Options in treating menopausal symptoms
Your patient is in her mid-40s and beginning to have hot flashes and disturbances in sleep patterns. She is at low risk for heart disease and osteoporosis. Do you consider complementary and alternative approaches to prescription hormone therapy in treating these menopausal symptoms?
Whether providers are looking at what has been termed "complementary and alternative," "alternative," or "unconventional" medicine, increasing numbers of patients are choosing it for relief of many symptoms, including those associated with perimenopause and menopause. In a 1990 national survey, one in three adults reported using at least one unconventional therapy in the last year.1 Many survey respondents used the therapies for chronic diseases, but among those who used alternative treatments for life-threatening illnesses, 72% did not report such activity to their health care providers.
Payers are starting to cover therapies
Many managed care organizations are responding to the move toward alternative medicine by including coverage for such therapies as acupuncture, homeopathy, and herbal remedies.2 How do providers educate themselves and their patients about the risks and benefits of complementary and alternative medicine (CAM), especially when it comes to dealing with menopause?
Just assessing the field of complementary and alternative medicine can prove challenging because it includes several disciplines and systems, says Barbara Kass-Annese, RN, CNP, MSN, manager of quality improvement with the Los Angeles Regional Family Plan ning Council and author of A Total Wellness Program for Women Over 30 (Health Choice Productions, Marina Del Rey, CA).
CAM includes such familiar practices as chiropractic, homeopathy, herbalism, and less-explored methods such as reflexology and aromatherapy, says Kass-Annese. Comprehensive health systems include traditional Chinese, Ayurvedic, and naturopathic medicine.
A further challenge for providers is obtaining research-driven safety and efficacy information for CAM treatments. For example, there is much German data on botanicals, but it has been hard to access, says Sadja Greenwood, MD, MPH, assistant clinical professor with the department of OB/GYN and reproductive sciences at the University of California San Francisco and author of Menopause, Naturally: Preparing for the Second Half of Life (Volcano, Volcano, CA). The American Botanical Council in Austin, TX, is working to translate the German monographs for use by American providers, and the Herb Research Foundation in Boulder, CO, is performing medical literature searches on requested herbal approaches, Greenwood says.
The Office of Alternative Medicine (OAM) at the National Institutes of Health in Bethesda, MD, is developing a searchable database of all CAM abstracts from MEDLINE, confirms Anita Greene, a press communications program officer with the OAM. The database is targeted for accessibility by fall or winter 1998.
Claims vs. evidence
For providers in women's health care who are accustomed to reviewing safety and efficacy research on birth control pills, seeking the same type of data when it comes to CAM approaches to treating menopausal symptoms can be a daunting task. Maida Taylor, MD, MPH, assistant clinical professor with the department of OB/GYN and reproductive sciences at the University of California San Francisco, has published an overview of research of alternatives to hormone therapy in menopause.3
Taylor expresses concern for methods that have little scientific evidence to back their claims of efficacy. Women who choose these methods should be told they are enlisting themselves in an uncontrolled clinical trial, she says.
"The question is [whether] people will use things that have no proven efficacy as substitutes for things that are proven to work, and that women will assume that because this guru or that expert says that this works and misquoted the literature or misrepresented the data, that they are, in fact, safe," Taylor asserts. "Not only are they assuming that they are getting the benefits, but they also are assuming a tremendous reduction in risk, which is not proven."
The provider's role
Providers must fulfill four important missions in serving as patient advocates when it comes to CAM and conventional medicine, says Ronald Chez, MD, professor of OB/GYN in the school of medicine and professor of community and family health in the College of Public Health at the University of South Florida in Tampa.
Providers must engage in reciprocal open communication, facilitate the patient's informed choice, avoid harmful or useless practices, and implement an integrated evidence-based care plan, he says.4 He developed this approach in collaboration with Wayne Jonas, MD, director of the OAM, following a six-month term of study at the OAM.
"I think it is important that patients take responsibility for their health, and I think that it is important, when possible, that we try to help them be educated about it," Chez explains. "But I fully accept that I cannot be all things to all patients. By saying that, it means I can really cite my point of view politely and in a way that I hope is informative and respectful," he says.
"If it is not listened to, that's the patient's right to say, `No thank you' to me. It's also her right to seek another prac titioner." (See story, p. 92, for sources of infor mation on complementary and alternative medicine.)
References
1. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993; 328:246-252.
2. Eisenberg DM. Advising patients who seek alternative medical therapies. Ann Intern Med 1997; 127:61-69.
3. Taylor M. Alternatives to conventional hormone replacement therapy. Comp Ther 1997; 23:514-532.
4. Chez RA, Jonas WB. The challenge of complementary and alternative medicine. Am J Obstet Gynecol 1997; 177: 1,156-1,161.
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