Menopausal women don't get enough guidance on treatment options

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"We're not promoting the use of these alternative therapies," said lead author Jun Ma, MD, PhD, research associate at the Stanford Prevention Research Center. "We're just saying that the demand for these therapies is growing and that physicians should be prepared to talk to their patients about it."

The study appears in the May/June issue of The Journal of the North American Menopause Society. The study was funded by GlaxoSmithKline Consumer Healthcare, which had no role in the study design, data collection or preparation of the manuscript for publication. The pharmaceutical company manufactures the herbal product RemiFemin Menopause.

The study was based on a 2004 online survey of a random sample of 781 U.S. women between the ages of 40 and 60. Because the sample size was small, Ma cautioned that the findings may not accurately represent all women, but said the data provide useful insights into women's attitudes toward menopause treatments and how much physician guidance they have received in deciding which therapies to use.

Among the women surveyed, nine out of 10 reported having experienced at least one menopausal symptom at some point. When it came to treating their symptoms, 37 percent reported using hormone therapy while slightly less than that—31 percent—used herbal products. Soy supplements were used by 13 percent.

What interested Ma and her colleagues was that three-quarters of the women who had formerly taken hormone therapy said they stopped primarily because of concern about potential risks. "A majority of the women who had discontinued their hormone therapy were not on any therapy—not because of lack of need or desire to continue, but because they didn't know which therapy would best suit their clinical needs," Ma said.

The concerns about hormone therapy stem largely from the federally funded Women's Health Initiative, a long-term study that turned the conventional wisdom about hormone therapy on its head. For many years, observational studies indicated that in addition to relieving menopausal symptoms, hormone therapy helped protect women against heart disease. However, the WHI found that neither estrogen nor the combination of estrogen and progestin helped prevent heart disease. Instead, although both forms of hormone therapy offered some benefits in easing menopausal symptoms, they both posed substantial health risks.

Despite these risks, hormone therapy is still considered the most effective approach for treating menopausal symptoms. Women are advised to use the lowest possible dose of hormones and to limit the duration of the treatment in order to minimize the risks.

But the new study shows that many women are instead turning to herbal and soy products to ease their menopausal symptoms. The most commonly used herbal products reported by survey participants were ginkgo biloba, ginseng, St. John's wort, black cohosh or a combination product.

"The reduced use of menopausal hormone therapy, while an appropriate response to the WHI findings, has left both patients and their physicians in a difficult position," said Randall S. Stafford, MD, PhD, associate professor of medicine and senior author of the study. "While other pharmaceuticals and alternative therapies are available, many physicians are not fully prepared to discuss these options, particularly given the limited data available about the effectiveness of these options."

Among the women who used herbal therapies, 55 percent chose the products because of concerns about hormone therapy while 45 percent said they wanted to use a natural remedy. But Ma said many women mistakenly equate the term "natural" with "safe," and falsely believe that herbal products won't interact with other medications. "That misperception really needs to be corrected," she said.

In fact, herbal products may have side effects. For instance, some studies have shown that St. John's wort interacts with selective serotonin-reuptake inhibitors, which are the most commonly prescribed class of antidepressants, and it is recommended that the two not be combined.

Additionally, Ma said there is little in the way of high-quality data on the efficacy of many of the alternative therapies, adding that most of the data are limited to short-term use of the products.

The women in the study regarded physicians as their most-trusted source of information about alternative therapies, yet many said they didn't get enough guidance in choosing a remedy for their menopausal symptoms. Nearly 75 percent of the women said that they—not their doctors—initiated discussions about possible treatments for their symptoms. And when it came to alternative therapies, 20 percent of the women weren't confident in their doctors' ability to discuss the treatments knowledgeably.

"Hormone therapy is unique in that patient preference is important in deciding what therapy to use," Ma said. "A balanced dialogue is essential because it's a treatment decision that a physician should make with a patient, not for a patient."

Ma suggested that physicians know enough about alternative menopause therapies to put them in four categories: those that have data suggesting some effectiveness, those that have data demonstrating concerns about side effects, those with neutral data and those lacking any data.

"It's OK to tell patients that little is known about a product, despite any anecdotal stories they may have heard. Anecdotal stories should not be taken as a substitute for rigorous clinical evidence," Ma said.

Stanford University Medical Center