28 April, 2014

In all fields of medicine, we, the health-care providers, witness a growing number of patients who use all sorts of complementary and traditional medicine (CAM). A new study, which was published in a journal with which most of us are not familiar, compared the results from two surveys done in two geographically and culturally diverse sites (Sydney and Bologna) to examine factors that determine the extent and pattern of CAM use to alleviate menopausal symptoms [1].

Women, aged 45–65 years, who were symptomatic when transitioning through menopause or asymptomatic but taking menopause-specific treatments, were recruited in Sydney (n = 1296) and Bologna (n = 1106) to complete the same voluntary, anonymous, and self-administered questionnaire. Demographics of the two cohorts differed significantly. CAM was more popular in Sydney.

The most significant determinants of CAM consumption were the use of CAM for other conditions besides menopause and the severity of vasomotor symptoms. Occupational status was a determinant of CAM use amongst Bologna respondents only.

In order to relieve symptoms, Australian and Italian women used different CAM modalities whose effectiveness was generally perceived as good. In general, CAM use was popular amongst menopausal women from Sydney and Bologna. Differences in the patterns of CAM use seem to depend on CAM availability and on the educational level and professional status of users. The complex interaction between market, social, and cultural factors of CAM use seems to be more influential on women's choice of CAM than the available evidence of their effectiveness.

Comment

First, let's see what's behind this article. Actually, this was a re-analysis of data extracted from two previous studies by the same group published in respectable journals [2,3]. The aim of the present evaluation was to compare the two cohorts, which have different social, cultural and ethnic characteristics. The Bolognese sample was significantly more homogeneous in nature, whereas the Sydney sample was much more heterogeneous. In general, the use of CAM was popular in both sites, yet indeed there were interesting differences between the Italian and Australian women.

For example, significantly more Sydney women used CAM products (48.7% Sydney, 23.6% Bologna, p < 0.001). The most commonly consulted therapists by women in Sydney were the naturopath and acupuncturist, while women from Bologna were more likely to see a herbalist or nutritionist. The most popular products were dietary soy and evening primrose oil (Oenothera biennis) for Sydney women and soy capsules or pills and dietary soy for women from Bologna.

The percentage of women who had not used any treatment for menopausal complaints during the previous 12 months was significantly lower in Sydney than Bologna (35.2% vs. 56.2%, p < 0.001). Another aspect highlighted in the current study was the availability and accessibility of CAM products in the reciprocal markets. A large variation was detected between the two cities in regard to the type of health-care providers who recommended these treatments. The question, whether or not there are non-medical certified CAM specialists, was raised as well. In fact, there is no national registration scheme for CAM practitioners in Italy, but greater regulatory freedom in Sydney. Also, there are more options to buy the products in Sydney (supermarkets, pharmacies, health food stores and even internet-based purchase) than in Bologna.

Another major argument is the price of conventional vs. CAM therapies. The Australian Longitudinal Study on Women's Health (ALSWH) conducts regular surveys of women in three age cohorts (born 1973–78, 1946–51, and 1921–26). A recent release of the data addressed the cost of both types of therapies [4]. Over 150,000 responses to the surveys were received, and 42,305 (27%) of these responses included free-text comments; 379 were relevant to medicines and health-care costs (from 319 individuals). Three broad themes were identified: costs of medicines (33% of relevant comments), doctor visits (49%), and complementary medicines (13%). Once again, it becomes very clear that costs are directly related to sales. Cheaper products are more popular than the more expensive ones, and natural products or alternative modes of therapy become sometimes unaffordable for those who might benefit from their use. Subsidizing all the appropriate products and modalities is of course the ultimate solution, but this is not feasible in most areas of the world. The use of complementary and alternative medicines is growing in Australia [5]. There were many comments made by participants in the ALSWH from all age cohorts regarding perceptions of benefits and preference for CAM over conventional prescription medicines (although these were not examined in detail in this study), and some women questioned why access to these medicines was not subsidized by taxpayers. The cost of CAM has been noted as a barrier to access in other studies of mid-aged women during menopause [6]. A challenge for the manufacturers of these medicines is to assemble the clinical data to support claims for the cost-effectiveness of CAM. Demonstration of cost-effectiveness is certainly a prerequisite condition for listing these therapies in any national health basket.

A side question: do health-care providers use CAM? The reported rates of CAM use among physicians are lower than among nurses or pharmacists. Medscape's Physician Lifestyle Report 2014 found a higher rate of CAM use among female physicians (48% vs. 30% among male physicians) [7]. The most common indications for CAM use were back and neck pain and arthritis, with the most common modalities being acupuncture, massage, and osteopathic or chiropractic manipulation. Overall, the literature suggests that nurses are most likely to report use of CAM, followed by pharmacists, whereas physicians demonstrated greater variability in and lower rates of CAM use. The surveys and studies among health-care professionals also suggest a link between self-reported use of CAM and recommendation to patients, whether the evidence was available for efficacy or not.

Amos Pines
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

References

1. van der Sluijs C, Lombardo FL, Lesi G, Bensoussan A, Cardini F. Social and cultural factors affecting complementary and alternative medicine (CAM) use during menopause in Sydney and Bologna. Evid Based Complement Alternat Med 2013;2013:836234
http://www.ncbi.nlm.nih.gov/pubmed/24459531

2. van der Sluijs CP, Bensoussan A, Liyanage L, Shah S. Women's health during mid-life survey: the use of complementary and alternative medicine by symptomatic women transitioning through menopause in Sydney. Menopause 2007;14:397-403
http://www.ncbi.nlm.nih.gov/pubmed/17202872 

3. Cardini F, Lesi G, Lombardo F, van der Sluijs C. The use of complementary and alternative medicine by women experiencing menopausal symptoms in Bologna. BMC Women's Health 2010;10:7
http://www.ncbi.nlm.nih.gov/pubmed/20187964 

4. Walkom EJ, Loxton D, Robertson J. Costs of medicines and health care: a concern for Australian women across the ages. BMC Health Serv Res 2013;13:484
http://www.ncbi.nlm.nih.gov/pubmed/24252248 

5. Xue CCL, Zhang AL, Lin V, Da Costa C, Story DF. Complementary and alternative medicine use in Australia: a national population-based survey. J Altern Complement Med 2007,13:643-50
http://www.ncbi.nlm.nih.gov/pubmed/17718647 

6. Gollschewski S, Kitto S, Anderson D, Lyons-Wall P. Women's perceptions and beliefs about the use of complementary and alternative medicines during menopause. Complement Ther Med 2008;16:163-8 
http://www.ncbi.nlm.nih.gov/pubmed/18534329

7. http://www.medscape.com/features/slideshow/lifestyle/2014/public/overview