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Menopause Live - IMS Updates
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Date of release: 28 April, 2014

Use of complementary and traditional medicine in the menopause


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.

Comentario

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. Womens 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 Womens 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. Womens 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


El siguiente comentario es una traducción de una contribución original en Inglés enviada a los miembros el Mayo 13, 2013. La traducción ha sido gentilmente efectuada por el

Dr Peter Chedraui

Andrógenos endógenos y grasa corporal en la menopausia

La menopausia se asocia a cambios dramáticos en el perfil hormonal y metabólico de una mujer. Mientras que la menopausia per se parece no afectar el peso corporal, la disminución de estrógenos en torno a la menopausia se asocia con una redistribución de la grasa corporal que favorece un patrón androide [1]. Además, aunque incapaces de producir estrógenos, el ovario después de la menopausia sigue siendo un órgano endocrino activo, que contribuye sustancialmente al nivel de andrógeno circulante [2]. Cao y colegas [3] en su artículo reciente realizaron un estudio transversal en mujeres postmenopáusicas tempranas (≤ 5 años) y tardías (≥ 10 años) para investigar la asociación de estos dos parámetros, a saber, la distribución de la grasa corporal y andrógenos séricos circulantes. Las mujeres postmenopáusicas tardías tenían un mayor porcentaje de grasa corporal, en comparación con sus contrapartes más jóvenes, aunque el índice de masa corporal (IMC) no difirió entre los grupos. Ambas mujeres obesas postmenopáusicas tempranas y tardías tenían niveles más altos de andrógenos y más grasa abdominal en comparación con las mujeres con peso normal. Los andrógenos séricos (testosterona libre en las postmenopáusicas tempranas y DHEAS en las tardías) mostraron una asociación positiva independiente y significativa con la adiposidad abdominal.

Comentario

El primer mensaje importante de este estudio es que la adiposidad corporal no se refleja por el IMC a medida que aumenta la edad. Aunque el IMC no fue diferente, el porcentaje de grasa corporal fue mayor en las mayores en comparación con las mujeres postmenopáusicas más jóvenes. Esto puede implicar que el envejecimiento postmenopáusico se asocia ya sea con un aumento de la masa grasa o con una disminución de la masa magra. Este último fenómeno, descrito como sarcopenia, es particularmente frecuente en los ancianos y se asocia con una considerable morbilidad y mortalidad. La sarcopenia es el mecanismo fisiopatológico que explica la "paradoja de la obesidad": las personas de edad avanzada con IMC "normal" que muestran mayores tasas de mortalidad en comparación con los individuos con sobrepeso de la misma edad, un hallazgo que probablemente refleja el efecto de la masa magra baja [4]. Al evaluar los parámetros antropométricos en las mujeres postmenopáusicas que envejecen, por lo tanto, el IMC no es un indicador fiable de adiposidad y parámetros de composición corporal deberían ser utilizados en la toma de decisiones de intervención. El segundo mensaje crucial del estudio por Cao y colaboradores [3] es que la obesidad en la mujer posmenopáusica es hormonalmente y metabólicamente más perjudicial, en comparación con la mujer en edad reproductiva. Las mujeres posmenopáusicas, ya sea joven o mayor, almacenan el exceso de grasa en la región abdominal. La grasa abdominal es una característica cardinal del síndrome metabólico, un importante contribuyente a la mortalidad cardiovascular en mujeres postmenopáusicas. La resistencia a la insulina es la principal vía patogénica, que media los efectos endocrinos de la obesidad abdominal: el flujo de salida de los ácidos grasos libres en el hígado y los niveles altos de triglicéridos como resultado de esto disminuyen la sensibilidad a la insulina hepática y captación muscular de glucosa [5]. Los niveles elevados de insulina, por otro lado, tienen un efecto estimulante sobre la producción ovárica de andrógenos después de la menopausia, tanto directa como indirectamente, mediante el aumento de receptores de la hormona luteinizante (LH) en el estroma ovárico, un efecto amplificado por los altos niveles de LH postmenopáusicos [2]. En un reciente análisis prospectivo de 1500 mujeres perimenopáusicas que fueron seguidas durante 9 años, se hizo evidente que el aumento de la grasa del tronco resultó en niveles más altos de testosterona, lo que indica que la adiposidad abdominal precede a las alteraciones en los andrógenos postmenopáusicos [6]. Los altos niveles de andrógenos en las mujeres pueden conferir un riesgo cardiovascular independiente, como se evidencia en estudios experimentales sobre el efecto de la testosterona sobre la vasculatura y estudios clínicos en mujeres con condiciones de exceso de andrógenos como el síndrome de ovario poliquístico [6]. En conclusión, la menopausia tiene importantes consecuencias cardiometabólicas, una de las principales es la acumulación de grasa central. La resistencia a la insulina que acompaña, junto a la disminución de la masa magra, debido a la disminución de la inactividad y la hormona sexual, acelera el proceso de envejecimiento y aumenta el riesgo cardiovascular. Las medidas de intervención deben apuntar principalmente a preservar la masa magra del cuerpo, ya que es la principal forma de aumentar la sensibilidad a la insulina y garantizar buen estado físico en la edad avanzada. Como el ejercicio físico regular predice el rendimiento físico en la edad adulta [7], las mujeres deben ser alentadas a incorporar el ejercicio en su rutina diaria como una forma natural y eficaz de contrarrestar el impacto metabólico de la menopausia.

Irene Lambrinoudaki

Associate Professor of Gynecological Endocrinology, Medical School, University of Athens, Greece and Vice President of the European Menopause and Andropause Society

References

  1. Davis SR, Castelo-Branco C, Chedraui P, et al. Understanding weight gain at menopause. Climacteric 2012;15:419-29.
    http://www.ncbi.nlm.nih.gov/pubmed/22978257

  2. Androgen production and therapy in women, UpToDate
    http://www.uptodate.com/contents/androgen-production-and-therapy-in-women?source=search_result&searc

  3. Cao Y, Zhang S, Zou S, Xia X. The relationship between endogenous androgens and body fat distribution in early and late postmenopausal women. PLoS One 2013;8:e58448.
    http://www.ncbi.nlm.nih.gov/pubmed/23484029

  4. Chang SH, Beason TS, Hunleth JM, et al. A systematic review of body fat distribution and mortality in older people. Maturitas 2012;72:175-91.
    http://www.ncbi.nlm.nih.gov/pubmed/22595204

  5. Insulin action. UpToDate
    http://www.uptodate.com/contents/insulin-action?source=search_result&search=abdominal+fat+metabolism

  6. Wildman RP, Tepper PG, Crawford S, et al. Do changes in sex steroid hormones precede or follow increases in body weight during the menopause transition? Results from the Study of Womens Health Across the Nation. J Clin Endocrinol Metab 2012;97:E1695-704
    http://www.ncbi.nlm.nih.gov/pubmed/22723312

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