Rethinking Menopause Treatment in TCM: Why You Should Start with the Liver

As acupuncturists, we are taught to stay adaptable, to look for the root, treat the pattern, and avoid rigid thinking. However, it’s easy to fall into the trap of formulaic treatment: does a sore throat with a cold always point to Yin Qiao San? Does itchy skin equal Xiao Feng San? Should we always use Tian Ma Gou Teng Yin for hypertension.  In my practice the answer is rarely “yes” to questions like this.  However after 20 years, it is still tempting to lean on symptoms and diagnosis that don’t pertain to the pattern. 

This is especially true for menopause.  Hot flashes are often attributed to Kidney Yin deficiency, leading to excessive Kidney Fire, Liver Yin depletion, and Liver Yang rising. As a result, TCM treatments for menopausal hot flashes tend to focus on nourishing Yin and clearing heat. Because of this, many practitioners immediately reach for Zhi Bai Di Huang Wan or other cooling Kidney Yin formulas. But Yin deficiency is only part of the picture—we often overlook other key contributing patterns.

The Missing Link: The Liver’s Role in Menopause

The Liver plays a major role in menopausal symptoms, yet its involvement is frequently underestimated. The Liver regulates emotions and Qi movement, and during menopause, women often exhibit both Kidney deficiency and Liver Qi stagnation. When the Liver is dysfunctional, other organs struggle to perform their roles.

We can understand this in modern terms as elevated cortisol reducing sex hormone functionality, or in TCM terms as Liver Qi stagnation backing up into the Lung, overburdening the Spleen, and depleting Yin in both the Liver and Kidney. This can disrupt digestion by impairing Spleen function, affect moisture balance by weakening the Kidneys, and reduce treatment efficacy if the Liver remains unchecked.

Even when treating Kidney deficiency directly, we may see little improvement unless Liver Qi stagnation is addressed first.

Free the Liver First

In my practice, I start with Liver regulation before addressing deeper patterns. If the Liver remains overbearing, the affected organs cannot recover fully. While this applies to many conditions, I see it most often in Spleen Qi deficiency and Kidney Yin deficiency patterns.

For menopausal symptoms, I typically begin treatment with our version of Jia Wei Xiao Yao San—Grace and Ease. This modified formula includes:

• Yi Mu Cao – Moves Liver Qi and cools Blood.
• Sheng Di Huang – Nourishes Yin and cools Heat.
• Dan Shen – Invigorates Blood and calms the Shen.
• Xiang Fu – Smooths Liver Qi flow.

These additions enhance the formula’s Blood-cooling effects while also enhancing the liver regulating effect. I have found it particularly effective for early-stage menopausal symptoms, especially in patients experiencing irritability, depression, and 4:30 AM waking insomnia.

I typically start with a larger dose, then reduce it once symptoms improve, either decreasing frequency or incorporating a secondary formula to target other deficiencies.

The Takeaway

Menopause treatment in TCM requires a comprehensive approach.  It is more than yin deficiency.  Organ pattern differentiation should be considered carefully and Liver Qi stagnation should never be overlooked. By addressing the Liver first, we remove obstacles to healing, allowing the Kidneys, Spleen, and other affected organs to regain function and restore balance - making for a happier and healthier patient.  Isn’t that the goal?