Exploring the prevention and treatment of perimenopausal hypertension based on the theory of "Preventive Treatment of Disease"

Qian Ma,Yuan-Yuan Guan,Zhi-Hua Yang,Yu Liu

1First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China. 2Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China. 3National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion,Tianjin,China.

Abstract

Keywords:Preventive Treatment of Diseases,Perimenopausal hypertension,Traditional Chinese medicine

Introduction

Perimenopausal hypertension is hypertension combined with perimenopausal syndrome. In addition to high blood pressure, blood pressure fluctuation is obvious and accompanied by increased gonadotropin secretion, plant nerve dysfunction syndrome and irregular menstrual cycle. These symptoms have a variety of variability, diversity. With the continuous improvement of modern living standards and diet habits changing, the incidence of perimenopausal hypertension has gradually increased. According to most recent 2017 ACA/AHA guidelines for perimenopausal hypertension, the prevalence of perimenopausal hypertension in premenopausal women is 44%, which is higher than men of the same age. Interestingly, women between ages 45-54 years(perimenopausal years) seem to have the greatest increase in the prevalence of perimenopausal hypertension with the new guidelines(from 27 to 44%)[1]. Perimenopausal hypertension has become a threat to the life and health of middle-aged and elderly women. So timely and correct prevention and treatment of this disease is an important task for doctors and patients.

1. The meaning of "Preventive Treatment of Disease"

The theory of "Preventive Treatment of Disease" is an important feature and advantage of traditional Chinese medicine (TCM).As early as in the Yellow Emperor's Internal Classic "Preventive Treatment of Disease" has been discussed.The idea of "Preventive Treatment of Disease" is to preserve health and prevent diseases in the“pro-disease”stage,treat“the coming disease”,prevent disease transmission and transformation in the“already-sick” stage [2]. It runs through the whole process of disease occurrence and development and is widely used to guide people to stay away from various diseases. In the process of disease prevention and treatment, it is necessary to master the law of the occurrence, development and change of the disease as well as the way of its transmission,early diagnosis and early treatment to prevent the disease from getting worse. "Recovery after cure" refers to the elimination of evil, the recovery of the disease, to prevent the occurrence of sequelae. After the illness is healed or stabilized, on the one hand, the Zheng Qi should be firmly protected so that the Zheng Qi can effectively resist the excess pathogenic factors.On the other hand,the evil factors should be eliminated so as not to cause the illness to relapse. Most chronic diseases can be prevented by measures to "cure the disease". At the same time, the theory of "Preventive Treatment of Disease" embodies the health concept of "the harmony between man and nature" and "unity of form and spirit" in TCM, and embodies the "holistic concept" of TCM, which is the characteristic and advantage of TCM. Curbing disease in its infancy also has practical implications for reducing medical costs.

2. Understanding of perimenopausal hypertension in TCM

There is no record on the name of perimenopausal hypertension in TCM. According to its clinical manifestations, it can be classified into the category of"various syndromes before and after menstruation".At present, most doctors believe that there are many causes of the disease, and the most basic cause is gradual decline of Shen Qi. Besides, deficiency of Yin and Yang of the body,dry climate,long-term emotional disorders,excessive anxiety and anger,disordered diet,and deficiency and loss of internal injuries can all cause the disease [3]. The ‘Disease Root’ is mainly located in the liver and kidney, involving the heart,lung and spleen. The pathogenesis is based on deficiency of liver and kidney, Yin deficiency and Yang hyperactivity.

3. To explore the prevention and treatment of perimenopausal hypertension with the idea of"Preventive Treatment of Disease"

3.1 Pay great attention to it, prevent it before it gets sick

Hypertension is the main risk factor for cardiovascular disease. To strengthen the health care awareness of perimenopausal women, community education activities, health education publicity, health screening,early screening and identification of high-risk groups should were carried out. Some studies on TCM constitution believe that mild constitution is its protective factor, while Yin deficiency and Qi deficiency constitution are more likely to suffer from perimenopausal hypertension, which should be paid close attention to [4]. In addition, recent studies have shown that some reproductive factors may be associated with the risk of cardiovascular disease in middle-aged and older women. Zhang Jing et al.found that body mass index ≥28kg/m2, premature delivery,and pregnancy-related hypertension were independent risk factors for perimenopausal hypertension, and women aged between 20 and 35 years of age for the first delivery were protective factors for perimenopausal hypertension [5]. Therefore, it is of great benefit to reduce the incidence of hypertension by strengthening the management of the risk factors of perimenopausal hypertension and improving the understanding of the protective factors of hypertension.

3.1.1 Moderate exercise and reasonable diet

Appropriate exercise for the prevention of disease has

an important role, which can promote the body's blood circulation. In terms of body maintenance, some slow-moving sports and fitness programs, such as Ba Duan Jin, Tai Chi and yoga, can reduce systolic blood pressure of hypertension patients by about 10 mmHg[6]. The investigation showed that vasomotor contraction and physiological menopause symptoms were related to poor sleep quality [7], which emphasized the importance of daily living. Sleep disturbance is the most common symptom of menopausal transition and postmenopausal. These include difficulty falling asleep, multiple awakenings during the night, and waking earlier than expected in the morning [8, 9]. TCM believes that incompatibility of heart and kidney and hyperactivity of liver and Yang are the main pathological mechanisms of perimenopausal sleep disorders. Therefore, the treatment is based on nourishing the kidney and clearing the heart, clearing the liver and calming the spirit [10].A large number of studies have shown that the formation of hypertension and high sodium intake are closely related and after exercise blood pressure can have a certain degree of decline, or even can be reduced to the normal range [11]. In addition,perimenopausal women are prone to metabolic syndrome and salt sensitivity due to obvious hormonal changes in their bodies. This requires perimenopausal women in diet, should be low sugar, low salt, low fat.In recent years, epidemiological studies have investigated the relationship between dietary factors and hypertension, and found that dietary intake of omega-3 and omega-6 fatty acids is inversely proportional to the risk of hypertension in adults [12].Wang Min et al. observed through clinical trials that increasing phytosterol and anthocyanin intake could reduce the risk of hyperlipidemia and hypertension in perimenopausal women[13].

3.1.2 Adjusting the spirit

Chinese medicine believes that: people's physical and psychological changes and mental activity are closely related.Emotional disorders can cause the disease[14].Perimenopausal women are prone to anxiety,depression and other negative emotions, which can reflexively cause blood pressure fluctuations. An investigation shows that 50% of perimenopausal women will show depressive symptoms,which may be related to the decrease of serum estradiol level in the body [15]. By activating the sympathetic nervous system [16] and stimulating the hypothalamus-pituitary-adrenal cortex system, anxiety and depression and other negative emotions can cause systemic stress response and affect the negative feedback regulation of the pituitary gland [17] to promote the increase of blood pressure.Therefore,it is especially important to maintain emotional intelligence activities for perimenopausal women. We should not only actively avoid the negative stimulation from the internal and external environment, but also actively improve the psychological adjustment ability of the human body. At the same time, the doctor carries on the psychological intervention correctly, reduces the patient’anxiety, the tension, the worry, the fear and so on.

3.1.3 Drug prevention

In 2003, the seventh report of the American Joint Committee on Hypertension Prevention, Diagnosis,Evaluation and Treatment (JNC7) officially put forward the concept of"prehypertension",which refers to the measurement of systolic blood pressure between 120 ～ 139mmHg and/or diastolic blood pressure between 80 ～89mmHg twice or more at different times without taking blood pressure lowering drugs[18].Although the patients at this stage do not meet the diagnostic criteria for hypertension, clinical patients often appear dizziness, headache and other hypertension manifestations. This period is equivalent to the TCM "no disease" stage, which requires early intervention to avoid disease progression. The guidelines for the treatment of hypertension issued by European authorities point out that patients with prehypertension combined with more than 3 risk factors should receive drug treatment in a timely manner, and patients with diabetes or target organ injury should first consider drug treatment[19].

3.2 Disease prevention and effective control

In the early stage of the disease, it is particularly important for doctors to differentiate and diagnose perimenopausal hypertension patients who do not have headache, dizziness and other typical hypertension symptoms as the chief complaint. At the same time, it is suggested that high-risk groups should prepare their own sphygmomanometers in order to timely monitor blood pressure changes. Other studies have shown that ambulate blood pressure monitoring is of great significance for the diagnosis of perimenopausal hypertension[20].

3.2.1 Early treatment to prevent transmutation

Prevention of transmutation refers to the early diagnosis and treatment to prevent the development of the disease on the basis of mastering the occurrence and development law of the disease and its transmutation path. As we all know, hypertension, if not treated early, long-term accumulation, may cause irreversible damage to the heart, brain, kidney,vascular function. Shi Hongxia et al. found that the main symptoms of perimenopausal women with hypertension were left ventricular hypertrophy and enlargement, right ventricular enlargement, left ventricular diastolic function and increased arteriosclerosis [21]. In view of the obvious damage to target organs, the fundamental goal of the treatment of perimenopausal hypertension is to reduce the total risk of cardiac, cerebral, renal and vascular complications and death. In the blood pressure management section of the 2011 AHA guidelines for the prevention and treatment of cardiovascular diseases in women, it was proposed that the blood pressure of women ≥140/90mmHg is the indication of drug therapy. At present, there is still a lack of unified understanding of the standardized medication, overall hypotensive strategy and blood pressure management of women in perimenopausal hypertension, and doctors' choice of drugs for patients presents a trend of individualization.

3.2.2 Western medicine treatment

At present, western medicine is mainly used to treat perimenopausal hypertension by controlling blood pressure, while hormone replacement therapy is still controversial. If patients have obvious anxiety and tension, anti-anxiety, anti-depression and other drugs to control their mental state should be given. Once the patient is diagnosed, the examination and condition assessment should be improved. Antihypertensive drugs should be given according to the patient's overall risk level. Angiotensin-converting enzyme inhibitors are the first choice for drug treatment, and diuretics and -blockers can also be used within a certain range[22]. Calcium antagonists can also be used in the treatment of perimenopausal hypertension,but because the side effects of the drug itself will aggravate the corresponding symptoms of perimenopausal syndrome,so in the use of stable hypotensive preparations, such as: non-dihydropyridine calcium antagonist Verapamil sustained release tablets. In addition, for the clinical treatment of perimenopausal hypertension in women,the combined drug therapy is more effective than the single drug therapy [23]. Jin Yue et al. observed through clinical comparative tests that the application of enalapril folic acid tablets combined with estradiol tablets/estradiol triprogesterone tablets in the treatment of perimenopausal H-type hypertension could effectively control blood pressure and improve dyslipidemia and insulin resistance[24].

3.2.3 TCM treatment

TCM has obvious and unique advantages in treating this disease. The pathogenesis of perimenopausal hypertension is complex, and the disease differentiation and syndrome differentiation should be combined. Most clinicians take tonifying liver and kidney, flattening liver latent Yang, soothing liver and regulating Qi, and harmonizing ChongRen Qi and blood as the basic treatment principles.The commonly used formulations include Erxian Soup, Xiaochaihu soup and Zhizichi soup, Liuwei Dihuang soup, Qiju Dihuang Soup, and Xiaoyao San [25-29]. Common proprietary Chinese medicines include Shensong Yangxin capsule [30]. In addition, TCM also has distinctive external treatment methods, such as acupuncture and moxibustion, auricular point pressing beans, etc., which can control blood pressure to a certain extent and have obvious clinical effects[31].In clinical practice, Li Honghong found that Dazhui acupoint application of huoxuezhitong plaster had a certain effect on menopausal fluctuating hypertension,which may be related to the pathological connection and pathogenesis of menopause, hypertension and cervical spondylosis,and it is worth further exploration and discussion[32].

TCM treatment is variegated. It has unique advantages in improving patients' anxiety and other bad emotions, regulating patients' constitution,promoting the early arrival of the disease recovery period, and preventing recurrence after the disease;Western medicine can control blood pressure quickly and effectively in the stage of disease progression, and both TCM and Western medicine have their own advantages. Rational and effective application of combined TCM and Western medicine in clinical practice can significantly improve patients' symptoms,improve treatment effect, and prevent disease progression or recurrence.

4. Summary

The number of perimenopausal women will increase significantly with the acceleration of population aging process. It is required to pay attention to health education, guidance and management of perimenopausal hypertension vulnerable groups, and guide them to reduce the incidence of this disease through life intervention based on the idea of"Preventive Treatment of Disease"theory.To delay the development of the disease and prevent the occurrence of complications, the patients should be treated based on syndrome differentiation. "Preventive Treatment of Disease" runs through to the prevention and treatment of hypertension in perimenopausal period from beginning to end, and it is of great benefit to the prevention and control of this disease.