Guidelines 2016 – Complementary and Alternative Therapies
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Increasingly, women are using complementary and alternative medicine (Cam) therapies for preventive and palliative care as alternative or adjunct therapies to their traditional medical care. We present an overview of the most commonly used therapies for perimenopause, premenstrual syndrome (pms), and depression. pregnant and lactating women should not use any Cam therapies without consulting with their care provider. it is important for the clinician to ask a woman about the use of Cam therapies at every visit.
I. DEFINITION
alternative therapies refer to treatment approaches that, though used for many years, have not been evaluated and tested by conventional methods. the term complementary therapies is used to convey the concept that these therapies are often used in conjunction with conventional, medically accepted treatments. When looked at in this manner, the term assumes a more holistic view of women’s health care needs.
II. GENERAL CATEGORIES OF CAM
a. natural products, including, but not limited to,
1. vitamins/minerals
2. dietary supplements (i.e., coenzyme Q10 [CoQ10])
3. herbals and other naturally occurring substances
4. phytoestrogens (plant based, such as soybeans, flax seed)
5. natural estrogen
6. natural progesterones
B. mind–body medicine
1. yoga, tai chi, qigong
2. Biofeedback
3. hypnosis
4. meditation
5. aroma therapy
6. mindful breathing
C. manipulative and body-based medicine
1. massage
2. acupuncture
3. Craniosacral therapy
4. Chiropractic manipulation
5. reiki
6. alexander method
7. therapeutic touch
d. other Cam practices
1. homeopathy
2. naturopathy
3. traditional Chinese medicine
4. traditional tibetan medicine
5. Wise woman traditional medicine
6. therapies based on oral tradition
III. REASONS FOR SELECTION/USE OF CAM
a. preference for more “natural” treatment
B. Belief in unconventional (non-Western) medicine
C. Concern about potential side effects of conventional medicines and treatments
d. dissatisfaction with or lack of confidence in conventional methods
e. desire to have control over one’s own health and health care
F. Being raised in a culture that believes in and uses Cam therapies
G. Belief in the body’s ability to heal itself
IV. PROBLEMS AND CONCERNS
a. lack of systemized research and sufficiently well-designed studies to measure safety and efficacy
B. self-medication based on insufficient information
C. lack of standardization of therapeutics
d. Failure to inform health care practitioner of Cam use; supplements can interact with prescription or over-the-counter (otC) medications
V. CAUTIONS
a. remember, “natural” is not synonymous with safe.
B. Cam should be used only for minor problems, not for conditions that have potential to be life altering or life threatening.
C. Cam should not be used in pregnancy or breastfeeding without discussion with an allopathic or osteopathic health care practitioner.
d. Use should be limited to recommended dosages for recommended time frames.
e. prescribers need to be knowledgeable about Cam methods. do not use Cam therapy that you have not personally researched and understood its use. the internet should not be the only source of research and information.
F. Use should begin with a smaller-than-recommended dose to observe for adverse reaction.
G. advise women to buy or seek therapies only from reputable manufacturers and practitioners. remember that in the United states, herbal and other natural preparations are regulated only as dietary supplements. they are not standardized or regulated by the U.s. Food and drug administration (Fda). See fnic.nal.usda.gov; ods.od.nih.gov; nccam.nih.gov; dsld.nlm.nih.gov.
VI. FREQUENTLY USED/RECOMMENDED CAM THERAPIES
a. menopause and perimenopausal symptoms
1. B complex vitamins
a. Usual dose 50 to 300 mg daily
b. indications for use
i. stress/depression
ii. Water retention
c. toxicity/adverse effects
i. none known
2. vitamin C (l-ascorbic acid)
a. Usual dose to total 1,000 to 2,000 mg daily from diet and supplements
b. properties and indications for use
i. Free radical scavenger/antioxidant
ii. linked with raising levels of high-density lipoprotein (hdl) and lowering levels of low-density lipoprotein (ldl)
iii. helps in maintaining the integrity of bone structures
iv. helps in maintaining healthy connective tissues
v. required for the biosynthesis of collagen, l-carnitine, and some neurotransmitters
vi. thought to play an important role in the prevention of cancer, cardiovascular disease, age-related macular degeneration, cataracts, and the common cold
c. Foods containing substantial levels of vitamin C
i. Citrus fruits and fruit juices
ii. vegetables
iii. Fortified grains and cereals
d. toxicity/adverse effects
i. low toxicity
ii. increased doses (over 2,000 mg daily) may be associated with intestinal gas and loose stools.
iii. With a history of gastric reflux or other stomach/intestinal issues, buffered vitamin C may be better tolerated.
iv. large doses may play a role in the formation of kidney stones.
v. Use with caution and medical supervision if history of compromised kidney function.
3. vitamin d
a. recommended dosages
i. Usual daily dose 600 to 800 international units (iU) (changing as researchers and clinicians study the role of vitamin d)2
ii. vitamin d at 400 iU per day for women younger than age 70
iii. vitamin d at 600 iU daily for women older than age 70; for women with darker skin, 1,000 iU daily as well as for elders without sun exposure
iv. serum levels of 25-hydroxyvitamin d in the range of 20 to 30 mg are sufficient for bone health.
v. vitamin d intake should not be more than 4,000 iU daily without consultation with a health care practitioner.
b. indications for use
i. osteoporosis—increase mineral absorption, bone mineral- ization
ii. the role of vitamin d in providing protection from falls, cancer, and possibly autoimmune diseases continues to be investigated.
4. vitamin e
a. Usual daily dose 400 to 800 iU; may be used up to 1,200 iU safely
b. indications for use
i. hot flashes
ii. Cardiovascular prevention (remains controversial), poor circulation
iii. atrophic vaginitis
c. toxicity/adverse effects
i. Use with caution if patient on high blood pressure medica- tion (may decrease blood pressure).
ii. Use with caution or not at all if patient is on anticoagulant therapy.
iii. Using more than recommended dose can result in nausea, flatulence, diarrhea, heart palpitations, fainting (all reversible with dose decrease).
5. Calcium
a. Usual daily dose in divided doses 1,000 to 2,500 mg; should be used in conjunction with vitamin d to aid in bone remineralization
i. adolescents should be taking 1,000 to 2,500 mg daily, preferably from a diet rich in calcium.
ii. pregnant women 19 to 50 should be taking 1,000 to 2,500 mg daily.
iii. Breastfeeding women 19 to 50 should be taking 1,000 to 2,500 mg daily.
iv. Women up to age 50 should be taking 1,200 to 2,000 mg daily.
v. after age 50, women should be taking 1,200 to 2,000 mg daily.
vi. remember, calcium should be taken in divided doses.
vii. Women should be advised not to take more than 2,500 mg per day from diet and supplements unless advised by a provider.
b. indications for use
i. osteoporosis (prevention and treatment)—provides reinte- gration of calcium into bones
ii. hypertension—aids in contraction and expansion of heart muscle
c. toxicity/adverse effects
i. Calcium has no known toxic effects in doses 2,000 mg or less (caution in use of antacids as calcium supplements; in addition to calcium, many of these products contain alumi- num, which interferes with calcium absorption).
ii. too much calcium from supplements may increase the risk of kidney stones and possibly heart attacks.
iii. Calcium can interfere with thyroid medication.
separating calcium supplements and thyroid medication by at least 4 hours is recommended.
d. Foods rich in calcium
i. Fortified orange juice
ii. milk, yogurt, and other dairy products
iii. Firm tofu
iv. Canned salmon/sardines with bones
6. essential fatty acids (eFas) omega 3, omega 6, and omega 9. omega 3 and omega 6 are polyunsaturated fats and cannot be manufactured in the body. omega 9 fatty acids are from a family of monosaturated fats that can be manufactured by the body but are additionally beneficial when found in food.
a. types of omega 3 fatty acids
i. epa (eicosapentaenoic acid)—found in fish sources such as herring, bluefish, and sardines
ii. dha (docosahexaenoic acid)—found in fish in fish sources as for epa
iii. ala (alpha-linolenic acid)—found in plant sources such as walnuts, flaxseed, and soybeans
b. types of omega 6 fatty acids
i. Gla (gamma-linolenic acid)—found in plant sources, almost exclusively from the borage plant
c. types of omega 9 fatty acids
i. oleic acid—found in canola, olive, sunflower oils; nuts; avocados; and olives
d. indications for use of omega 3 fatty acids
i. omega 3 fatty acids have been shown to be helpful in
a) lessening stiffness and pain in joints; may boost the effects of anti-inflammatory medications
b) lowering elevated triglyceride levels
c) Currently studied regarding the anti-inflammatory process of asthma
d) Current studies are suggesting a positive effect on mental health status, not in the role of a primary treatment, but in combination with therapy and psychotherapeutic medication.
e) research is suggesting a protective effect against the memory loss of alzheimer’s disease.
ii. sources of omega 3 fatty acids
a) Wild fish, such as anchovies, bluefish, herring, mackerel, sardines, tuna
b) Walnuts, flaxseed, flaxseed oil, soybean oil
e. indications for use of omega 6 fatty acids
i. omega 6 fatty acids have been shown to be powerful in decreasing the chronic inflammation of
a) eczema
b) asthma
c) rheumatoid arthritis
d) atherosclerosis
e) diabetes
f) obesity
g) potentially mood instability associated with psychiatric conditions
ii. sources of omega 6 fatty acids (Gla)
a) almost exclusively from the borage plant
b) other omega 6 fatty acids, not Gla, can be found in corn oil, soybean oil, poultry, and eggs. these should be consumed in smaller amounts.
f. indications for use of omega 9 fatty acids
i. research has shown omega 9 fatty acids increase hdl and decrease ldl and help to decrease plaque formation in arteries.
ii. Cooking oils high in omega 9 eFas, such as canola and sunflower, are excellent replacements for partially hydrogenated cooking oils.
iii. may provide a protective benefit against metabolic syndrome
g. recommended dosages of combined omega oils
i. according to the U.s. department of agriculture 2010 dietary Guidelines for americans the recommendation is a daily intake of combined omega 3 fatty acids (epa and dha) of 0.7 to 1.6 g/d and omega 6 fatty acids 7 to 16 g/d depending on age and gender.
ii. recommended dosages for specific conditions may be found at www.mayoclinic.org/drugs-supplements/omega- 3-fatty-acids-fish-oil-alpha-linolenic-acid/background/ hrb-20059372
h. toxicity/adverse effects
i. no known adverse effects
7. CoQ10 (ubiquinone)
a. Usual recommended daily dose within a range of 60 to 400 mg/day
b. indications for use
i. the name ubiquinone is appropriate because CoQ10 is found everywhere in the body; a powerful antioxidant, it stimulates the immune system, increases tissue oxygenation, and has vital anti-aging effects.
c. toxicity/adverse effects
i. no known adverse effects
8. Black cohosh (Cimicifuga racemosa), derived from a plant in the buttercup family, does not act like an estrogen but is now thought to behave similarly to serotonin in the brain, acting to relieve feelings of depression and regulating body temperature.
a. Usual daily dosage—consult individual preparation
i. Counsel women that therapeutic effects generally begin after 2 weeks and that maximum effects are usually seen within 8 weeks.
b. indications for use
i. hot flashes
ii. Fatigue
iii. irritability
iv. night sweats
v. headaches
vi. insomnia
vii. heart palpitations
c. toxicity/adverse effects
i. low incidence of adverse effects with moderate dose
a) avoid during pregnancy and lactation
b) avoid use in women with aspirin sensitivity because it contains salicylates
c) avoid in women with liver problems, including a history of hepatitis
ii. overdose of black cohosh may cause nausea, vomiting, dizziness, and nervous system and visual disturbances
9. Ginkgo biloba medicinal preparations are made from extracts of the leaves of the plant.
a. Usual daily dosage—consult preparation directions
b. indications for use
i. Circulation
ii. Cognitive impairment, forgetfulness
iii. Cold hands and feet
iv. antitoxin/anti-inflammatory
c. toxicity/adverse effects
i. headaches
ii. nausea
iii. heart palpitations
iv. dizziness
v. allergic skin reactions
vi. do not use if taking aspirin, anticoagulants, or prior to surgery.
vii. do not use if patient has a history of seizure disorder.
10. st. John’s wort (derived from the wild flowering plant Hypericum perforatum)
a. Usual daily dose—300 mg (range in clinical trials has indicated a dosage of 900 mg daily in three divided doses)
b. Conditions
i. depression, anxiety, mood swings, sleep disorders, smoking cessation
c. toxicity/adverse effects
i. may alter liver enzyme function in processing some drugs, including hiv medications, digoxin, warfarin, oral contraceptives, antidepressants
ii. Because of numerous interactions, women should check with all their care providers prior to using.
iii. adverse reactions include
a) dry mouth
b) nausea
c) Change in bowel habits
d) photosensitivity
e) Fatigue
f) dizziness
g) insomnia
h) headache
11. Ginseng
a. there are three kinds of ginseng: asian (Chinese or Korean), american, and siberian. the first two are authentic ginseng. siberian ginseng is not; however, it looks similar and has similar effects on the body.
i. Usual daily dose 100 to 400 mg—varies with origin and preparation
b. indications for use (it is advised to limit use to 3 months consecutively, then take a 3-month break before resuming.)
i. stress
ii. Fatigue
iii. loss of libido
iv. memory problems
v. vaginal dryness—ginseng has a direct estrogenic effect.
c. toxicity/adverse effects
i. Central nervous system symptoms, headache, agitation, confusion, drowsiness
ii. Gastrointestinal problems; vomiting, abdominal pain
iii. lowered blood pressure
iv. should not be used by women with
a) inflammatory bowel disease
b) multiple sclerosis
c) rheumatoid arthritis and systemic lupus
d) allergic rhinitis, asthma, or eczema
e) a risk for cancers associated with or affected by hormones
v. severe side effects can include
a) rash/hives
b) itching
c) difficulty breathing
d) tightness in chest
e) swelling of mouth, lips, tongue, face
f) vaginal bleeding
12. dietary phytoestrogens are naturally found in foods. these compounds may produce effects similar to estrogen; they are found in cereal, legumes, and grasses.
a. three main groups of phytoestrogens: isoflavones, lignans, and coumestans
i. isoflavones are found in soy, garbanzo beans, and other legumes. they may be consumed in the form of soy, miso, tofu, alfalfa, and peanuts.
ii. lignans are found in seed oils such as flaxseed and sesame seeds as well as in cereals (rye, wheat, oats, barley); cruciferous vegetables (broccoli, cabbage); and some fruits (apricots, strawberries).
iii. Coumestans are found in red clover, sunflower seeds, and bean sprouts.
b. phytoestrogens are thought to be helpful in minimizing hot flashes, maintaining bone density, and lowering cholesterol, ldls, and triglycerides.
c. natural progesterones manufactured from wild yams: patients should be discouraged from using otC preparations of topical progestins for their progesterone imbalance because there is no standardized compounding. replacement hormones are usually synthesized.
13. melatonin
a. Found in many plant sources, including, but not limited to
i. Feverfew
ii. Bananas, cherries, grapes, and tomatoes
iii. rice and corn
iv. olives
b. mechanism of action
i. acts as a free radical scavenger and wide-spectrum antioxi- dant with an inflammatory effect
c. indications for use
i. sleep disorders—by acting to help synchronize the body clock
d. recommended dosages
i. sleep disorders
a) difficulty falling asleep—melatonin 5 mg, 3 to 4 hours before bedtime for at least 4 weeks
b) difficulty staying asleep—a controlled-release dose 2 hours before bedtime
e. toxicity/ adverse reactions
i. depression
ii. dizziness
iii. excessive daytime somnolence
iv. headache
v. nausea
f. avoid driving after ingestion of melatonin
14. other modalities
a. relaxation techniques
b. Biofeedback
c. meditation
d. tai chi and qigong
e. yoga
f. acupuncture
this technique can help the body regain homeostasis, thus making it better able to adapt to change without increasing stress.
g. ayurvedic and Chinese herbals may also be used. there are several preparations on the market. although readily available otC, women should be advised to consult with an ayurvedic or Chinese medicine provider prior to using.
h. homeopathic remedies are based on the premise that the body has the capacity to heal itself. Formulas are compounded that use minute quantities of an agent to trigger the body’s innate capacity to heal. preparations specific to a symptom can be found in health food stores for self-treatment. homeopathic practitioners are also available to work with a patient to customize preparations to fit the person’s symptoms.
B. premenstrual syndrome
1. B complex vitamins
a. Usual dose 50 to 300 mg/d; best taken with food
b. symptoms
i. stress/depression
ii. Water retention (especially B6)
c. toxicity/adverse effects
i. When taken on an empty stomach, can cause nausea
ii. When taken late in day, can cause restlessness and dreams
2. vitamin B6—usual dose 100 to 200 mg/d
3. magnesium—usual dose 200 to 400 mg/d
4. vitamin e—usual dose 400 to 600 mg/d may help to relieve breast tenderness
5. eFas—also helpful with dysmenorrhea
a. Usual daily dose—as indicated on individual preparation/no daily optimum dose
b. Conditions
i. help to reduce depression, irritability, cramps, nausea, bloat- ing, and headaches. Correct balance of eFas is essential for the rebuilding and production of new cells—decreases inflammation, moderates hormone imbalance.
6. licorice (Glycyrrhiza glabra)
a. Usual daily dose varies with preparation
b. Conditions addressed—lowers estrogen and increases proges- terone; helps in irritability, mood swings; stimulates adrenal glands
c. toxicities—should not be used by women with kidney problems, high blood pressure; patients taking potassium; can increase water retention. not advisable for use in persons who are on low-salt diets or persons taking diuretics, corticoid treatments, cardiac glycosides, or medications for hypertension.
7. Black cohosh (Cimicifuga racemosa)
a. Usual daily dosage—as indicated on individual preparation
b. Conditions
i. nervousness/anxiety
ii. irritability
iii. sleep disturbances
iv. depressive moods
v. headache
vi. mood swings
8. evening primrose oil—from the oil of the primrose plant/closely related to eFas
a. Usual daily dosage—as indicated on individual preparation
b. Conditions addressed
i. vasomotor symptoms
ii. Cyclical breast tenderness
c. toxicities
i. should not be used by women with seizure disorders
C. depression
1. depression is a serious condition, and the use of alternative medications has not been proven to be effective. any alternative method should be used with extreme caution and only with the guidance of an experienced professional.
2. however, alternative methods may be added to traditional medi- cine, including
a. acupuncture
b. aroma therapy
c. Biofeedback
d. meditation
e. relaxation therapy
f. yoga
g. dietary supplements
i. essential fatty acids
ii. B complex vitamins; B6 is especially helpful
See Appendix F and Bibliographies.
Websites: www.ncbi.nlm.nih.gov/pubmed?term=complementary%20alternative% 20medicine; nccam.nih.gov; www.therapeutic-touch.org; www.herbalgram.org
NOTES
1. Consult the guideline on emotional and mental health issues in Chapter 11.
2. a. C. ross, J. e. manson, s. a. abrams, J. F. aloia, p. m. Brannon,
s. K. Clinton, … s. a. shapses. (2011). the 2011 report on dietary reference intakes for calcium and vitamin d from the institute of medicine: What clinicians need to know. Journal of Clinical Endocrinology and Metabolism, 96(1), 53–58. doi: 10.1210/jc.2010–2704