuries and modern Western women, in dietary constituents, amount of manual labor, frequency of child bearing, and life span, affecting the incidence and nature of various menopausal symptoms. There could also have been a less frequent seeking of medical attention for menopausal syndrome which, even if the symptoms were significant, might not have been deemed serious enough to require treatment. By contrast, women today are asked to address the long-term implications of menopause, such as osteoporosis and the risk of heart disease, even if their symptoms of menopause are currently negligible. The occurrence of symptoms, even if not severe, simply increases the urgency of this already-expected seeking of assistance.

Although little valuable information about early treatments for menopause is available, we do have access to an ancient description of female aging and loss of fertility from the first pages of the Neijing Suwen (ca. 100 B.C.). The changes in the body are depicted in seven year intervals (2):

At 28 years, the bones and tendons are well developed and the hair and secondary sex characteristics are complete. This is the height of female development. At 35 years, the stomach and large intestine channels (yangming channels) that govern the major facial muscles begin to deplete: the muscles begin to atrophy, facial wrinkles appear, and the hair begins to thin. At 42, all the yang channels (taiyang, shaoyang, yangming) are exhausted, the entire face is wrinkled, and the hair begins to turn gray. At 49 years, the ren and chong channels are completely empty, and the tiangui has dried up. Hence, the flow of menses ceases and the woman is no longer able to conceive.

This description still applies reasonably well, though we know that each individual women ages differently and not precisely according to a set 7-year cycle. The main difference between modern experience and this description is that with skin care products, modern diet (rich in vitamins), and less sun exposure, fewer women have their entire face wrinkled by age 42. In the same text, there is an explanation for the rare cases where older men and women are still able to have children. This capability is said to be due to two factors:

These individuals inherited an unusual abundance of jing and also realized how to lead their lives properly and protect their vitality. At age 64 for males and 49 for females, these individuals still have excess kidney energy as well as qi and blood, so they still have the capacity to procreate.

For those who have not inherited an abundance of jing or have not protected it via their lifestyle, herbalists hold out some hope, if not for restoration of fertility, at least for fewer signs of the associated aging process, by providing tonics that nourish the kidney energy, the qi, and the blood. Such treatment may slow down the physiological changes that lead to uncomfortable menopausal symptoms.

FORMULAS RECOMMENDED FOR MENOPAUSE

Rehmannia, because it is said to nourish yin and blood, benefit the kidney and marrow, and reduce fevers (see: Rehmannia), is an herb commonly selected for treatment of menopause by modern Chinese doctors. This herb is often used in the context of a formula that is focused on nourishing kidney yin or kidney yang or both, depending on the needs of the individual. Following are several currently-recommended menopause formulas derived from several modern Chinese textbooks that have been translated to English, and from one article that presented a survey of several clinical practices in China. These formulas are described in terms of a one-day dose in decoction form; the amounts are in grams. Most herbs are prescribed in the standard doses of 9–15 grams, with larger amounts of the mineral materials (e.g., 30 grams for dragon bone, dragon tooth, oyster shell), and smaller amounts for strong-acting herbs, such as aconite, cinnamon bark, and coptis, or for herbs that are added to benefit the stomach function, such as ginger, jujube, and licorice (when licorice is not also a main herb of the formula). Rehmannia is sometimes used in heavy doses of 24 grams or more.

From Clinic of Traditional Chinese Medicine (3):

Deficiency of Kidney Yin	Deficiency of Kidney Yang	Deficiency of Yin and Yang
Rehmannia, cooked: 24	Rehmannia, cooked: 24	Rehmannia, cooked: 9
Dioscorea: 12	Cornus: 9	Tang-kuei: 9
Cornus: 9	Aconite: 6	Anemarrhena: 9
Lycium: 12	Cinnamon bark: 6	Phellodendron: 9
Peony: 12	Antler gelatin: 9	Curculigo: 9
Uncaria: 12	Eucommia: 9	Epimedium: 9
Tortoise shell: 9	Cuscuta: 9	Morinda: 9
Placenta: 12	Epimedium: 9	Ligustrum: 9
Ligustrum: 9	Codonopsis: 12	Eclipta: 9
Eclipta: 9	Atractylodes: 12
	Ginger: 3
	Baked licorice: 12

From English-Chinese Encyclopedia of Practical Traditional Chinese Medicine (4):

Kidney Yin Deficiency	Kidney Yang Deficiency
Rehmannia, cooked: 15	Rehmannia, cooked: 15
Dioscorea: 15	Dioscorea: 15
Cornus: 12	Cornus: 12
Hoelen: 12	Lycium: 15
Lycium: 18	Cinnamon bark: 6
Peony: 15	Aconite: 6
Licorice: 6	Cuscuta: 24
Dragon bone: 30	Antler gelatin: 12
Oyster shell: 30	Eucommia: 30

From Clinical Manual of Chinese Herbal Medicine and Acupuncture (5):

Deficiency of Kidney Yin	Deficiency of Kidney Yang
Rehmannia, cooked: 10	Rehmannia, raw: 10
Dioscorea: 10	Cornus: 10
Cornus: 10	Hoelen: 10
Lycium: 10	Lycium: 10
Uncaria: 15	Epimedium: 6
Maurita shell (zibeichi): 15	Curculigo: 6
Lotus plumule: 3	Codonopsis: 10
	Atractylodes: 10
	Uncaria: 10
	Maurita shell: 10
	Ginger: 6
	Citrus: 6

From A Clinical Guide to Chinese Herbs and Formulas (6):

Deficiency of Kidney Yin Hyperactive Liver Yang	Deficiency of Spleen and Kidney
Rehmannia, raw: 15–30	Rehmannia, cooked: 15–30
Dioscorea: 15	Dioscorea: 15
Cornus: 10	Cornus: 10
Hoelen: 10	Lycium: 10
Moutan: 10	Aconite: 2–5
Lycium: 10–15	Cinnamon bark: 2–5
Tortoise shell: 10–15	Deer antler: 5–10
Anemarrhena: 10	Cuscuta: 15
Phellodendron: 10	Tang-kuei: 10
Dragon bone: 15	Codonopsis: 10
Oyster shell: 15–20	Atractylodes: 10

In Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine (11): the author suggests the bolus of Rehmannia Six Formula (Liuwei Dihuang Wan) with Bupleurum and Tang-kuei Formula (Xiaoyao Wan), each one 6 grams each time, three times daily, for predominance of yin deficiency. Alternatively, for predominance of yang deficiency, use the bolus of Rehmannia Eight Formula (Jingui Shenqi Wan) with the bolus of Ginseng Spleen Tonic Pills (Renshen Jianpi Wan), each one 6 grams each time, three times daily. Alternatively, he recommends the following general formula, a modification of Rehmannia Six Formula called Zishui Qinggan Yin, which is designed to specifically aid psychological distress as a manifestation of menopause:

Rehmannia (half raw, half cooked): 20

Dioscorea: 12–15

Cornus: 10

Moutan: 10–12

Alisma: 12

Hoelen: 15

Epimedium: 12

Bupleurum: 10–12

Zizyphus: 30

Lily: 21–24

Gardenia and peony could be added to this prescription for symptoms of irritability and prolonged feeling of heat. The large dose of zizyphus and lily is directed at treating insomnia and night sweating. Further modifications of the formula are recommended for various syndromes; for example, if there is yin deficiency of liver and kidney, one can add anemarrhena, scrophularia, tortoise shell, dragon’s tooth, and magnetite.

From Menopause syndrome treated by traditional Chinese medicine (7):

The author reports that "the classic formula" and "the one considered most effective for menopausal syndrome" is Zuogui Yin modified with tortoise shell, ligustrum, and epimedium, as follows:

Rehmannia, cooked: 15

Dioscorea: 20

Cornus: 15

Hoelen: 20

Lycium: 15

Tortoise shell: 30

Ligustrum: 15

Epimedium: 6

Baked licorice: 5

He then relayed the recommendations at several hospitals and colleges around China. Some examples of those treatments follow.

The Shanghai College of Traditional Chinese Medicine recommends three formulas:

Deficiency of Kidney Yin	Deficiency of Kidney Yang	Deficiency of Yin and Yang
Rehmannia, raw: 15	Ginseng: 9	Rehmannia, cooked: 20
Dioscorea: 15	Tang-kuei: 6	Dioscorea: 10
Cornus: 10	Atractylodes: 9	Cornus: 15
Hoelen: 12	Hoelen: 12	Lycium: 15
Alisma: 9	Zizyphus: 12	Tortoise shell: 20
Moutan: 6	Ginger, fresh: 3	Anemarrhena: 9
Anemarrhena: 9	Aconite: 3	Phellodendron: 9
Phellodendron: 9	Astragalus: 12	Aconite: 6
Magnetite: 20	Longan: 12	Cinnamon bark: 3
Shen-chu: 12	Saussurea: 6	Licorice, baked: 6
Cinnabar: 3	Polygala: 9
	Licorice, baked: 6
	Jujube: 5

Beijing City Hospital of Traditional Chinese Medicine recommends these formulas:

Deficiency of Liver and Kidney	Deficiency of Kidney Yang	Kidney and Heart not Communicating
Rehmannia, raw: 15	Curculigo: 15	Rehmannia, raw: 15
Rehmannia, cooked: 15	Epimedium: 15	Rehmannia, cooked: 15
Lycium: 15	Morinda: 15	Cornus: 10
Tortoise shell: 20	Tang-kuei: 15	Fu-shen: 10
Morus fruit: 15	Codonopsis: 15	Lycium: 15
Oyster shell: 30	Deer antler: 15	Ligustrum: 10
Dragon bone: 30	Fenugreek: 15	Asparagus: 10
	Cuscuta: 15	Lily: 10
		Lotus heart: 6
		Dragon teeth: 30
		Scrophularia: 15
		Ophiopogon: 10
		Polygala: 6
		Coptis: 5
		Cinnamon bark: 5

From Practical Therapeutics of Traditional Chinese Medicine (16), the main prescription recommended is Zuogui Yin, with tortoise shell and ho-shou-wu added to reinforce the effects of nourishing yin and subduing yang; but for a case dominated by yang deficiency, Yougui Wan is recommended instead, combined with Lizhong Tang:

Deficiency of Kidney Yin	Deficiency of Kidney Yang
Rehmannia, cooked: 24	Rehmannia, cooked: 24
Dioscorea: 12	Dioscorea: 12
Cornus: 12	Cornus: 9
Lycium: 12	Lycium: 12
Hoelen: 9	Antler gelatin: 12
Baked licorice: 6	Cuscuta: 12
Tortoise shell: 30	Eucommia: 12
Ho-shou-wu: 15	Cinnamon bark: 6
	Aconite: 6
	Tang-kuei or Nutmeg: 9
	Ginseng: 12
	Atractylodes: 9
	Ginger, dry: 9
	Baked licorice: 6

In the yang-deficiency therapy, tang-kuei is replaced by nutmeg in cases of loose stool. For a combination of yin and yang deficiency syndromes, the authors mention in passing the use of Erxian Tang, which is a modern prescription that was developed to treat post-menopausal hypertension. This formula was outlined, above, for deficiency of kidney yin and yang in the first set of formulas from Clinic of Traditional Chinese Medicine.

SUPPORTING RESEARCH

In an overview of integrating Chinese and Western medicine approaches (8), Zhou Jinhuang and Zhang Yongxiang selected Rehmannia Six Formula as an example of an ideal agent to indicate the progress that is being made through this approach. They reported that, with regard to menopausal syndrome:

The use of Rehmannia Six Formula not only relieves the symptoms and ailments of the patients, but also brings back the normal balance of their female sex hormones, i.e., an increase of serum estrogen level with a lowering of the high FSH (follicular stimulating hormone) and LH (luteinizing hormone).

Analysis of the physiological effects of the traditional prescription in terms of biochemical markers is the aspect of integrative medicine that the authors were illustrating. One mechanism by which Rehmannia Six Formula leads to changes in sex hormones has been suggested to be via the adrenal cortex. A recent study of cortisol production tends to confirm this. Twenty women with periodontitis and low plasma cortisol levels were treated with Bushen Guchi Wan, a derivative of Rehmannia Six Formula with hoelen and dioscorea replaced by lycium and drynaria (9). The herbs were powdered, made into a pill with honey and administered in a dose of about 7 grams of herbs each time, twice daily, for three months. The treatment increased the plasma cortisol levels and this effect was maintained for a year. It is possible that the active constituents interact directly with the adrenal cortex, or via other endocrine glands (e.g., pituitary or hypothalamus as has been suggested for ginseng and deer antler), or both.

In a study of Rehmannia Six Formula in women with menopause of recent onset (mean age was 51 years), 9 grams of the formula was administered daily (in two divided doses) for two months (10). It was reported that the treatment resulted in decline of serum FSH and LH by half, and increase of estradiol of 20%. Estrogen receptors in peripheral leukocytes more than doubled. The authors suggested that this formula benefited menopausal women by regulating both hormone levels and hormone receptors.

When Rehmannia Six Formula in pill form (9 grams per day in two divided doses) was given for a year to women who suffered early menopause due to surgery (15), it was found that the level of FSH decreased slightly, while the level of estradiol increased markedly. According to the analysis by the authors, the effect of administering the herbs was observed within three months, and then became more notable by six months, and was sustained at that level for the rest of the year. However, the authors also reported that the already atrophied vaginal epithelium was not affected by the treatment.

A study of tonification therapy to treat osteoporosis in post-menopausal women (12) revealed that a modification of Rehmannia Six Formula, with main ingredients rehmannia, cornus, dioscorea, epimedium, and cuscuta, markedly increased estrogen levels, especially during menopause, but also in women treated 5-10 years after menopause. The dosage used was 6-12 grams each time (in pill form), twice daily for three months. Bone mass density was only marginally improved.

A similar study (13) of women suffering from osteoporosis yielded better results on bone density. The patients were first diagnosed as to the type of kidney deficiency syndrome suffered. Half the cases were described as general kidney deficiency (sometimes called kidney qi deficiency), while most of the other half of the cases had a dominance of kidney yin deficiency. The women were treated with a formula that included rehmannia, cornus, tortoise shell, schizandra, dipsacus, drynaria, morinda, loranthus, and placenta; for cases of deficiency of kidney yin dominating, the formula was adjusted to include dioscorea, lycium, and polygonatum. The formula was given in the dose of 9 grams each time (in pill form), three times daily for 10-12 weeks. The treatment markedly increased bone density as measured at the radial bone (arm); at the same time, symptoms of kidney deficiency syndrome, which often reflect the decline in hormones in menopausal women, were partially alleviated. The dosage of herbs was higher in this study than in the previous one.

Aside from effects on estrogen, Rehmannia Six Formula was shown to increase the level of activated vitamin D in the serum of laboratory animals with osteoporosis that had been induced by corticosteroid administration (14). The herb formula was able to counteract the loss of bone density, restoring the density close to the levels of normal control animals, and the effect was thought to be partially mediated by the vitamin D.

SUMMARY

As this review of the literature illustrates, there are numerous prescriptions that have been recommended as a basis for treating menopause. In most cases, alternative formulations were mentioned that are intended to address the less common manifestations of menopausal syndrome. The most commonly used ingredients in these formulas are rehmannia, cornus, dioscorea, hoelen, lycium, tortoise shell, epimedium, and licorice. This list of ingredients matches the modification of Zuogui Yin cited by Luo Yuankai, and his colleagues (in the survey article on menopause formulas) as the one considered most effective, except that ligustrum might not be included. The modified Zuogui Yin can be viewed alternatively as a modification of Rehmannia Six Formula (Liuwei Dihuang Wan), with moutan and alisma deleted, and replaced by two yin and blood tonics (lycium, tortoise shell), one yang tonic (epimedium), and one qi tonic (baked licorice). Lycium fruit plus epimedium has been used by Chinese physicians as an inexpensive substitute for deer antler: deer antler or antler gelatin is an ingredient of several of the formulas listed in this article.

The modification of Rehmannia Six Formula with additional tonic herbs that might be recommended on the basis of this survey of menopause formulas is:

Menopause Formula #1

Rehmannia, cooked: 15

Dioscorea: 12

Cornus: 12

Hoelen: 12

Lycium: 15

Tortoise shell: 15

Epimedium: 9

Baked licorice: 6

The dosages of the individual ingredients given here are characteristic of those recommended in the numerous sources; for some ingredients, they are somewhat less than the dosage recommended by Luo Yuankai. The total decoction involves 96 grams of herbs, which can also be prepared as dried hot-water extracts, with a daily dosage of about 16-18 grams/day. This formula addresses menopausal syndrome of the type described as deficiency of kidney yin or deficiency of kidney and liver, which is usually the first one mentioned in the literature because it is the most common syndrome. Since several experts also offer a treatment for kidney yang deficiency, practitioners are advised to check for evidence of significant yang deficiency before electing to use this particular formulation. Based on the formulations described above, if yang deficiency is noted, one may add either the combination of cinnamon bark and aconite (especially for chilly symptoms or pain) in a dosage of about 5-6 grams each, or a combination of deer antler (or antler gelatin) and cuscuta (herbs that are less warming and more nourishing than cinnamon plus aconite) in a dosage of about 9-15 grams each; tortoise shell may be deleted, especially when adding antler and cuscuta. In early menopause, while menstrual bleeding is still occurring irregularly, raw rehmannia in place of cooked rehmannia, and a larger dose of tortoise shell, may contribute a hemostatic effect if bleeding is excessive.

REFERENCES

1. Yang Shouzhong (translator), The Heart and Essence of Danxi’s Methods of Treatment, 1993 Blue Poppy Press, Boulder, CO.

2. Maoshing Ni, The Yellow Emperor’s Classic of Medicine: A New Translation of the Neijing Suwen with Commentary, 1995 Shambhala, Boston, MA.

3. Zhang Enquin, Clinic of Traditional Chinese Medicine, 1990 Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai.

4. Xu Xiangcai (chief ed.), English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 12 (Gynecology), 1989 Higher Education Press, Beijing.

5. Zhou Zhong Ying, and Jin Hui De, Clinical Manual of Chinese Herbal Medicine and Acupuncture, 1997 Churchill Livingstone, London.

6. Chen Songyu and Li Fei, A Clinical Guide to Chinese Herbs and Formulae, 1993 Churchill-Livingstone, London.

7. Luo Yuankai, et al., Menopause syndrome treated by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1989; 7(1-2): 55-64.

8. Zhou Jinhuang and Zhang Yongxiang, The pharmacological basis of the Chinese integrative medicine, Chinese Journal of Integrated Traditional and Western Medicine, 1997; 3(4): 242-245.

9. Zhao Ruifang and Sun Xigao, Effect of Bushen Guchi Wan on plasma cortisol level in patients with periodontitis, Journal of the Fourth Military Medical College 1989; 10(3): 205-207.

10. Zhang Jiaqing and Zou Dajin, Changes in leukocytic estrogen receptor levels in patients with climacteric syndrome and the therapeutic effects of Liuwei Dihuang Wan, Chinese Journal of Integrated Traditional and Western Medicine, 1995; 1(1): 9-12.

11. Shao Nianfang, The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine, 1990 Shandong Science and Technology Press, Shandong.

12. Liu Hedi, et al., The influence of kidney tonic herbs on relative parameters and bone mass density in post-menopausal females, International Journal of Oriental Medicine, 1998; 23(4): 205-207.

13. Liang Li, et al., Clinical observation on osteoporosis treated with traditional kidney-tonifying medicaments, Journal of Traditional Chinese Medicine, 1994; 14(1): 41-44.

14. Chen Yanping, et al., Effects of Liuwei Dihuang Wan and some other TCM drugs on bone biomechanics and serum 25(OH)D₃ content in rats, Journal of Traditional Chinese Medicine, 1994; 14(1): 41-44.

15. Wu Xiening, et al., Comparative effectiveness of Chinese H3 and Liuwei Dihuang Wan in female climacteric and their mechanism of action, Journal of Traditional Chinese Medicine 1987; 7(4): 266-268.

16. Yan Wu and Fisher W, Practical Therapeutics of Traditional Chinese Medicine, 1997 Paradigm Publications, Brookline, MA.

APPENDIX: Nutritional Supplements for Menopause.

Nutritional supplements may become necessary, even with a good quality diet, to compensate for lowered nutritional absorption (and, in some cases, reduced ingestion of high nutrient foods) associated with aging or with chronic illness. In particular, nutrients that aid bone mineralization are critical during and after menopause to help prevent loss of bone density. A collection of research abstracts regarding nutrition and menopause has been published by Dr. Melvyn Werbach, in his book Nutritional Influences on Illness (1996 Third Line Press, Tarzana, CA.). Following are some examples of important nutrients.

Boron: 1-2 mg per day (do not exceed this dosage). Boron helps calcium absorption by the bones and may potentiate the action of estrogen.

Calcium: Total intake should be 1200-1500 mg per day; typical dietary intake is 500-900 mg/day in menopausal women, so 300-1,000 mg supplementation may be necessary. Hydroxyapatite (derived from bone), calcium citrate, and calcium malate are currently thought to be the best sources for preventing and treating osteoporosis. Milk and milk products are also good sources of calcium. In Chinese herbal preparations, calcium is present in various shells (tortoise shell, oyster shell, maurita shell), fossils (dragon bone and dragon teeth), antler (deer antler), and other animal and mineral source materials.

Fluoride: Fluoride helps increase bone density. Black tea has 1-4 mg fluoride per cup. Fluoride as a supplement is currently available only by prescription; excessive ingestion can harm bones and is toxic. Many city water supplies have added fluoride.

Folic acid: 800 mcg per day. Folic acid reduces build-up of homocysteine, an amino acid which is associated with increased risk of heart attack and with impairment of bone formation.

Magnesium: Total intake should be as high as 600-700 mg per day (about twice the recommended daily intake for younger adults). Current recommendations are to consume at least half as much magnesium as calcium. High levels of magnesium cause loose stool or diarrhea (magnesium retains water in the intestines): this is the limiting factor in magnesium dosage. Magnesium enhances calcium absorption and retention. Like calcium, magnesium is a component of shells and fossils used in Chinese medicine.

Manganese: 20-40 mg per day. Manganese is necessary for bone mineralization.

Silicon: This mineral is often available in the form of plant extracts, such as from "horsetail." Silicon aids calcium absorption into bone and is a component of bones, ligaments, and tendons that adds strength. The appropriate dosage level has not been determined as yet.

Zinc: 15 mg per day. Zinc is necessary for bone formation; it also increases vitamin D activity and promotes immune functions. Avoid increased levels of zinc in cases of autoimmune disorders, as the immune stimulus promoted by zinc may intensify the level of autoimmune responsiveness.

Vitamin B₆: 10-40 mg per day. Like folic acid, vitamin B₆ reduces homocysteine levels.

Vitamin D: 400 IU per day during menopause; for women over 65, use 400-800 IU per day. Vitamin D increases calcium absorption. Vitamin D is produced in the body in response to exposure to sunlight (15 minutes per day without sun blocking agents is sufficient); those who do not get enough sun exposure must supplement with vitamin D₃. Milk has vitamin D₃ added; for those who do not consume milk products (lactose intolerance is a frequent problem in post-menopausal women), vitamin D supplements should be used.

Vitamin E: 400–800 IU per day. Sudden introduction of high doses of this vitamin is contraindicated in cases of high blood pressure, as it can cause an increase in blood pressure; gradual increase in dosage avoids this problem. Dry forms of vitamin E are preferred over oily forms when using higher dosages. Vitamin E is an antioxidant and potentiates the action of estradiol.

Vitamin K: 50-100 mcg per day. This vitamin plays a role in bone calcification.

Most of these vitamins and minerals can be obtained by using a single vitamin/mineral supplement, so it is usually not necessary to obtain several different nutritional pills. Seed herbs used in Chinese formulas, such as ligustrum and cuscuta, provide some omega-3 fatty acids; omega-3 fatty acids decrease excessive plasma lipids, soften the skin, and reduce inflammation. Large doses (15 grams per day or more) of these seed herbs in decoction will provide a clinically significant level of the fatty acids. Menopausal symptoms may be reduced in some women by ingestion of sufficient levels of this type of fatty acid. Other sources are fish oils, which mainly provide eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA), and seed oils of evening primrose, black currant, borage, and flax. The suggested dosage of the oils (as isolated, they are usually provided in 500 mg soft gelatin capsules) is 3 grams per day.

March 1999