As spring comes into full bloom with the approach of May, people are flocking outside to run, jump, play… and get injured. Such is life! So now is the perfect time to discuss the most common varieties of common exercise-induced injuries: the sprain and its sibling the strain. When you pull a muscle or roll your ankle, it’s likely that you have sprained or strained something.
The broad definition of this painful condition is that you have stretched or torn a ligament (sprain) or a muscle or tendon (strain) without the joint popping out and becoming dislocated. Any time that something pulls or pushes on tissue with more force than it can resist, a sprain or strain is likely to occur.
Once a force is exerted on tissue and something tears, Qi and blood rush in to clear away the damaged tissues and bring nutrients in for the process of repair.
As this process gets under way, the area swells and will often become red, hot and painful. If the injury is severe enough, the joint may become too tender and swollen to bear weight or to use. Over a few days or weeks, the intensity of the repair process will decline, and so the swelling and pain will subside gradually until all is well again. This is the ideal circumstance, in which very little intervention from the outside is needed.
Unfortunately, this happy progression is not always what occurs.
One reason sprains and strains in the limbs are more often discussed is that the tendons and ligaments in our limbs don’t have excellent blood flow through them (fancy medical words: they are not well-vascularized). This means that the process of inflammation and repair has less resources to work with, a bit like the difference between a car crash in a city center and one in a remote area. The ambulance will get there as fast as it can in both cases, but it might be a while if you are far out in the wilderness.
The other tricky variable to consider in how quickly an injury will heal is the underlying physiology if the individual person. Here is a very zoomed-out overview of the organ systems that could be involved in healing a musculoskeletal injury from a Chinese medicine perspective:
- Liver feeds blood to the tendons and ligaments
- Spleen feed nutrients to muscles
- Lung ensures that Qi is circulated to the whole body
- Gallbladder moves fluid in the joint spaces
- Heart is in charge of moving and controlling blood in the whole body
- Sanjiao (Triple Burner) moves fluid in every space between organs and body cavities
- Kidney builds and maintains the bones
You can see that many organ systems are involved in the repair of injuries!
But which organs are impacted and to what degree is often best explained as an outgrowth of your constitutional tendencies. If you have digestive issues that your spleen is already dealing with, then its ability to repair your muscles will be compromised.
If you have liver Qi stagnation from a stressful job, the liver will have a harder time getting blood to the tendons or ligaments to repair them. When people are blood-deficient the liver doesn’t have much to work with in the first place.
“This is why treatment for an injury in Chinese Medicine is so individually tailored; it’s often a matter of treating underlying problems that are preventing the healing process from perfectly unfolding.”
What can you do the next time you roll your ankle or throw out your back?
Acupuncture, Chinese herbs, and especially topical herbs are very important for healing injuries quickly and completely. In addition, here are some home remedies based on prior imbalances that you can try out yourself:
- For Liver Qi stagnation (depression, stuck anger, frequent sighing, discomfort in the ribs): journaling, nature walks, talk therapy, exercise
- For blood deficiency (frequent waking from sleep, anxiety, abnormal-for-you pale complexion, forgetfulness) eating organ meats, leafy green veggies, possibly iron and b vitamin supplementation
- For Spleen Qi deficiency (fatigue, loose stools, feeling tired after meals, poor appetite) simple foods (grains, sweet potatoes, congee), regular meals (as in at a similar time every day), medicinal vinegars before meals (check out your local Asian market for delicious drinking vinegars), eating meals while focused on the food rather than in front of a screen or in the car.
- For Sanjiao stagnation (swollen lymph nodes, frequent itching of the skin, swollen and red areas in the neck and ears, chronic illness such as Lyme): proper hydration, gently detoxifying foods like citrus, fresh herbs, and burdock root
- For Kidney Qi or Yang deficiency (deep exhaustion, low back ache, chronic pain made worse by cold, frequent urination at night): rest, meditation, foods from the sea, quiet spaces, warm compresses
Have fun, take care, and drop us a line if you take a spill!
Watershed Wellness brings you a new series! You’ve received health care from our wonderful practitioners. Perhaps you’ve chatted with them for a quick minute before and after your appointment. But what is your practitioner like in everyday life? To help you on the path to knowing your practitioners better, we’ll start with a fun, informal interview. This quarter’s spotlight is on Rowan Everard, one of our brilliant Chinese Medicine practitioners. Rowan’s strong allegiance to queer/transgender care as well as a focus on chronic/acute pain management makes him a huge asset to both the Portland and Astoria clinics.
We sat down to chat about everything from music, to the kind of health care he admires, to what is so great about the Pacific Northwest!
- Thank you for sitting down to chat! Your patients and colleagues alike LOVE having you in this space. You’ve been at Watershed for over a year now, how’s that year been?
Yes! I feel excited to continue to grow my practice and my connections to the community of SE Portland. It’s been wonderful working with so many talented practitioners.
- What was the last awesome concert you went to?
- If money was no object, where would your next dream vacation be?
- What’s your favorite neighborhood in Portland and why?
North Portland/St John’s; it’s got such a lovely view of the hills and such good food.
- What’s in your Netflix queue right now?
The new Star Trek, of course.
- If you weren’t a healthcare practitioner, what would your next career choice be?
Probably an aid worker for the UN or Oxfam
- What do you love most about the Pacific Northwest?
That we have access to almost every kind of climate and topographic feature in this state; deserts, mountains, rivers and forests!
- Favorite cuisine?
Lately I’ve been really into Chinese street food.
- Out of the five basic natural elements (earth, air, fire, water, ether), which one do you identify with the most? As a practitioner of Chinese medicine, you’re required to answer this question! (Kidding, mostly).
- It’s your day off and you have no responsibilities. How are you spending your leisure day?
Hiking somewhere in the forest, most likely.
- Your top five favorite movies?
The Fountain, Shortbus, But I’m a Cheerleader, Fargo, and Bound.
- What’s your favorite season of the year?
- Which do you prefer, tea or coffee? Any favorite tea makers or coffee roasters?
Coffee. I’m partial to Equal Exchange because their business model is fantastic and their coffee is high quality.
- Would you rather read a book or listen to a podcast?
Listen to a podcast/book.
- What was your “aha!” moment that made you realize you wanted to be a healthcare professional?
I was imagining being a professor or working in an office somewhere. Then I realized that I would rather be working with people one on one than pushing papers around somewhere!
- Three words that describe your personality?
Empathetic, loyal, passionate.
- Where are you from originally, or where did you first call “home”?
The Chicago suburbs.
- What’s in your music queue right now?
- Where do you hope your practice lands in the next five years? What’s your biggest goal and hope with what you do?
I just want to help people heal and become the best physician I can be. Wherever that takes me, will be somewhere I’m excited to be.
- What is a health care modality that fascinates you, that you’d like to learn more about, or that you just greatly admire?
Functional neurology is super cool, and they seem to take a very Chinese Medicine approach to the body.
Stayed tuned for the next Practitioner Spotlight segment – coming in May!
Editor’s note: This interview was done by none other than Amanda Koennecke, despite the fact that Rowan is listed as the author. 🙂
One day as a medical intern during my schooling, a faculty member came in for a treatment for acute pain. He had just rolled his ankle outward, which is the harder and more painful way, and it was swollen almost to the same size as his knee. He wanted to know if I knew how to do acupuncture for acute pain, because he was leaving for a vacation the next day, and wanted relief! I said yes, and did what I considered to be a fairly simple acupuncture treatment to drain heat (inflammation) and move blood. We also applied a poultice of Chinese herbs guided by the same principles.
I’ve seen countless successes with acupuncture for acute pain since that time as an intern. Classical Chinese medicine, as I have written before, is designed to treat the most common maladies that people experience. However, because of the relatively recent introduction of Chinese medicine to the American system, combined with some structural problems in our healthcare system itself, means that people rarely consider an acupuncturist when they are injured. The way that injuries are approached from a Chinese medicine context is quite different from how they are approached in biomedicine (also called Western medicine).
Biomedicine, let’s be clear, is responsible for incredible recoveries – seeming miracles in many cases. For treatment of trauma, and enacting life saving measures in the face of poor prognosis, biomedicine is incredible. However, some have found that full treatment of those injuries to a pain free state, or overall treatment of chronic pain, seems not to be as well developed in this system. Could this be because the approach to acute injuries in biomedicine comes from work in extreme circumstances, such as battlefield medicine & high performance sports contexts?
If you consider this possibility, it does make sense, because people dealing with extreme circumstances tend to innovate and create useful technologies. Many pioneering approaches have come out of battlefield medicine, such as ready-made tourniquets and quick-clot. There is a dark side here, though: both sports and battlefield situations have different aims than regular civilian life. They both require people to be ready to exert themselves again as quickly as possible. This is not the same thing as healing an injury as fully as possible.
In fact, sometimes healing as quickly as possible can impede fullest recovery over the longer term
A simple illustration of this can be seen in the RICE protocol. RICE stands for rest, ice, compression and elevation. It has long been the standard approach to sprains and strains, and it comes from sports medicine. Icing an injury certainly does cause the swelling to go down. It allows someone to put weight on the joint again sooner, and get back on the field.
After the first day or two however, as the intense heat of swelling recedes, it begins to introduce cold in the site. Cold tends to slow biological activity, and can kill cells. From a perspective in Chinese medicine theory, cold injuries Yang, Qi and blood. In my clinical experience, and that of my teachers, this can lead to instability in the joint as it heals, and increased scar tissue. In extreme cases, it can an acute injury and creates a chronic one. Using acupuncture for acute pain – before it becomes a chronic condition – may be part of the answer!
How do acupuncturists look at acute injuries differently?
We’ll return to sprains in later posts, but for now let’s examine how Chinese medicine theory relates to acute injuries. There are various types of acute injuries, of course: breaks, cuts, punctures, dislocations, crush injuries, and endless variations and combinations of those types. From a CM perspective, what all of these types of injury share is that they cause Qi and blood stagnation. Wait – blood stagnation? You may wonder “how can a bleeding cut or similar be blood STAGNATION?” There’s a lot to say about that, but let’s summarize by saying that we define blood stagnation as any situation where blood is not flowing properly inside of the vessels. Being outside of the vessel, and pooling between layers of tissue, qualifies.
This becomes more clear if you imagine the process of wound healing with clotting, scabbing over and then scarring. Qi stagnation happens anytime that the body’s abilities to communicate is compromised, even at a cellular level. As cells are destroyed by an injury, dead zones of communication are created.
Stages of injury in Chinese medical theory
Acupuncturists treating acute pain recognize three stages that all acute injuries move through.
- Stage 1: The site of the injury becomes hot and swollen, and dead tissue builds up, which was think of as heat toxins. The body sends Qi and blood to the site to repair the damage.
- Stage 2: Some of the acute heat swelling recedes, and stagnation of Qi and blood due to tissue damage begins to create pockets of cold
- Stage 3: All acute heat and swelling are gone and only stagnation remains, largely as scar tissue, which leaves the area vulnerable to wind and cold becoming trapped.
Our acupuncture for acute pain treatment strategies flow naturally and rationally from these stages of healing.
- Stage 1: We drain heat toxins, stop bleeding and move Qi and blood
- Stage 2: Some draining and moving and some warming methods are used
- Stage 3: Warming and nourishing methods used, some moving Qi and blood but more gently
When treated properly with the above methods, injuries tend to resolve more completely. We accompany the patient through all of the stages of healing, giving them support every step of the way. This leads to a much more stable joint/limb/body cavity, with less scarring and often less pain. Simply put : acupuncture for acute pain helps avoid needing treatment for chronic pain down the road. While acupuncturists absolutely can, and do, treat old injuries – preventing them is much more satisfying.
What you can do on your own for acute injuries
You can always come see me if you get hurt, I specialize in acupuncture for acute pain! But, sometimes treatment isn’t feasible – or not feasible soon enough! In that case, here are some take-home strategies for self-treatment!
- Sanhuang San (pronounced Sahn Hwahng Sahn): known as herbal ice, this external herbal formula clears heat and moves Qi and blood, thus reducing swelling and pain. It works with the body to improve circulation, rather than shutting it down. You can mix the powdered herb with any ointment and apply thickly to the site of the injury, like icing on a cake. Do not use on open wounds! You can find the powder here, among other places.
- Warm/cool hydrotherapy: you can improve circulation in and out of the area by alternating warm and cool soaks or washcloths. Shoot for 10 minutes of one and 10 minutes of the other, for no more than an hour at a time. This will help flush toxins out of the area and then assist the body in bringing the circulation back.
- Don’t ice after the first two days! Really, please don’t. Use warm/cool hydrotherapy instead – protect that yang qi!
- Massage out bruises. Be gentle, of course, but from a Chinese medicine theory perspective, bruises are stagnant blood that needs to be broken up – moved. A little goes a long way here!
Use your injured body part gently and stretch. Circulation of Qi and blood is vital to the healing process, and needs to be balanced with rest. Listen to your body as you learn your limits during your healing process.
Have you ever tried acupuncture just after an injury or accident? If so – what was the result?
It’s a dilemma that trans-masculine people know all too well: the need to reduce the painful experience of dysphoria on the one hand, and concerns about longterm health on the other. At first, the decision is easy; we strap down our breast tissue somehow some way, whether with ace bangs, commercially-made binders or compression shirts. The internal alarm bell that goes off when we look into the mirror or down at ourselves quiets, and we finally get some relief. All seems well for weeks, maybe months.
Unavoidably though, a new problem arises: pain.
Where the pain resides exactly depends on the person and the binding method, but it will arise. Compression of our rib case, and the soft tissues beneath, can lead to a wide variety of problems. Rib pain, shortness of breath, dizziness, and even scary chest pain can all becomes staples of daily life during binding.
Let’s examine how to think about this situation using the tools & science of Chinese Medicine. In this way of thinking, the trunk of the body is divided into three compartments, or Jiao. The upper Jiao contains the lungs, heart and pericardium. The middle houses in the liver, gallbladder, stomach and spleen, while the lower is the home of the kidney, bladder and both intestines. The final organ, the Sanjiao or Triple Burner, is a network of water passages that connects all three for the purposes of transport and communication.
In addition to the organs, we also have meridians or Chanels associated with each organs, as well as larger channels that connect all twelve.
The most-often-used metaphor for this system is a watershed that runs through the deepest parts of our bodies, which then consolidates and emerges into broad rivers between the muscles and fascia, finally concluding as small streams at our surface. What a nice metaphor – and it has broad utility. This network, according to Chinese medical theory, carries information, regulates water metabolism, and ensures that homeostasis (the balance inside our body that enables health) is maintained by subtly responding to all of the weird things that happen us throughout our lives.
Given this system’s intricate levels of communication through different kinds of tissues, imagine what might happen if we took the entire thing in the upper and middle Jiao, and squeezed. Not just once, but constantly, every day, during every waking hour and sometimes sleeping hours as well. One can imagine that all sorts of processes could be negatively impacted!
Here are a few of the potential consequences, on this view:
Blood flow: blood is hugely important process that our bodies use to transport nutrients, gasses and yang (life force) from place to place, and its functions are especially associated with the heart, pericardium and liver. If blood flow is impeded, these organs can become either too full of blood (stagnation) or have their blood supply be subtly reduced (deficiency).
Symptoms can include chest pain, pain in the ribs and abdomen, anxiety and depression.
Water metabolism: The spleen, lung and kidney are all important organs that ensure the proper flow of moisture around the body. The kidney is said to seam water up into the upper Jiao, the spleen to transform and transport it from food and drink into the other organs, and the lung to accumulate moisture and then rain it back down to the rest of the body. If the lung becomes physically compressed, moisture can accumulate and build up as phlegm.
Over time, the heat of the body can cook this immobilized phlegm into a hot goo that results in chronic congestion, hot chest pain, cough and anxiety.
Qi transformation: the work of the organs is done around the body by their associated channels, through a process called Qi Hua or Qi transformation. To give one example; the stomach channel carries the hot and drying Qi of the stomach organ up the front of the body to assist with digestion, heat distribution and immune functions.
Cutting down the size of its pathway through the chest can impede its flow, resulting in stomach organ issues like reflux, nausea or vomiting. It can also have implications for our immune systems.
All of the issues that can arise from binding can be treated through acupuncture, herbs, bodywork, and targeted exercise, but their cause is the practice itself. I want to be careful here not to engage in victim-blaming. Many healthcare providers think about this issue and say “yes, my patients should certainly stop binding if it’s causing so many problems!” But that ignores the entire reason that we do it in the first place. Dysphoria is a very real health problem with severe mental health implications.
Binding is often a life-saving act of harm reduction that allows us to life our lives without the constant mental anguish that dysphoria creates.
Surveys of people who bind find that the vast majority of people are doing it while they await the ability to access a surgical solution. Until very recently, top surgery was not covered by insurance and was only available to those who could pay out of pocket. This has begun to change in some states, but remains the case for most people. Therefore we should remember that binding is a self-preserving response to a societally-imposed scarcity of medically-necessary healthcare.
While we engage in the activism needed to change this, here are some harm reduction strategies to consider:
- Stretch it out: engage in stretching poses that open the chest and ribs, for at least five minutes a day
- Build strength: strengthening the muscles of the back and chest may help hold the body of your ribcage in place and protect them from the longterm effects of compression
- Move your body: qi and blood move when we do, and exercise of any kind helps prevent stagnation. Depending on how you bind, running may not be a great plan, but walking is wonderful for both our bodies and our moods.
- Get some acupuncture: we can reduce stagnation and pain by unblocking channels and moving qi and blood in targeted ways
- Take some herbs: chest stagnation and digestive issue in particular respond well to Chinese herbals formulas
- Listen to your body: only you can know what is right for you in terms of when to bind, how to move, and how to balance all of the considerations in your life.
Above all, be gentle with yourself as you navigate the complexities of trans experience. If you want support in your journey, schedule an appointment and let’s see how we can work together.
Top surgery, like so much of trans healthcare, is a subject about which much information in desired, but little is available from trusted sources. Every surgeon has their own particular instructions on how to prepare and heal, and most of them do not have good websites. I personally don’t know how anyone transitioned before the advent of YouTube (I guess talking to other people in real life?), but random people in the internet may or may not be good sources of knowledge about a complex medical procedure.
To help solve this problem, I want to offer some basic information about how Chinese Medicine thinks about surgery in general, and top surgery in particular, and then outline some basic steps that you or a loved one can take to have the best possible experience.
First of all, what do we really mean by the term top surgery? This is really an umbrella term for a few different procedures that reconstruct a person’s chest to have a flat appearance, if that person has grown breast tissue that they do not want. Most people who undergo such procedures are trans-masculine and non-binary people. Broadly speaking, there are two categories of surgeries: the kind that use long incisions to remove tissue and re-size nipples, and those that use only a small incision near the nipples. The first kind is used for most people who have a B cup or larger, which the second is reserved for those who have a small amount of tissue to remove. While the procedures involving only liposuction and a small incision are less invasive that those where more tissue is cut away, they both require recovery time and can be hard on the body.
A key thing to know about surgery is that the body does not really differentiate between a surgical procedure and a stab wound.
A surgical cut is much cleaner than the average wound, and is closed with staples or sutures to increase the speed and comfort of the body’s repair cycle, but it stills goes through all of the regular stages of the healing process.
In Chinese Medicine, all wound healing has three basic stages:
- First stage wounds and injuries are characterized by heat, severe pain, and swelling. This stage can last anywhere from a few hours to several days, depending on the severity of the wound. In this stage, we want to help the body clear away the damaged tissue, which we consider a form of toxicity, and dispel the heat of the inflammation. We use cooling, fluid moving and blood moving herbs, either internally or topically, to help this stage resolve as quickly as possible.
- The second stage begins when the heat in the injury subsides. There is still Qi and blood stagnation in this stage, as the body continues to mobilize resources into the area, and this congestion can cause stiffness and pain. This stage is where the incisions begin to consolidate into the beginning of scars, and we want to keep Qi and blood moving so that all incisions heal quickly and with minimal pain.
- Third stage healing is the cleanup phase, where all incisions have fully closed and scarred, but there can be lingering pain and stiffness, and sometimes numbing or other odd sensations. A fresh wound is vulnerable to the environment, particularly to dampness and cold, because the skin is open and Qi and blood are not not circulating normally in the area. If dampness or cold become lodged in the tissue, chronic pain and stiffness can result. Is this stage we focus more on using herbs that warm tissue and expel cold and dampness, as well as moving Qi and blood.
The body does an excellent job of rebuilding itself after being damaged, and our goal with natural medicine is to help modulate the body’s actions and make them as efficient as possible. The third stage of healing need not become chronic, so long as the first two stages are managed well. However, if there are complications then chronic symptoms can arise.
A variety of issues can arise as a result of even uncomplicated surgeries.
First, scarring. Sometimes people’s scars are larger or most noticeable than they would like. This can occur from moving the arms too much during the first few weeks after surgery, and sometimes can just happen even if utmost care is being taken. Life happens. Keloids can also occur, and may be more likely to form in those with darker skin. A keloid is a hard growth of scar tissue that is raised, hard, and smooth. It is not dangerous or malignant, but it can be more noticeable than non-keloid scar tissue. Most scaring is considered an issue of blood stasis in Chinese Medicine.
Second, restricted movement. If scars do not heal well, movements involving raising the arms or turning to the side can become more difficult because of the pulling effect. Qi and blood stagnation in the channels that were cut into is usually also involved.
Third, numbness/loss of sensation: some surgical methods involve cutting the nerve stalk that connects the nipples to the rest of the nerve structure of the chest. This causes of loss of sensation, and can also lead to numbers or tingling in other parts of the chest in some cases. This is often due to dampness or wind that has sneaked into the area, and become a third-stage problem. And fourth, pain. Pain from surgical wounds can persist beyond full healing. This is generally, but not always, seen along with some numbness or loss of sensation.
Acupuncture and Chinese herbs can treat all of these issues, even years later. A combination of herbs, acupuncture, gentle movement and appropriate dietary adjustments can continue the healing process in gentle, but effective ways. However, the goal of this article is to help you reduce the chances of any of those things from happening in the first place! With that goal in mind, here are some steps that you can take to prepare your body for surgery and recover well.
- Take good care of yourself in general. Eat nourishing foods, get plenty of sleep, and exercise in ways that feel good to you. The better you feel before surgery, the better you will feel afterwards.
- Take some herbs. Much of the difficulty in healing from surgery comes from the blood loss inherent in the process. Taking herbs that help build blood prior to the procedure gives the body the most resources possible to do the job.
- Treat any underlying health concerns. If you have digestive problems, breathing issues, chronic pain, or anything else that is really bothering you, surgery is going to add stress. Most people get a date far in advance, so plan ahead and access as much care as you can beforehand.
- Supplement strategically. Vitamin C, Zinc and Selenium are all involved in the process of synthesizing collagen, which is the main building block of new tissue in our bodies. They are cheap individual supplements to buy, and you can take them in the weeks leading up to the procedure, and then start again a few days after.
- Take some herbs, again. Faster and less painful healing is a huge win. We like to prescribe Wangbuliuxing Tang (Vaccaria Seed formula) 2 weeks before and 2 weeks after surgery. This is an
herbal formula traditionally used to treat cuts from knives. It speeds things up by moving blood and fluid, and treats pain quite well.
- Get some acupuncture. Acupuncture treats pain, reduces swelling, decreases scarring, and helps people recover emotionally from the difficult experience of a medical procedure.
- Follow the instructions of your surgeon. When they say not to lift heavy things, please listen. Ditto for raising your arms. Try to set up your living area so that everything is at waist height, and ask for help if you can’t reach something. Your future self will thank you.
Lastly, I want to say a bit about the emotional experience of top surgery.
As I said earlier in this article, our bodies don’t really know the difference between an on-purpose surgery and a stabbing. This is also pretty true of our minds/psyche/spirit. Mentally, we may be excited about one and fearful of the other, but a sharp metal object is piercing our skin either way. This is important to understand, not only to frame the steps of healing, but also to put into context the feelings that can arise after going under the knife. People are generally quite happy to be in a body that feels more aligned with their felt sense of themselves, but there can also be powerful feelings of helplessness, fear and even anger that arise after waking up covered in bandages and in pain.
Bearing this in mind, it helps to do everything that you can to create a cozy and loving environment for yourself or your loved one to settle into once they leave the surgery center or hospital. Comforting foods, movies, careful snuggles and pet friends can all help people return from the experience more quickly and fully. Give yourself space to feel whatever you feel, and know that the scary stuff will pass.
Much thanks to Hamilton Rotte, who provided the bulk of the information about the three stages of injury healing. More information about his work can be found by clicking this link.
Estrogen is a complex hormone with myriad effects on many systems throughout the body. Over centuries of medical research characterized by sexism, it has been cast as a hormone that governs cycles solely in the bodies of cisgender women, and also as a chemical that is “less strong” than testosterone. These beliefs are not accurate appraisals of human physiology, however. Estrogen has diverse effects throughout all kinds of bodies, many of which are vital to the health and wellbeing of everyone.
It is true that estrogen creates feminine secondary sex characteristics, IE breast growth, pubic and armpit hair growth, and hip widening. Estrogen regulates menstruation in people with uteruses, along with progesterone. It regulates breast milk production in people who are nursing babies. It is also vital to the clotting process, which is initiated when a person is injured and bleeding, as well as to the cycle bone formation , repair and growth. Estrogen strengthens the lining of vaginal and uterine walls, and also the walls of people’s urethras.
I want to stress the universal nature of estrogen’s power because, in the context of hormonal transition, pernicious narratives about estrogen’s “weakness” play a particularly intense role in the framing of transition as a medical process.
The mythology goes like this: the effects of estrogen are “easy to erase”, which the effects of testosterone are more “resilient”. These ideas happen to neatly dovetail with prevailing sexist notions that femininity is “weak” and masculinity is “strong”, and the projection of these ideas onto the biochemical processes that people feel correlate with gender expression is pretty transparent, and leaves a lot to be desired on a scientific level. For example, the fact that beard growth is difficult and painful to reverse through electrolysis is often put forward as proof of testosterone’s superior “staying power”, but no one ever raises the fact that the widened hips brought about by estrogenic puberty are impossible to erase.
All of this is to say that, when considering how to think about the effects and side effects of estrogen in Chinese Medicine, there is a lot that needs to be unpacked before we can ever begin.
There is a parallel retrograde school of thought within some corners of Chinese Medical thinking, wherein testosterone is yang and therefore “good” and estrogen is yin and “bad”. Men are more yang, and therefore virile and stalwart, while women are more yin, and must be protected because they are fragile and retiring. Similar sexist imperatives have been at work in China over the last many hundreds of years as in the west, and it shows. This view, however, is also a willful misrepresentation of science, within our medical framework, and must be similarly challenged.
Yin and yang can be seen as concepts of duality. In the world of philosophy and metaphysics, they are often positioned as light and dark, good and evil, sun and moon, etc. This is all well and good, and the philosophical roots of Chinese Medical theory should be kept in mind, but we need to also remember that there is no good and evil in human physiology. The human body is a finely balanced organism that constantly keeps all factors within a tight range of homeostasis to avoid death. We can characterize disease as evil, perhaps, but parts of human physiology not so much.
A more defensible definition of yin, in physiological terms, is that which is physical, and also fluid.
Yin builds the bones, the blood, and regulates the spaces in the body where new human beings are grown. Yin produces the fluids in the body that moisten and protect, while yang causes things to move and expand. The complementary nature of two becomes clear when framed in this light. A person with only yang in their body would soon dry up and become a fiery, desiccated husk. Similarly, a person who was solely yin would overflow and spill out into the world with no perceptible boundary, much like the “Blob” of the 1950’s horror movie. Of course neither of these extremes exist in nature, but we can see the symptoms of imbalance in this light.
Here are some potential side effects of too-high estrogen levels: fatigue, depression, loss of sex drive, weight gain, abdominal pain, cold hands and feet, breast tenderness, insomnia, and anxiety. For the most part, they fall mainly into the Chinese Medical categories of yin accumulation and blood stagnation. We must remember that too much yin also inherently means too little yang, because they are relational concepts. So if a person is producing more fluids or blood than their body can move properly, they will settle around the body and cause problems. The body will work harder to move them, and if it still cannot summon the yang needed to do so, heat will be produced in the effort, which leads to heat symptoms like insomnia and anxiety.
It must be said that these are symptoms of internal imbalance, not inevitable effects.
Often lowering estrogen dose, adding progesterone, or supplementing very small doses of testosterone will resolve them. However this is not always possible, as some of these effects are the result of an internal imbalance that preceded hormone therapy, and is being worsened by it. This imbalance would need to be treated either way, and the effects of hormone supplementation are simply revealing it.
Chinese medicine has been used for thousands of years to regulate hormones, particularly estrogen.
The use of acupuncture and herbal medicines for key hormonal experiences like pregnancy, menopause and andropause far predates the practice of hormone prescribing. The two together can be even more powerful, as the blunt power of the hormones can be directed more precisely by the subtlety of acupuncture and herbs.
One excellent formula to consider is the formula “Wen Jing Tang” or “flow-warming decoction”. It pairs herbs that warm and transform fluids, such as ginger and pinellia, with herbs that supplement and move blood like Angelica and Chinese lovage root. The picture of this formula is a person who is quite depressed, with cold and hands and feet, nausea, abdominal pain, menstrual irregularity and/or infertility. Menstruation is not a required feature however, but an expression of blood stagnation and cold in the lower abdomen, which cause the other symptoms as well. Along with warming and clearing acupuncture techniques, this formula will resolve the above symptoms within a few weeks.
Estrogen, like all things in the human body, is powerful and vital in the correct balance. Any person with a hormonal imbalance can experience unpleasant effects as a result, and Chinese Medicine can be an important tool in righting the ship. As medical providers, acupuncturists and Chinese herbalists are bound by the same medical ethics as any other profession: to see our patients and their suffering clearly, and treat accordingly.
This article describes some possible ways that estrogen imbalance could look or feel, but there are many possibilities. If you want to start feeling better now, come on in for a new patient visit!
Here are some articles that I used in researching this piece:
- Bienfield, Harriet , and Efram Korngold . “Menopause, Hormones and Chinese Medicine.” Acupuncture.Com – Menopause, Hormones and Chinese Medicine – February 2009, www.acupuncture.com/newsletters/m_feb09/menopause%20chinese%20medicine.htm. Accessed 26 Sept. 2017.
- Blakeway, Jill, Ms LAc. Addressing Estrogen Dominance in Perimenopausal Women Using TCM.” Pacific College, 14 Sept. 2016, www.pacificcollege.edu/news/blog/2016/01/14/addressing-estrogen-dominance-perimenopausal-women-using-tcm. Accessed 26 Sept. 2017.
- Bradford, Alina. “What Is Estrogen?” LiveScience, Purch, 2 May 2017, www.livescience.com/38324-what-is-estrogen.html. Accessed 26 Sept. 2017.
- Weizenbaum, Sharon. “Wen Jing Tang according to Huang Huang” http://www.pdxacustudio.com/wp-content/uploads/2015/10/Wen-Jing-Tang-.pdf. Accessed 26 Sep. 2017.
Hormone supplementation can be a very helpful tool for some transgender people to live full and authentic lives. There is also a great deal of fear-mongering about the side effects of hormones, usually from non-transgender doctors. While more long-range study is needed, a large-scale recent long-term trial found no elevated risk for mortality, either broadly or specifically, for transgender people taking hormones. (1)
Care providers who try to scare trans people away from hormones are not standing on firm evidence in doing so.
That being said, the lack of mortal danger does not mean that there are never annoying or difficult side effects from hormones. Any medication, taken over a long period, can cause some unwanted experiences to occur. In the next two articles in this series, I’m going to break down some of the most common side effects of testosterone and estrogen supplementation, and explain how Chinese Medicine can help resolve them.
Testosterone, as we’ve discussed in the past, is primarily a hot and yang substance. What this means in practice is that it makes this growth, move faster, and makes people feel warmer. What it can also mean is that it can cause some people to get too hot, and develop unpleasant symptoms as a result. In Chinese Medical thinking, the yin of the body, or the cooling and moistening substances, need to be able to balance out the yang.
Over time if the yin is taxed by something, whether it’s a stressful life event or something we are consuming, the heat can overwhelm the system.
Some signs that this may be happening include; night sweats, anxiety, heart palpitations, changes in hunger, hot flashes, acne and pain in the legs. These are mostly symptoms that are associated with puberty or menopause, and there is a very good reason for that: people who are taking testosterone are inducing puberty and menopause, concurrently. This is not a bad thing; it’s just a life process.
But it can be a lot for the body to deal with.
In addition to heat, sometimes testosterone can lead to reduced blood flow in the lower abdomen, or what we call “blood stagnation” in Chinese Medicine. Blood stagnation can manifest as frank tissue changes, like polyps or tumors, but most often it shows up as pain from impaired microcirculation.
This can result from muscular changes in the pelvis bowl (particularly that pesky psoas muscle), the cessation of menses, or from the surgical removal of reproductive organs. Some trans people who take testosterone find that they develop mysterious wandering pain in the lower abdomen after several years on testosterone.
The fact that some people experience these unpleasant effects can feed back into the medical world’s desire to pathologize transgender people and say that taking hormones is just bad and dangerous.
This is rarely said, of course, for most other medications. Very few people say “metformin can cause diarrhea in some people, so no one should ever take it”, because it is seen as a life-saving drug. Hormones are also life-saving, and deserve the same medical care and respect as therapies. The correct way to think about this situation is not to say that testosterone is bad, but rather that we need to help the body integrate the changes from hormone supplementation in a more efficient way.
Acupuncture and Chinese herbs to do this, along with dietary changes in some cases.
The body is intelligent, and can learn how to self-regulate under new conditions. We can help it to vent excess heat, supplement yin, move blood, and adapt. Acne can be treated, night sweats disappear, hunger cues return to normal, and the body changes in a normal and healthy way. Instead of yelling at people about the “dangers” of the medications they take, we can work with people and make their experience be the smoothest it can possibly be.
Note: Not all people will have unpleasant side effects from testosterone, and not all side effects will look like what is described above. Each person in unique, both in their constitution and in their life experiences and circumstances.
If you are taking hormones and experiencing any difficulties, feel free to schedule an appointment with me so we can talk through what classical Chinese medicine might be able to do for you.
(1) Largest Study to Date: Transgender Hormone Treatment Safe. Kathleen Louden. July 02, 2017 http://www.medscape.com/viewarticle/827713
This week I want to turn to a topic that is rarely discussed in any medical forum, eastern or western: hormonal transition. Hormonal transition can really refer to several experiences: puberty, menopause, andropause, and health-related hormonal shifts are all normal processes that bodies go through. Puberty for transgender people is also normal; it just happens to be medically-assisted.
There are many myths and misunderstandings about this process, and Chinese medicine can help us to see our way through them and towards a more comprehensive view.
Before we dive in, a general disclaimer: hormonal transition is a process that some, but not all, transgender people go through. Efforts to withhold access to hormonal transition over the last hundred-ish years have created very bizarre gate-keeping systems around who can access this kind of care, and although this is changing there continue to be people in the world who want to hormonally transition but have not yet been able to. Being on hormones does not make someone “more” trans or more “real”; it is simply a decision that some trans people make, in consultation with their healthcare practitioners.
Almost every body contains some mixture of estrogen and testosterone.
These hormones are responsible for a wide range of processes throughout the body, but they are best know for their roles in secondary-sex characteristics such as hair texture and pattern, body composition, skin texture and muscle mass. They both move in cycles, although the testosterone cycle is not accompanied by blood, so it tends to fly under the radar.
Yin and Yang are not concepts that map perfectly onto estrogen and testosterone, but they have a history of being framed that way. Though there can be conceptual problems with a 1:1 comparison, there is some utility to using them. To do so well, though, we have to keep a few things in mind.
First, yin is not “bad” and yang is not “good”.
Yin processes are generally cooler, slower, and more physical, while yang processes are hotter, faster and more about energy. Both are equally required for life to occur. Similarly, estrogen and testosterone exist within relationship to one another in healthy human bodies, and though the mix is different from person to person, it is that relationship that creates physiological balance.
Second, yin is not “weaker” than yang, and estrogen is not “weaker” than testosterone.
There is a strong desire to map sexist notions onto these concepts and molecules, and while I understand where that comes from, it’s misleading at best. Yin is required for life; without rest and darkness we would die. Estrogen is an extraordinarily powerful hormone that influences just as many physiological processes around the body as testosterone, including libido. Estrogens have powerful regulatory effect on bone density, metabolism and protein synthesis that people don’t often know about, because these functions are often thought of as being “masculine”.
All of these misconceptions feed into the way that people understand medical hormonal transition, even for medical providers.
This is a topic too big for this essay, but it suffices to say that people who transition to estrogen-dominance are often saddled with the dumb sexist tropes that already get hung around estrogen, yin, and femininity in general. There is more medical scrutiny, more concern (trolling), and sometimes even more monitoring. Folks who transition to testosterone dominance get the shiny things that sexism awards to men, but also sometimes experience a weird form of medical negligence that assumes that men don’t need care and that minimal monitoring is fine.
It is important to frame hormonal transition correctly: it’s puberty.
Puberty is a normal process that people go through, some earlier in life and some later. Like pregnancy, itis not an illness or a disease process, but it is wise to have a medical provider around when it’s happening. Like any puberty process, it involves a massive shift in the chemical soup of the body, in myriad ways. Appetite changes, sex drive changes in both its level and quality, and the appearance of the body also shifts. What can complicate this process for trans people who did not have access to care as young people is that one hormonal process has to be shut off, and another has to begin, simultaneously.
For people who are transitioning to testosterone dominance, this means that they are going through menopause (declining estrogen levels) and masculine puberty at the same time. For those who are transitioning to estrogen dominance, there is a simultaneous andropause (decline of testosterone) and feminine puberty.
These two processes can be a bit taxing for any body on their own, and together they can sometimes be challenging.
This is where Chinese medicine comes in. Our medicine is all about the balance of yin and yang in the body, and these hormonal shifts are just another manifestation of that process. When we treat any kind of symptom, it is within the context of thinking “is this a yin symptom or a yang symptom?”. We treat menopausal symptoms quite often, usually seen as Kidney Yin deficiency and Liver blood deficiency, and similar symptoms can appear with testosterone supplementation. Andropause can cause coldness, lethargy and sadness, which we usually see as Kidney or Spleen yang deficiency, and we sometimes see similar patterns in people who are supplementing estrogen.
None of these symptoms are terrible, and they usually disappear over time, but we can get them to resolve much more quickly by treating them.
Transgender people have been informed, either explicitly or implicitly, that our healthcare is a burden and that we should just be grateful for whatever we get, regardless of quality. The time for accepting this message is rapidly coming to an end. People can transition without any help with side effects, and we have been doing so for decades, but we don’t need to. We can have an even better and more fulfilling experience of transition with a little bit of extra help from a medicine whose entire raison d’etre is balancing yin and yang.
I’ve helped many people through this process already, and I’m excited to work with you. Please get in touch if you have questions – otherwise you can just get on my schedule.
The lower abdomen is sometimes referred to, in kinesthetic medicines of various kinds, as “the basement of the body”. It’s where issues that we can’t deal with at the moment, whether emotional or physical, get put so that can work on them later. Hopefully.
This dynamic can be illustrated in a few ways: sexual assault survivors have a heightened risk for pelvic inflammatory disorder (3), inflammatory bowel disease (a complex issue for another article), and menstrual pain (2). Increased pelvic pain, urinary tract infections (UTIs) and back pain have been documented in women who are survivors of domestic violence (1).
More broadly, the Adverse Childhood Experiences study has found that adults with childhood traumas are many times more likely than baseline populations to experience a wide variety medical problems, including all-cause mortality (4). The pelvic bowl is not the only place where traumatic events show up as physical symptoms later on, but it is one of the main things that manual medicine providers see clinically.
This literature can feel pretty scary for survivors of any kind of traumatic event, so I want to be super clear about something: risk factors are not guarantees of future illness.
It is not the case that 100% of survivors go on to have serious medical problems beyond the effects of aging. It is also the case that risk factors, and their early symptoms, are often quite treatable, which I’ll discuss further down the page.
I’ve written before (link to previous article) about the higher instances of untreated illness among queer and trans populations, and here is a place where we should return to those findings. Not all queer and trans people have experienced severe trauma over the course of our lives, but many have. This has obvious implications for the baseline risk factors that we have in the world, but it can also combine with societal risk factors to create a pretty toxic sludge of comorbidity (the medical term for multiple medical risk factors or illnesses occurring at once).
For example, imagine a cisgender gay man who is also a sexual assault survivor, and who is experiencing unexplained testicular pain.
If his medical provider is uncomfortable with queer patients, that person may not inquire deeply enough about said pain, or may be unwilling to properly examine the patient. In such case, a possible tumor might not be discovered until it has progressed into something much more difficult to treat. Because we are dealing with complex human beings, the many possible permutations of these phenomena are pretty much endless.
In East Asian medicine, we also have some extra tools available to us in terms of early treatment.
Basically, from this perspective, most problems begin as stagnation of Qi (the body’s life force), and if Qi stagnation goes on for too long then blood begins to stagnate. In the case of pelvic pain, let’s say that a 25-year-old bisexual trans man presents with wandering and intermittent pain in his lower abdomen. The pain began shortly after he experienced a car accident, and has been getting worse every since then. In this case, the emotional shock to the heart from the accident has lead to Qi stagnation in the liver channel, which is closely linked with the heart and passes through the pelvic bowl.
If left untreated, such a patient could develop more overt disease symptoms, such as uterine fibroids or polyps. When a symptom manifests with a physical tissue change, and is accompanied by a fixed pain rather than a wandering one, then something has progressed into the realm of blood stagnation. Both Qi and blood stagnation are treatable, but Qi stagnation resolves more quickly and is far less frightening and painful for the patient. If this can be treated at the stage of pain that no one can pin down, this is ideal.
Needless to say, having a safe provider to see about this pain is one of the biggest factors in whether or not this patient would be able to access care for it.
Assuming that he did, treatment in the early stages for such a case would involve acupuncture techniques to reestablish proper flow of Qi in the liver channel, as well as other channel in the lower abdomen, and also to restore the Qi of the heart. This would generally have the knock-on effect of also resolving any anxiety, depression or sleep issues that may be lingering from the car accident. If treatment were to occur in the blood stagnation stage, then the above steps would be taken, along with needling techniques and herbs to break up stagnant blood and help the body to reestablish the appropriate flow and rhythm of blood in the lower abdomen.
In either case, this patient being aware of his own bodily and emotional experience is the most important factor in accessing any kind of care.
The best way that we can care for ourselves is to understand how our lives effect us. East Asian medicine can be an important tool for anyone who wants to recover from a traumatic event, treat an early-stage illness, or finally address a problem that has been bothering them for a long time.
(1) Campbell J, Jones AS, Dienemann J, Kub J, Schollenberger J, O’Campo P, Gielen AC, Wynne C. Intimate Partner Violence and Physical Health Consequences. Arch Intern Med. 2002;162(10):1157–1163. doi:10.1001/archinte.162.10.1157
(2) Jacqueline M. Golding. Sexual-Assault History and Long-Term Physical Health Problems. Current Directions in Psychological Science Vol 8, Issue 6, pp. 191 – 194. First published date: June-24-2016
(3) Latthe Pallavi, Mignini Luciano, Gray Richard, Hills Robert, Khan Khalid. Factors predisposing women to chronic pelvic pain: systematic review BMJ 2006; 332 :749
(4) Vincent J Felitti, Robert F Anda, Dale Nordenberg, David F Williamson, Alison M Spitz, Valerie Edwards, Mary P Koss, James S Marks, Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults, American Journal of Preventive Medicine, Volume 14, Issue 4, 1998, Pages 245-258, ISSN 0749-3797, http://dx.doi.org/10.1016/S0749-3797(98)00017-8.