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Alternative treatments
for menopausal symptoms
Qualitative study of women's experiences
Maja M. Seidl, MHSC Donna E. Stewart, MD, FRCPC

OBJECTIVE To describe women's experiences with alternative treatments for symptoms attributed to menopause.
DESIGN Descriptive qualitative study.
SETTING Personal interviews and focus groups were conducted in private rooms at The Toronto Hospital;
telephone interviews were conducted at mutually convenient times.
PARTICIPANTS Thirteen perimenopausal women with a mean age of 52.6 2.6 years who were experiencing
symptoms attributed to menopause and were using alternative therapies participated in the study.
METHOD Women using alternative therapies for menopausal symptoms were recruited via posted notices and were
screened over the telephone. Data were collected during semistructured personal interviews, telephone interviews,
and a focus group. All interviews were audiotaped, transcribed, and mailed to participants for verification.
Recruitment continued until theme saturation was reached.
MAIN FINDINGS Because of their "natural" origin, the women perceived alternative treatments to be safe and
considered them somewhat effective. Factors influencing use of alternative therapies included personal control over
health, confidence in advice from nonphysicians, perceived pressure from physicians to use hormone replacement
therapy, and physicians' disinterest and frequently negative attitudes toward alternatives.
CONCLUSION Personal control was a central issue. Helping women during their menopausal years feel they have
some control over their health, including their informed choice of treatments, might help them to trust their
physicians more and to feel more confident in their ultimate treatment decisions, which might include
improvements in health behaviour.

OBJECTIF Decrire l'experience de femmes ayant eu recours aux medecines douces dans la therapie symptomatique
de la menopause.
CONCEPTION Etude descriptive qualitative.
CONTEXTE Des entrevues individuelles et des groupes de discussion ont eu lieu dans des salles privees du Toronto
Hospital; des entrevues telephoniques ont ete organisees 'a des moments propices aux interlocuteurs.
PARTICIPANTS Ont participe 'a l'etude 13 femmes en perimenopause, dont l'age moyen se situait entre 52,6 2,6
ans, souffrant de sympt6mes attribues 'a la menopause et suivant des therapies de medecines douces.
METHODE Des avis ont ete affiches aux fins de recruter des femmes qui suivaient des therapies de medecines
douces pour leurs symptomes de menopause. Celles-ci ont ensuite ete selectionnees 'a la suite d'une entrevue tele-
phonique. Les donnees ont ete recueillies durant des entrevues individuelles relativement structurees, au telephone
et dans des discussions de groupe. Toutes les entrevues ont fait l'objet d'un enregistrement sonore. La retranscrip-
tion a ensuite ete envoyee aux participantes par la poste aux fins de leur ve'rification. Le recrutement s'est poursuivi
jusqu'a ce qu'on ait epuise le thieme 'a etudier.
PRINCIPALES CONSTATATIONS En raison de leur origine naturelle, les femmes percevaient ces traitements de
medecines douces comme etant securitaires et d'une certaine efficacit&. Au nombre des facteurs qui influencaient ces
femmes 'a utiliser des therapies d'appoint sont ressortis la maitrise de leur propre sante, la confiance accordee aux conseils
de praticiens non medicaux, et l'impression que les medecins preconisent davantage l'hormonotherapie substitutive, qu'ils
manquent d'interet ou sont souvent negatifs a l'endroit des medecines douces.
CONCLUSION La maitrise de sa propre sante etait au cceur de la question. Aider les femmes, durant leurs annees
de menopause, 'a sentir qu'elles ont une certaine maitrise sur leur sante, notamment la possibilite de faire des choix
eclaires, pourrait contribuer 'a ce qu'elles aient davantage confiance en leur medecin et qu'elles se sentent plus 'a
l'aise avec les decisions qu'elles prennent en bout de ligne, ce qui pourrait comporter notamment de meilleures
habitudes de vie.

This article has been peer reviewed.

Cet article a fait l'objet d'une evaluation externe.
Can Fam Physician 1998;44:1271-1276.

- FOR PRESCRIBING INFORMATION SEE PAGE 1368 VOL 44: JUNE * JUIN 1998 +Canadian Family Physician . Le Medecin defamille canadien 1271
 RESEARCH
Alternative treatnents
for menopausal symptoms
se of alternative and complementary thera-
I I I I
pies is on the rise in Canada. The 1995
National Population Health Survey' of
17626 Canadians revealed that an estimat-
ed 15% of those aged 15 and older (3.3 million people)
had used some form of alternative health care in the
year preceding the survey. Alternative health care use
was most prevalent among women, among people
aged 45 to 64, and among those with higher incomes.
Interest in using alternative medicine for manag-
ing menopausal symptoms has increased greatly dur-
ing the last few years. '4 As approximately 4 million
Canadian women are now perimenopausal or post-
menopausal5 and demographic projections show that
the number of women in older age groups is increas-
ing,6 use of alternatives for menopausal symptoms is
likely to continue to increase. Despite this trend, the
available scientific literature on the safety and effica-
cy of alternative treatments for menopausal symp-
toms fails to provide scientific evidence for the
effectiveness of any of these treatments.
This study aims to describe women's experiences
with and to identify their motivations for using alter-
native treatments for menopausal symptoms. We
hope to familiarize family physicians with the reasons
women seek alternatives, the factors that affect their
decisions, the perceived effectiveness of the alterna-
tive treatments, women's views on hormone replace-
ment therapy (HRT), and their views on their
physicians' attitudes to alternative treatments.
METHOD
Qualitative methods were used to explore women's
experiences with alternative treatments. Ethics
approval for the study was obtained from The
Toronto Hospital Committee for Research on Human
Subjects. Subjects were recruited via notices posted
in downtown Toronto hospitals, women's clinics,
health food stores, a hospital newsletter, and pam-
phlets left at alternative health care providers' and
physicians' offices.
Potential subjects were screened by telephone to
determine study eligibility (ie, menopausal woman
Dr Stewart is Professor ofPsychiatry, Obstetrics and
Gynecology, Anesthesia, Surgery, and Medicine in the
Department ofFamily and Community Medicine at the
University of Toronto. Dr Stewart is also the Lillian Love
Chair of Women's Health at the Toronto Hospital and
University of Toronto. Ms Seidl is Chair of Women's Health
at The Toronto Hospital and the University of Toronto.
1272 Canadian Family Physician Le Medecin defamille canadien 4 VOL44: JUNE * JUIN 1998
I
experiencing symptoms attributed to menopause
using one or more alternative treatments). Subjects
were recruited until an adequate sample was
attained, as determined by the achievement of
theme saturation with no new information uncov-
ered. All interviews used the same structure and
key questions, including symptoms that women
commonly attribute to menopause, reasons women
do or do not use HRT, sources of alternative prod-
ucts, sources of information about alternative prod-
ucts, the role of cost, effectiveness and any
perceived side effects of alternatives, and physi-
cians' awareness of patients' use of alternatives.
Interviews were not modified by ongoing analysis. A
search for contradictory responses and common
themes was undertaken during categorical summa-
ry and synthesis of the data.
Three methods were used in data collection:
semistructured personal interviews with nine sub-
jects, telephone interviews with two subjects, and a
focus group involving three subjects, to allow triangu-
lation and to assist reliability. All interviews were
audiotaped and transcribed by the interviewer.
Confidentiality was ensured by using unique identify-
ing codes. Personal interviews and focus groups
were conducted in private rooms at The Toronto
Hospital. Participants were mailed copies of their
own transcribed interviews so they could validate
their responses. Following each interview, partici-
pants were asked to complete an anonymous ques-
tionnaire on age and personal data, symptoms
associated with menopause, history of HRT use, and
use of alternative treatments.
Both authors were involved in study design, data
analysis, and manuscript preparation. The interview-
er's role also included recruiting subjects, conduct-
ing and transcribing interviews, and summarizing
findings.
Main findings
Average age of participants was 52.6 2.6 years.
Twelve of the 13 subjects had college or higher
education. Despite efforts to recruit women from a
variety of ethnic backgrounds, all women were
white. Eight women were currently married or liv-
ing with partners. Nine women had children (mean
age of children 24.5 4.1 years); five of these had
children living at home. Subjects' occupations
included teachers (four), nurses (three), writers
(two), homemakers (two), pharmacist (one), and
executive secretary (one). Several themes emerged
from the analysis.

Context of menopause. Menopause occurred
when many other changes were taking place in
women's lives. These changes included coping
with aging parents, "My emotional state is partly
associated with menopause, but I also had a very
difficult time with my father, who went into a nurs-
ing home about a year ago." Dealing with adoles-
cent children also coincided with menopause for
several women, "I got very emotional over any-
thing, but I don't know if that was a stage of my life
run by menopause or due to very strong-willed
teenage children at home who I was trying to deal
with." Death of a spouse occurred during
menopause for one woman, 'There was a lot going
on with the death of my husband, so I can't
attribute everything to menopause, because at that
time my whole life changed."
Menopause in the context of aging also emerged
as a theme. One woman said, "I had to get a grip that
we can still exist and be over 50," and another admit-
ted, "I certainly think more about aging than I used
to, and that surprised me. I am more conscious of
looking older than I would like to be."
Symptoms attributed to menopause. Several
common symptoms associated with menopause
were identified. Hot flashes with accompanying
night sweats and sleeping difficulties were
reported by almost all subjects. Emotional
changes were commonly reported, including
depression, mood swings, anxiety, increased irri-
tability, personality changes, and "feeling very
emotional." Symptoms identified less frequently
included vaginal dryness, decreased libido, mem-
ory loss, and weight gain.
Fear of side effects of HRT. Women were asked
about their reasons for using or not using HRT. Only
three of the 13 women had ever used any form of
HRT. Two of the women currently taking HRT and
alternative treatments were satisfied, "I feel fitter
physically and mentally now that I am on HRT."
Among those not using HRT, fear of cancer
emerged as the primary deterrent. Most women
also stated that they preferred to deal with
menopause "naturally" (ie, through use of alterna-
tive treatments). "I am not keen on taking hormones
if I don't have to; I would rather take a natural reme-
dy." Another stated, 'Women think they don't need
HRT since their mothers did not need it. They are
afraid of the side effects, and they want to know
what else is available."
VOL44: JUNE * JUIN 1998 + Canadian Family Physician . Le Medecin defamille canadien 1273
RESEARCH
Alternative treatnents
for menopausal symptoms
Alternative product sources. Health food stores
were the primary sources of alternative products.
Several women also reported visiting and obtaining
remedies from naturopaths, homeopaths, chiroprac-
tors, and massage therapists.
Personal control. Personal control emerged as an
important issue.
Women are not aware of what is out there... I would like to tell
women that there are alternative methods and that they don't
just have to listen to their physician who will tell them which
hormones to take, like in a candy store.
Another said,
You have to create your own way to enjoy and enhance your
life.... All of that alternative stuff makes you feel more in
contiol of what is happening to you; that it is your body and
that it is your privilege and right to make decisions about
what you do.
A woman with a family history of breast cancer
said, "Knowing that I was advised not to take hor-
mones and that I would have to cope with
menopause, I am going to cope with it, using alter-
natives when I need them." Another woman said, "I
feel good that I am doing something positive for
myself, and that's important."
Information and decision making. Lay informa-
tion sources, including magazines, books, television
shows, friends, and health food store personnel, were
cited most frequently as sources of information on
alternative treatments. "I have a friend who is into all
of this alternative stuff. I also went to libraries and
health food stores where they are very knowledge-
able." Several subjects were confident in the validity
of the advice offered by health food store employees,
'The person I went to at the health food store was
great. Everything she said was right on." A few par-
ticipants, however, were not satisfied with the infor-
mation available at health food stores, 'There is not
enough information at health food stores for con-
sumers, and I don't really trust the information."
One woman identified the existence of a placebo
effect and the importance of taking personal control
of her health as factors in her decision,
I feel that the information from health food stores and maga-
zines was quite accurate, but it may be psychological because I
read all of these things and then I feel it. I feel good that I'm
doing something positive for myself.
None of the women felt pressured to purchase,
either from health food stores or alternative health
care providers. None mentioned the potential conflict
of interest that health food stores or alternative
 RESEARCH
*---00000000000000
Alternative treatments
for menopausal symptoms
providers might have in recommending products that
they directly market.
Cost played a role in decision making for about
half the subjects. One said,
You can go to a health food store and get all of the things you
need for menopause, but it makes it terribly expensive. When I
run out, I really have to think about going back.
For others, cost was not a great obstacle. An evening
primrose oil (EPO) user said, "I like to buy it on sale,
but I will not stop buying EPO no matter what the
cost, because it has made my life so much more bear-
able." One woman who said she is usually quite
thrifty indicated that when it came to her health,
money was no object, "I feel there is no cost [limit] to
health. It was money well spent."
Effectiveness and side effects. A variety of alter-
native treatments were cited as helpful in treating
symptoms attributed to menopause. The most popu-
lar was EPO, followed by vitamin E, dong quai, soy
products, homeopathic remedies (pulsatilla, lach-
esis, and sepia), menopausal herbal combinations,
and vitamins.
Evening primrose oil was used predominantly for
hot flashes, either alone or in combination with other
remedies (making it difficult to discern its effective-
ness). Most EPO users found it very effective, "Since
I don't take anything else but the EPO, I have to
attribute to EPO the fact that the hot flashes went
away in a month or two."
Some women also found soy products to be help-
ful with hot flashes. As one said, "Since I have been
taking soy milk, I have not had any hot flashes."
Another said, "Maybe it is psychological, but I feel
positive about the soy. I think I just take it because I
know it's supposed to help you." This nonspecific
effectiveness was also attributed to wild yam, "I can't
attribute any change to it specifically, but I think the
wild yam did help," and to vitamin E,
I can't tell you that there was a drastic improvement because I
didn't see anything like that with the vitamin E. It was sort of
gradual because over months and years it got better.
The natural abatement of menopausal symptoms was
seldom considered by the women in the attribution of
improvement over months or years.
Ginseng and dong quai were both noted as mak-
ing women feel more energetic, "Dong quai gave me
higher energy levels and stamina," and, "Ginseng
increased my energy levels." One woman also found
that dong quai decreased her hot flashes.
1274 Canadian Family Physician Le Medecin defamille canadien * VOL 44: JUNE * JUIN 1998
Homeopathy was beneficial for some,
Homeopathy finished what was slowly happening;... it made
menopause happen with minimal discomfort compared to other
people, accelerating the natural process of menopause.
Another woman said, "Sepia (a specific homeopathic
remedy) is magic for night sweats. I could not believe
it." One user of homeopathy summed up her feelings
on homeopathy and alternatives with, 'Time cures
everything they say, and I had a helping hand with
these alternative things."
None of the women had noticed any side effects
from the alternative treatments they were using.
Most of the women believed that, because the alter-
natives were "natural," they were somehow safer
thafi prescribed medication,
I did not have any side effects. That's why I like the herbal
things. I don't feel they give me any side effects, while I do get
bad reactions from prescription drugs.
Physician awareness of patients' use of alter-
native therapy. Most participants admitted that
their physicians were not aware they were using
alternative remedies. A variety of reasons were
given, including physicians' lack of interest in alter-
natives, "My doctor doesn't ask me and he doesn't
seem interested"; the perception that physicians feel
threatened by alternatives, "I get the feeling my MD
feels a little bit threatened by alternative medicine";
lack of time for exploring patients' use of alterna-
tives, "No, my doctor doesn't know. He doesn't care.
They are so busy."
A lack of communication was also evident from
some comments,
My MD is not aware that I am taking anything else, and he
probably doesn't even know that I am no longer on HRT. I will
probably get a lecture about osteoporosis, heart disease, and
the fact that my organs are dying [when he finds out].
Some participants said their doctors were
aware they were using alternatives and that their
responses varied from indifference to support.
Comments included, "My doctor knows that I am
trying alternative treatments, but I don't think he
cares"; "My doctor knows I take alternatives....
He says, 'If it works, take it"'; and "My family doc-
tor is aware and she is very supportive." Some
women said they felt pressured by their physi-
cians to use HRT,
My old doctor knew that I was into natural therapies, but she
was always pushing HRT. It got to the point where she was
harassing me and I was not comfortable with that.

Conflict in health professionals' use of alter-
native treatments. Health professionals (nurses
and the pharmacist) were asked whether they
ever experienced conflicts between their medical-
ly oriented training and their personal use of alter-
native treatments. Most admitted they tended to
be more critical of the alternatives and they expe-
rienced some conflicts. A nurse summarized her
feelings as,
I have to compartmentalize myself somewhat because I find
that I have conflicts inside, but nursing helps to pay the
bills.... 1-guess my problem with medicine is the need for
double-blind, placebo-controlled studies. When you are deal-
ing with a lot of these alternatives, you are dealing with quali-
tative evidence.
Discussion
This study provides qualitative comments on some
of the issues involved with menopause, motivations
for using alternative treatments, factors involved in
decisions, women's personal experiences with
alternative treatments, and their perceptions of
their physicians' attitudes toward alternative medi-
cine. With the increasing use of alternative health
care, this information might enhance family physi-
cians' understanding of patients' motivations and
ability to address patients' questions about
menopausal treatments. While the selection
process did not purposefully choose satisfied users
of alternative therapies, most participants were sat-
isfied with the products and were thus self-selected
to participate. This might explain the absence of
contradictory findings.
This study describes menopause as a time in wom-
en's lives when they need to cope with changes or dif-
ficult situations that often are linked to a sense of loss
of control over their lives and that also make it diffi-
cult for women to be certain that their symptoms are
solely due to menopause. Hot flashes and night
sweats were identified as the symptoms most com-
monly attributed to menopause and most frequently
responsible for the search for treatment.
Despite medical evidence for HRT use, the women
interviewed were mos,tly against HRT, predominantly
for fear of cancer. The scientifically proven benefits of
HRT (ie, short-term symptom relief, cardiovascular
and bone protection) were not seen to outweigh the
potential risks and side effects of HRT.
Professional advice (from either medical doctors
or alternative health care providers) did not emerge
as an important factor in decision making about initi-
ating alternative treatment. Lay information and
VOL 44: JUNE * JUIN 1998* Canadian Family Physician . Le Medecin defamille canadien
RESEARCH
Alternative treatnents
for menopausal symptoms
f Key points
Il Use of alternative therapies for menopausal symp-
| toms provides women with a sense of control over
|
this period of adaptation.
Physicians' attitudes to alternative therapies vary
from support to opposition; women feel pressured by
their physicians to use hormone replacement therapy.
w
advice from friends and health food store employees
was more influential. While cost was a factor for some
women, the real or perceived benefits of alternative
treatments were usually felt to be worth the price.
Women did not seem concerned about potential side
effects or long-term hazards of alternative treat-
ments, believing that because alternatives are "natur-
al," they are free from harmful effects. Since the toxic
effects ofsome "natural" products and product substi-
tution or unreliable doses have been documented,7
this lack of concern reflects a lack of adequate infor-
mation about these products and might suggest a
teaching opportunity for family physicians.
A lack of communication and lack of coonfidence in
physicians was evident among many of the women
who admitted that their physicians were unaware of
their use of alternatives. While many physicians have
difficulty supporting their patients' use of alternative
therapies because of the lack of scientific evidence
about the safety and efficacy of these products, it is
important that they are aware of what their patients
are using and that they assess possible reactions and
interactions with other medications and monitor for
potential side effects or toxicity.
Several women said they felt pressured by their
physicians to use HRT. Despite family physicians'
professional responsibility to inform women fully
about the strength of scientific evidence supporting
HRT use for acute menopausal symptoms and pro-
phylaxis of osteoporosis and cardiovascular disease,
the choice of treatment is ultimately their patients'.
Personal control was clearly a central issue for many
of the women interviewed in this study.
Conclusion
Helping women feel they have control over their
health during menopause, including their informed
choice of treatments, might assist them to trust
their physicians more and to feel more confident in
their ultimate treatment decisions, which might
include health behaviour improvements with or
without HRT
1275
 RESEARCH
Acknowledgment
Funding was provided through a Medical
Research Council of Canada Summer
Research Scholarship to Maja M. Seidl.
Correspondence to:DrDonna E. Stewart,
The Toronto Hospital, 200 Elizabeth St,
EN-1-222, Toronto, ON M5G 2C4; tele-
phone (416) 340-3846; fax (416) 340-4185;
e-mail dstewart@torhosp.toronto.on.ca
References
1. Millar WJ. Use of alternative health care
practitioners by Canadians. Can J Public
Health 1997;88:154-8.
2. O'Leary CJ. Why women choose not to take
HRT. A Friend Indeed 1993;10:1-3.
3. Wind Wardell D, Engebretson JC. Women's
anticipation of HRT. Maturitas 1995;
22:177-83.
4. Notelovitz M. Non-hormonal management
of menopause. In: Berg G, Hammar M,
editors. The modern management of meno-
pause: a perspective for the 21st century. New
York: Parthenon Publishing Group Ltd;
1994. p. 513-24.
5. Society of Obstetricians and Gynaecologists
of Canada. Canadian Menopause Consensus
Conference. Journal SOGC 1994;16:1645-97.
6. Pinn VW. Women's health issues: a US per-
spective. Can J Obstet Gynecol 1994;6:671-5.
7. Cetaruk EW, Aaron CK. Hazards of
nonprescription medications. Emerg Med
Clin North Am 1994;12:483-510.
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