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Part One
Patients, Illness and Disease:
CIM Use and its Context in Primary
Health Care
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Primary Health Care, Complementary and Alternative Medicine and Womenâs Health: A Focus upon Menopause
Amie Steel, Jane Frawley, Jon Adams,
David Sibbritt, and Alex Broom
1.1Introduction
Australian women are integrating primary health care (PHC) and comple-mentary and alternative medicine (CAM) to alleviate a range of symptoms and conditions. This chapter introduces the use of CAM for womenâs health in general and more particularly, explores the integration of CAM alongside mainstream PHC by women during the menopause (Xue et al., 2007; Adams et al., 2003).
It has been argued that the trend identifying women as higher users of CAM is unsurprising as women also use conventional health care services more frequently than men (Beal, 1998). Research examining the general Australian population suggests that some women use acupuncture (9.6%), chiropractic (17.1%) and osteopathy (5.8%) as part of their health management. However, research has only provided preliminary investigation of the specific usage patterns of Australian women. One study (Adams et al., 2007) estimates that 11% of mid-age Australian women consult with naturopaths and herbalists and that these women are more likely to live in non-urban areas, and in contrast with the general population, are less likely to have completed post-secondary education. Adams et al. (2007) also identified these women using naturopaths and herbalists as likely to experience symptoms of both general health complaints (back pain (53%), stiff or painful joints (50%), allergies (45%) and severe tiredness (43%), as well as symptoms related to womenâs health (hot flushes (50%) and night sweats (37%)). Consistent with the general population these women appear to be engaging with both conventional PHC and CAM practitioners (Rayner et al., 2009; Stankiewicz et al., 2007). The reasons for womenâs integration of CAM and PHC are complex but some trends have been observed. For example, a lack of satisfaction with biomedical care tends to be associated with higher CAM use for women ( Adams et al., 2011a), except in rural communities with some research suggesting CAM use is linked to poorer access to conventional PHC (Adams et al., 2011b) rather than dissatisfaction with conventional care. When viewed in conjunction with the high CAM use amongst women, this reinforces the potential PHC role of CAM practitioners and treat-ments. It also suggests that, given the high number of female CAM users with menopause-related symptoms such as hot flushes and night sweats, an examination of the relationship between PHC utilisation and CAM use amongst menopausal women is warranted.
1.1.1The rise of CAM use in menopause
Emerging international data identifies high levels of CAM use by women for the management of menopausal symptoms. Recent data suggests 80% of menopausal women (n = 3,302) in the US have used some form of CAM in the previous six years for symptom control (Bair et al., 2008), and another US study (n = 1,206) found that almost 50% of women used alternative treatments for symptom management, the most popular being diet/nutrition, exercise/ yoga, relaxation/stress management and homeopathic/naturopathic remedies (Daley et al., 2006). Rates of CAM use elsewhere in the world have also been found to be high with 91% of women in Canada and 82.5% in Australia using CAM during the period of menopausal transition (Lunny and Fraser, 2010; Gollschewski et al., 2004). Another Australian study found that 53.8% of women had used a CAM product and/or consulted a CAM practitioner for the relief of menopausal symptoms during the previous 12 months (van der Sluijs et al., 2007). Other studies have found that 33.5% of Italian women utilise CAM during menopause along with 43% of menopausal women in the UK who employed over-the-counter nutritional supplements (Cardini et al., 2010; Gokhale et al., 2003).
Differences in prevalence rates of CAM across cultures and studies may be due, at least in part, to varying definitions of CAM and time frames employed. However, regardless of these differences, current CAM usage during menopausal transition appears significant. Bair et al. (2008) examined the use of CAM during menopause transition and whether there were any variations in utilisation due to ethnicity (Bair et al., 2008). The authors reported that around 80% of all participants had used some form of CAM during the six-year study period. White and Japanese women had the highest prevalence of use (60%), followed by Chinese (46%), African American (40%) and Hispanic (20%) women. White women were not found to alter their use of CAM as they transitioned through menopause, whilst Chinese and African American women increased their CAM use as they transitioned to perimenopause and decreased usage in postmeno-pause. Hispanic and Japanese women were found to decrease use in early perimenopause, increase use as they transitioned into late perimenopause and decrease use again as they proceeded to postmenopause.
Common drivers of general CAM use such as previous CAM use, tertiary education, age, health beliefs, symptom sensitivity, personal experience and health co-morbidities (Bair et al., 2002; 2005; 2008; Gold et al., 2007; Gollschewski et al., 2005; Lunny and Fraser, 2010) are also pertinent during menopause. A US study found that women who commonly used CAM for menopausal symptoms were higher conventional health care users when compared with non-users of CAM (Bair et al., 2005). Another study identified women who use herbal medicines as more likely to: experience good overall health, be under 55 years of age, have previously (but not currently) used hormone replacement therapy (HRT) and to have carried out breast self-examinations in the last two years (Gollschewski et al., 2005).
1.1.2CAM products and practices commonly used in menopause
Complementary medicines such as soy products and herbal medicines are commonly used during the menopause to control problematic symptoms. Randomised clinical trials (RCTs) of soy products have found both positive (Scambia et al., 2000; Upmalis et al., 2000; Faure et al., 2002; Albert et al., 2002; Crisafulli et al., 2004; Nahas et al., 2007) and negative findings (MacGregor et al., 2005; Burke et al., 2003; Nikander et al., 2005; Knight et al., 2001). These conflicting results may be due to large variations that exist in the isoflavone content of soy products (Boniglia et al., 2009).
A recent review examined the evidence from systematic reviews, RCTs and epidemiological studies and found that while phytoestrogen- containing products may have only minimal benefits for hot flushes, they may nevertheless provide other positive health effects such as reducing plasma lipid levels and bone loss (Borrelli and Ernst, 2010). Black cohosh (Cimicifuga racemosa/Actaea racemosa), red clover (Trifolium pratense) and hops (Humulus lupulus) are amongst the most common herbal remedies utilised during menopause. It is believed that these herbs exhibit hormonal modulating effects through various mechanisms. Black cohosh has attracted the most rigorous investigation for the treatment of hot flushes in menopause and overall, RCTs have been positive (Borrelli and Ernst, 2010; Cheema et al., 2007). However, many difficulties exist in herbal medicine research alongside, and in addition to, the normal methodological considerations of a rigorous RCT, such as quality of the herb material, dose, standardisation and phytoequivalence issues.
1.1.3A time for integration?
The symptoms of menopause are primarily managed by a general practi-tioner (GP), as opposed to a specialist. Previous research has shown quite clearly that women would like to gain information on all facets of menopause including CAM use from their GP in order to make informed choices (Armitage et al., 2007), and are often dissatisfied with the infor-mation they are given (Sayakhot et al., 2011). Women report several frustrating challenges when gathering information about the menopause, namely a lack of time to gather this information, a dearth of relevant information and poor information quality. These challenges may be exacerbated by limited consultation times with their GPs to discuss information related to their condition in sufficient detail (Taylor, 2009). Additionally, these women also express an interest in material relating to the general menopausal process and conventional and CAM treatments, including information on safety.
Health care professionals such as GPs are ideally placed to advise women about the safe use of CAM during the menopause. However, many have often had very limited training in complementary medicine and may not feel confident recommending or prescribing such treatments (Pirotta et al., 2011), and despite some evidence that CAM practitioners are attempting to provide a bridge between conventional medicine and CAM practice ( Wardle, 2010), this is still the exception rather than the rule.
Unfortunately, menopausal women do not appear to be disclosing their use of CAM to their conventional care providers (Wade et al., 2008), which may be due to patientsâ perceptions that doctors hold a negative attitude towards CAM and are likely to be judgemental or disinterested (Robinson and McGrail, 2004). Pharmacists are also in a prime position to offer advice on the use of complementary medicines for the menopause. Most pharmacies supply both conventional and complementary medications, enabling the pharmacist to advise on the use of CAM products and check any potential interactions with prescription medication, a service preferred by pharmacy customers (Braun et al., 2010) and considered important by pharmacists (National Prescribing Service, 2010) (also see Chapter 7 for a more detailed discussion of the role of pharmacists in CAM consumption). This chapter will now focus upon the findings from a recent study examining the integration of PHC providers and CAM for the management of symptoms during the menopausal transition.
2.1Methods
1.2.1Sample
The survey data analysed in this chapter is from a substudy of the Australian Longitudinal Survey on Womenâs Health (ALSWH). The ALSWH was designed to investigate multiple factors affecting the health and well-being of a cohort of women over a 20-year period. Women in three age groups (âyoungâ 18â23, âmid-ageâ 45â50 and âolderâ 70â75 years) were randomly selected from the national Medicare database (Brown et al., 1998). The baseline survey, Survey 1 (n = 14,779), was conducted in 1996 and the respondents have been shown to be broadly representative of the national population of women in the target age groups (Brown et al., 1999). The focus of this substudy is women from the mid-age cohort. A total of 2,120 women who had indicated in Survey 5 (2007) that they consulted a CAM practitioner were sent a questionnaire, of which 1,800 women completed and returned. From these 1,800 respondents, 853 women indicated that they had consulted a CAM practitioner in the previous 12 months (July 2008â July 2009) and that they were experiencing menopausal symptoms. It is these women that were included in the analyses for this study. Relevant ethical approval was gained from the Human Ethics Committee at the University of Queensland and University of Newcastle, Australia.
1.2.2Demographic characteristics
The address of usual residence at each survey for each woman in the ALSWH has been geo-coded and allocated an ARIA+ remoteness score according to the ASGC (Australian Standard Geographical Classification) Remoteness Areas classification released in 2001 by the Australian Bureau of Statistics (Australian Institute of Health and Welfare, 2004). The ASGC classification categorises areas of residence as âmajor citiesâ, âinner regionalâ, âouter regionalâ, âremoteâ and âvery remoteâ, based on road distance from a locality to the closest service centre. The participants of this study were categorised into four areas of residence: major cities (ARIA+ score: 0â0.20), inner regional (>0.20â2.40), outer regional (>2.40â5.92) and remote/very remote (>5.92). The women were asked about their current marital status. A measure of the womenâs disposable income was obtained from a question asking how they managed on the income available to them.
1.2.3Rating of health care providers/services
The women were asked to rate their level of satisfaction with various aspects of conventional health care providers (such as access to a female GP, hours when a GP is available, outcomes of medical care, quality of care provided). Each aspect was rated via a five-point Likert scale, where 1 = excellent and 5 = poor. The women were also asked their level of agreement to a series of statements regarding alternative medicine (such as âAn alternative health practitioner spends a longer time with me in consultation compared with my doctorâ, âI find it easier to talk to an alternative health practitioner...
