Hepatogenic “endocrine disorders”- disorders of sexual hormones

The endocrine disorders seen in liver disease patients usually present singly (that is simple insufficiency of female sex hormones, simple insufficiency of thyroid hormones or diabetes), but sometimes, multiple disorders of hormones may exist.  This article discusses only the affect of chronic liver disease on sex hormone disorder so that when endocrine disorder is encountered, one should consider the possibility of the presence of liver disease.

According to the TCM classification of chronic hepatitis, the degree of severity of the disease is revealed through the symptoms of heart, liver and lung fire, symptoms of weakness of liver and kidney and results of physical examination.  Therefore, basing on clinical manifestations, it is not difficult to find out the pattern of development of hepatophilic virus disease and endocrine disorder induced by chronic hepatitis can usually be diagnosed by the history and physical signs.  If one can use the method of syndrome differentiation, adopt the therapeutic method of treating simultaneously the cause and symptoms, one may control the disease in the early stage, prevent impairment of liver function and avoid aggravation of the endocrine disorder.

When hepatophilic virus has invaded the body in the form of pestilential evil, and if the patient’s resistance is insufficient and the energy to drive out the evil is weak, the evil would hide in the blood and attack the five zang and six fu organs, disturb qi and blood causing impairment and gradual pathological changes of the latter.  Clinical observation shows that deficiency of qi and blood is usually due to prolonged invasion of pestilential evil and persistent damage of five zang and six fu organs (especially infection during infancy and childhood).  In fact, “endocrine disorder” is the most common consequence in the deficiency of qiand blood form of the TCM chronic hepatitis classification.

In various kinds of endocrine disorder of hepatogenic causes, the most common clinical types are “sex hormone disorder”, “diabetes” and “hepatogenic osteal malnutrition”.  According to the statistics of our clinic, hepatogenic sex hormone disorder reaches 4.73% in which females occupy the majority, being 5.91% and males only 2.63%.  As to hepatic osteal malnutrition, its amount is 13.69% in which males 12.53% (143:1141) and females 14.33% (291:2030).

According to the 3191 cases of abnormal margin of liver dullness in our clinic, it is obvious that significant difference exists between male and female patients in the TCM blockage of channels and stasis of blood form (male 22.86%, female 62.16%) and deficiency of blood and weakness of qi form (male 8.7%, female 31.96%).  This difference indicates the necessity of early diagnosis and treatment of liver disease before the adolescent period in females.  Females have to take up the burden of human generation; if they are infected by hepatophilic virus and cannot be treated in time, human beings would have the viral infection passed from generation to generation forming a vicious cycle.

Endocrine disorder in different stages

Endocrine disorder is extremely common in chronic hepatitis patients.  Clinically, it is found that sex hormone disorders usually advance gradually; they may penetrate through all stages of life, from infancy, childhood, adolescence to climacteric and old age.  The reason is that the majority of endocrine hormones metabolize in the liver (such as growth hormone, thyroid hormone, adrenocortical hormones, insulin, glucagons, male hormones, female hormones).  When hepatitis occurs, endocrine disorders are produced in the body, manifesting clinical symptoms of different diseases.  Therefore, strictly speaking, many common disease like hypoglycemia, abnormal thyroid function, diabetes, osteoporosis, sexual hormone disorders, maybe the result of chronic hepatitis.  Treating disease from the fundamental requires understanding of the presence of chronic hepatitis.  Systemic TCM therapy can often delay the progression of various endocrine disorders and combination of WH and TCM treatment can yield therapeutic effects with much less effort.

If chronic hepatitis patients were infected during infancy or childhood (from 2 months to 10 years), the abnormal liver function would cause endocrine disorder.  The metabolic disturbances of hormones in liver disease are complicated and varied; they may lead to hypersomatotropinemia, decrease of growth hormone, disturbance of inactivation of renin and sub-aldosterone, abnormality of thyroid function, rise of insulin blood level and decrease of glucose tolerance.

In liver disease there may be inhibition of sex hormone stimulating hormone, leading to significant rise of basic level of blood estrogens and prolactin and decrease of male hormones.  The above endocrine abnormality can dominate the child’s growth and development, especially type B and C hepatitis infection occurring directly through the mother-infant perpendicular infection.  Such infection would show persistency and chronicity.

If the infant’s chronic hepatitis is not diagnosed or has been neglected by the doctor or parents, the chance of treatment is lost.  Some of them stubbornly resist TCM therapy and let the course of disease prolonged, the disturbance of metabolism and endocrine hormones aggravated.  In fact, TCM therapy cannot cure radically, but systemic therapy can often attain clinical cure.  There may also be lowering of glucose tolerance or appearance of hypoglycemia.  Pediatric patients in the hepatitis convalescent period have increased appetite and if not controlled properly, secondary obesity and fatty liver may result.

In addition, hormonal imbalance may cause disorder of nutritional metabolism and together with gastrointestinal absorptive disturbance; liver disease can lead to malnutrition.  Due to calcium deficiency, the child may suffer from hepatogenic osteal malnutrition, delay of growth or even abnormal skeletal development.  Therefore, hepatophilic infection may affect the child’s stature in two extremities: “ricketic dwarfism” and “secondary obesity”.

Female adolescence starts from 13 to 15 years of age.  If the patient presents endocrine disorder at this time, she will have deficiency of estrogen and progesterone, and will lose the chance of developing secondary sexual characteristics and this effect may be carried throughout life.  Because the anatomic structure and physiologic functions of female are different from male, so if she suffers from hepatophilic virus disease, the course would manifest a different feature.

In the early stage, liver stagnation and lung dryness form or wetness-heat vaporization form produces symptoms like wetness-heat of the stomache and intestines, wetness-heat of skin and wetness-heat of lower-jiao, the symptoms of these conditions are similar to the male.  With the advance of disease, due to the difference in reproductive and endocrine systems, in the female post adolescent stage, hepatophilic virus disease cause liver stagnation, blockage of channels and stasis of blood which lead to abnormality of the blood clotting mechanism.  The monthly menstruation becomes a potential damage to the chronic hepatitis patient.  Menstrual disorder, menorrhagia, large amounts of blood clots, severe response before or after menstruation, severe dysmenorrheal, habitual abortion are common conditions that can induce gradually further disturbance of endocrine function, aggravate underdevelopment and malnutrition, anemia, hypoglycemia, hypoproteinemia, hypotension, hepatogenic infertility, hepatogenic osteal malnutrition or even formation of benign or malignant tumors of reproduction system, hepatic edema and secondary obesity.

• Common characteristics of female patients with sex hormone disorder:
• lean stature,
• long limbs,
• BMI in the low range,
• usually associated with underdevelopment and malnutrition,
• dryness and scarcity of hairs,
• yellowish pale skin,
• dryness of skin, susceptibility to pruritus,
• pigmentation or even desquamation of skin of face and lower extremities,
• and when associated with excessive male hormone, obstinate acne with infection, hirsutism,
• underdevelopment of female secondary sexual characteristics,
• deficiency of subcutaneous fat,
• menstrual disorders,
• excessive or scanty menstruation,
• menstrual blood dark color with abundant clots,
• dysmenorrhea,
• postmenstrual exopathy,
• vertigo,
• fatigue,
• headache.

If the disease progresses into the climacteric stage (45-50 years), the degree of disorder of endocrine system depends on the severity of hepatophilic virus disease.  The usual picture is increasing severity of clinical symptoms; early appearance of weakness of liver and kidney causes the patient’s apparent senility and prolonged suffering from symptoms of weakness of liver and kidney.  When a woman enters climacteric stage, her ovarian function gradually weakens, the ovarian follicles can not develop in the regular pattern and there is no corpus luteum formation.  The endometrium remains in the proliferative phase, the regular cyclic changes disappear, the menstrual interval is prolonged and the progressive decrease of menstrual blood indicates impending amenorrhea.

Because of decrease of female sex hormones, under the condition of appearance of flaring up of liver fire symptoms following liver stagnation and lung dryness and deficiency of yin in liver and kidney, the female patient may suffer from climacteric symptoms such as flush of face and ear, feverish and hot sensation of five visceral organs, migraine, headache, vertigo, tinnitus, imbalance of auricular fluid, palpitation, insomnia, tremor of hands, hidrosis, boldness, pigmentation or generalized senile plagues, apparent restlessness and depression.

If estrogen insufficiency causes deprivation of calcium, hepatic asteal malnutrition may result.  Prolonged existence of liver, heart and lung fire causes consumption of kidney fluide, leading to decreased ability of kidney fluid to nourish bones and tendons.  Therefore, the patient is prone to develop osteoporosis and hyperosteogeny (spur).  Hepatic osteal malnutrition patients often suffer from wondering joint pain, swelling and deformity of urticulations, pain of bones and tendons and in severe cases, progressive rheumatoid arthritis, acute gout, shortening of body height, humpback or fracture.  When the patient passes into menopause and old age, her genital organs gradually become atrophic, her metabolism slows down and she possesses a fat stature and becomes susceptible to senile vaginitis.

Statistics by scholars in Hong Kong have show that 60% of climacteric women suffer from insomnia and bone disease.  They suggest that these women should be treated with medication for estrogen deficiency to alleviate symptoms like flush, insomnia and bone disease, and also for climacteric heart disease, osteoporosis and senile dementia.  For female patients with chronic hepatitis, it is advisable to have treatment width systemic TCM therapy followed by sex hormone medication directed by physicians to cape with the clinical symptoms induced by “sex hormone disorder”.

In fact, the ill effect of hepatophilic virus on female is more serious than on male.  It is because the investigation and treatment of the clinical symptoms of many females have not been raised to the level of hepatogenic disease, that the prolonged illness of many females are not much improved.  The following clinical cases are introduced for the elucidation of the effectiveness of TCM drugs in treatment of endocrine disorders.

Case 1

Chan – (code number 1973), female, age 33 years.  Her first visit was in October 1999 complaining chiefly of chilliness, fatigue, constipation, bowl movements once in 2-4 days.  For a long time, she suffered from repeated acne and generalized sweat stains and in the recent years, she had abundant leukorrheal discharge of greenish yellow color associated with purities of vulva.  The diagnosis by western medical doctors was moniliasis, but repeated treatment did not cure the disease.  She had blood examination last year and found hypofunction of thyroid which was not treated.

Physical examination: body height 1.7m. weight 56 kg, BMI = 19.37, long limbs, lean, female secondary sexual characteristics not apparent, pulse slow, 52/minute, percussion tenderness over hepatic region, hepatomegaly of 3 cm, (+) pitting edema of lower extremities.  The diagnosis was chronic hepatitis, with TCM classification of wetness-heat vaporization form (wetness-heat of stomache, intestines and lower-jiao) and endocrine disorder (hypothyroidism and estrogen deficiency).

After taking 3 parcels of TCM drugs, she had belching, distension of abdomen, abdominal pain, bowl movements once a day.  Her digestion was poor, sleeping not so good, urine yellowish but her liver was normal.  Then, TCM drugs were not taken for nearly 25 days because of work.  At the return visit, her menstruation had just occurred for one day, but its amount was large; she also had constipation, oral ulcers, swelling pain of gingivae and a poor mental state.  She had common cold symptoms for 2 days and also had numbness of limbs, shortness of breath, enlargement of tongue with furrows and the first relapse of hepatomegaly of 3 cm.  After taking 3 parcels of TCM drugs, the liver returned to normal.  Systemic TCM therapy continued for 5 weeks.  She was followed up afterwards.

After TCM therapy, she received one contraceptive injection.  Thereafter, she had significant improvement in secondary sexual characteristics, especially the breasts.  Three months later, her menstrual blood amount decreased greatly, the menstrual days shortened and purulent leukorrheal discharge disappeared.  Her gynecological illness had been cured.

Yang-, (code number 2815), female, age 34 years.  She first visited the clinic in March 2002 with the complaint of insomnia and a diagnosis of depression.  She was taking for a long time sleeping pills and psychotic drugs.  She also suffered from acne, epigastria discomfort after wine drinking, occasional hematochezia; her menstruation delayed, amount decreased and with clots and dysmenorrheal.

Physical examination: height 1.68m. weight 51 kg, BMI = 18.08, slender stature, long limbs, hairy lower extremities, skin dry, coarse and pale yellowish with scattered patchy depigmentation areas (vitiligo), lips lineate and with desquamation, tongue clean, hypochondriac anomaly, hepatomegaly of 1.5 cm, percussion dullness over splenic region.  The diagnosis was hepatomegaly for investigation, sexual hormone disorder, hepatogenic psychoneurotic disease (depression), vitiligo.

After taking 3 parcels of TCM drugs, the liver was normal and the splenic dullness turned typanitic.  She still experienced fatigue, had bowl movements four times a day and also flatulence, insomnia, poor sleeping and generalized soreness of body.  Pulse 100/minute. TCM drugs later could help her sleeping better but she was dreamful, tired and occasionally anxious.  She had loin pain, flatulence and her bowl movements became smooth, being once a day.  Totally, 59 parcels of TCM drugs were taken, after which clinical cure was obtained and she was followed up.

A return visit was made six months later, at which time she was free of psychotic symptoms and her sleeping was good, being over 5 to 6 hours a night.  She still had occasional loin pain, hidrosis and pruritus ani; pulse 88/minute, tongue showing teeth prints, (+) edema of lower extremities, liver margin normal.

By WONG Kwok Hung

Published on 6th March 2003

Translated by Professor Zheng in May 2005