Volume 22, Issue 1, February 2014, Pages 94–98
The use of complementary and alternative medicine by women transitioning through menopause in Germany: Results of a survey of women aged 45–60 years
Summary
Objectives
To
describe prevalence rates of complementary and alternative medicine
therapies (CAM) for the relief of menopausal complaints among German
women. Furthermore, to investigate the perceived effectiveness of these
therapies.
Design
A self-administered questionnaire was sent to 9785 randomly selected women in Germany aged between 45 and 60 years.
Results
A total of 1893 (19.3%) questionnaires have been sent back. The mean age of all participants was 52.6 ± 4.3 years. 81% (n = 1517)
of the responding women stated that they had experienced menopausal
complaints at least once. Symptoms ranged from vasomotor symptoms,
including hot flushes and night sweats, in 71.2% of cases, to bladder
problems in 42.7%. The average symptom score (MRS II total score, range
1–44) among the respondents was 12.76 ± 9.6. More than half (56%; n = 1049/1872)
of the responding women had used some form of therapy to alleviate
their symptoms at least once. The majority of women undertaking a
therapy (64.8%; n = 679/1049) had used only CAM interventions (either one or more type of CAM), 14.2% (n = 149) had used hormone replacement therapy (HRT) only, while 21.1% (n = 221/1049)
had tried both CAM and HRT. Popular CAM interventions by the
respondents were an alteration of lifestyle (28.7%), St. John's wort
(18.3%) and homoeopathy (14.9%). An alteration in lifestyle was rated as
the most effective CAM treatment with 84.9% (n = 457). Other treatments like hormone yoga (79.2%; n = 42), homoeopathy (73.7%; n = 205) and TCM (59.1%; n = 94) were also perceived to be effective. Phytoestrogens were rated as the most ineffective (45.5%; n = 50).
Conclusion
CAM interventions to alleviate menopausal complaints are popular among German women, with 48.2% (n = 900/1872)
of respondents reporting having used CAM either alone or in combination
with HRT. However, the users rated the effects of CAM differently, with
some reporting CAM to be highly effective, while others indicate lower
effectiveness. Nevertheless, women with a significantly higher symptom
scoring tend to use both CAM and a conventional therapy (HRT).
Keywords
- Conventional and alternative medicine;
- Survey;
- German women;
- Hormone replacement therapy;
- Efficacy;
- Menopause
Introduction
Menopause
is characterised by changing levels of oestrogen and progesterone due
to the declining function of the ovaries. Oestrogen deficiency often
leads to the evolution of menopausal complaints, including hot flushes,
vaginal dryness, night sweats and sleep disturbance1 and 2.
For decades, Hormone Replacement Therapy (HRT) has been the most
effective treatment prescribed for these symptoms. However, the
publication of results from prospective studies, including Women's
health Initiative (WHI) and HERS, resulted in a controversial discussion
regarding the safety of HRT, particularly referring to breast cancer
and cardiovascular effects. These findings caused a dramatic decline in
the use of HRT in elderly postmenopausal women, although most of the
disadvantages were not durable due to statistical reasons3, 4 and 5.
Consequently, the interest in ‘Complementary and Alternative Medicine’
(CAM) including St. John's wort, black cohosh, homoeopathy etc. has
increased5.
Several studies have examined the prevalence of CAM among menopausal
women and have reported the application of CAM among more than one third
of women1, 6 and 7.
However, the efficacy of most of the treatments has not been evaluated
in placebo-controlled randomised trials. Accordingly, the effectiveness
of some CAM products remains questionable1, 8, 9 and 10.
Thus,
the aims of the present study were to determine the prevalence of CAM
and the perceived effectiveness in symptom management among German women
aged between 45 and 60 years. We sought to detect the most commonly
used CAM treatments and perceived effectiveness to conventional
treatments like HRT. Furthermore, we aim to examine the associations
between severity of symptoms and type of therapy use.
Methods
A
self-created, anonymous questionnaire was sent to 9785 women in Germany
aged between 45 and 60 years. The addresses were obtained from the
“Schober Group” address broker. Their system contained a total quantity
of 11,619,220 addresses of women in this age group, so a randomised
selection was extracted using every 162nd address. As an incentive for a
quick reply, we distributed 20 gift-coupons among the first 100
respondents and an additional 50 gift-coupons among all respondents. The
questionnaire was sent via mail at the end of December 2011, asking the
women to return the questionnaire in an addressed pre-stamped envelope
by January 10, 2012 at the latest. The 12-item questionnaire began with
information about age, educational status and area of residence.
Furthermore, we asked if the women had ever experienced menopausal
symptoms. To assess these menopausal symptoms and their severity, we
used the Menopause Rating Scale II (MRS II). The MRS II consists of a
list of 11 symptoms, which are evaluated on a scale from 0 to 4 points
(0 points = no complaints; 4 points = very severe complaints). The
values for the 11 items were added for the total MRS score (range 1–44).
Furthermore, women were asked about their use of HRT and CAM products,
as well as the perceived effectiveness of each therapy. We defined ‘CAM
only users’ as women who used at least one CAM product (phytoestrogens, St. John's wort, chast tree, acupuncture, traditional Chinese medicine (TCM), hormone-yoga, alteration of lifestyle, homoeopathy, black cohosh). An alteration of lifestyle was classified as one form of CAM therapy and includes physical exercise.
Statistics
We analysed data using SPSS Statistics version 19.0. The results are represented as n
(%) and mean ± standard deviation (SD). Distributions for demographic
characteristics, menopausal symptoms and type of therapy were
determined. To assess associations between type of therapy (CAM/HRT or
both) and menopausal complaints, as well as education and age,
respectively, the χ2-test was used. The statistical
significance of the differences in mean age and symptom severity score
(MRS II total score) across therapy categories was determined by using
analysis of variance. A value of p < 0.05 was considered statistically significant, and <0.001 was statistically highly significant.
Results
By
the end of January 2012, a total of 1893 questionnaires had been
received via mail, representing a response rate of 19.3%. 1872 of these
were eligible and were included in the analysis. The mean age of all
participants was 52.6 ± 4.3 years. A total of 81.7% (n = 1529) of the respondents had finished their general certification of secondary education (German Mittlere Reife). Of those, 45.1% (n = 690) had also passed their German A-levels (German Abitur). 17.0% (318) of the respondents went to secondary modern school (German Hauptschule) and only 0.4% (n = 8) did not graduate from school or did not go to school at all. A total of 65.3% (n = 451) of the women who had passed their A-levels also held a university degree.
Altogether, 81% (n = 1517)
of the responding women stated that they had experienced menopausal
complaints at least once. Of the eleven assessed menopausal symptoms,
the highest prevalence rates were reported for vasomotor symptoms
(71.2%), sleep disturbances (68.5%), irritability (62.7%) and physical
and mental exhaustion (62.5%). The lowest prevalence estimate was stated
for bladder problems (42.7%). Overall, somatic symptoms including
vasomotor symptoms, joint and muscular discomfort, heart discomfort and
sleep problems were stated most often (80.1%; n = 1500/1872). More than half (56%; n = 1049)
of the responding women had used some form of therapy to alleviate
their symptoms at least once. Among these women, the majority (64.8%; n = 679/1049) reported the application of at least one type of CAM (only CAM), 14.2% (n = 149) had been under treatment of HRT only (only HRT), whilst 21.1% (n = 221/1049) had tried both CAM and HRT. Approximately 41% (n = 277/678) of the CAM-users had used one CAM intervention only, while 29.6% (n = 201/678) used two different forms and 28.8% (195/678) had tried three or more. Amongst all of the HRT-users (n = 369), the majority had tried several forms of therapy (60.2%), whereas just 39.8% used HRT alone (p < 0.001). Table 1
shows the different therapy forms (only CAM, only HRT and both CAM
& HRT) by demographic characteristics and severity of menopausal
symptoms (MRS II Total score). On average, CAM users were younger than
HRT users (52.7 ± 4.0 vs. 54.6 ± 4.2; p < 0.001). More CAM users started therapy at a younger age (45–49) than HRT users (p < 0.001).
Compared to CAM users, HRT users had a lower education level than CAM
users. The highest educational degree of 29.3% of the HRT patients was
graduation from secondary modern school, while the rate among CAM users
was 12.4% (p < 0.001). 41.6% of CAM users absolved German
A-Levels or a higher degree, compared to 23.6% of the HRT users.
Significant differences could be observed between the average symptom
scores (MRS II total score) and the therapy forms. The MRS II-total
score was significantly higher among women who used both CAM and HRT
(MRS-total score 20.23 ± 7.61 vs. 16.2 ± 7.8 for CAM alone, vs.
16.3 ± 8.0 for HRT alone) than among women in other categories of
therapy use. Fig. 1
presents the frequency and efficacy of each CAM therapy, characterised
by the responding women. An alteration of lifestyle (e.g. physical
exercise) was the most widely used CAM intervention (28.7%; n = 538/1872). More than 80% (84.9%; n = 457)
of the users assessed this therapy as useful. St. John's wort, as well
as homoeopathy, were also applied quite often (18.3%; n = 343 and 14.9%; n = 278,
respectively). Among the applicants of these therapies, most found them
useful (St. John’ wort: 51.9% and homoeopathy: 73.7%). Less commonly
applied therapies, such as acupuncture and hormone-yoga (4.5%; n = 85 and 2.8%; n = 53)
were deemed ‘effective’ by more than half of the women (acupuncture:
58.8% and hormone-yoga: 79.2%). Phyto-oestrogens and black cohosh were
regarded as the most ineffective, with rates of 45.5% and 49.7%,
respectively, indicating success in only half of the cases. Overall,
therapies were rated less effective if women had worse complaints ( Table 2).
For women with severe complaints (MRS total score >17), HRT was
rated as the most effective treatment (82.3%). An alteration of
lifestyle was also evaluated as effective by 78% of the women with
severe complaints, but the efficacy of an alteration of lifestyle and
St. John's wort as well as homoeopathy dropped by nearly 15% if women
had ‘severe complaints’ in comparison to ‘moderate symptoms’. However,
the efficacy of HRT dropped by 4.4% only by women with ‘severe symptoms’
compared to women with ‘moderate symptoms’.
- Table 1. General demographic and health characteristics for the total sample and by therapy used.
Total sample (n = 1872) CAM (n = 680) HRT (n = 147) CAM & HRT (n = 222) p-valuea Age (mean ± SD) 52.6 ± 4.3 52.7 ± 4.0 54.6 ± 4.2 54.3 ± 3.8 p < 0.001 45–49 487 (26%) 154 (22.7%) 23 (15.6%) 29 (13%) 50–52 457 (24.4%) 174 (25.6%) 22 (15%) 41 (18.5%) p < 0.001 53–56 510 (27.2%) 199 (29.3%) 44 (29.9%) 83 (37.4%) 57–60 410 (21.9%) 148 (21.8%) 57 (38.8%) 68 (30.6%) Education Secondary modern school 318 (16.9%) 84 (12.4%) 43 (29.3%) 39 (17.6%) Secondary school 839 (44.8%) 306 (45.1%) 67 (45.6%) 94 (42.3%) p < 0.001 German A-Levels 239 (12.8%) 104 (15.3%) 10 (6.8%) 28 (12.6%) University 451 (24.1%) 179 (26.4%) 25 (17%) 60 (27%) MRS-Total Score (mean ± SD) 12.76 ± 9.6 16.2 ± 7.8 16.3 ± 8.0 20.23 ± 7.6 p < 0.001 - a Overall χ2 test for comparisons between mean-age, age-groups, education and MRS-Total score.
- Figure 1.
CAM therapy forms usage and their perceived effectiveness. Yes, in response to the questions ‘Which of the listed treatments did you apply?’ and ‘Was it effective?’.
- Table 2. Treatment forms and the rated effectiveness of each treatment across four categories of severity of symptoms.
Total sample (n = 1865) No, little 0–4 MRS-Total mild 5–8 Score moderate 9–16 Severe 17+ Total sample (n = 1865) 453 231 501 671 HRT 369 13 28 105 221 Effective 312 (84.5%) 12 (92.3%) 26 (92.9%) 91 (86.7%) 182 (82.3%) Alteration of lifestyle 538 17 72 188 259 Effective 257 (84.9) 14 (82.3%) 65 (90.3%) 172 (91.5%) 202 (78%) St. John's worth 343 4 25 95 217 Effective 178 (51.9%) 4 (100%) 17 (68%) 57 (60%) 99 (45.6%) Homoeopathy 278 8 31 89 148 Effective 205 (73.7%) 7 (87.5%) 30 (96.8%) 72 (80.9%) 94 (63.5%) Phyto-oestrogens 110 3 6 30 69 Effective 50 (45.5%) 1 (33.3%) 3 (50%) 15 (50%) 30 (43.4%) Black-cohosh 225 5 18 67 133 Useful 112 (49.7%) 2 (40%) 12 (66.7%) 46 (68.7%) 51 (38.3%) Chast tree 129 3 11 39 74 Effective 66 (51.9%) 3 (100%) 8 (72.7%) 26 (66.7%) 28 (37.8%) TCM 159 4 17 41 96 Effective 94 (59.1%) 3 (75%) 12 (70.6%) 27 (65.9%) 51 (53.1%) Acupuncture 85 2 4 20 59 Effective 50 (58.8%) 1 (50%) 3 (75%) 15 (75%) 59 (52.5%) Hormone-yoga 53 3 7 14 28 Effective 42 (79.2%) 2 (66.7%) 7 (100%) 11 (78.6%) 21 (75%)
Discussion
Our
results showed that almost half of our sample (48.2%) had used at least
one form of CAM, either alone or in combination with HRT, to alleviate
their menopausal complaints. Women used CAM five times more often than
HRT as treatment against symptoms. Comparable results could be observed
in some previous studies, but the CAM prevalence rates ranged widely
between 33.5% and 82.5%6, 7, 8, 11 and 12.
However, a comparison between CAM prevalence rates is difficult and
must be observed carefully, as study designs vary. Furthermore, there is
no general agreement about which therapies and remedies could be
embraced under the term ‘complementary and alternative medicine (CAM)’,
which also could have biased the prevalence rates11.
Although
‘complementary and alternative treatment’ is a consistent subject of
current discussions in the literature, there is still no convincing
evidence about the benefits on menopause for most of the CAM treatments17.
Nevertheless, some randomised placebo controlled trials reported about
the beneficial effects of black cohosh in combination with St. John's
wort. Similarly, physical exercise was perceived as beneficial to
menopausal symptoms13, 14 and 15.
Interestingly, an alteration of lifestyle, which includes physical
activity and dietary change, as well as St. John's wort, were the most
commonly used CAM interventions in our survey. Apparently, women tend to
use CAM interventions more often, which are supported by some
scientific evidence. Contrarily, women in our survey also perceived
homoeopathy as very useful (73.7%) in managing their symptoms, but
evidence from systematic reviews and placebo-controlled trials
supporting its effectiveness, are very limited1 and 19.
Women with very severe complaints tended to use both CAM and HRT in our survey; more than one third (32.5%; n = 221)
of the CAM users had also used HRT. However, we are not able to
determine whether HRT was used sequentially or concurrently with CAM.
This must be considered when examining the effectiveness of each form of
therapy. Overall, most CAM interventions in comparison to HRT were
rated less useful if women had more severe complaints. Interestingly,
CAM-using women had a higher education than HRT-using women in our
survey.
Altogether, this
survey shows that complementary and alternative medicine plays an
important role in symptom management by menopausal women.
Limitations
This
study should be interpreted in the context of several limitations.
First, as this was a voluntary survey, the responding women could be
biased. Respondents may be more health-conscious and more interested in
CAM and HRT, and thus more likely to respond. Therefore, the true
prevalence of CAM and HRT could be overestimated in our survey.
Furthermore, the response rate of 19.3% is low in comparison to other
surveys and could, therefore, introduce selection bias. However, our
sample size of 1893 responders is one of the largest samples compared to
similar surveys6, 7 and 18.
Moreover, the incidence of somatic, psychological and sexual complaints
measured by the MRS-rating scale is comparable to data from an earlier
survey among German women, which showed similar MRS-rating scores16.
Therefore, we could state that the earlier survey and our survey might
be comparable and not influenced by the fact that women with more or
less severe symptoms are more likely to answer the questionnaire. One
strength of our study is that we questioned women from all parts of
Germany. There is a slightly shift of approximately 10% to a higher
educational level. Since the address broker has no information about the
educational level we cannot differentiate if the basic population has a
higher educational level or the respondents rate is higher in this
group. Therefore we give the data splitted by educational level.
Although aware of those possible biases, we believe that our survey is
representative of German women.
Conflict of interests
The authors declare no conflict of interest.
References
Copyright © 2013 Elsevier Ltd. All rights reserved.
