A case study by Fiona Brannigan
Introduction
The subject of the perimenopause is a hot topic at the moment with what appears to be more discussions, debates, news articles, social media posts, books, t.v. and radio programmes than ever before. Yet despite this level of interest, the discourse seems limited to highlighting the symptoms not the solutions, and defaults to the overmedicalising of women’s health. It must be remembered that the perimenopause is not a disease state.
From the Greek meno (monthly) and pausis (to stop), the word menopause literally translates as stopping menstruation and can only be ‘diagnosed’ retrospectively, 1 complete year from the date of your last period. This usually occurs between 45-55 years of age. Also termed the climacteric, the peri (around/about) menopause is defined as the time leading up to the cessation of menstruation lasting on average 4-5 years but which can be up to 10 years for some.
Mediated by hormonal changes (switching from ovarian oestradiol to adrenal oestrone), the perimenopause is simply a time of adjustment and transition from one physiological state to another accompanied by the psychological impact these changes bring about. For context, it is analogous with puberty.
Whilst hormone replacement therapy (HRT) may be a therapy of choice for some, it’s not for everyone and indeed doesn’t suit everyone. The term itself is misleading and begs the question why we are replacing hormones that are naturally declining at this life stage.
This is where supporting women through this time of transition with carefully chosen herbs, prescribed by a qualified herbalist following a detailed case history holds a totally unique position in healthcare offering a viable, highly effective, invaluable alternative to allopathic approaches.
The following case demonstrates the extensive scope of herbal medicine treatment at a time of natural flux; helping the body to balance and adapt, and gain a greater understanding of the physical, emotional and spiritual realities that the menopause can bring. It can be a positive time, a galvanising time and moreover, a liberating time as you re-evaluate ones purpose in life.
Presentation & Case history
Female, 49 years old, with a lean athletic build, seeking support with hot flushes, night sweats, irritability, low mood, low self-esteem, anxiety, brain fog, poor concentration, and erratic menstrual periods. She also complains of feeling too hot most of the time.
Anna (not her real name) works as a teacher and has done for the past 25 years. She has always had a level of palpable stress but feels recently less able to deal with juggling work and family life balance. She is married and has 4 children, 2 of which are at university. She is “always busy”. She reports that the last time she felt like ‘herself’ was over 3 years ago.
Anna first noticed a change in her menstrual cycle 12-18 months previously with erratic periods every 3-4 months. Her LMP (last menstrual period) was 3 months prior to our 1st appointment and she feels a very traumatic event with her son heralded the onset of hot flushes and changes to her emotional wellbeing. The duration of her periods remain unchanged, as does her menstrual flow and character. She describes feeling “warmer” prior to menstruation – and can also feel this at the time of an absent/missed period.
Anna describes herself as usually optimistic and energetic but now feels she is more anxious, often waking so, with periods of low mood and self esteem. Interestingly, Anna also describes herself as having “lost her navigation” by the absence of regular menstruation as she used it as her “guide” – otherwise known as an infradian rhythmn.
Symptoms, particularly the hot flushes had been getting worse ( 4-5 episodes daily) over the previous 4-6 weeks and were the biggest concern for the Anna. None of note in the daytime, first onset was in the evening and at bedtime, and this has continued. She could be woken by night sweats but has found she settled back to sleep easily. She has always been a “good sleeper”, and sleeps for 8 hours on average.
Anna finds stress/anxious thoughts aggravate the onset of hot flushes and she has found nothing relieves them.
Anna has a history of migraines, usually aggravated by stress or tiredness but has not had any recent episodes.
She has noticed her nails are more brittle and her hair is thinner but her skin texture remains unchanged.
Digestive function is good – but Anna has an occasional tendency to constipation if slightly dehydrated.
No other health concerns. Anna is usually in good health. She recovers well from seasonal colds/flu with little after effect.
She has no history of hormonal contraception usage.
Anna has a history of marathon running and runs a few miles 3 times a week. She also walks 2-3 miles daily. She attends regular yoga and pilates classes and finds this helps manage stress levels.
Investigations
A physical examination was not performed as the consultation took place online. Anna appeared visibly tired and emotional.
Diagnosis
Based on the information gathered from an in-depth consultation and Anna’s presentation, she is demonstrating a clinical picture with classical signs indicative of late stage perimenopause.
Approach to treatment
Not everyone experiences perimenopause in the same way – symptoms and presentation are as individual as you are, as is your treatment.
Providing symptom management whilst building, balancing and strengthening deeper reserves, especially of the adrenal glands, often forms the blueprint of the herbalist’s approach to treatment, in addition to developing a therapeutic patient/practitioner relationship; it can often take a number of appointments before a pattern emerges and a clearer understanding of the presentation can be gained.
Creating a bridge between menstruation and menopause, herbal treatment supports you from one to the other, assisting with the adjustment to change, with a view to eventually withdrawing herbal treatment.
It can often be the case, as clearly demonstrated in this presentation where the stresses and exhaustion in the patients everyday life actually creates their inability to cope with the added physical and emotional changes that can occur in perimenopause and not so much the perimenopause itself. The focus of treatment will therefore centre around nervous system support rather than hormonal – ‘hormonal’ problems don’t always call for hormonal solutions!
As is evident in the following 3 prescriptions, small changes are made to accommodate both subtle and sizeable progress with a continuous focus on improving Anna’s overall wellbeing and vitality.
The treatment energetics are of a cooling nature as Anna presented with a hot constitution.
- Adaptogens are given to help the body adapt to stress, support normal metabolic processes and restore balance. The adaptogens chosen improve adrenal gland function – very important as the ovaries slow down and the adrenal glands take over the role of producing hormones – and vital in chronic stress.
- Gentle oestrogen modulating herbs are used to help balance and support through this time of fluctuating hormone levels, with sage (salvia officinalis) being a specific for hot flushes and sweating.
- Nervines and relaxants are used to restore and strengthen the nervous system and to provide comfort and help alleviate a negative emotional state.
- Liver herbs are a vital adjunct to any hormonal issue supporting healthy digestion (which is key to overall wellbeing) and aiding elimination and the processing of hormones through the liver pathways.
First prescription
| Tincture | Quantity (ml) | Description |
|---|---|---|
| Schisandra chinensis fruit 1:2 | 25 | Tonic for the reproductive system, increases vitality, a specific for night sweats of menopause. Adaptogenic. Hepatoprotective. Nervine tonic. Antioxidant. Calms the shen. |
| Astragalus membranaceus root 1:1 | 15 | Tonifies Qi/energy and blood/nutritive. Cooling. Adaptogenic. Cardiotonic. Tonic. |
| Taraxacum officinale root 1:1 | 15 | Cooling bitter tonic. Choleretic/chologogue. Mild laxative. Tonic to the digestive system with reflex on the whole body. Gentle detox. |
| Salvia officinalis leaf 1:2 | 15 | Cooling plant oestrogen. Specific for hot flushes in menopause. Nervous exhaustion. Improves cognitive function/memory/brain fog. |
| Verbena officinalis herb 1:2 | 10 | Lifting nervine and liver tonic. Exhaustion and low mood. Cooling. |
| Cimicifuga racemosa root and rhizome 1:2 | 10 | Oestrogen modulating. Uterine tonic. Nervous system tonic. |
| Withania somnifera root 2:1 | 15 | Tonic. Adaptogenic. Immune modulating. Nervous exhaustion and general debility due to stress. |
| Rosa damascena petal 1:1 | 5 | Cooling relaxant. Energetic use in trauma/grief and times of change. |
Total 440 ml – 5ml taken 3 times daily, last dose 1 hour before bed, over a 4 week period.
Treatment plan
Anna was advised to continue with yoga/pilates and walking, but to rest from running if feeling exhausted, and not to run at night (can be too stimulating). She was also advised to include meditation or breathwork practice into her day.
We discussed the importance of sleep hygiene and sleep architecture and the importance of creating a sense of calm a couple of hours before bedtime – including taking a magnesium supplement at this time, and a herbal infusion. I have avoided prescribing a separate sleep mix in order to see if the main mix alone can provide support in this area.
She was encouraged to implement changes to her diet, most importantly to focus on a diet rich in vegetables and fruit, nuts and seeds (including freshly gound flaxseed), pulses and legumes, oily fish and lean meats, wholegrains, healthy fats, complex carbohydrates rather than refined, and to limit or omit refined sugar. Protein is to be eaten at every meal. Balancing blood sugar is key at this life stage and can be a bigger challenge with hormonal flux.
Anna was also advised to take appropriate supplements if she found she was unable to meet her requirements through diet.
Other medications and treatments
No other medications or supplements.
Follow-up appointments
1st follow up appointment (after 4 weeks)
Anna noticed a decrease in the frequency of hot flushes (1-2 episodes) but night sweats continued. She was also feeling “less hot” generally.
She went on to describe feeling like there had been a release from some of the stresses of previous months (including her son’s accident). She had cried a lot but felt this was cathartic, and very much needed. We discussed the grief that can be present at this time in a woman’s life – a grief for the life that you are learning to let go of.
Anna was also beginning to feel less anxious and a little more like herself.
I removed rosa damascena and added leonurus cardiaca for additional cooling, relaxing, and nervine actions and continued with adaptogenic, hormone modulating, liver herbs.
2nd follow up (8 weeks from initial appointment)
Anna was delighted to report her hot flushes had gone and that her energy was beginning to rise. Her brain fog was clearing, and her focus and emotional wellbeing improving.
As a result of the progress made, I tweaked the prescription to include tonics and trophorestoratives to strengthen and improve adrenal gland function, nourish and balance the nervous system further and help build a deeper level of resilience.
3rd follow up (16 weeks from initial appointment)
A short follow up.
Anna continues to make notable progress in all areas with a total absence of hot flushes and night sweats, and generally feeling cooler. Her mood has improved and she feels less overwhelmed, and more able to cope. She is managing her work load. She is also looking very positively towards the future and the feeling of “letting go of things that don’t really matter”.
She had what she describes as “ a proper period” without any associated symptoms after an absence of 5 months.
Anna cannot believe how well she feels!
Follow-up prescriptions – with rationale for changes
First follow up:
| Tincture | Quantity (ml) | Description |
|---|---|---|
| Schisandra chinensis fruit 1:2 | 20 | Tonic for the reproductive system, increases vitality, a specific for night sweats of menopause. Adaptogenic. Hepatoprotective. Nervine tonic. Antioxidant. Calms the shen. |
| Astragalus membranaceus root 1:1 | 15 | Tonifies Qi/energy and blood/nutritive. Cooling. Adaptogenic. Cardiotonic. Tonic. |
| Taraxacum officinale root 1:1 | 15 | Cooling bitter tonic. Choleretic/chologogue. Mild laxative. Tonic to the digestive system with reflex on the whole body. Gentle detox. |
| Salvia officinalis leaf 1:2 | 15 | Cooling plant oestrogen. Specific for hot flushes in menopause. Nervous exhaustion. Improves cognitive function/memory/brain fog. |
| Verbena officinalis herb 1:2 | 10 | Lifting nervine and liver tonic. Exhaustion and low mood. Cooling. |
| Cimicifuga racemosa root and rhizome 1:2 | 15 | Oestrogen modulating. Uterine tonic. Nervous system tonic. |
| Withania somnifera root 2:1 | 10 | Tonic. Adaptogenic. Immune modulating. Nervous exhaustion and general debility due to stress. |
| Leonurus cardiaca herb 1:1 | 10 | Relaxing nervine tonic. Cardiotonic. Reduces hot flushes. |
Total 440ml. Anna continued with 5ml three times daily with the last dose taken 1 hour before bed, over a 4 week period.
Second follow up:
| Tincture | Quantity (ml) | Description |
|---|---|---|
| Schisandra chinensis fruit 1:2 | 20 | Tonic for the reproductive system, increases vitality, a specific for night sweats of menopause. Adaptogenic. Hepatoprotective. Nervine tonic. Antioxidant. Calms the shen. |
| Asparagus racemosa root 1:2 | 20 | Adaptogenic. Nutritive tonic. Rejuvenative. |
| Taraxacum officinalis root 1:1 | 15 | Cooling bitter tonic. Choleretic/chologogue. Mild laxative. Tonic to the digestive system with reflex on the whole body. Gentle detox. |
| Salvia officinalis leaf1:2 | 15 | Cooling plant oestrogen. Specific for hot flushes in menopause. Nervous exhaustion. Improves cognitive function/memory/brain fog. |
| Verbena officinalis herb1:2 | 10 | Lifting nervine and liver tonic. Exhaustion and low mood. Cooling. |
| Avena sativa seed 1:1 | 20 | Lifting nervine tonic. Anxiolytic. |
| Withania somnifera root1:1 | 15 | Tonic. Adaptogenic. Immune modulating. Nervous exhaustion and general debility due to stress. |
Total 880ml, then a repeat of a further 440ml. Anna continued with 5ml three times daily over a 12 week period, with short check-ins for updates and progress reports.
Final outcome
Anna stopped treatment after 20 weeks delighted (and amazed) that her overall wellbeing had improved so significantly.
She now feels more able to deal with high stress levels, feeling much calmer, focussed, less anxious and more resilient. She also feels much more in tune with herself and able to read the signs of overwhelm more readily and act positively towards them.
This was a straightforward case with few complexities but I wanted to share it to demonstrate how simple measures, under the guidance of an experienced practitioner can go a long way. There is always something new to learn from patients, and in this instance I feel that lies in simplicity – of treatment, of lifestyle changes and of perspective.
It highlights the integrative nature of herbal medicine in the successful treatment of the perimenopause. Medicinal herbs not only provide physiological support but emotional also, which was very much needed in this case. The process of an indepth consultation and continuous support proved invaluable in helping Anna reflect on the underlying causes of her symptoms and helped uncover some very useful insights that have served to reframe this next life stage into a positive one.
Anna left with a greater understanding of the changes occurring in both her body and mind, fully armed with the diet and lifestyle tools to manage an easier transition into menopause – and happy to return should she need further herbal support.