complementary and alternative medicine use for vasomotor symptoms among women who have discontinued...

Complementary and AlternativeMedicine Use for Vasomotor SymptomsAmong Women Who HaveDiscontinued Hormone TherapyElizabeth M. Kupferer, Sharon L. Dormire, and Heather Becker

CorrespondenceElizabeth M. Kupferer, PhD,WHNP-BC, 2703 GrandOaks Loop, Cedar Park, [email protected]

Keywordscomplementary and alterna-tive medicine systemsmenopausevasomotor symptoms

ABSTRACT

Objectives: To explore the use and perceived usefulness of complementary and alternative medicine therapies

and nonhormonal conventional medicine alternatives to treat vasomotor symptoms occurring after withdrawal from

hormone therapy.

Design: Retrospective, single cross sectional descriptive study.

Setting: Study volunteers were recruited via a direct mailed questionnaire sent to a sample of women throughout the

United States. Additional respondents were recruited through flyers and postcards advertising the study placed with

permission at several health care provider offices and other locations.

Participants: A sample of 563 menopausal women who had discontinued the use of hormone therapy completed a

questionnaire describing their experiences with the use of complementary and alternative medicine.

Main Outcome Measures: Responses to an investigator developed survey.

Results: Nearly half of the women surveyed used complementary and alternative medicine. The most common

choices of complementary and alternative medicine were (a) multivitamins and calcium, (b) black cohosh, (c) soy

supplements and food, (d) antidepressants, (e) meditation and relaxation, (f) evening primrose oil, (g) antihyperten-

sives, and (h) homeopathy. Of the alternative therapies that were used by at least 5% of the sample, antidepressants

were perceived as the most useful.

Conclusions: With the increased adoption of complementary and alternative medicine, it is important for health care

providers to be familiar with the various methods so they are comfortable discussing the benefits and risks with their

patients to assist them in making informed decisions.

JOGNN, 38, 50-59; 2009. DOI: 10.1111/j.1552-6909.2008.00305.x

Accepted September 2008

Management of menopause has changed sig-

ni¢cantly in the past 5 years as a result of

¢ndings in key clinical trials on the e¡ects of hor-

mone therapy (HT) (Grady et al., 2002; Hulley et al.,

1998; Rossouw et al., 2002). Historically HT has

been widely used to manage discomforts related

to menopause as well as to prevent illness associ-

ated with midlife. However, more recent studies

provided evidence to indicate that risks of exoge-

nous hormones may outweigh bene¢ts in some

situations. Findings from these pivotal clinical trials

have shifted the perspective of menopause from a

natural life event experienced uniquely by each woman

to a condition that requires medical management.

Current clinical guidelines recommend that estrogens

should only be prescribed for the treatment of meno-

pausal vasomotor and urogenital symptoms at the

lowest possible dose for the shortest time possible (Na-

tional Institute of Health, 2005; U.S. Food and Drug

Administration, 2004). As a result, women and clinicians

have turned to a more individualized treatment

approach to HT and away from routine use of HT for

varied health conditions.

In response to these historical events/pivotal clini-

cal trials, clinical practice patterns now re£ect a

more judicious use of hormones at menopause

as well as a noted use of lower doses in current

prescriptions for HT (Barber, Margolis, Luepker, &

Arnett, 2004; Bestul, McCollum, Hansen, & Saseen,

Elizabeth M. Kupferer,PhD, WHNP-BC, is amedical science liaison atDuramed Research, Inc.,Medical Affairs, BalaCynwyd, PA.

Sharon L. Dormire, PhD,RN, is an assistant professorat The University of Texasat Austin, School ofNursing, Austin, TX.

Heather Becker, PhD, is aResearch Scientist at TheUniversity of Texas atAustin, School of Nursing,Austin, TX.

JOGNN R E S E A R C H

50 & 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org

i:/BWUS/jogn/305/[email protected]

2004; Blˇmel et al., 2004; Buist et al., 2004; Hersh,

Stefanick, & Sta¡ord, 2004; Hillman, Zuckerman, &

Lee, 2004; Wysowski & Governale, 2005). There is

also documentation of a growing trend toward

shorter duration of HTuse; however, there is little in-

formation about how this trend will a¡ect women’s

menopausal experiences. Given that HT was once

considered very bene¢cial for women and that wo-

men were likely continue HT for most of their life

postmenopause, information is lacking about wo-

men’s personal experiences related to withdrawal

of HT. The purpose of this study was to assess the

use of complementary and alternative medicine

(CAM) therapies and nonhormonal conventional

medicine alternatives that women have undertaken

to treat their vasomotor symptoms after withdraw-

ing from HT. Women’s perception of the e⁄cacy of

their chosen CAM therapy was also explored.

The National Center for Complementary and Alter-

native Medicine (NCCAM) de¢nes CAM as a ‘‘group

of diverse medical and health care systems, prac-

tices, and products that are not presently

considered to be part of conventional medicine’’

(NCCAM, 2005, p. 1). Nonhormonal methods such

as antihypertensives, anticonvulsants, and antide-

pressants are not usually considered CAM but

were included in this analysis because they are a

commonly used alternative to the traditional HT.

BackgroundAlthough, the use of HT has received much atten-

tion, estimates have shown that only approximately

15% (Amato, Christophe, & Mellon, 2002) to 38%

(Buist et al., 2004) of menopausal women actually

use HT. Of those women who do begin HT, surveys

have shown that nearly 50% of them discontinue

use within 1 year (Amato et al.). Some of the most

common reasons women avoid or discontinue HT

are fear of cancer and side e¡ects such as bleed-

ing, the return of menses, breast tenderness,

bloating, and headaches (Amato et al.). These fears

often lead women to look for alternative ways to

control menopausal symptoms and prevent chronic

disease, such as CAM treatments to relieve vaso-

motor symptoms (e.g., hot £ash, hot £ushes, night

sweats) and chronic illness associated with the on-

set of menopause and normal aging.

Kaufert, Boggs, Ettinger, Woods, and Utian (1998)

found that nearly 80% of the menopausal women

surveyed at a health conference used CAM thera-

pies to treat menopausal symptoms. In a second-

ary analysis of the health conference data, Kam,

Dennehy, and Tsourounis (2002) found that the

majority of health conference attendees used

herbal treatments for menopausal symptoms (e.g.,

soy, ginkgo biloba, black cohosh). An additional

¢nding noted that only 54% of these women ever

reported their use of herbals or supplements to their

clinicians.

In a telephone survey of over 800 women age 44 to

65, Newton, Buist, Keenan, Anderson, and LaCroix

(2002) also found that use of CAM for menopausal

symptoms is common. Seventy-six percent of the

women surveyed reported using some type of

CAM. Twenty-two percent of the women used CAM

speci¢cally to treat symptoms of menopause, al-

though women who were current users of HT were

less likely to use CAM. The most common types of

CAM were stress reduction, herbals, homeopathic

or naturalistic remedies, or soy supplementation. A

limitation of the study, however, was that the women

surveyed were predominantly White and well edu-

cated; the results were not representative of the

population of menopausal women.

Factor-Litvak, Cushman, Kronenberg, Wade, and

Kalmuss (2001) conducted a pilot survey of a system-

atically diverse group of 300 women (100 White,

100 African American, and 100 Hispanic) in New

York City. The researchers used a telephone inter-

view methodology to examine demographic

information, use of CAM, and perceived e⁄cacy of

CAM. Over 50% of the women used some type of

CAM therapy, and 40% had visited a CAM provider.

Interestingly, however, few racial/ethnic di¡erences

were found regarding CAM use.

Studies of Japanese and Chinese women who con-

sume a soy-rich diet have shown that their risk of

breast cancer, heart disease, and experience of

menopause-related vasomotor symptoms were less

than the risks for American women (Nagata, Takat-

suka, Kawakami, & Shimizu, 2001; Nagata et al.,

1999). Given the growing awareness of the cultural

disparity of the menopausal experience, research-

ers postulated that the typical Japanese diet high

in soy might play a part in this disparity (Adlecreutz,

H�m�l�inen, Gorbach, & Golden,1992).

Bair et al. (2002, 2005) examined the use of CAM

amongmidlife women who participated in the Study

of Women’s Health Across the Nation (SWAN). This

study is a10-year cohort study of over 3,300 African

American, Hispanic, Japanese, Chinese, and White

women. Nearly half of the SWAN study participants

used some type of CAM during the menopause

transition. Consistent with other surveys, those

who used CAM were more likely to be older,

JOGNN 2009; Vol. 38, Issue 1 51

Kupferer, E. M., Dormire, S. L., and Becker, H. R E S E A R C H

married, report a higher socioeconomic status, and

lower health status than nonusers. There were also

no racial and ethnic di¡erences regarding CAM use

in the SWAN study.This was a consistent ¢nding in a

subsequent study report on the types of CAM use

and ethnicity (Gold et al., 2007). The most recent re-

port on the SWAN study (Bair et al., 2008) noted

that approximately 80% of all the study participants

had used some form of CAM during the reported

study period (6 years).White and Japanese women

had the highest rates of use (60%), followed by

Chinese (46%), African American (40%), and

Hispanic (20%) women. The authors noted that

use of CAM did not appear to be associated with

change in menopause transition status.

Given the changes in medical perspectives on

menopause management and the resultant cha-

nges in HT use, there is an urgent need to under-

stand the symptom experiences of women who

discontinue HT. There is little information available

regarding the symptom experiences of women as

they withdraw from HT. As the previous studies have

illustrated, research indicates that women are using

CAM therapies to manage both their symptoms and

improve their health. It is not known what therapies

they are using or how e¡ective the therapies are

perceived to be. Findings from this study will provide

information clinicians can use to counsel their

menopausal patients.

MethodsDesign and ParticipantsA retrospective, cross sectional descriptive design

was used to explore the use of alternative therapies

used by menopausal women who had discontinued

the use of HT.

IRB approval was obtained at the host University

before initiation of data collection. A convenience

nonprobablity sample of women was recruited be-

tween September 1, 2006 and December 31, 2006.

Eligible participants were menopausal women over

the age of 40 living in the United States, previously

prescribed and taking HT but having discontinued

or taken a break from prescribed HT. Inclusion

criteria also included the ability to read, write,

and speak English and willingness to complete the

survey. Participants were not eligible if they were

not menopausal, never used, or inconsistently

used prescribed HT for less than 3 con-

secutive months before discontinuation. Women

who became menopausal as a result of cancer

treatments were not included in the ¢nal analysis

because it is known that cancer itself can also be

a cause of hot £ashes (Spero¡ & Fritz, 2005; Wilkin,

1981).

A limitation of published menopause and HTstudies

is the lack of sample diversity. Women who present

to their health care providers for treatment of meno-

pause symptoms represent only a limited number of

all who experience menopause. Many women,

especially those who may not experience di⁄cul-

ties or do not embrace the biomedical paradigm

of menopause, may never seek help from a

health care provider. Their voices are lost in studies

that recruit participants only from health care

provider clinics. Therefore, varied recruitment

strategies were used in this study to promote sam-

ple diversity.

The primary source of participants was a random

sample from a mailing list. The mailing list was pur-

chased from a general health care marketing ¢rm

and was derived from a selection of women

throughout the United States who had ¢lled out a

general information survey for the list owner, a

credit bureau. The general information survey was

pen and paper, non-Internet based, and completed

within the 6 months before purchase of the list for

the current study in the fall of 2006. The survey was

not speci¢c to menopause; it gathered general

information such as survey respondent’s demo-

graphics, purchasing preferences, and health

interests.

The available demographics of the mailing list re-

vealed that the majority of the women (61%) were

married, were between the ages of 45 and 64 years

of age (83%), and had at least a high school edu-

cation (61%). The mailing list sample was fairly well

balanced for reported income with the majority of

the women (57%) reporting an income falling be-

tween $30,000 and $99,000. This recruitment

technique was highly successful in including lower

income women. Thirty percent of the mailing list

sample reported an income of less than $30,000

per year. Such economic diversity in menopause re-

search is rare. Race data were not collected by the

list owner, but ethnicity data entered by at least 75%

of the sample revealed only 3% Hispanic origin.The

purchased list was narrowed to include only women

who were over the age of 40 and who had noted on

the questionnaire that they had an interest in meno-

pause. Additional participants were recruited

Research indicates that women use complementaryalternative medicine therapies to manage both their

menopausal symptoms and their health.

52 JOGNN, 38, 50-59; 2009. DOI: 10.1111/j.1552-6909.2008.00305.x http://jognn.awhonn.org

R E S E A R C H Complimentary and Alternative Medicine and Vasomotor Symptoms

through £yers and postcards placed with permis-

sion at several health care provider o⁄ces, a

weight loss program, and a grocery store in Central

Texas. Business cards with the study overview and

contact information were also distributed to groups

of menopausal women.

Questionnaire DevelopmentThe CAM and Menopause Vasomotor Symptoms

Questionnaire (CAMVMS) was developed by

the investigator through an extensive review of

the literature on the etiology, cultural in£uences,

and contextual factors associated with the

experience of hot £ashes in women. The CAMVMS

included (a) demographic information, (b) meno-

pause history, (c) in£uences related to HT

discontinuation, (d) discontinuation vasomotor ex-

periences, (e) CAM use and perception, and a (f)

health behavior history.

The CAM use portion of the questionnaire was

guided by the ¢ve categories de¢ned by the

NCCAM. The ¢rst category, alternative medicine

systems, included modalities such as homeopathic

medicine and traditional Chinese medicine (TCM).

The second category encompassed mind-body in-

terventions such as meditation, prayer, or therapies

that use creative outlets such as art, music, or

dance. The third category included biologically

based ‘‘natural’’ therapies such as herbs, foods,

and vitamins. The fourth category included ma-

nipulative and body-based methods such as chiro-

practics or massage. The last category, energy

therapies, included bio¢eld therapies such as Reiki

and Therapeutic Touch or bio-electromagnetic-

based therapies using electromagnetic ¢elds

(NCCAM, 2005). Driven by the review of the literature

for treatment of vasomotor symptoms, only the cat-

egories of alternative medicine systems, mind-body

interventions, and biologically based therapies

were included in the questionnaire. Also included

in this section were conventional medicine nonhor-

monal alternatives to HTsuch as antihypertensives,

antiepileptics, and antidepressants.

Once the questionnaire was constructed, a multi-

disciplinary group was asked to review the

document and provide input. This expert group

consisted of two physicians (MD), two registered

nurses (RN), and ¢ve advanced nurse practitioners

(ANP) whose daily clinical practices involved the

care of menopausal women.The group provided in-

put on the general content and face validity of the

questionnaire. The experts indicated that the ques-

tionnaire was complete and did not recommendany

additional items.

The questionnaire was piloted with a small group of

menopausal woman. The intent of the pilot study

was to test the instrument for ease of completion,

readability, and understandability. The question-

naire was created as a Microsoft Word document

that was printed out as a hard copy. The question-

naire was also designed to be used via e-mail in a

protected Word format with check boxes, drop

down selections, and text entry spaces. Some of

the participants requested and completed an

e-mail version of the questionnaire without prob-

lems. There were participants who requested the

e-mail version but had di⁄culty opening, saving,

and/or returning the questionnaire via e-mail. The

problems encountered were related to type of

e-mail server (America Online vs. Microsoft Out-

look) and a lack of computer literacy. Because of

the di⁄culty for some participants in completing

an electronic version of the questionnaire, it was

converted into a hard copy version for the larger

study.

The ¢nal section of the pilot questionnaire con-

tained speci¢c questions about the questionnaire’s

understandability and readability: (a) How long did

it take you to complete the questionnaire, (b) Are

any of the questions hard to understand or unclear,

(c) Are there any words contained within the ques-

tionnaire that are di⁄cult to understand, (d) Are

there any experiences you had that are not shown

on the questionnaire, and (e) Are there any items

that you think are not necessary or should be

removed from the questionnaire?

The participants indicated that it took an average of

11 minutes to complete the questionnaire with a

range of 5 to 15 minutes. Although some partici-

pants did not understand the terms aryuvedic

medicine and homeopathy, the terms were not

changed. It was thought that if the participants were

unfamiliar with the term then they had not likely

utilized this alternative medicine system.

ProcedureAll women who volunteered for this study received

the questionnaire via postal mail. The questionnaire

was sent in a packet that contained a cover letter

describing the study and providing contact infor-

mation, the questionnaire, and a preaddressed

stamped return envelope in which to return the

questionnaire.

Once the completed questionnaires were received

they were opened, the envelope discarded, and

the questionnaire itself was labeled with an ID num-



ber by the primary investigator. The data from

the questionnaire were entered into a database.

After data entry, the database was reviewed for ac-

curacy by comparing it against the raw data and

running frequencies on each variable to assess for

any inaccuracies in data entry (outliers, missing

values, etc.).

Two thousand, ¢ve hundred and ¢fty questionnaires

were distributed to women throughout the United

States. Of those questionnaires, 2,250 were se-

lected randomly from the purchased mailing list of

4,350 using an every other person method of selec-

tion. The remaining 300 questionnaires were either

distributed by health care colleagues or requested

by the participants. Twelve of the 2,550 question-

naires mailed were returned as undeliverable. From

all sources, a total of 628 completed questionnaires

were returned; 563 of the returned questionnaires

were considered usable. Fifty-one questionnaires

were not usable because the participant either

never started HT (n 5 35), never stopped (n 517),

or the questionnaire had signi¢cant missing data

(n 513).

ResultsSampleWhile this was not a population-based survey, ques-

tionnaires were received from women in every state

in the United States except Hawaii. Frequency distri-

butions revealed a fairly evenly distributed sample

from each region of the United States, with 23.8%

from the Northeast, 26.7% the Midwest, 31.6% the

South, and 17.9% from theWest (Table 1).

The participants were primarily White (89.3%), with

a mean age of 58 years (range from 40 to 82 years).

Participants who provided their weight and height

had an average BMI of 29.5.

The majority of the participants (61.5%) were mar-

ried, followed by 16.2% divorced, 8.3% widowed,

7.5% single, 3.9% partnered, and 2.7% separated.

Of the participants who reported their educational

status nearly 68% held only a high school diploma

or less. Eight percent of those womenhad a General

Equivalency Diploma (GED) or did not complete

high school. Approximately 23% of the women

completed an undergraduate degree and 9.2%

had completed a graduate degree.

The low-income cut point was chosen to re£ect the

U.S. Department of Health and Human Services

(DHHS) low-income description of an individual

whose family’s taxable income for the preceding

year did not exceed 150% of the poverty level

amount. The 2006 poverty level was set at $20,000

for a family of four (DHHS, 2006). Using a family unit

of four as the U.S. average, the low-income cut point

was women who reported a total family income of

Table 1: Sample Demographics (N 5 563)

Characteristic n (%)

Current agea

40-50 years old 59 (10.6)

51-60 years old 298 (53.8)

61 years old or over 197 (35.6)

Years postmenopauseb

1 or less 7 (1.3)

More than 1-5 77 (14.1)

More than 5-10 145 (26.5)

More than 10-20 216 (39.4)

More than 20 103 (18.8)

Ethnicity/race

Black 44 (7.8)

White 503 (89.3)

Other 16 (2.8)

Asian 2 (0.4)

Hispanic 7 (1.2)

Native American 6 (1.1)

Mixed 1 (0.2)

BMI rangesc

Underweight (o18.5) 16 (3.1)

Normal range (18.5-24.9) 138 (27.1)

Overweight (25-29.9) 152 (29.8)

Obese (430) 204 (40.0)

Regiond

Northeast 132 (23.8)

Midwest 148 (26.7)

South 175 (31.6)

West 99 (17.9)

Highest level of educatione

HS Diploma (or less) 380 (67.9)

Undergraduate degree 128 (22.9)

Graduate degree 52 (9.2)



less that $30,000 which is 150% of the poverty level

for a family of four. Household income analysis

revealed that 40.7% of the participants were con-

sidered to be low income with a total household

income of $30,000 or less (Table 1).

The mean age for the onset of menopause of the

participants was 45 years of age. The mean years

postmenopause for the participants was approxi-

mately 14 years with a range from less than a

year to 45 years. The majority of the participants

(63.6%) experienced natural menopause.

Complementary and AlternativeMedicine Therapies UsedOf the 563 participants, 45% reported the use of

CAM to treat vasomotor symptoms. Women who

were between the ages of 40 to 50 and fewer than

5 years postmenopause onset were more likely to

use CAM. Alternative methods used were (a) multi-

vitamins and calcium (27%), (b) black cohosh

(21%), (c) soy supplements and food (19%), (d) an-

tidepressants (14%), (e) meditation and relaxation

(12%), (f) evening primrose oil (8%), (g) blood pres-

sure medications (6%), (h) homeopathy (6%), (i)

red clover (3%), (j) antiseizure medications (4%),

(k) bio-identical hormones (3%), (l) TCM (1%), (m)

acupuncture (1%), and (n) aryuvedic medicine

(0.2%). In a designated ‘‘other’’ category, partici-

pants reported the use of Estroven, £axseed or

progesterone cream, New Phase, St. Johnswort,

Bellergal, colchicines, echinacea, Estro-life, GNC

Menopause, and Phyto Prolief Arborne.

Perceived Usefulness of CAM TherapiesWomen were asked to comment with regard to their

vasomotor symptoms on whether the method

helped, did not help, or if they were unsure if it

helped. Given the relatively small numbers of

women using some of the methods, assessment of

what was the most e⁄cacious method is not feasi-

ble.There were eight alternative therapies that were

used by at least 30 women to treat vasomotor symp-

toms. These were multivitamins and calcium, black

cohosh, soy supplements and food, antidepres-

sants, meditation and relaxation, evening primrose

oil, homeopathy, and blood pressure medications.

The participants perceived antidepressants as

one of the most e⁄cacious method followed by

homeopathy, meditation and relaxation, evening

primrose, antihypertensives, black cohosh, soy

products, and multivitamins and calcium (Figure 1).

Regarding methods less frequently identi¢ed,

21 women used antiseizure medications, but only

4 (19.1%) felt it helped. Red clover was used by 19

women, and 8 (50%) felt it helped. Bio-identical

hormones were used by 16 women, and 7 (43.7%)

felt they helped. Seven women chose TCM, and

4 (57.1%) felt it helped their symptoms. Six women

tried acupuncture, and 3 (50%) of them felt it

helped their symptoms. One woman reported using

aryuvedic medicine and reported that it helped her

symptoms.

Correlates of CAM UseThe relationship between CAM use and the follow-

ing selected demographic factors was also

explored: educational level, family income, age,

years postmenopause, type of menopause (surgi-

cal vs. natural). For these analyses, the authors

chose the eight CAMS used by at least 5% of the

sample: Black cohosh, multivitamins/calcium, soy,

antidepressants, evening primrose oil, meditation/

relaxation, blood pressure medication, and home-

opathy. Relationships with use of any CAM were

also explored. Because most demographic vari-

Table 1. Continued

Characteristic n (%)

Family incomef

o$30,000 (low income) 200 (40.7)

$30,001-$60,000 (middle income) 179 (36.5)

$60,001-$90,000 (middle/upper) 71 (14.5)

4$90,001 (high income) 41 (8.4)

Type of menopauseg

Natural 358 (63.9)

Surgical 193 (34.5)

Medically induced 9 (1.6)

Note.aMissing data for current age for 9 participants, posted per-

centages represent valid responses only.bMissing data for years postmenopause for 15 participants,

posted percentages represent valid responses only.cMissing data for BMI for 53 participants, posted percentages

represent valid responses only.dMissing data for geographical location for 5 participants,

posted percentages represent valid responses only.eMissing data for educational level on 3 participants, percent-

ages represent valid responses only.fMissing data for income for 72 participants, percentages

represent valid responses only.gMissing data on type of menopause for 3 participants,

percentages represent valid responses only.

Forty-five percent of respondents reported the use ofcomplementary alternative medicine to treat vasomotor

symptoms.



ables were measured at the ordinal not the interval

level, the nonparametric Spearman’s correlation

was used for these analyses.

As shown in Table 2, only age was signi¢cantly re-

lated to general CAM use. Older women were less

likely to use CAM (r 5� .17, po.01). Younger wo-

men and those who experienced menopause most

recently were more likely to use all CAM therapies

except blood pressure medication. The pattern of

CAM use is further broken down by age categories

inTable 3.Younger women (ages 41^50) were more

likely to use evening primrose oil, meditation/relax-

ation, and antidepressants than older women.

Women ages 51 to 60 more frequently used soy

products than did women of other ages.

Soy use was more highly related to the demo-

graphic characteristics examined here, but none of

these characteristics accounted for more than 2%

of the variance in predicting CAM use. Most other

correlation coe⁄cients between types of CAMused

and background characteristics were not statisti-

cally signi¢cant.

There were statistically signi¢cant correlations

among use of most CAM therapies, although only

7 of the 28 correlations resulted in moderate e¡ect

sizes. The strongest correlation was between multi-

vitamins/calcium and soy supplements (.52). In

other words, women who used one CAM were more

likely to use other CAM options.

DiscussionPrior studies have shown that 50% to 80% of mid-

life women have used some type of CAM. (Bair

et al., 2002, 2005, 2008; Factor-Litvak et al., 2001;

Kaufert et al., 1998; Kronenberg, Cushman, Wade,

Kalmuss, & Chao, 2006; Kronenberg & Fugh-

Berman, 2002). These studies illustrated that many

di¡erent cultural groups of women adopt CAM, yet

women of lower socioeconomic status are less

likely to use CAM. The 45% rate of CAM use re-

ported in this study is slightly lower than reported

0%10%20%30%40%50%60%

Antide

pres

sant

s (n =

80)

Homeo

path

y (n =

31)

Med

itatio

n an

d re

laxat

ion (n

= 6

5)

Evenin

g pr

imro

se o

il (n =

43)

Antihy

perte

nsive

s (n =

34)

Black c

ohos

h (n

= 1

16)

Soy (n

= 1

06)

Mult

ivita

mins

(n =

148

)

Figure 1. Perceived usefulness of complementary

and alternative medicine therapies used. Percentages

reflect the percentage of women indicating each

method was useful in treating their menopausal

vasomotor symptoms. Number in parentheses

indicates number of women using the method.

Table 2: Relationship Between CAM Use and Selected Background Characteristics

Age

Years

Postmenopause

Family

Income Education

Type of

Menopause

CAM use � .17�� .09

�.03 � .01 � .04

Multivitamins/calcium � .15�� .09

�.01 � .01 � .04

Black cohosh � .13�� .13

��.05 � .01 � .03

Soy � .04 � .11��

.13��

.09�

.07

Antidepressants � .19�� .11

� � .05 � .05 � .04

Meditation/relaxation � .19�� .05 .002 .04 � .04

Evening primrose oil � .15�� .09

�.03 .001 � .03

Blood pressure medications .003 .08 � .09� � .03 � .15

��

Homeopathy � .04 � .01 .02 .04 � .002

Note. CAM 5 complementary and alternative medicine.�po.05.

��po.01.

The most common choices of complementary alternativemedicine modalities were botanicals such as multivitamins

and calcium, black cohosh and soy supplements and/orsoy foods.



in previous studies. Discrepancies in ¢ndings may

be due to di¡erences in samples or timing of stud-

ies. In addition, earlier studies may not have asked

respondents to report only CAM used speci¢cally

to treat vasomotor symptoms, as was done in the

current study. Eight alternative therapies were used

by at least 30 women (multivitamins and calcium,

black cohosh, soy supplements and food, antide-

pressants, meditation and relaxation, evening

primrose oil, homeopathy, and blood pressure

medications). Given the vast number of alternatives

that can be used and the small numbers using each

method, it was not possible to discern the most

e¡ective methods.

While some statistically signi¢cant relationships

were observed between demographic characteris-

tics and CAM use, it is important to recognize that

the correlations are modest (below .20).The strong-

est relationships tended to be with age, suggesting

that younger women are more likely to try CAM,

although women in the 51 to 60 years age group

more frequently used soy products. Because there

were only modest relationships between demo-

graphic variables and CAM, other variables such

as perceived severity of menopausal vasomotor

symptoms or knowledge of CAM may account for

CAM use.

The most common choices of CAM modalities were

botanicals such as multivitamins and calcium,

black cohosh and soy supplements and/or soy

foods. Other more commonly chosen CAM meth-

ods included meditation and relaxation. Although

early research is emerging on the usefulness and

safety of alternative medical systems such as home-

opathy, acupuncture, and TCM, very few women

listed these as an option they had used. There is a

need for community based awareness programs to

educate women about menopause, HT, and the

available alternatives for treatment of vasomotor

symptoms. Because older women in this sample

were less likely to use CAM, educational e¡orts

should target them as well.

Many women reported the use of antidepressants

speci¢cally taken to relieve vasomotor symptoms.

In fact, womenwho used antidepressants perceived

them to be one of the most e⁄cacious methods.

Vasomotor symptoms are far more complex than

previously thought and the underlyingmechanisms

behind them are poorly understood. Research has

shown that serotonin (5-HT) levels are decreased

in natural or surgically menopausal women. When

estrogen is given, these levels have been shown

to return to normal (Gonzales & Carillo, 1993). Low

serum estrogen levels have been associated with

high concentrations of the 5-HT2A receptor subtype

on platelets, thus it may play a role in the occur-

rence of hot £ushes. Estrogen withdrawal

decreases 5-HT in the blood stream that increases

5-HT2A receptors in the hypothalamus. An increase

in 5-HT2A receptors results in a change in the the-

rmoregulation set point causing a need for heat

dissipation as seen in hot £ashes. Blocking the

5-HT2A receptors could result in reducing hot

£ashes. Treatment with a selective serotonin

reuptake inhibitor activates the 5-HT2C receptor,

which in turn inhibits the 5-HT2A receptors (Berend-

sen, 2000).

Implications for Health Care ProvidersThese study ¢ndings demonstrate that many wo-

men do try some type of CAM therapy to treat their

vasomotor symptoms after discontinuation of HT. As

more women seekout alternatives for the relief of va-

somotor symptoms, there is an increased demand

by women and clinicians alike for clinical informa-

tion about the safety and e⁄cacy of these

alternatives. In addition many women may not re-

port the use of alternatives to their health care

providers, so it is important for the provider to spe-

ci¢cally ask about use of alternatives so that any

drug/drug interactions can be avoided and the

safety of chosen methods are discussed.

Implications for Future ResearchMany of these emerging CAM therapies such as

over-the-counter botanicals, acupuncture, medita-

tion, and yoga classes can be costly and may not

Table 3: Frequency of CAM Use by Age

CAM Type

40-50

Years

(n 5 59)

51-60

Years

(n 5 298)

Over

60 Years

(n 5197)

Black cohosh 15 (25%) 72 (24%) 27 (14%)

Evening primrose oil 8 (14%) 28 (9%) 7 (4%)

Soy supplements/food 9 (15%) 66 (22%) 32 (16%)

Multivitamins/calcium 20 (34%) 93 (31%) 35 (18%)

Meditation/relaxation 13 (22%) 43 (14%) 9 (5%)

Homeopathy 5 (9%) 15 (5%) 10 (5%)

Antidepressants 19 (32%) 46 (15%) 15 (8%)

Blood pressure

medication

3 (5%) 20 (7%) 11 (6%)

Note. CAM 5 complementary and alternative medicine.

Percentages represent percent of women in each age category

using that CAM.



be available in some areas or to all women. This

suggests that some women do not use CAM be-

cause it is not accessible to them or they cannot

a¡ord it. Yet study ¢ndings suggest that in general,

CAMuse is not related to family income level. Family

income alone may not provide information on dis-

posable income or prescription drug coverage that

would make prescription alternatives, such as anti-

depressants, a¡ordable. Future studies should

examine the relationship between CAM and ¢nan-

cial resources in greater depth.

In this study, women were asked to indicate if each

method helped, did not help, or they were unsure if

it relieved their vasomotor symptoms. The term

‘‘helped’’ as used in this study may have referred to

a wide range of responses ranging from some relief

to eliminating the symptoms all together. Future

studies should use a more re¢ned measure that en-

ables women to indicate how the various CAM truly

impact symptoms.

This sample was predominantly White, non-

Hispanic, therefore a di¡erence in CAM use by eth-

nicity/race was not analyzed. Future research

should investigate CAMuse in minority populations.

In addition, an inclusion criterion for this study was

that women had discontinued the use of HT; wo-

men who never used HT were excluded. Future

studies should examine CAM use and perceptions

of e¡ectiveness among women who have never

sought medical management for vasomotor symp-

toms.

ConclusionsThis study contributes to the literature on HT dis-

continuation experiences of menopausal women.

A strength of this study was that a group of meno-

pausal women with a lower educational and

income status were recruited. The majority of stud-

ies of menopause and HT have been conducted

with middle-class women.The study ¢ndings reveal

that many menopausal women who discontinue HT

experience vasomotor symptoms after discontinua-

tion. These ¢ndings are consistent with other

related studies (Grady et al., 2002; Ockene et al.,

2005). This study also shows over a third of the wo-

men used some type of alternative medical or CAM

therapy to treat their symptoms, and a range of

CAM modalities is being used by women of various

socioeconomic levels.

This study provides a glimpse into what types of

CAM women accept, use and perceive as helpful.

In a 2004 Position Statement on the treatment

of menopause related vasomotor symptoms, the

North American Menopause Society (NAMS) rec-

ommended that for women who are experiencing

only mild vasomotor symptoms, CAM methods

(e.g., soy foods and iso£avone, black cohosh, or vi-

tamin E) may be used even though clinical trial

results are insu⁄cient to either support or refute

e⁄cacy. The statement indicates that at this time

no serious side e¡ects have been associated with

short-term use of these therapies (NAMS, 2004).

Given these recommendations and women’s con-

cerns about HT, nurses should anticipate an

increase in both questions regarding CAM e¡ec-

tiveness and use. The evidence in this study

indicates that women are ¢nding their way to CAM

modalities for relief of menopausal symptoms.

Therefore further studies are needed to delineate

recommendations for a variety of CAM strategies

as well as their safety and e⁄cacy.

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