Title: Women’s perceptions and beliefs about the use of complementary and

alternative medications during menopause

Authors:

Sara Gollschewski BHSc (Hons)1

Simon Kitto PhD 2

Dr Debra Anderson PhD 1

Dr Philippa Lyons-Wall DipNutrDiet PhD 3

1 Institute of Health and Biomedical Innovation, Queensland University of

Technology, Brisbane, Australia

2 School of Rural Public Health, Monash University, Brisbane, Australia

3 School of Public Health, Queensland University of Technology, Brisbane, Australia

Corresponding Author

Sara Gollschewski

Centre for Health Research

Queensland University of Technology, Kelvin Grove Campus

Brisbane, Australia 4059

Phone: 61 7 3864 5621

Fax: 61 7 3864 3369

Email: s.gollschewski@qut.edu.au

Word Count: 3061

Introduction

Within the context of menopause, complementary and alternative medications

(CAMs) have the potential to treat acute menopausal symptoms and promote long-

term well-being. More than 300 therapies, supplements and activities are currently

classified as CAMs(1). The World Health Organisation has defined CAMs as a diverse

group of medications, therapies, techniques and exercises which incorporate a range

of approaches and philosophies. In addition, the definition recognises CAMs as a

multi-treatment approach which aims to ‘prevent illness’ and ‘maintain well-being’

rather than to cure a condition(2).

Clinical trials have tested efficacy of specific CAMs in reducing hot flushes however

the results are inconclusive(3, 4). Despite a lack of proven efficacy, research suggests

menopausal women are using CAMs to treat their symptoms with reported

prevalences between 22 and 83%(5-9). In previous work by the current authors, the

prevalence and sociodemographic factors associated with CAM use were explored

among 886 Australian menopausal women(10, 11). CAM use in the sample was high,

with 82% using at least one type of CAM. Nutrition was the most commonly cited

(67%) individual therapy, followed by phytoestrogens (56%), herbal therapies (41%)

and CAM medications (25%) and the characteristics and sociodemographic profile of

a CAM user were also identified.

Preliminary research has been undertaken with menopausal women to identify reasons

that influence CAM use during this transition. A lack of health practitioner support,

previous CAM use(12) and personal control over menopause and symptoms(13) were

identified in previous research as reasons for using CAMs. In a study with 82

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American women, CAMs were used to reduce menopausal symptoms and as a

preventative measure for long-term health(14). The use of CAMs was seen to embrace

the health of the whole body and strengthen the connection between the mind and

body. While an understanding of the types, prevalences and factors associated with

CAM use is emerging, descriptions and insight into women’s experiences of CAM

use during the menopause requires further exploration. This study aimed to

contextualise women’s CAM use during menopause by identifying and describing the

factors that women self-report as being influential in their decision to use CAMs.

Methods

Sample

Women who are currently using CAMs, aged between 47 and 67 years and fluent in

English, volunteered to participate in this study. They were recruited through an

advertisement placed in a newsletter distributed by a large Metropolitan hospital, a

flyer displayed on noticeboards of Council libraries and shopping centres, and a media

release. The method of recruitment, volunteer sampling, ensured that the perceptions

and experiences of women who are using CAMs during menopause are explored. This

sampling technique does limit the generalisability of the data, however a qualitative

research approach was undertaken to explore the factors influencing decisions to seek

CAM treatments for their menopausal symptoms and will produce conceptually

generalisable findings(15) that will facilitate a deeper understanding of the phenomena.

A total of 15 women participated in the study, with 13 in three focus groups and two

telephone interviews. Two women who lived in rural Queensland were interested in

participating in the study after hearing the media release and consequently, two

telephone interviews were undertaken to capture these woman’s experiences.

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Ethical approval for the study was granted by the Queensland University of

Technology Ethics Committee.

Data Collection

Focus groups were used as the primary source of data collection as they encourage

interactions, open discussions and allow participants to react and build on the

responses of other members(16, 17). The questions in both the focus groups and

interviews focussed on the following issues: 1) types of symptoms experienced during

menopause, 2) therapies other than hormones used to cope with menopause and 3)

benefits of using these therapies, and 4) how women learned about these therapies.

For this study, women were asked to detail ‘anything you use other than hormone

therapy to treat symptoms’. The question was posed this way to avoid preconceptions

about the terms complementary and alternative, which would enable women to

disclose anything they were currently using for symptom treatment. Focus groups

were tape recorded and moderated by the main investigator. Theoretical saturation,

where no new or relevant data has been produced, was used to determine the number

of focus groups (18).

Data analysis

Data from the focus group and interviews were transcribed and analysed by thematic

analysis utilising open, axial and selective coding(19). Data triangulation, whereby

focus groups and semi-structured interviews were used to collect information(20).

Researcher triangulation was also employed to collect and analyse the data to capture

the complexity of the phenomena studied and enhance the validity of the findings(20)

was utilised in this project. An assistant was present to provide supplementary notes

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on the focus groups and subsequently to aid in the validation of themes and

conclusions drawn. With regard to rigorous reflexivity (the impact of the researcher

on the data collection and analysis)(17), both the participants and moderator were

female which assisted in creating an open and relaxed atmosphere.

Results

The majority of women were aged less than 55 years, married or defacto and

employed (Table 1). Empowerment was the central theme to emerge from the data.

This concept of control was embedded within the four themes identified: 1) self

management of symptom experiences; 2) menopausal CAM use: types, individual

needs and costs; 3) informed choices: the need for validation and control; and 4)

health practitioners and their influence on CAM use. The themes that emerged from

the data are modelled in Figure 1.

Self management of symptom experiences

Women expressed a desire to have ownership and control over their menopause

experience and treatments used. Self management was intrinsically linked to this

control; women wanted to be aware of their body’s individual needs and the

menopausal symptoms experienced, and they wanted to have the answer to effectively

manage it. Hot flushes, a loss of vitality and tiredness were the most commonly

reported symptoms and stress, mood swings, sweating, memory loss, sleep

disturbances and tiredness were also reported. The effects of hot flushes generated a

lot of discussion within the focus groups and women were eager to share their

negative experiences in the work environment, commonly describing a loss of control.

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“Its embarrassing and overwhelming, especially if you’re the one whose

supposed to be talking at the time [in a meeting], they look at you and you can

feel the red face coming, it can be quite difficult” (Person 4).

The source of symptoms was questioned, with most women believing the symptoms

they were experiencing related to ageing and life stresses. Women felt menopausal

symptoms, such as hot flushes, were exacerbated by increased external stressors (such

as changing in work and family life) during this time. Most women believed a

positive mind frame would overcome any symptoms and described menopause as just

another phase of life.

“I always think for every negative, there’s a positive, so okay I’m going

through menopause. Okay that’s fine but…. face it... address it so when you go

through it you can still carry on” (Person 2).

Menopausal CAM use: types, individual needs and costs

The women in the focus groups reported using a number of CAMs including non

prescription menopausal supplements, herbs, physical activity, nutrition, massage, oil

burning, and aromatherapy and practitioners including a naturopath and Chinese

herbalist. By participating in activities such as exercise, healthy eating and taking

vitamins women believed they had control over their current symptoms, were

improving their health status and ensuring long term health.

“We are living a lot longer and therefore we going to have a lot more women

who are going to have a lot more years ahead of them and want to live really

healthy independent lives” (Person 1).

Incorporated in this was women’s desire to be aware of their body’s individual needs

and more importantly, finding appropriate treatments and therapies to suit them.

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“Friends of mine have had the cream and haven’t had the success with it, but

everyone is different we all go what’s inside we don’t know and you’ve got to

find something to suit the individual” (Person 5).

The use of hormones to treat symptoms was evident in the study, with only two

women indicating that CAMs were not effectively managing their symptoms.

However, both women expressed discomfort taking hormone therapy and were

actively seeking an alternative that would suit their needs. The high cost of CAMs

used and costs of alternative practitioners were cited as barriers to use. Women

expressed concern that the high cost of CAMs was compromising their beliefs and

control about their body and the treatments used during menopause.

“I spent hundreds of dollars on it [naturopath] and I was a student and not

working and I got to the stage where I really cannot afford to keep going”.

(Person 6)

Informed choices: the need for validation and control

A perceived loss of control over their body and symptoms experienced was a common

occurrence and information was seen as a positive way to overcome this. Information

on alternative therapies was primarily sourced from friends, but also from the internet,

magazines, books, work colleagues and general practitioners. Talking to others and

sharing information was evident and women were eager to share stories about CAMs

and exchanged contact details of supportive general practitioners.

“I’ve got a very good solid group of girlfriends and we go to lunch once a

month and there’s always someone at a different stage” (Person 4).

Women searched for information from multiple sources until they were satisfied with

their answers however, reliable information was not easily found, and up to-date,

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scientific information was considered essential as women equated knowledge to

having control over their own choices.

“People want a lot of information to, to work out what’s best for them”

(Person 7).

In a discussion of the recent publication of the Women’s Health Initiative study,

which questioned the safety of hormone use(21), most women questioned the outcomes

of the research. However, several women felt that it validated their concerns about

the use of hormones, and the research supported their use of alternative therapies.

“I wasn’t going there anyway, so I wasn’t influenced anyway, but I was like,

aha!, I was right about the hormone replacement” (Person 7).

Health practitioners and their influence on CAM use

Personal experiences with doctors were mostly negative, with women saying ‘you

don’t get the option of natural’ or doctors are ‘only interested in hormone therapy’.

The relationship between a woman and her health practitioner was perceived to be

imbalanced, with many women citing that it was difficult to find a doctor they felt

happy and comfortable with. If women perceived their health practitioner was not

open to CAMs or accepting of their beliefs, they searched for a practitioner who

accepted their decision to use CAMs during the menopause. Women who perceived a

negative relationship were less likely to disclose their current use of CAM, and were

more likely to self medicate CAMs. Women were adamant about active participation

during menopause, in particular, the importance of questioning medical results,

reasons for taking a particular medication (hormones), ingredients and the side effects

of medication. There was a perceived need for women’s clinics, where women could

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easily obtain information on menopause and CAMs, but also general practitioners

open to alternative therapies. As one women described

“…a lot of the doctors are not receptive to the combination of general

practitioner work and natural therapy because that’s been their upbringing,

that’s been their teaching…I think people in society today are looking for

alternatives because we’ve been a little bit sick of going to the doctor and

saying here’s your script see you next time and off you go” (Person 2).

Discussion

A qualitative methodology has enabled an in-depth exploration of women’s

perceptions of menopause, and in particular, their experiences of CAM use during this

transition. Women were using a variety of CAMs during menopause for two

purposes: firstly, to address their current symptoms (in particular hot flushes), and

secondly, to promote long term health and wellness. Used in combination, women

believed that regular exercise, a balanced lifestyle, healthy eating and the use of

vitamins and supplements were an effective way to control over symptoms

experienced and protect the body and internal organs. The use of CAMs as both a

treatment and prevention is also evident in the literature(14).

Threaded throughout the four main themes identified in data was empowerment.

Funnel et al (1991, p.#) describes this concept as, “Patients are empowered when they

have the knowledge, skills, attitudes and self-awareness necessary to influence their

own behaviour…to improve the quality of their lives(22). Empowerment during

menopause is not new; in focus groups with 13 women, personal control over health

and the treatments used during menopause was a fundamental priority to women (13).

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Similarly, women’s autonomy during menopause was explored in interviews with

general practitioners(23). The concept of empowerment during menopause was

illustrated by women in the current study in a number of ways including a desire for

ownership of their bodies, self management of symptoms, the use of preventative

health methods and access to reliable information and a range of therapies and

treatment options (both conventional and CAMs).

Central to women’s need for empowerment, was the need to be informed. Murtagh

(2003) describes being informed during menopause as not just receiving information,

but rather actively seeking and using a variety of information sources to make active

decisions about health care during and after menopause(23). Participants in the current

study seemed to represent a generation of information seekers, where women actively

sourced information on CAMs from a variety of tools; with the internet and friends

cited as primary sources. Through access to information, women perceived they were

able to gain a better understanding of the changing needs of their bodies, symptoms

they were experiencing, and the therapies available to them. The increase in

knowledge gained through wider access to a variety of information sources has

empowered and enabled women to become more active in their health care

decisions(24). Women linked information to personal control over menopause and

symptoms experienced, however a lack of scientific validation and information on

CAMs was not a deterrent for uptake or continuation of use. Further, women believed

that the reduction in the symptoms they experienced outweighed a lack of scientific

validation, and if more research was undertaken, positive results for CAMs would

become apparent.

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One of the findings from the focus groups was the majority of women perceived

negative relationships with their general practitioners and that this was a factor in their

decision to seek treatment outside orthodox medical services as well as not disclosing

the full range of therapies they were currently taking. In talking about their

experiences with general practitioners, women were describing the asymmetrical

power relationship between the patient and medical practitioner. Women wanted to

be heard by their doctor, to feel as though their experiences and perceptions were

important. Once the decision to use CAMs had been made, women expected their

doctor to respect their decision and work collaboratively to meet their needs. Women

felt ignored and out of control of the situation when their doctor pressed the use of

hormone therapies. The women expressed frustration over the closing down of any

opportunity for them to explore CAMs for their menopausal symptoms with their

doctor. In previous research, a perceived lack of health practitioner support alongside

previous CAM use was identified as reasons for choosing CAMs to manage

symptoms during the menopause(12, 13).

While most women had an avenue, usually through family or friends, with whom

could openly talk with, they still expressed a desire and need to talk about the changes

in their lives. The need to be heard and the need to share their experiences is further

evidence of this group of women’s desire to gain control over, and feel empowered

during their menopause experience. Roberts (2004) suggests that in social situations

with friends and family, women are vocal and expressive about their health care, but

in the presence of health practitioners become less assertive and more cooperative (24).

This was evident to an extent within the focus groups as women openly discussed

effective CAMs and swapped contact details of general practitioners open to

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alternative therapies with other women. When talking to general practitioners some

women were vocal and questioning, whereas other women felt pressured into

decisions that were not relevant for their body and instead of talking to their

practitioner, women sought alternative practitioners.

This group of women desired control over their symptoms and the changes occurring

during menopause. The need for empowerment during this transition was exemplified

by women in the way they perceived their symptoms, the types of CAMs used, the

need to find a CAM which suited the individual body’s needs, the need for

information and education and the need for supportive health professional’s who

respected their decision to use CAMs. While this study has identified and

contextualised the factors that influence women to use CAMs, it is important to

interpret the findings within the following limitations. Women were recruited through

volunteer sampling (which limits generalisability), with the final number of

participants lower than anticipated, although seven women in the study were

employed full time and women’s busy schedules may have impacted upon the low

numbers. Additionally, the sensitivity of the issue may have been underestimated.

During the focus groups, women expressed negative feelings towards symptoms and

described how menopause was not an openly discussed issue. However, from the

women who participated in the focus group, it was evident that there was a need to

talk and share experiences of menopause. While low numbers were present,

theoretical saturation was reached by the third focus group. The strengths of this study

lie in the methodological rigour (both data and research triangulation), and the

conceptual generalisability(12) of the key category of empowerment found in this study

and its affects on structuring women’s health seeking behaviour in relation to CAMS.

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There are a number of implications that can be drawn from this research. Firstly,

there is a need for information and education about menopause and the range, safety

and efficacy of CAMs. Increased education about the processes and biological

changes at menopause empowers women with the knowledge of what is happening to

their bodies and may help ease some the stresses occurring during menopause.

Additionally, there is the need for women’s groups or centres, where women can

share their menopause and treatment experiences. Secondly, there is a need for strong

participatory relationships between women and their health professionals, particularly

general practitioners. Developing such relationships will improve women’s perceived

control over their menopause experience, particularly over the types of treatments

used to address symptoms.

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Table 1 Demographics of the focus group and telephone interview sample

Variables N

Age

55 years and under

Over 55 years

10

5

Marital Status

Married/ de facto

Separated/ divorced/ widowed

Single / Never Married

8

5

2

Country of Origin

Australia

Other

11

4

Location

Urban

Rural

13

2

Education Level

Senior school

Trade, technical or diploma

University or college degree

6

5

4

Employment Status

Employed full time/ part-time

Home duties

Student

Retired

8

3

2

2

Figure 1 Factors influencing control during menopause

Empowerment during menopause

Therapy useSuit the bodies individual needs

Hormones used Range: supplements, herbs, exercise

Self managementPrevention

Cost of CAMs

Informed ChoicesKnowledge of CAMsSharing information

Education on menopause/CAMsScientific research on CAMs/

hormone therapy

Symptom experiencesIndividual experiencesAffects daily activitiesSocially debilitating

Affecting work capabilitiesCauses: menopause or ageing?

Health Practitioner SupportDr/patient relationship

Dr’s perception of CAMsPersonal experiences

Self medicatingEqual relationship desired

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