TOPICS IN GYNAECOLOGY PART ONE MENOPAUSE

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1 TOPICS IN GYNAECOLOGY PART ONE MENOPAUSE JANE LYTTLETON INTRODUCTION This series of articles addresses the health problems particular to women in their forties, fifties and onwards, i.e. the sorts of things occurring in the years leading up to, during and after the menopause. Large numbers of women in these age groups are consumers of health care and they frequently present a clinical challenge. They have in the past been a neglected area of the population and yet in modern society an ever increasing percentage of the population comprises this age group. Let us first look in detail at what happens to a woman s physiology as she approaches menopause, usually around age 50 but sometimes as much as ten years earlier. We shall do this first from a western scientific medical (WSM) perspective and examine the social and cultural context of the menopause. We shall then look at a traditional Chinese medical (TCM) understanding of the same events. WHAT HAPPENS DURING MENOPAUSE The ovaries are covered with eggs (like sago). Each month one egg ripens under the influence of a hormone produced by the pituitary gland, viz. follicle stimulating hormone (FSH), and the ovary will begin to produce oestrogen. The egg is released from the ovary and leaves behind it a structure known as the corpus luteum. The corpus luteum continues to produce oestrogen and progesterone unless there is no pregnancy. The follicles are depleted month by month and the ovaries gradually become scarred. There are however plenty of unripened follicles left when a woman reaches middle age. Ovulation becomes less frequent until it eventually stops. This process is called involution of the ovaries. Oestrogen blood levels fall below the point necessary to produce utrerine bleeding so periods become less frequent and then cease. For the next year there is a further slight decline in the secretion of oestrogen until it becomes stable with virtually no oestrogen secreted from the ovaries. WSM describes a connection between ovarian involution and the brain in physiological terms and psychological functions, e.g. emotional changes like vulnerability, loss of concentration, irritability etc. The feedback mechanism to the brain (pituitary) when the oestrogen and progesterone fall, is no longer operating and the pituitary keeps producing FSH and luteinising hormone (LH) at high levels. Blood tests to determine if a woman is going through menopause test the it is easy to see why the medical profession has adopted the attitude that menopause is a disease requiring treatment concentration of these hormones. Although the type of oestrogen responsible for the menstrual cycle is no longer produced, there is still a form of active oestrogen prduced after menopuase. Now the ovaries and adrenals produce androstenadione which is changed to oestrone (a type of oestrogen) in the fat cells of the body. Many women put on weight after menopause possibly in an attempt to produce enough of this oestrogen. Even if other forms of oestrogen are given as treatment after menopause, the body rapidly changes this oestrogen to oestrone. THE CLINICAL PICTURE 20% of women suffer marked symptoms at the menopause, 20% have none and 60% suffer mild symptoms. Those 20% of women who suffer badly at menopause and perhaps some of the 60% who suffer mild symptoms are the women who present themselves at doctor s surgeries requesting help. Hence it is easy to see why the medical profession has adopted the attitude that menopause is a disease requiring treatment. The assumption is made that when the ovaries stop producing oestrogen all women must necessarily be deficient in oestrogen (see later for discussion of hormone replacement therapy). Implicit in the idea of oestrogen deficiency is the notion that women need the same level of oestrogen after menopause that they needed in the reproductive years, and that for one third of their lives the body is malfunctioning. But a woman whose body is no longer preparing for pregnancy each month does not need the same high levels of oestrogen that went with the reproductive cycle. Another theory/idea used to explain the physical symptoms of menopause is the rate theory i.e. the symptoms are a temporary reaction to the relatively sudden fall in total oestrogen levels; a withdrawal similar to a drug withdrawal. So rather than a hormonal deficiency it may be more reasonable to talk of menopause as a period of adjusting to changing levels and types of sex hormones which adversely affects some women a great deal, some women not at all, and the majority of women in a mild and transient way. (NB - TCM with its emphasis on balance can certainly help smooth the way in times of adjustment and may well be able to predict those women likely to suffer more during the menopause years... see TCM section following). So just what exactly are the symptoms of menopause? Looking at medical literature reveals an inconsistent and 5

2 varied list of symptoms. Similarly publications of TCM and Kanpo (traditional Japanese medicine) origin list a variable number and type of symptoms. In 1976 there was an international medical conference held to try and clear up the disagreements. Its proceedings state that informed medical opinion considered only hot flushes and vaginal atrophy to be true oestrogen deficiency symptoms. 1 Hot flushes and sweating (either severe or mild) occur in 70-80% of menopausal women, while vaginal atrophy occurs in 10% of women. Other associated symptoms which were universally agreed to be part of the clinical complex were palpitations, pain in the joints, headaches, insomnia, psychological disturbances (anxiety, irritability, nervousness, and moodiness), and osteoporosis. All these symptoms can occur in women without menopause or in men (except vaginal atrophy). However it is the clustering or combination of these symptoms that forms the menopausal syndrome. SOCIAL AND CULTURAL FACTORS Many health workers believe that there is an overlap between menopausal symptoms and stress symptoms. Why is it that stress occurs in menopausal women more than other women? Or is it that a special sort of stress occurs which produces the above constellation of symptoms? Or is it the change in hormones that makes a woman more prone to stress? To answer this we need to look at menopause in its cultural and social context. This has been covered by S. Ballinger and W.L.Walker in their excellent book on menopause called Not the Change of Life. 2 Let s look first at cultural stereotypes. Stereotypes are powerful tools which mould the social reality of individuals. Cultures like the Rajput caste in India where a woman s status increases after menopause and she no longer has to wear a veil over her face and is given certain privileges report virtually no symptoms related to menopause. 3 Similarly the Lugbara women in Uganda who also gain status after menopause say they experience no menopausal symptoms. 4 The Indian women of Mexico become heads of their married sons families and households when they reach menopause and sail through it without a hiccup. 5 This is obviously in sharp contrast to our society where youth and beauty in women is revered (in the media especially) and the wisdom of age is either ignored or ridiculed more than respected. If this is an important factor in the occurrence or perception of menopausal difficulties then we would expect it to be a greater problem here than in China where women are appreciated more for what they offer society than for their youth or looks. It is my impression that this is so, i.e. it is a common presenting problem in my clinic but not so frequently seen in TCM clinics in China compared to other gynaecological disorders. More evidence that backs up the effect of positive or negative cultural factors on the severity of menopause is seen in surveys of women in societies similar to our own. Frequency and severity of symptoms is associated with low status or self esteem. Most notably those women The Indian women of Mexico become heads of their married sons families and households when they reach menopause and sail through it without a hiccup. with tedious and boring factory jobs report the most symptoms, even more than those without jobs at all. 6 As well as different cultural stereotypes producing different experiences of menopause, the expectations of the female population of different countries also influences their experience. Women in Australia and the USA have similar expectations of what menopause will bring and indeed report similar symptoms in type and frequency. However women in Norway dread the menopause more and have an even more difficult time on average than other Western nations. 7 Whether it is the expectation or the perception of symptoms that brings about the wide variation in the experiences of women around the world is not known. It is possible that women do in fact have similar symptoms but perceive them differently. S.Ballinger and W.L.Walker give the example of childbirth, which in some countries is a medical crisis and in others is an event which hardly interrupts the daily routine. Another way of looking at this is that if an event is perceived positively then it is experienced differently from one perceived negatively, e.g. the nausea and abdominal discomfort of pregnancy can be severe but cause much less distress than similar symptoms experienced by a woman with a pelvic tumour for which she is receiving nausea-producing chemotherapy. So while menopause continues to be promoted as a disease in our society it tends to guarantee or create the symptoms and the experience of them. In addition to the largely unconscious stresses of reduced status and the expectations of the appearance of symptoms at menopause, there are some other very real stresses that tend to occur during the years of 40-60, as big lifestyle adjustments have to be made, e.g. a radical change of role in the home or workforce, empty nest syndrome, retirement, and changes of relationship within the family such as the retirement of the husband, the arrival of granchildren etc. S.Ballinger and W.L.Walker hold that in fact the physiological adjustment to changed hormone levels may contribute very little to the overall stress inherent in this phase of life, i.e. menopause is not necessarily a major influence on how a woman feels in these middle years. They maintain that as more understanding of middle age and menopause is gained it is becoming clearer that the biological event of menopause does not appear to be the central event in women s middle age. Rather it is the psychological impact of the events of middle age (above), only one of which is menopause, that forms the major concern for women during this life stage. TCM in its description of menopausal syndrome does take this into account, even though it is not specifically stated. Rather then being seen as an oestrogen deficiency disease, it is understood to be a time of particular changes and stresses which produce certain patterns of disharmony. In Kanpo medicine a set of symptoms is recognised which Japanese doctors call by the rather horrifying title of women s erratic syndrome. Another catch phrase frequently heard referring to women in Japan is autonomic nervous system disorder - a term used to describe the middle age dilemmas of Japanese women. 6

3 TCM AND MENOPAUSE TCM theory talks about the Chong, Ren and Kidney channels rather than the ovary, pituitary and oestrogen. According to the theory of the 7 year cycles for women, the Kidney-Qi begins to decline as the 7th cycle is approached. Thus it is at about the age of 49 years that the Kidney-Qi begins to decline or the Tian Gui becomes exhausted, and the Chong and Ren channels are no longer nourished. This manifests in the irregular nature of the periods which come at erratic intervals and with varying quantities of blood. The imbalanced functioning of the Chong and Ren channels and the declining Kidney-Qi often lead to predisposition to Yin and Yang disequilibrium, giving rise to symptoms typical of Kidney-Yin (or less frequently Kidney-Yang) deficiency. This may then give rise to deficiency in other organs, e.g. Spleen-Yang-Xu or Heart- Blood-Xu or Liver-Yang rising. Chinese gynaecology texts describe the symptoms of menopause as: irregular periods, emotional lability, irritability, listlessness, flushing and sweating, dizziness, vertigo, palpitations, insomnia, thirst, poor appetite, 5 hearts hot, tinnitus, forgetfulness, hypertension, lumbar soreness, abnormal bowel movements, dry skin and vagina, and formication (a sensation of insects crawling on the skin). These symptoms are grouped into three main categories, and for the purpose of herb prescribing, a 4th type: i. Kidney-Yin-Xu (with Liver-Yin-Xu and Liver- Yang rising). ii. Kidney-Yang-Xu (with Spleen-Yang-Xu). iii. Heart-Blood-Xu. iv. Kidney Yin and Yang Xu. DIFFERENTIATION AND TREATMENT 1. Kidney-Yin-Xu (with Liver-Yin-Xu and Liver-Yang rising) Rising heat is the distinguishing feature of this type - flushing in the face (especially after midday) and sweating - insomnia - irritability and temper - dizziness, vertigo, headache, blurred vision, tinnitus - weakness and soreness of the lower back and legs - 5 hearts hot - thirst - constipation Tongue: red body with little coating Pulse: rapid and thready Treatment principle: nourish Yin, calm the Liver, subdue Yang and tonify the Stomach and Spleen. Taichong LIV-3 or Ququan LIV-8 - to calm the Liver and subdue Yang Fengchi GB-20 - for dizziness etc. from Liver Yang rising Zhaohai KID-6 - to tonify Kidney Yin Daling P-7 - for irritability etc. from Liver Yang rising Shenshu BL-23 - for lower back pain from Kidney deficiency Pishu BL-20 or Zusanli ST-36 - to strengthen Acquired Qi (see next section for details) Zhi Bai Di Huang Wan Da Bu Yin Wan Zuo Gui Wan Liu Wei Di Huang Wan Er Xian Tang 2. Kidney-Yang-Xu (with or without Spleen Yang Xu) - pallor - aversion to cold, cold limbs - lower back pain - clear copious urine or scanty urine - oedema - loose stools - abdominal distention, fullness of the epigastrium - low appetite - phlegm - obesity Tongue: pale with white sticky coating Pulse: deep, weak and slippery Treatment principle: warm the Kidney, regulate Qi, resolve Phlegm, and invigorate the Spleen. Shanzhong REN-17, Zhongwan REN-12, Qihai REN-6 - to regulate Qi and resolve phlegm. Use moxa. Guanyuan REN-4 - to warm the Kidney. Use moxa Zhigou SJ-6 - to promote the smooth circulation of Qi Fenglong ST-40 - to remove phlegm Sanyinjiao SP-6 - to invigorate the Spleen and Kidney You Gui Wan Ba Wei Di Huang Wan (Lui Jun Zi Tang) 3. Heart-Blood-Xu This type is often an outcome of Kidney-Yin-Xu or may be caused directly by constant mental stress. A deficiency of Blood may also be related to Spleen deficiency. - palpitations, shortness of breath - poor memory, emotional lability - insomnia and dreams - itchy skin - fatigue - pallor or yellow complexion - fullness of the epigastrium or low appetite Tongue: pale Pulse: thready and soft Treatment principle: tonify Heart-Blood, nourish Kidney-Yin, strengthen the Stomach and Spleen. Xinshu BL-15 - to tonify the Heart and calm the mind Pishu BL-20 - to tonify the Spleen to manufacture Blood; moxa may be used Shenshu BL-23 - to tonify Kidney-Yin and harmonise the Heart and Kidney Geshu BL-17 - to reinforce Blood Sanyinjiao SP-6 - to tonify the Spleen to nourish Blood; moxa may be used Xuehai SP-10 - to tonify Blood to reduce internal Wind; for itchy skin 7

4 Gui Pi Tang Tian Wang Bu Xin Dan 4. Kidney Yin and Yang Xu This type is a mixture of Kidney-Yin and Kidney-Yang deficiency where signs of both heat and cold are present. Treatment principle: reinforce Kidney-Yin and warm Kidney-Yang, and reduce empty fire. Taixi KID-3, Zhaohai KID-6, or Fuliu KID-7 - to tonify Kidney Yin and Yang Rangu KID-2 - to reduce blazing fire Guanyuan REN-4 - to tonify the Kidney Zusanli ST-36 - to support the Acquired Qi Sanyinjiao SP-6 - to support the Acquired Qi and the Kidney Er Xian Tang combined with Zuo Gui Wan. commonly used in menopausal patterns 8 1. Zhi Bai Di Huang Wan or Zhi Bai Ba Wei Wan This is Anemarrhena, Phellodendron and Rehmannia formula or 8 Flavour Tea and consists of Lui Wei Di Huang Wan (Rehmannia Six formula) plus two herbs to clear heat. When used in menopausal patterns it is often suggested to add a further two herbs to calm the spirit. a Blood tonic herb which also nourishes Yin and tonifies the Kidney; Shan Yao (Radix Dioscoreae Oppositae) - Qi tonic to invigorate the Spleen; Shan Zhu Yu (Fructus Corni Officinalis) - an astringent herb which warms and tonifies the Liver and Kidney and consolidates the essence (especially Liver-Yin); Fu Ling (Sclerotium Poriae Cocos) - a diuretic herb which helps to remove damp produced by the tonifying herbs, and tonifies the Spleen; Ze Xie (Rhizoma Alismatis Plantagoaquaticae) - a diuretic herb but used here to prevent Kidney fire flaring; Mu Dan Pi (Cortex Moutan Radicis) - a cooling herb to purge fire from the Liver and Kidney Zhi Mu (Radix Anemarrhenae Asphodeloidis) - clears heat; Huang Bo (Cortex Phellodendri) - clears heat; Long Gu (Os Draconis) - calms the Shen; Mu Li (Concha Ostreae) - calms the Shen This formula is used to nourish Yin, tonify the Kidney, and control flaring up of fire due to Yin deficiency. 2. Da Bu Yin Wan This is available in pill form. It tonifies the Yin and is often used for menopausal disorders if there is fire blazing. - tonifies Kidney Yin; Gui Ban (Plastrum Testudinis) - subdues Yang; Huang Bo (Cortex Phellodendri) - clears heat ; Zhi Mu (Radix Anemarrhenae Asphodeloidis) - clears heat 3. Tian Wang Bu Xin Dan or Bu Xin Wan This formula (available in pill form) also tonifies the Kidney and lowers blazing fire but pacifies the heart more strongly than the previous formula. It belongs to the Tranquillising and Sedating category of formulae, unlike the others which belong to the tonification categories. Sheng Di Huang (Radix Rehmanniae Glutinosae) - cools the Blood; Xuan Shen (Radix Scrophulariae Ningpoensis) - cools the Blood; Tian Men Dong (Tuber Asparagi Cochinchinensis) - Yin tonic; Mai Men Dong (Tuber Ophiopogonis Japonici) - Yin tonic. These are all used to nourish Heart Yin. Fu Shen (Poriae Cocos Pararadicis Sclerotium) - calms the Shen; Yuan Zhi (Radix Polygalae Tenuifoliae) - calms the Shen; Bai Zi Ren (Semen Biotae Orientalis) - calms the Shen; Suan Zao Ren (Semen Ziziphi Spinosae) - calms the Shen These all soothe the nerves of the Heart and replenish Heart Yin. Wu Wei Zi (Fructus Schisandrae Chinensis) - consolidates Heart-Yin; Dang Gui (Radix Angelicae Sinensis) - tonifies Heart-Blood; Dang Shen (Radix Codonopsis Pilosulae) - tonifies the Qi; Jie Geng (Radix Platycodi Grandiflori) - raises herbs to the Upper Heater; soothes and consolidates the Yin of the Heart. This formula is useful in nourishing Yin, tonifying Blood and soothing the nerves. It is chosen when menopausal symptoms are accompanied by extreme insomnia and anxiety. 4. Zuo Gui Wan This is a Yin tonifying formula, based on Liu Wei Di Huang Wan. It tonifies the Liver and Kidney and replenishes Yin and Blood more strongly than does Liu Wei Di Huang Wan, i.e. for more depleted and possibly older patients, with Kidney and Liver weakness. It does not treat Yin deficient fire. astringent. This is the base of Liu Wei Di Huang Wan. Tu Si Zi (Semen Cuscutae) - Yang tonic; Gou Qi Zi (Fructus Lycii Chinensis) - Yin tonic These two herbs tonify the Liver and Kidney. Lu Jiao Jiao (Colla Cornu Cervi) - Yang tonic; Gui Ban (Plastrum Testudinis) - Yin tonic These herbs replenish Yin and Blood. Niu Xi (Radix Achyranthis Bidentatae) - regulates Blood This herb is used to strengthen the tendons and bones. 5. Er Xian Tang This is a Yang tonifying formula designed specifically for use in menopause because it tonifies the Kidney, removes fire and regulates the Chong and Ren channels (therefore useful if the periods are coming erratically in early menopause). It can be combined with Zuo Gui Wan to tonify both Kidney Yin and Yang. Xian Mao (Rhizoma Curculiginis Orchioidis) - Yang tonic; Xian Ling Pi (Herba Epimedii) - Yang tonic; Ba Ji Tian (Radix Morindae Officinalis) - Yang tonic These 3 herbs warm Kidney yang. Huang Bo (Cortex Phellodendri) - clears heat; Zhi Mu (Radix Anemarrhenae Asphodeloidis) - clears heat Dang Gui (Radix Angelicae Sinensis) - Blood tonic. This herb nourishes Blood to regulate the Chong channel. 8

5 NB Care should be taken with long term use because Xian Ling Pi (also known as Yin Yang Huo) can damage Yin. It has androgen like activity on male organs and no demonstrable oestrogen effects. This formula can be used in menopausal patterns of deficient Liver and Kidney Yin (and rising Yang), as well as deficient Kidney Yin and Yang patterns where it is combined with Zuo Gui Wan. 6. Gui Pi Tang, or Kwei Pi Tang (Ginseng and Longan formula) This is another useful menopausal formula. It soothes the nerves and nourishes the Heart but its main action is to invigorate the Spleen and replenish Qi. It is especially useful if the periods in early menopause are very heavy. Ren Shen (Radix Ginseng) - Qi tonic; Huang Qi (Radix Astragali) - Qi tonic; Bai Zhu (Rhizoma Atractylodis Macrocephalae) - Qi tonic; Fu Ling (Sclerotium Poriae Cocos) - diuretic; Zhi Gan Cao (Radix Glycyrrhizae Uralensis) - Qi tonic; Hong Zao (Fructus Zizyphi Jujubae) - Qi tonic. These all invogorate the Spleen and replenish Qi. Suan Zao Ren (Semen Ziziphi Spinosae) - calms the Shen; Yuan Zhi (Radix Polygalae Tenuifoliae) - calms the Shen; Long Yan Rao (Arillus Euphoriae Longanae) - Blood tonic; Dang Gui (Radix Angelicae Sinensis) - Blood tonic. This group tonify Blood to nourish the Heart and soothe nerves. Mu Xiang (Radix Saussureae seu Vladimirae) - regulates Qi; Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) - warming. If is added to this formula it is called Hei Gui Pi Tang and provides stronger Blood tonification. 7. Ba Wei Di Huang Wan This is used for patterns of menopause due to deficiency of Kidney-Yang since it warms and tonifies the Yang of the Kidney. It is based on Liu Wei Di Huang Wan with the addition of warming herbs. It treats Kidney-Yang deficiency syndrome, i.e., cold and sore legs and lower back, difficult urination, incontinence, frequent nocturia and diarrhoea etc. and associated Spleen-Yang deficiency symptoms such as retention of body fluids and accumulation of phlegm, i.e. it warms the lower body. astringent. These herbs are three tonics for the Kidney, Spleen and Liver Yin. Fu Ling (Sclerotium Poriae Cocos) - diuretic; Ze Xie (Rhizoma Alismatis Plantago-aquaticae) - diuretic. To improve diuresis to remove damp and/or stagnation from tonic herbs. Mu Dan Pi (Cortex Moutan Radicis) - cools Blood. Used to clear heat from the Liver and Kidney. Gui Zhi (Ramulus Cinnamomi Cassiae) - Yang tonic; Fu Zi (Radix Aconiti Carmichaeli Praeparatae) - Yang tonic To warm and tonify Kidney Yang. Because these last two herbs are very drying and warming, this formula should not be used if there is any deficiency of Yin or fluids. 8. You Gui Wan This is a tonification formula used in menopausal patterns with Yang deficiency (usually with some additions). It warms the Yang of the Kidney. It is appropriate to use when there is evidence of failing of Ming Men fire. It is based on Fu Gui Ba Wei Wan (Rehmannia Eight Formula) minus Fu Ling, Mu Dan Pi and Ze Xie. This formula may also be used in menopausal patterns where the symptoms are due to deficiency of both Yin and Yang of the Kidney. However You Gui Wan has a stronger action in warming and tonifying Kidney. astringent. This group nourishes the Kidney, Liver and Spleen Yin. Lu Jiao Jiao (Colla Cornu Cervi) - yang tonic; Tu Si Zi (Semen Cuscutae) - Yang tonic; Du Zhong (Cortex Eucommiae Ulmoidis) - Yang tonic; Gou Qi Zi (Fructus Lycii Chinensis) - Yin tonic. This group of herbs warm and tonify the Kidney. Dang Gui (Radix Angelicae Sinensis) - Blood tonic Fu Zi (Radix Aconiti Carmichaeli Praeparatae) - warms the interior; Rou Gui (Cortex Cinnamomi Cassiae) - warms the interior. These two herbs warm and tonify the Yang of the Kidney. N.B. Warming herbs are contraindicated in Yin deficiency cases with heat, but note that a symptom like flushing can occur in Yang deficiency cases where the deficient Yang floats upwards. In this case the heat in the upper body would be combined with severe cold symptoms in the lower body, e.g. cold in the back and legs and diarrhoea. In such cases a herb like Rou Gui (Cortex Cinnamomi Cassiae) can be used to lead fire back to its source. Some common additions to this formula are the following: Dang Shen (Radix Codonopsis Pilosulae) - Qi tonic; Bu Gu Zhi (Fructus Psoraleae Corylifoliae) - Yang tonic; Yin Yang Huo (Herba Epimedii) - Yang tonic; Xian Mao (curculingis) - Yang tonic. References 1. P.A.Van Keep, R.Greenblatt and M.Albeaux-Fernet (eds) Concensus on Menopausal Research, MTP Press, Lancaster S.Ballinger and W.L.Walker, Not the Change of Life, Breaking the Menopause Taboo, Penguin Books M.P.Flint, Transcultural Influences in Perimenopause, in A.A.Haspels and H.H. Musaph (eds), Psychosomatics in Perimenopause, MTP Press, Lancaster, J.Middleton, The Lugbara of Uganda, Holt, Rinehart and Winston, NY, Y.Beyene, Climacteric Expression in a Cross Cultural Study, Paper presented at the fourth International Congress on the Menopause, Florida, Oct P.A.Van Keep and J.M.Kellerhalls, The impact of Socio- Cultural Factors on Sympto Formation, in Psychotherapy and Psychosomatics, 1974, vol. 23, p M.Hepworth, Sociological Aspects of Mid-life in P.A.Van Keep, W.M.Utian and A.Vermeulen (eds) The Controversial Climacteric, MTP Press, Lancaster, 1982 pp Handbook on TCM (Zhejiang college) and The Shanghai College text. 9