|01/10/2006 - TCM and the Contraceptive Pill by Gavin Hurlimann. |
Contraception comes from the Latin words contra, meaning against and concipere meaning to take in. American FDA approval for clinical use of the contraceptive pill was granted in 1960, however a number of high profile court cases involving the medication prevented its' general release until 1963. The first commercially marketed oral contraceptive pill was introduced in North America under the brand name Enovid by the pharmaceutical company G. D. Searle. In New Zealand, approximately 250,000 women per year are prescribed the oral contraceptive pill.
Female oral contraceptive medication is prescribed for the following;
• Dysfunctional uterine bleeding e.g. amenorrhea & menorrhagia,
• Mittleschmerz (intermenstrual pain),
• Anaemia, and
• Delayed menarche.
Western medical mechanisms
Colloquially known as 'the pill', oral contraceptives are produced in a variety of formulations. These formulations can be categorized as;
• Oestrogen and progestin combinations (combined oral contraceptive pill)
• Progestin only preparations (the mini pill)
Oestrogen/progestin combination mechanism e.g. Loette and Nordette 21
These medications contain extremely small amounts (up to 35 micrograms) of a synthetic oestrogen and one of a number of different progesterone chemical analogues. They are ingested orally for 21 days within approximately 12 hours of the same time each day and followed by 7 days of placebo pills. During the placebo interval, a woman will experience a withdrawal bleed that is often erroneously referred to as the menstrual period. Depending on the manufacturer, each patent or generic formulation will contain differing amounts of oestrogen and will be either monophasic - 1 dose of oestrogen/progesterone over the 21 days or multiphasic - varying doses over the same time period.
The drug acts by suppressing the secretion of the pituitary gonadotropic hormones; follicle stimulating hormone (FSH) and luteinizing hormone (LH). This action prevents ovulation and essentially reformulates the female body steroid chemistry to mimic that of pregnancy. Consequently, the prospect of fertilization is reduced to 2.8%. Oestrogen/progestin combinations also induce changes to the reproductive tract itself. The cervical mucus becomes more hostile to spermatozoon penetration and the endometrial lining thins - effectively resisting implantation of the fertilized ovum.
Progestin only preparation mechanism (mini pill) e.g. Levonelle and Noriday 28
Progestins contain synthetic progesterone only and are taken on a continuous basis without a placebo interval. The mechanism of the 'mini pill' is not yet completely understood, but it is thought that the drug causes alterations to the cervical mucus which inhibits the penetration of spermatozoon, suppression of ovulation and changes to the endomerial lining. The mini pill is prescribed when estrogen/progestin combinations are not tolerated or recommended (e.g. breastfeeding). Although some women report metrorrhagia and/or oligomenorrhea in the initial months of taking the drug, this tends to settle into a regular pattern with continued use.
User compliance is critical in the efficacy of the mini pill and when taken at the same time each day, the contraceptive has a failure rate of only 0.5%. However, by taking the mini pill as little as 3 hours past or before the time ingested the previous day, the chance of fertilization increases to 3.9%. Due to the fewer side effects, progestin only preparations are more popular with women over 35.
Emergency birth control preparations e.g. Ovral and Noridol
Emergency birth control pills (EBCs) informally known as 'the morning after pill', are an oral drug containing high doses (up to 1.5 mg) of the same hormones found in regular oral contraceptive pills. When taken after unprotected sexual intercourse, EBCs' assist to prevent pregnancy from occurring.
Like progestin only preparations, how EBCs prevent pregnancy is not yet fully understood. Depending on the time ingested during the menstrual cycle, the drug may inhibit or delay ovulation, inhibit tubal transport of the ovum or sperm cell, or interfere with fertilization. Where the drug fails to prevent fertilization, it is thought it may act by preventing implantation of the fertilized ovum in the endometrium. In general, emergency contraceptive pills work by triggering similar hormonal changes in the body as regular birth control pills (or even breastfeeding) - but they require much higher doses and are less effective than ongoing hormonal contraceptives. Debate surrounds the EBCs' mechanism of preventing endometrial implantation of the fertilized ovum and whether the drug is a contraceptive or abortive agent. The effectiveness of EBC oral medication in preventing pregnancy is 75% - 89%.
TCM theory of contraception mechanism
Traditional Chinese Medicine believes that conception occurs via the meeting of the mother and fathers' essence or Jing, through sexual intercourse. The mothers' ability to conceive is largely dependant on the state of her pre and post natal Qi and Blood, Jing essence, emotional nd environmental factors and the state of Ministerial Fire, Xiang Huo. Ministerial Fire is stored in the Kidney, Sanjiao, Gallbladder and Liver and one of its' functions is to promote the mothers' reproductive essence for conception to occur. Oral contraceptives are COLD in nature and primarily affect the Kidney; hence the cold nature of the drug inhibits the action of Ministerial Fire in promoting reproductive essence resulting in little or no chance of conception. The drug also affects to a lesser extent the Heart, Liver and Spleen.
The TCM mechanism of the oral contraceptive pill is illustrated below.
Western medical adverse effects
As with most Western medications the effectiveness of oral contraceptives is juxtaposed against the potential side effects. Common unwanted effects of the pill include;
• Breast tenderness,
• Gastrointestinal disturbance,
• Fluid retention,
• Vaginal infection,
• Acne, and
• Hirsutism (excessive body hair).
TCM discussion of Western medical adverse effects
Unlike Chinese medicine, Western pharmaceuticals do not syndrome differentiate or connect treatment to the individual person. This is highlighted when a particular oral contraceptive produces little or no adverse effects in one female while the same drug causes the unwanted effects of weight gain or hypertension in another. The adverse effects and syndromes discussed below occur in women who have a pre-existing weakness to, or a constitutional tendency for such syndromes.
Nausea: relates to the TCM syndrome of rebellious Stomach Qi, Wei Qi Shang Ni. The Stomachs' Qi direction is downward and the organ requires a wet & warm environment to perform its' function of rotting and ripening food & drink efficiently. The coldness of the drug can interfere with the Stomachs' warm climate causing Qi to stagnate and manifest as nausea.
Hypertension and breast tenderness: relates to contraction of the blood vessels, Han Zhu Shou Yin. The cold nature of the drug can contract the blood vessels resulting in less volume in the lumen and therefore a raised blood pressure. The drugs' coldness can also contract meridians and collaterals located in the chest area causing pain that manifests as breast tenderness.
Headache: relates to Spleen Qi deficiency, Pi Qi Xu. The Spleen requires a warm & dry climate to efficiently perform its' function of transporting and transforming (T & T) Qi, Blood and body fluids. The Spleens' Qi direction is upwards. The drugs' cold nature can inhibit the Spleens' function of transporting the clear Yang Qi to the head which results in insufficient Qi & Blood to nourish the brain marrow giving rise to headache.
Gastrointestinal disturbance, fluid retention and vaginal infection: relate to - in descending order - Spleen Qi deficiency, phlegm dampness accumulation, Tan Shi Yun Jie and damp heat accumulation, Shi Re Yun Jie. As in the adverse effect of headache, the drug can cause the Spleens' function of T & T and upward Qi movement to be compromised leading to gastrointestinal disturbances such as diarrhoea or constipation. The drug can inhibit the Spleen’s transportation of body fluids efficiently, resulting in the formation of phlegm/dampness or the Western diagnosis of fluid retention. This is particularly apparent in the lower abdomen, hips and buttock areas. Phlegm dampness accumulation combined with the Spleens' inability to circulate and transport these substances eventually leads to the build up of heat giving rise to damp heat accumulation in the lower jiao manifesting as vaginal infection.
Amenorrhea and metrorrhagia: both symptoms of dysfunctional uterine bleeding relating to disharmony of the Chong and Ren meridians. In TCM gynaecology, the Chongmai is referred to as the Sea of Blood, Xue Hai and the Renmai controls the fetus, Ren Zhu Bao Tai. Oral contraceptives can disturb the Qi and Blood circulation of these meridians giving rise to the absence of menstruation or bleeding outside of the normal cycle.
Acne and hirsutism: relates to a syndrome known as 'driving out of Yang Qi to the exterior' or Ge Yang Yu Wai. Only seen in patients with pre-existing Yin deficiency or internal excess heat. The cold nature of the drug can accumulate in the bodys' interior, driving Yang Qi to the exterior and manifesting as acne or excessive body hair. Even in healthy females, the long term use of oral contraceptives usually results in Kidney Yin deficiency, Shen Yin Xu and /or Qi & blood deficiency, Qi Xue Xu.
Kidney Yin deficiency is caused by the cold nature of the drug compensating for the Yin aspect of Kidney energy. As with all Western medications, the drug possesses no Yin nourishing qualities; eventually resulting in a type of atrophy or shuai jie to Kidney Yin that is not uncommon after long term use. This can be seen in younger women who present with classic Yin deficient signs like dry skin, rapid fine pulse and red tongue with little coating after some years of being on the pill.
Qi and Blood deficiency is caused by the drugs' affect on the Spleen. As previously mentioned, the Spleen has an affinity to a warm and dry environment and an aversion to cold (and dampness). The drugs' cold influence on the Spleen causes the transformation of food & drink into Qi & Blood to be impaired, resulting in a deficiency of both these substances. Cold extremities, pale complexion, fatigue, a pale swollen tongue body with a thick coating and thin weak pulse will be the common signs of this syndrome.
Female, 21 yrs old.
Main complaint: Oligomenorrhea/secondary amenorrhea
Duration: 1 yr
Significant signs and symptoms: Thin body type, pale complexion, inability to gain weight, poor appetite, bloated stomach after fried foods, light-headedness, dull headaches, mood swings, anxiety, sore back and neck, cold extremities, aversion to cold, ankle oedema, red tongue body with thin scanty yellow coating in lower jiao region, slightly rapid thready deep pulse. Breast augmentation at 16 yrs of age. Familial history of kidney disease.
This patient complained of irregular/scanty menstruation. She had been prescribed an oral contraceptive pill since age 14 due to delayed menarche and poor mammoplasia. In the past 12 months, menstruation has become scanty with some bleeding periods missed altogether despite taking the scheduled placebo pills.
Diagnosis: Spleen Yang deficiency, Kidney essence deficiency and Liver Yin deficiency
Discussion: In TCM gynaecology the organs and meridians involved in menstruation are the Heart, Liver, Spleen, Kidney, Chongmai and Renmai.
Firstly, the ‘factory’ of post-natal Qi and Blood is the Spleen. A deficient Spleen pattern impairs the transformation and transportation of essential Qi to the Lungs and Heart to be ‘reddened’ and transformed into Blood. Insufficient production of Blood in females is one TCM aetiology of oligomenorrhea and/or secondary amenorrhea
Spleen Yang deficiency is also seen in the patients attendant cold signs of pale complexion, cold extremities and aversion to cold as well as the poor appetite, bloated stomach after fried foods, light headedness, dull headaches, ankle oedema and deep pulse.
Secondly, the patients’ Kidney essence deficiency contributes to the impaired engenderment of Blood. When there is a surplus of Kidney essence, the essence will be transferred to the Liver and stored as Blood. The patients Kidney deficient signs of familial Kidney disease, sore back and neck, delayed menarche and poor mammoplasia reveal no surplus of Kidney essence to be stored as Blood in the Liver.
Thirdly, part of the Livers’ function is to ‘govern the emotions’ and ‘store Blood’. The lack of Blood engenderment mentioned above, results in the organ receiving insufficient Blood to be stored during rest and to nourish the Liver. As an even emotional state relies on smooth flowing Qi and a well functioning Liver, the patients’ mood swings and anxiety are reflective of the Livers’ involvement in the disorder. Blood is a Yin substance; therefore, a deficiency of Liver Blood is seen in the Liver Yin deficiency signs of thin body type, inability to gain weight, red tongue body, thin scanty yellow coating and slightly rapid thready pulse.
Fourthly, as we have seen previously, the Chongmai and Renmai are important in TCM gynaecology. The Chongmai originates from the uterus; it is referred to as the ‘Sea of Blood’, Xue Hai. When the Blood in the Chongmai is full, it is expelled as menstruation. The patient underwent breast augmentation at 16 years of age. As the Chongmai disperses in the chest, the operation may have impaired the flow of Qi and Blood in the Vessel, contributing to the patients’ menstruation irregularities.
Treatment principle: Tonify/raise Spleen Yang, nourish Kidney and Liver, restore and regulate menstrual flow. The patient was advised to discontinue the oral contraceptive medication.
Acupoints: CV 4 Guanyuan, CV 6 Qihai, ST 36 Zusanli, SP 9 Yinlingquan, SP 6 Sanyinjiao, KID 3 Taixi, KID 13 Qixue.Tuina: Slow, circular abdominal massage, anti-clockwise from the umbilicus outwards 50 times, then repeated 50 times clockwise inwards to the umbilicus was performed before each treatment to relax the patient and stimulate Qi and Blood. A TDP lamp was placed over the patients’ abdomen while the needles were retained for 20 minutes.
The patient discontinued the contraceptive pill and was treated every 2nd day, 1 week before the scheduled bleeding period was due. Treatment was stopped at the commencement of bleeding. This protocol was repeated for 3 menstruation cycles. The patient responded well with her menstruation returning to a regular 29-30 day natural cycle and a significant improvement in her general health.
This case illustrates the TCM effect of taking an oral contraceptive pill on a long term basis. The patients’ menstruation cycle is ‘artificial’ in a sense due to the drugs mechanism. Over time, the COLD nature of drug has replaced the Yin aspect of the patients’ Kidney energy and impaired Spleen function. As previously discussed, Western pharmaceuticals do not nourish Yin (or Yang) energy. This is reflected in the diagnosis of Spleen Yang deficiency, Kidney essence deficiency and Liver Yin deficiency.
The TCM nature, Zang fu affected and TCM adverse effects are summarized below;
Our primary focus as always should be on the patient as a holistic entity. This focus includes the TCM nature and effect of Western medications and is an important aspect of our clinical practice. Contraceptives complicate our task as their action can have a masking affect on symptoms and in general deplete a patient when taken on a long term basis. Although well intentioned, the contraceptive pill has been over prescribed by GPs for a number of disorders ranging from dysfunctional uterine bleeding to delayed onset of menarche. The long term TCM effect of these drugs is not often seen until a patient presents at our clinics with a problem that is not responding to conventional medical treatment. The clearer we are about the nature and effects of pharmaceuticals like the pill, the better able we will be to offer solutions and effective treatment for a wider range of disorders.
Gavin Hurlimann is the editor for the NZRA Journal of TCM and a registered acupuncturist practising in Auckland, New Zealand.
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