中医分期辨治原发性“甲减” Hypothyroidism


Hypothyroidism often occurs when there is an inadequate secretion of thyroid hormones, resulting in a slowing down of the body’s metabolism. While low production of these hormones results in Hypothyroidism. The most common type of inflammation of the thyroid gland failure is autoimmune thyroiditis, a form of thyroid inflammation caused by the patient’s own immune system. Autoimmune thyroiditis accounting about 96% of Hypothyroidism. This disease can occur in all ages, mostly common seen in female.

Treatment options involve Thyroid hormone replacement therapy. Taking L-T4 for hormone replacement can cause other side effect. Recent reach on age over 60s with Hyperthyroidism they are frequent presentation is with atrial fibrillation, people can experience the sensation of chest pain, breathlessness, heart palpitation causing Angina Pectoris. Even though using hormone replacement, considering the pathology of hypothyroidism can injuring the internal organs like heart failure, kidney dysfunction and brain damage.

Liver Qi stagnation, spleen Qi deficiency

Hypothyroidism may correspond to exhaustion (Xu Lao) or oedema in Chinese Medicine.

Clinical manifestations of hypothyroidism earlier stages of symptoms can be seen in female patients of emotional depression, slight breathlessness sadness, lump in the throat, oligomenorrhoea, dry, flaky skin and puffy face, puffy eyes, tiredness, weight gain, constipation, pale tongue, white coating, wiry and weak- deep – slow pulse. In TCM can be defined as Liver- Qi stagnation, Spleen-Qi deficiency and phlegm. Often seen clients with medical history of emotional sadness, work with pressure, mental restlessness.

At this stage the treatment principle will be sooth the Liver, move Qi, tonify Spleen Qi, resolve Phlegm, and soften masses. Herbal medicine can be prescribed with ‘XIAO YAO SAN’, if weaken with spleen Qi then the herbal medicine can combine with ‘SEN LING BAI ZHU SAN’; for feeling of oppression of the chest, the herbal medicine can be modified with the addition of herbs like (He Huan, Yu Jin); with difficulty in swallowing, feeling of a lump in the throat, the herbal medicine can be modified with the addition of herbs like (Chen Pi, Xia Ku Cao, Mu Li). Liver Qi stagnation can be seen as the root causing the disease, so to moves Qi of the Heart and Liver with clear the soul and bright spirit.

spleen Qi deficiency, Qi and Blood Deficiency

Spleen functions to perform the digestion, absorption and transmission of nutrient substance. Spleen is considered to be the main Zang organ for the manufacture of Qi and Blood. The main symptoms can be seen as cold feeling of 4 limbs, puffy face and under eyes and neck, weight gain, bloated, dry flaky skin, thin and brittle fingernails, tiredness, poor memory, constipation, tongue pale and swollen, pulse weak-deep-slow. Female often experience irregular bleeding, with anaemia. In TCM theory it can be define as spleen dysfunction, when spleen Qi deficiency it failed to confining the blood circulating in the blood vessels; this lead to blood ‘overflowing’, combine with damp retention such symptoms as oedema, phlegm and swollen of the thyroid gland.

This symptoms can prescribed with Chinese Herbal Medication ‘Jia Wei Bu Zhong Yi Qi Tang’. Adding addition herbs like (Yuan Zhi, Shu Di, Fu Shen, Long Yan Rou) for boosting blood deficiency; severe condition of Qi and blood deficiency recommend use Chinese Herbal Medication of ‘Ba Zhen Tang Hu Zai’. Depends on person condition for speed up blood circulation purpose add additional herbs like (Chuan Qiong, Mu Dan Pi, Wang Bu Liu Xing); to resolve phlegm or dissolve masses add additional herbs like (Chuan Bei Mu, Chen Pi); to dissolve damp retention can add additional herbs like (Cang Zhu, Ze Xie, Yi Yi Ren); to deflame thyroid gland can add additional herbs like (San Leng, Er Zhu, Xia Ku Cao, Mu Li).

spleen and kidney Yang deficiency, Water retention

The symptoms may vary from mild to severe, and at this stage the pathology of the hypothyroidism can be complicated. In TCM theory causing body organs disease has the root lead to severe kidney yang deficiency. Kidney plays an extremely important role in regulating the distribution of body fluid and water metabolism and excretion. Kidney Yang warms and promotes the functions of Zang-Fu organs and tissues. Kidney Yin and Kidney Yang both restrict and promote each other in the human body so as to maintain a dynamic physiological balance. If this balance is disrupted, pathological changes will manifest such as: puffy and swollen body surface, joint or muscle pain, slow reflexes, poor memory, constipation, pale tongue, weak deep pulse, classified as Spleen and Kidney- Yang deficiency in TCM.

This is a server stage of Hypothyroidism, can be seen significant of Qi and Blood deficiency, clinical manifested as inflammation of the thyroid gland, causing dysfunction of the patient’s own autoimmune system.

This symptoms can prescribed with Chinese Herbal Medication ‘Jin Kui Shen Qi Wan’; for patients with Spleen and Kidney- Yang deficiency manifesting on weight loss, tiredness, feeling cold and pain in abdomen and lower back, oedema, lose appetite, bloated, poor digestion or abnormal urination will occur. Tongue pale and swollen, pulse weak-deep-slow. The treatment principle include nourish Kidney, add additional herbs like (Huang Qi Tang, Wu Pi Yin).

Heart and Kidney Yang deficiency with clinical manifestations like palpitation, suppression in the chest, tiredness, desire to lie down, pale face and dark lips, abnormal urination, tongue purple colour, white and slippery, pulse weak-deep-slow. Treatment principle warm Heart Yang, tonify kidney Qi. Add additional (Lin Gui Zhu Gan Tang). For cold Limbs and add (Xian Ling Pi), according to ‘Zhang Jing Yue' Theory adding (Huang Jing, Gou Qi) is nourishes kidney Yang in order to maintain the thyroid function to a normal level.

(Translated by Fan Wang Ms)

甲状腺功能减退症简称甲减,是较常见的内分泌疾病之一。其中原发性甲减多见,约占甲减的96%,是由甲状腺本身的病变引起的。本病在各年龄段均可发生,以女性居多。及时的甲状腺激素替代治疗能改善甲减症状,恢复甲状腺功能。然而激素替代疗法存在如下不足:长期不适当服用L-T4治疗可导致亚临床甲状腺功能亢进症。研究显示亚临床甲亢可导致60岁以上患者心房纤颤发生的危险性增加3倍,而心房纤颤可导致动脉栓塞的危险性增加,同样也可导致骨密度显著下降。相当一部分病人,尤其是老年人及有冠心病病人对替代治疗耐受性较差,常诱发心肌缺氧,导致心绞痛,甚至心梗、心衰,防碍甲状腺功能的达标。即使替代成功,甲减致心肌、肾脏、大脑等重要脏器的损伤也很难恢复。

原发性甲减多属于中医“虚劳”、“水肿”、“溢饮”等范畴,临床以脾肾阳虚型为多见。然而,近年来随着发病率的提高,本病越来越引起临床医生的重视,许多甲减患者被早期发现,笔者认为单纯以“脾肾阳虚”不足以概括本病的病机,并提出本病当分初期肝郁、中期脾虚、后期“肾虚”三期辨证论治。

初期:肝郁及脾

原发性甲减初期阶段,临床症状往往不典型,常被误诊为他病。此期多见女性就诊患者,常表现为情志抑郁,善太息,胸胁或少腹胀满,或见瘿瘤,或有月经量少、痛经,或见面色不华或虚浮、眼睑浮肿,肢体倦怠,常常伴有轻度体重增加,大便秘结,舌淡苔白,脉弦细或缓等肝气郁滞兼见脾虚湿困之证。追问病史,其病因多为情志不遂,郁怒伤肝,或生活工作压力过大,思虑过度,或脑力劳动太过,劳倦所伤,与巢元方《诸病源候论·气病诸候》“结气病者,忧思所生也。心有所存,神有所止,气留而不行,故结于内”的说法不谋而合。此期患者实验室检查完全符合甲减的诊断,但临床表现除以上症状外极少见到肾、脾、心阳不足的证候。

此期辨证要点为:情志抑郁,善太息,或见瘿瘤;兼见面色不华或虚浮,眼睑浮肿,肢体倦怠。舌淡苔白,脉弦或缓。治疗当以疏肝理气为主,此期临床症状较轻,可以单纯应用中药治疗,而且尚无记忆力、智力等的改变,临床用药越早越好。方药:逍遥散加减。脾虚明显者,可合用参苓白术散加减;兼见胸胁胀痛者,可加用合欢、郁金;兼有颈前肿大者,可加陈皮、夏枯草、牡蛎等。肝气郁结是情志病,除用药物治疗外,还应注重精神上的调适。

中期:脾气虚弱,气血不足

饮食、劳逸等各种因素均可损伤脾脏,导致脾虚不运,化生乏源,但是此期病因以情志所伤、劳倦过度多见。七情中以忧思为主,如《灵枢·本神》云:“脾,愁忧而不解则伤意,意伤则悗乱”,或思虑太过,劳神过度而“劳则气耗”,损伤脾气。此外药物影响或甲状腺手术失当等,也可致脾气虚衰。

脾居中属土,具有消化、吸收和转输水谷精微的生理功能,为后天之本,在维持人体生命活动中起重要作用。“内伤脾胃,百病由生”,此期病理表现以脾气虚及气血亏虚为主。证见形寒气怯或四肢不温,肢体浮肿多见于眼睑及胫前,或体重增加,腹胀纳差,面色少华或萎黄,或口唇爪甲无华,皮肤干燥甚则脱屑,神疲乏力,失眠健忘,大便秘结,舌淡胖或有齿痕,苔白滑,脉缓弱或沉迟。妇女可伴见月经紊乱或合并有不同程度的贫血。某些病例因气虚无力行血,血虚脉道不充兼见血瘀证的表现,若脾虚水湿不化,聚而生痰,痰气、瘀血结于颈前则发为瘿瘤。方药:补中益气汤加味。如心血不足偏重者,加远志、熟地、茯神、龙眼肉;气血亏虚明显可合八珍汤化裁。考虑到疾病的传变,临床根据患者具体情况配伍以活血,如川芎、丹皮、王不留行;化痰,如贝母、陈皮;祛湿,如苍术、泽泻、薏苡仁;消瘿,如三棱、莪术、夏枯草、牡蛎等中药。

后期:脾肾阳虚衰,水湿内停

这一期也是临床常见到的阶段,病机也较为复杂。“五脏之伤,穷必及肾”,脾阳虚日久可及肾阳,或久病失养,或甲减失治误治,损伤肾之精气,必生多种疾病。又肾为先天之本,中寓元阳真火,人身五脏诸阳皆赖肾中元阳以生发,肾阳虚衰,可导致其他脏腑阳气衰弱:如肾阳不足,命门火衰,火不生土,不能温煦脾阳,或肾虚水泛,土不制水而反为所侮,脾阳受伤,而出现脾肾阳虚;肾阳虚衰,不能温煦心阳,而致阴寒内盛,血行瘀滞,水湿停留则会形成心肾阳虚;肾阳不足,命门火衰,日久则肾阳极度亏损,阳损及阴导致肾之阴阳两亏。其肾阳虚主症为:颜面肢体浮肿,腰膝酸冷,反应迟钝,智力减退,大便秘结,舌淡苔白,脉沉细弱。可兼见脾阳虚及心阳虚之症。

原发性甲减发展到此期多是脏腑机能衰退、气血生化不足,其病变部位是甲状腺,主要责之于肾,也可波及他脏,阳虚生内寒是其主要病理机制。临床辨证要始终抓住肾阳虚这个特点。可以说这一期是甲减的极期,临床表现复杂多样,辨证时必须分清主次,灵活用药。方药:金匮肾气丸加减。脾肾阳虚者除肾阳虚主症外兼见消瘦乏力,嗜睡倦怠,腰腹冷痛,面浮肢肿甚或全身水肿,压之凹陷不起,食少腹胀,下利清谷或五更泄泻,小便频数或小便不利,舌质淡胖或边有齿痕,脉沉细或沉迟等症。治宜温肾健脾,通阳利水。治用上方合防己黄芪汤、五皮饮加减。心肾阳虚者兼见心悸怔忡,胸闷憋痛,神倦嗜卧,面白唇紫,小便不利,舌质淡暗或青紫,苔白滑,脉沉微。治宜温通心阳,补肾益气。治用上方合苓桂术甘汤加减。形寒肢冷明显者,加仙灵脾。根据张景岳“善补阳者,必于阴中求阳”之理,临症时多用黄精、枸杞之类。在温补肾阳为主的组方中酌配滋补肾阴之品,防温燥伤阴之弊。

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王秋兰 主任中医师

硕士毕业于南京中医药大学,曾经拜师于数名全国名老中医,搏采众长,参与编写(明清医学荟萃)等大部中医学著作,曾被评为南京市中青年拔尖人才及跨世纪人才,曾两次被江苏省政府选派到日本进行医学交流。擅长治疗妇科病,不孕不育,皮肤病,各种痛症,肝肾疾病等,国内外行医20余年来,积累了丰富的临床经验,治愈患者众多,深得病人的好评

行医地址:7 Wardour Street, London W1D 6PE 电话:0207734 8886 电子邮件:London12@everwell.co.uk

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