|Home | About | Journals | Submit | Contact Us | Français|
While almost half of women use complementary and alternative medicine (CAM) during their menopause, almost no literature explores why women choose CAM for menopausal symptoms. Clinician–patient conversations about CAM can be unsatisfactory, and exploration of women’s choices may benefit communication.
The objective of this study was to describe women’s choices to use CAM for menopausal health issues.
This is a qualitative study utilizing semi-structured interviews.
Convenience sample of 44 menopausal women ages 45 to 60 recruited in two primary care clinics. Both users and non-users of CAM were included.
Transcripts of semi-structured interviews were analyzed for themes that were refined through comparison of labeled text.
Four themes emerged in decisions to use CAM: (1) valuing CAM as “natural”, although the meaning of “natural” varied greatly, (2) perceiving menopause as marking a change in life stage, (3) seeking information about menopause generated from personal intuition and other women’s experiences, and (4) describing experiences before menopause of using CAM and allopathic medication in patterns similar to current use (patterned responses).
Women’s decisions about using CAM during menopause can be understood through their perspectives on menopause and overall health. Increased clinician awareness of these themes may promote supportive discussions about CAM during counseling for menopause.
The online version of this article (doi:10.1007/s11606-008-0537-9) contains supplementary material, which is available to authorized users.
Research suggests that 40% to 76% of women use complementary and alternative medicine (CAM) during their menopause.1–3 Use of CAM has been associated with being older, more educated, and in poorer health,1 but little research examines why menopausal women use CAM. A small study (n=14) noted women using CAM for menopausal symptoms felt in control through their choices, and described CAM as “natural” and effective.4 Studies of CAM use more generally indicate that people report using CAM because it is congruent with their values and philosophical orientation towards health and life,5 is perceived to be safer and have fewer side effects than medication,6,7 seems to be effective,6,8 and helps them feel in control 6.
Patient–clinician communication about CAM is poor. Studies of general populations8–10 and menopausal women11 suggest that as few as half disclose their CAM use to physicians. Physicians, in addition, are unlikely to ask about CAM.12 Patients have reported frustration when doctors focus exclusively on clinical evidence about CAM13 or do not appreciate that their CAM use is motivated by an effort to be healthy.14 Research elucidating patient decisions on CAM could expand the scope of clinical conversations and improve communication.
After Committee on Human Research approval, participants were recruited through posters in two urban primary care clinics. One clinic is in a middle to upper class neighborhood and is university-affiliated. The other is in an urban working class neighborhood, physician-owned, and affiliated with a private hospital. Both clinics accept private and government-subsidized insurance plans. Interested women contacted the researchers via telephone. Eligible women were between the ages of 45 and 60, self-identified as entering, within, or ending menopause, and had not undergone surgical or pharmacological menopause. Initial screening for exclusion criteria was conducted over the phone. Forty-six women contacted the researcher. One woman was excluded because she had undergone surgical menopause. A second woman declined to participate because she wished to join an intervention trial. The remaining 44 women were interviewed by the first author. Interviews lasted 45 to 90 minutes and occurred at the participant’s home or a non-clinical setting. No reimbursement was given.
Interviews were semi-structured. The question template was developed, then tested in three practice interviews with volunteers who provided feedback. A senior anthropologist helped refine the questions based on this feedback. The participants were asked about personal menopausal experiences, influences on perceptions of menopause, and experiences with hormone therapy and CAM, reflecting an assumption that decisions about CAM can be understood within the context of an individual’s understanding of menopause and their previous experiences of health.5,9 CAM was defined broadly to include herbal and nutritional supplements, exercise, relaxation techniques, dietary changes, and therapies supervised or performed by a non-allopathic caregiver.
All interviews were taped and transcribed. Identifying names and information were changed to protect participants’ privacy. Transcripts were read in their entirety by the first author to create descriptive codes identifying possible understandings of menopause and perceptions of CAM and hormone therapy as treatment options.15,16 The transcripts were then coded using QSR NVivo 2.0 software. All blocks of text labeled with a code were then examined together to test assumptions and elucidate variation.17 Excerpts of these texts were discussed with two experienced qualitative researchers (Gay Becker, PhD and Lisa Bourgeault, MA). Both of these processes yielded new, interpretive codes that better captured the essence of the transcripts.17 These broader codes were tested by re-reading the texts under the codes and discussion with coauthors (JM, DT). Data collection was concurrent with data analysis.
“Reflexivity” and “member checks” were used to increase the trustworthiness of qualitative data. Reflexivity is a process by which researchers continually examine how their personal experiences and assumptions affect the research process at all stages.18 The first author wrote notes on her changing assumptions about menopause, hormone therapy, and CAM therapy during the project conceptualization. These notes were discussed in an anthropological research seminar. After each interview, the first author wrote notes on her perception of connectedness with the participant and how this influenced the interview process.18 Member checks, or sharing early analysis of data with research participants, are another way of improving the validity of qualitative research.17 In the later interviews, initial themes related to the meaning of menopause were presented to participants for feedback, and participants’ responses were examined.
Forty-four women were interviewed. Table 1 shows demographic characteristics of the participants and CAM use at time of interview. Thirty-eight CAM approaches were discussed by the participants, including herbs, nutritional supplement, soy-rich foods, meditation, acupuncture, massage, and reiki. Four themes associated with using CAM are described below and summarized in Table 2. The online appendix includes representative quotes for each theme.
Most women who used CAM valued that it was “natural,” although the precise meaning of “natural” varied. “Natural” sometimes meant gentler or safer than medication. Many described a desire for a “natural” approach because menopause is a “natural” transition, not a disease. Some women identified non-allopathic traditions that emphasize “balance” in the body as more “natural.” Several women explained that their mothers and grandmothers underwent menopause without medical advice or medication, leading them to seek approaches that did not involve physicians. For a small group, “natural” was explained through socio-political orientations, such as believing that health care is overly influenced by the pharmaceutical industry or tying one’s identity to the 1970s women’s health movement. Most women identified more than one concept of natural.
Many participants noted that their understanding of menopause as principally a life stage, rather than a medical condition, influenced their use of CAM. A life stage model of menopause suggests it is a distinct period of life in which aging becomes apparent and personal health should be prioritized. Therefore, CAM was chosen to concurrently treat symptoms and enhance general health. One woman described focusing all her effort on her work and her partner’s poor health until she realized she was in menopause. She then re-focused on her personal health by starting nutritional supplements and increasing exercise to address hot flashes and overall health.
Many CAM users described using multiple sources of information to learn about menopause and chose treatment based on information that might be disregarded by medical experts. The most common was the personal experiences of family, friends, and co-workers who had experienced menopause. Some women described this experiential information as less reliable than a clinician’s recommendation but justified their choice because they felt only limited research exists on CAM and some physicians have negative attitudes about CAM. Other participants questioned whether research on menopause was applicable to them because their lives or bodies seemed unusual and thus poorly represented by the average.
A second alternative source of information on menopause was personal intuition or “listening” to one’s body. Some participants explained that certain CAM “just felt right.”
Many participants, in explaining their decision to use CAM, described patterns of response to health problems that they developed long before menopause. Some personally researched CAM for their symptoms or depended on CAM professionals (acupuncturist, chiropractor, etc.) as a first alternative, while others followed the advice of allopathic physicians at first, and used CAM if the advice did not help. While numerous patterns were described, distinct in this theme was that each participant could identify a response that had worked in the past for concerns predating their midlife and that was why they were currently using or considering CAM.
Contrasting themes were noted among women who were not interested in CAM. The concept of “natural” was mentioned as outdated or unscientific. Biological models of menopause were discussed more extensively than life stage models. This group was more interested in information on menopause from allopathic medical experts. The theme of “patterned responses” arose in that these participants described variable patterns of seeking allopathic health care. A sense of personal control has not been included as a final theme because it arose in descriptions of both choices to use medicinal and CAM therapies.
Many authors recommend that physicians ask their patients about CAM use.3,10,14 Research about such conversations, while limited, suggests that many patients find these discussions unsatisfactory.8,13 Limited research suggests that the major reason physicians want to learn about CAM is so they can dissuade patients from using unsafe or ineffective modalities.12 These results suggest several avenues that could expand the discussion about CAM beyond efficacy and safety. The first would be inquiring if there is an aspect of a therapy “being natural” that is particularly important to an individual patient, as many meanings were identified in this study. This research also suggests that clinicians might inquire about whether other sources of information—such as the experiences of friends or personal intuition—matter to a patient.
“Patterned responses” is a concept that highlights the importance of longitudinal patient–clinician relationships in primary care. Congruent with previous research, patients choose between CAM and allopathic medicine in different patterns.9 Some participants in this study wanted their physician’s opinion before choosing CAM, while others depended first on personal research or information from a CAM expert. Clinicians who explore when and how individual patients use CAM modalities over time may be better able to identify and discuss their patients’ preferred approach to menopause.
A life stage model of menopause, described by CAM users in our study, has been described previously in qualitative research19,20 but not linked with CAM use. The general concept of menopause as a marker for a stage in aging is particularly important to primary care clinicians, as this model may encourage women to make behavioral changes to improve their health.
Our research extends previous research describing a preference for CAM because it is “natural.” Previously, “natural” was described as “lacking harmful side effects” and “gentle.”4,6 Our study identified additional meanings of “natural” including “appropriate for non-disease states” and congruent with socio-political orientations.
There are several limitations to this study. Like much qualitative research, this study depended on a volunteer sample, and the findings cannot be generalized to all women. In addition, recruitment material for this study used the word “menopause” and may have attracted women with particularly strong menopausal experiences or concerns. Nevertheless, these themes may be important to many women who talk with clinicians about menopause.
Our study avoided some of the weaknesses of previous research on CAM. Other studies have missed modalities because researchers rather than the participants defined CAM.21 In addition, we examined the decision processes in women who used and who did not use CAM. Finally, through our use of a qualitative rather than survey approach, women who were unclear about what constituted their menopause, and therefore what constituted a menopausal treatment, could describe this ambiguity.
This research suggests that partnerships in decision making require clinicians to investigate patients’ understanding of menopause and CAM. The themes that emerged in this research could be an excellent platform for broader discussions of women’s needs and desires in the face of menopausal symptoms.
Below is the linked to the Electronic supplementary material.
We would like to thank Gay Becker PhD and Lisa Bourgeault MA, who contributed to the analysis of this data. Incidental expenses were covered by the University of California, San Francisco Department of Family and Community Medicine.
Conflicts of interest statement None disclosed.
Parts of this paper were presented at American Anthropological Association Annual Meeting (New Orleans, 11/21/02) and North America Primary Care Research Group Annual Meeting (Banff, Canada 10/28/03).
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0537-9) contains supplementary material, which is available to authorized users.