During Spiro- Reducing Toxic Load on the Liver

What follows is an exposition of Flagyl (Metronidazole) according to Chinese medicine, and an analysis for treating its side effects, namely digestive discomfort and liver toxicity. This is relevant to transgender health care in that long-term medication use–for instance, of Spirolactone to suppress androgens–may be associated with some degree of liver toxicity. Because Flagyl is incredibly hepatotoxic, any treatment of its side effects, especially those to the liver may be useful in palliative treatment of patients on hormone-replacement therapy (HRT) for gender transition.

Metronidazole (MNZ), or Flagyl as it is commonly known, is a nitroimidazole antibiotic and anti-parasite medication, in this case used to treat amebiasis, such as E. histolytica. It works by inhibiting nucleic acid synthesis in the DNA of microbial cells.

Common side effects include nausea, diarrhea, abdominal pain, headache, and dizziness. High doses and long-term treatment are associated with leucopenia, neutropenia, and central nervous system toxicity. It is listed by the US National Toxicology Program as a reasonably anticipated human carcinogen, and by the WHO International Agency for Research on Cancer as a possible carcinogen.

flagyl1flagyl2

 

 

 

 

 

 

From the perspective of Chinese medicine, Flagyl is very cold in nature and bitter, like other antibiotics and antimicrobial herbs. As such, taking it in large doses over a short period of time to treat parasites can be thought of as excess cold invading the middle jiao, particularly the ST. Likewise, the SP prefers to be warm, and its qi will be damaged by a course of Flagyl. The SP is the source of post-natal essence and is responsible for generating blood. If this function is damaged, there is less blood available which will aggravate the LV. The LV organ is very testy, and as such requires a dynamic balance of blood/yin, and movement/yang. Any disruption in this balance will lead to stagnation. In relation to Flagyl, deficient SP qi due to the invasion of excess cold could lead to less generation of LV blood and resultant qi stagnation. In a way, the LV then is both depleted and agitated simultaneously.

Hence, in the herbal formula from the previous post, several herbs that have an affinity for the LV are combined to restore and maintain this yin-yang balance, namely Yin Chen (Herba Artemisiae Scorpariae), Bai Shao (Radix Paeoniae Alba), and Gou Qi Zi (Frustuc Lycii). This may provide the basis for a general LV-protective protocol for countering the adverse effects of medication use.

Yin Chen has demonstrated hepatoprotective effects, in that studies have shown that herbal formulas in which it is the chief herb effectively reduce liver enzyme (ALT, AST) serum levels (1). Furthermore, Yin Chen has shown success in treating patients with acute infectious hepatitis, reducing fever, jaundice, and overall liver size (2). The herb also has antihyperlipidemic qualities, and has been shown to lower plasma cholesterols and beta-lipoproteins in rabbits (3). Though not listed in traditional herbal books as a function, these features can be thought of as cleaning the LV.

yin-chen

Bai Shao in Chinese medical theory is said to nourish the LV blood and preserve yin, calm LV yang, and smooth/soften the LV. These functions and by extension this herb are relevant to all potential LV disfunction, whether excess of deficiency. In the case of a course of Flagyl, it can soften and smooth the LV and likewise tonify any aspects of the LV that are deficient. A thorough intake including tongue and pulse readings will determine the necessary quantities of Bai Shao and its relevant combinations with other herbs.

In pharmacological terms, Bai Shao as been used to treat dysenteric disorders with rectal tenesmus. In other words, its qualities can treat any residual symptoms from intestinal amebiasis such as occasional urgent diarrhea (4). It is also an anti-inflammatory and antibiotic, with inhibitory actions against Bacillus dysenteriae, E. Coli, Salmonella typhi, and others (5).

baishao

The final LV related herb in the formula is Gou Qi Zi, which nourishes LV yin. This herb has been shown to be immunostimulatory, and is associated with an increase in non-specific immunity such as phagocytic activity of macrophages and the total number of T cells (6).

gou_qi_zi_1

The synergistic combination of these herbs may form the basis of a LV balancing and hepatoprotective addition to formulas for patients undergoing HRT and other long-term medication use. Proportions and dosage as always are determined by the patient’s condition and the practitioner’s diagnosis on that day.

Works Cited

  1. Guo Wai Yi Xue Zong Yi Zhong Yao Fen, Monograph of Chinese Herbology from Foreign Medicine, 1986; 8(5):22.
  2. Fu Jian Zhong Yi Yao, Fujian Chinese Medicine and Herbology, 1959; 7:42.
  3. Zhong Yao Yao Li Yu Ying Yong, Pharmacology and Applications of Chinese Herbs,1990; 15(6): 52.
  4. Xin Zhong Yi, New Chinese Medicine, 1989; 21(3): 51.
  5. Zhong Yao Zhi, Chinese Herbology Journal, 1993: 183
  6. Zhong Cao Yao, Chinese Herbal Medicine, 19(7):25.

One Month on Spiro

The previous treatment helped stimulate appetite and regulate the digestive system as my body adjusted to the Spiro. However, I was also later diagnosed with intestinal amoebas following a 3-month stint in China. I was prescribed a 10-day course of Metronidazole (Flagyl), 500mg TID, which I completed. What follows is diagnosis and treatment for mitigating the side effects of Flagyl, and restoring overall balance to support the body in its on-going adjustment to the Spiro.

Overview:

While taking the Flagyl, I experienced digestive discomfort as well as lower energy. At the same time, my bowel movements began to form up and become more regular, whereas they had not been as consistent for some time. Also, any occasional urgency with BMs subsided.

Relevant 10 Questions:

-Digestion: approximately 2x/day, fully formed and no longer loose.

-Energy: more energetic overall following the last Chinese medicine treatment as well as the anti-parasite treatment. However, continue to experience declining muscular stamina. In other words, do not feel more tired upon exercising, but cannot perform to the same degree and intensity as before.

-Labido: decreased sex drive. No change in sexual performance or capacity, but less interest.

Pulses: thin, bowstring

IMG_2930

Diagnosis: Internal excess cold in the middle jiao, SP qi deficiency, LV qi stagnation

Treatment:

Herbs: Modified Li Zhong Tang, 3 bags, 1 cup/day x 6 days.

-Gao Liang Jiang (9g)- warm interior, especially the ST and disperses cold

-Dang Shen (9g)

-Bai Zhu (9g)

-Hou Po (6g)- aromatically transform dampness, regulate qi of the middle jiao

-Gou Qi Zi (12g)- nourish LV yin

-Bai Shao (12g)- nourish LV blood, soothe the LV

-Yin Chen (6g)- clean the LV

-Gan Cao (3g)

Chinese Herbs and Trans Care

What follows is a dialogue between Western pharmacological analysis and Chinese medical theory as to the effects of the herbs from the previous post’s treatment. Each component of the herbal formula will be introduced from the perspective of Chinese medicine, and then individual ingredients’ pharmacological effects will be presented. It should be noted that in Chinese herbal medicine, single herbs are almost never prescribed alone. Instead, practitioners rely on the synergy of herb combinations to achieve therapeutic effect. None of the following herbs should be taken in isolation, nor considered without the guidance of a trained professional.

Qi Tonics: tonic herbs in Chinese medicine improve the function of internal organs, strengthen the body’s constitution, boost immune function, and improve overall health. Qi tonifying herbs in particular primarily act on the SP and LU organs to improve their functions in transforming food and breath into usable energy, or qi, for the body.

Dang Shen (Radix Codonopsis) in particular has a modulating, adaptogenic effect on the CNS, enabling the body to better adapt to stress. Intraperitoneal injection of Dang Shen greatly enhances resistance to hypoxia in mouse studies (1). It also has been documented to increased the amount and activity of macrophages (2). It furthermore has been shown in cat studies to increase cardiac output and blood profusion to the brain, lower extremities, and internal organs (3). Gastrointestinally speaking, Dang Shen shows a marked protective effect in relieving peptic ulcers, decreasing their severity and increasing the amount of prostaglandins in the stomach (4).

dangshen

Bai Zhu (Rhizoma Atractylodis Macrocephalae) has similar adaptogenic and immunostimulant effects, while in differing dosages can treat both diarrhea and constipation (5). This herb also has diuretic effects and a patient’s water intake and electrolyte balance should be monitored if they are on a concurrent diuretic (such as Spirolactone).

baizhu-chao

Zhi Gan Cao (honey-fried Radix Glycyrrhizae) balances Bai Zhu‘s diuretic effects with its mineralocorticoid effects—leading to increased re-absorption of sodium and water, and excretion of potassium (6). This is especially useful with a prescription of Spirolactone, which is a potassium-sparing diuretic for which electrolyte imbalance is a serious potential side effect. Gan Cao also has strong anti-inflammatory effects, approximately 1/10 that of cortisone (7). Other relevant qualities of Gan Cao for trans care include its antitoxin effects, including but not limited to drug and food poisoning, enterotoxins, herbicides, and pesticides (8). It is a hepatoprotective herb, in that is increases the amount of cytochrome p-450 enzyme in the liver, and moreover is antibiotic and antihyperlipidemic (Ibid).

sheng gan cao       Zhi-Gan-Cao-B

Aromatic, transform dampness herbs: “aromatic and fragrant, these herbs enhance the function of the Spleen to dissolve, dry or disperse dampness, transforming and transporting substances that would otherwise accumulate to cause damp imbalance or obstruction” (9).

The pharmacological effects of this class of herbs are both gastrointestinal and antibiotic. They can stimulate the gastrointestinal system to increase peristalsis and the production of gastric acid. They also treat indigestion, fullness and distention of the abdomen, and treat abdominal spasms and cramps. Some herbs in this category—such as huo xiang (Herba Agastache)–is broad spectrum antibiotic against Candida albicans, Staphylococcus aureus, and E. coli, as some examples. It can also be used topically as an anti-fungal (9). Pei Lan (Herba Eupatorii) also has similar antibiotic effects as well as essential oils that are antiviral towards the influenza virus.

Huo-Xiang  pei-lan2

Qi-regulating herbs: “herbs [in this category] regulate qi function to promote normal circulation of qi, correct reversed flow of qi, and eliminate qi stagnation. The proper, natural circulation of qi is essential to health. Qi brings energy to all parts of the body, and leads the circulation of blood. Without proper flow of qi, appropriate blood circulation is not possible. When normal qi circulation is disrupted, the flow of qi becomes impaired or reversed, and the resultant qi stagnation may cause disease. Without appropriate qi flow, the body’s organs [are not able to carry out their normal functions]. Disruption of the normal qi flow interferes with delivery of energy and nutrients to various parts of the body”.

Injection of Chen Pi (Pericarpium Citri Reticulatae)has been shown to stimulate contraction of smooth muscle and to increase intestinal peristalsis (10). Furthermore, intraperitoneal administration has shown its ability to decrease permeability of the blood vessels and reduce inflammation in mice (11)

chen pi

Works Cited

  1. Zhong Yao Tong Bao, Journal of Chinese Herbology, 1986; 11(8):53
  2. Zhong Xi Yi Jie He Za Zhi, Journal of Integrated Chinese and Western Medicine, 1985; 5[8]: 487
  3. Zhong Yao Xue, Chinese Herbology, 1998; 739-741
  4. Zhong Yao Yao Li Yu Lin Chuang, Pharmacology and Clinical Applications of Chinese Herbs, 1990; 6[6]: 9
  5. Chang Yong Zhong Yao Cheng Fen Yu Yao Li Shou Ce, A Handbook of the Composition and Pharmacology of Common Chines Drugs, 1994; 739:742
  6. Zhong Yao Zhi, Chinese Herbology Journal, 1993; 358
  7. Zhong Cao Yao, Chinese Herbal medicine, 1991; 22[10]:452
  8. Zhong Yao Tong Bao, Journal of Chinese Herbology, 1986; 11[10]:55
  9. Chinese Medical Herbology and Pharmacology, Chen and Chen, Art of Medicine Press, 1991.
  10. Zhong Yao Xue, Chinese Herbology, 1998; 323:324
  11. Jiang Su Zhong Yi Za Zhi, Jiangsu Journal of Chinese Medicine, 1981; [3]:61
  12. Zhong Yao Yao Li Yu Ying Yong, Pharmacology and Applications of Chinese Herbs, 1983; 567

Spirolactone, day 4

Intake, diagnosis, and treatment posts will begin with a synopsis, followed by relevant information from the standard 10 questions used in Chinese medical inquiry. There will also be subjective pulse information, a picture of the tongue on that day, and a resultant diagnosis. If treatment is implemented, it will be presented and discussed. Analysis and commentary from fellow practitioners are enthusiastically encouraged.

Overview:

Generally speaking I’ve noticed some mild changes in my digestion and energy. Whereas I usually have a very healthy appetite and sometimes overeat for various reasons, I find myself unable to determine if I’m hungry or not, or if eating would make me feel better or worse. I have some discomfort and abdominal distention that developed after I started the medication, but I’ve consistently felt good with eating. My energy is lower than before, but I’m waiting to see if it’s associated with the medication or other life situations, including the beginning of the Fall season/daylight savings time. I have to pee a little bit more frequently after taking the medication twice each day.

Relevant 10 Questions:

Digestion- BM- 1-2x/day, formed; slight abdominal distention, no bloating

Appetite- lower than normal, and a sense of confusion like, “am I hungry?” or “would eating make me feel better, or would it make me feel nauseous?” Consistently feel better with eating, and continue to eat a healthy amount despite these sensations

Energy: greater fatigue in spite of resting and less activity

Emotions: less competitive, not as easily irritated, a sense of settledness in spite of some worry around these new symptoms; maintaining a sense of curiosity about changes

Urination: somewhat more frequent after taking medication, BID; clear, greater volume

Pulses: markedly thinner than usual, sl. floating, bowstring

IMG_0428

Diagnosis: SP qi deficiency leading to disregulation and rising of ST qi, slight damp accumulation in the middle jiao, KD qi def

Treatment:

Acupuncture: St-36, bu and then xie technique; indirect moxabustion on ST-36 and KD-3 the next day

Herbs: Modified Liu Jun Zi Tang; 3 bags, 1 cup/day for 6 days

-dang shen (9g) – tonify SP qi

-bai zhu (9g) – tonify SP qi, dry dampness

-fu ling (9g) – drain dampness, support the SP

-zhi gan cao (6g) – tonify SP qi, harmonize herbal formula

-huo xiang (3g) – harmonizes the middle jiao, relieves nausea/vomiting, especially when accompanied by dampness and turbidity

-pei lan (3g) -awakens the SP, stimulates appetite; combined with huo xiang to treat damp accumulation in the middle jiao that manifests in nausea, vomiting, fatigue, and heavy sensations

-chen pi (9g) -regulates qi by moving and descending the qi of the middle jiao

-sheng jiang- 3 slices -warm ST, harmonize middle jiao, treats nausea

Lifestyle modifications/diet changes: take medication with food, increase water intake to offset diuretic function of medication, gradually decrease caffeine

Spiro in Chinese Medicine: Some Predictions

As the title suggests, what follows below is an exploration of the anti-androgen medication Spirolactone from the perspective of Chinese medicine. Allopathic information on this drug can be found the in previous post.

The Kidneys in Chinese medicine rule growth, maturation, and development, as well as sexual function. This is akin to the function of hormones, and testosterone can be thought of as the yang aspect of the endocrine system. Therefore, an anti-androgen medication can be thought of as artificially suppressing KD yang, which would explain Spirolactone’s various urogenital side effects: increased urination, decreased libido, sexual dysfunction/infertility, etc. The medication also has potential digestive side effects such as nausea and vomiting, which we would associate with the ST qi rising. ST qi is the counterpart to SP qi, and dysfunction in one suggests dysfunction in the other. Combining these symptoms with other potential side effects such as fatigue, suggests that the SP qi may become deficient as a result of the medication. The SP is the root of post-natal qi, while the KD is the root of pre-natal qi—qi and yang are synonymous or of the same nature. If we seek to overall suppress yang (male-presenting) qualities in the body with Spirolactone, this will inevitably include qi—thus, we can expect to see symptoms and signs associated with qi deficiency in the body.

Treatment with Chinese medicine to mitigate the side effects of taking Spiro will most likely look like tonifying qi and possibly yang, depending on the extent of deficiency in each patient (current and pre-existing). The bedfellow of qi deficiency, particularly with the SP and KD, is the formation of dampness. It is unclear if this will occur in the lower jiao, given that Spirolactone is a diurectic and may thus function similarly to the “drain dampness/promote urination” category of Chinese herbs. If it occurs in the middle jiao, we can expect to see thicker fur on the tongue, and this may inspire the use of “aromatic/transform dampness” herbs.

What further physiological changes or pathological developments do you think might develop according to Chinese medicine’s zang-fu theory?

The Skinny on Spiro

Below you’ll find information about this medication from a Western medicine perspective. It will be followed by a hypothesis post about how this medication may affect the body from the perspective of Chinese medicine.

Spirolactone (brand name: Aldactone), fondly referred to as “spiro” in the trans/gender-nonconforming community, is a potassium-sparing diuretic commonly used to treat fluid build up due to heart, liver, or kidney disease. It is a synthetic, steroidal, antimineralcorticoid, and so antagonizes the action of aldosterone at its receptors.

Spironolactone-Androgen-Inhibitors-and-Acne-640x550

Spiro has also been used to treat hirsutism in cis-women, or excessive hairiness due to high levels of male hormones. It is used off-label by health providers serving trans patients as an anti-androgen, or testosterone suppressant. Further, spiro is a progestin and anti-gonadotropin. In the U.S. it is often the medication of choice for this due to its safety, accessibility, and cost.

Spiro suppresses blood testosterone levels (to the level of female-sexed persons when combined with estrogen) by antagonizing androgen receptors and preventing its production. The result is overall feminization, characterized physically by less male-patterned body hair, some breast tissue development, etc, though effects and intensity vary from person to person.

Common side effects include: urinary frequency, fatigue, nausea, vomiting, headache, lowered blood pressure, electrolyte imbalances (high levels of blood potassium, decreased sodium reabsorption), dry skin, decreased labido, testicular atrophy, reversible infertility, and other sexual dysfunction.

spiro pic

 

Health History Prior to Launch

In preparation for starting the spirolactone tomorrow and beginning to observe bodily changes and potential signs and symptoms, here is a full health history. What further questions would you ask?

General:

30 year old, trans/genderqueer person; “they, them, their” pronouns

5’10”, 138 pounds

Currently partnered, but polyamorous

Full-time graduate student, part-time employee (academic tutoring/teaching assistant, private nutritional consultant, organizational trainer)

Psychosocial/spiritual:

-consistently in therapy for several years, large support system including mentors, recovery community, spiritual practice (zen), daily meditation and journaling, gardening, no arts practice at this time

-Chinese element/zodiac association: yin, wood, ox

Lifestyle and diet:

-exercise: 2x/week (running and circuit weight lifting), regularly walks and rides bicycle as primary mode of transportation; 5 year history of Thai boxing

-attempts to take 20-40 min “nap” each day

-diet:

AM: 1-1.5 cups caffeinated beverage, followed by meal about an hour later: smoked salmon or egg with brown rice and vegetables

Snack: fruit with nuts

Lunch: beans and vegetables, sweet potato, often a cup of caffeinated tea after the meal

Snack: dark chocolate

Dinner: protein, vegetables

Cups of water/day: 6-10

Sugar cravings/addiction, both related to mood/experience and in isolation of circumstances

Meds/supplements:

-AM: L-tyrosine- 2500mg (ADHD/attentiveness), 300mg 5-HTP (mood, insomnia)

-Afternoon- L-tyrosine (2500mg), 200mg 5-HTP

-Spirolactone (anti-androgen)- 50mg, BID, increasing to 100mg BID in a week’s time

-Omega-3 fatty acids (deep sea fish oil)- 4,500mg EPA, 3,300 DHA, 1,800 other omega-3s

-Various Chinese herbal formulas as needed, not on an on-going basis (ex: chai hu shu gan san, xiao yao san, mod. si jun zi tang, etc)

Family Health History:

-Self: seasonal allergies, history of drug/alcohol abuse (alcohol, cocaine, benzodiazapines, prescription narcotics–> clean/sober x 6 years); situational high blood pressure (with substance abuse), postural hypotension and currently LBP

-Maternal: HTN (mother, aunt, grandmather), diabetes (grandmother), breast cancer (aunt), multiple sclerosis (mother), lymphoma (grandmother)

-Paternal: no info at this time

Ten Questions:

-hot/cold: tends to run colder compared to the past, especially sensitive in the low back and upper shoulder/du-14-ub-12 areas; feels warmer at night, easy agitated by temperature changes

-sweating: past hx of night sweats, but not currently; does not sweat easily or spontaneously

-thirst- average

-urination- light yellow to clear-ish; occasional strong odor; no frequent urination but a low tolerance for slight needs to urinate; compulsion to urinate can increase with anxiety; wake 1x/night to urinate on average

-appetite: average-high; propensity to overeat as this is associated with safety and soothing; sugar cravings almost daily

-BM: 1-2x/day, formed or tending towards loose; some urgency and frequency after foreign and domestic travel; being testing for intestinal parasites

-sleep: in bed approximately 8 hours/night (10:30PM-6:30AM); hx of difficulty getting to sleep; wakes at least one time; frequently wakes up earlier than expected; racing mind in AM

-energy: moderate given daily level of activity and engagement; low tolerance for sleepiness, and so frequent use of caffeine daily

-labido- moderate, healthy for me; sex approximately 2x/week, orgasm approximately 4x/week; less with fatigue

-emotions: tends towards chronic, low-grade irritability; frequent over thinking/worry

Tongue and pulse:

Pulse: overall: BS, long, strong, rate 60 BPM; (R) overall slightly thin and BS, strong root, including in chi positions; (L) overall BS, cun relatively smallest

Tongue: often slightly enlarged, red tip, prickles in the margins, divots and cracks in center, moderate white-sl. yellow fur in rear

10/29/15

About

The purpose of this blog is to add the vast wisdom of Chinese medicine in supporting people achieve their goals around gender expansion, transition, and identity.

I will do this by first using my own personal experience with medical transition in real-time, by documenting the changes I experience through the cosmology of Chinese medicine and its unique system of diagnosis. In addition to trying to articulate in Chinese medical terms some of the common goals and side effects of my Western medical treatment, I will be using such modalities as acupuncture, herbal therapy, diet, etc, to address any difficulties and optimize my overall health and wellbeing.

In these ways, I hope to lend my personal and clinical experience in helping to create Chinese medicine Standards of Care and treatment protocols to support others in reaching their goals around gender actualization.

Parties who may be interested in this blog include: members of the transgender or gender-variant/queer community, practitioners of Chinese and Asian medicines, Western medical practitioners, etc.

If you have any questions, comments, concerns, or suggestions, please refer them to yinwithinyangblog@gmail.com