11830 Westline Industrial Drive St. Louis, Missouri 63146 WOMEN’S HEALTH IN COMPLEMENTARY AND INTEGRATIVE MEDICINE: ISBN 0-443-06639-6 A CLINICAL GUIDE Copyright © 2005, Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail: [email protected]. You may also complete your request on-line via the Elsevier Science homepage (http://www.elsevier.com), by selecting ‘Customer Support’ andthen ‘Obtaining Permissions’. Distributed in the United Kingdom by Churchill Livingstone, Robert Stevenson House, 1-3 Baxter’s Place, Leith Walk, Edinburgh EH1 3AF, Scotland, and by associated companies, branches, and representatives throughout the world. Notice Knowledge regarding the proper use of drugs, herbs, and supplements is ever changing. Standard safety precautions must be followed, but as new research and clinical experience broaden our understanding, changes in use may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each product to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating licensed practitioner, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. This publication is not intended as a substitute for medical therapy nor as a manual for self-treatment. Readers should seek professional advice for any specific medical problems. Neither the Publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from this publication. International Standard Book Number 0-443-06639-6 Publishing Director:Linda Duncan Editor:Kellie White Developmental Editor:Jennifer Watrous Editorial Assistant: Kendra Bailey Publishing Services Manager:Linda McKinley Project Manager:Judy Ahlers Design Project Manager:Bill Drone Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 From the midwives in the village to the physician in the clinic to the scientist in the research laboratory—this book is dedicated to all who work tirelessly to improve the health and well-being of women throughout the world. TLD and MSM Preface The landscape of complementary and alternative medicine (CAM) has changed dra- matically since I started practicing as an herbalist in the desert Southwest 25 years ago. The marketplace has expanded at a pace that far outstrips that of research. With newspa- pers, magazines, and mass media providing a steady daily diet on the risks or benefits of a particular herb, nutritional supplement, or CAM practice, much misinformation abounds. The scientific data are confusing and contradictory, leaving patients confused and overwhelmed by their choices. Separating practices and products of possible benefit from those of poor quality or with little evidence of efficacy is a daunting task, especially for practitioners with limited time and minimal experience. This book was written to help health care providers become more conversant in offering informed guidance to women in their use of integrative treatment strategies. Integrative medicine—the term being used by a growing number of practitioners who recommend both conventional and CAM therapies—describes an effort to offer patients the best of evidence-based treatments. If acupuncture reduces chemotherapy-induced nausea and vomiting, patients should be encouraged to seek the services of a trained acupuncturist. If calcium or chastetree berry safely reduces the symptoms of premenstrual syndrome, this should be conveyed to women as part of a treatment plan. If there is no evidence that essiac or shark’s cartilage cures cancer, the public should be told in no uncer- tain terms, while practitioners gently guide patients to proven therapies. Each treatment must be judged objectively and not simply accepted, or rejected, because it is conventional or CAM. One day in the future I hope we discard these arbitrary terms and simply embrace the practice of medicine, in all of its unique forms. Until that time, the term integrative medicine most closely reflects my own philosophy. This book takes an evidence-based approach to numerous practices and products used by women either to treat an illness or to enhance their health and well-being. Critical analysis of the scientific evidence is essential for clinicians, yet it is only part of the prac- tice of medicine. Most women want to know what works so they can base their health care decisions on the evidence. But they also want to be treated with kindness, compassion, and respect by their health care provider. They want to be seen as whole human beings: as part of a family, community, faith, culture. Women want to be listened to and have their viewpoint considered. vii viii Preface The therapeutic relationship is a sacred one. Every patient encounter is an opportunity to sow the seeds of healing. As providers of health care, we must remember that we are healers first and foremost; we use science as our foundation so that we may effectively practice the art of medicine. For when the soul, not just the body, is nurtured and cared for, we enhance the lives of our patients and maybe even…our own. Tieraona Low Dog, MD Corrales, New Mexico May 2004 Acknowledgments This book was birthed only through the generous mentoring, help, and encouragement I have received from teachers, colleagues, students, and friends over the many years. From the martial arts instructors who trained my body and disciplined my mind to the mid- wives, herbalists, and physicians who taught me the wonders and magic of the plants, medicine, and healing; I have been blessed by many in my life. There are a few, though, that I would like to specifically acknowledge: Arthur Kaufman, MD, and Alan Firestone, MD, whose passion for medicine inspired me throughout my medical training and beyond; Rosemary Gladstar, David Winston, David Hoffman, Michael Moore, Roy Upton, and Mark Blumenthal, whose love and commitment to herbal medicine has helped keep this noble tradition alive in the United States. There are those in the academic and scientific com- munities who have been mentors and friends along my journey: Fredi Kronenberg, PhD, Adriane Fugh-Berman, MD, Andy Weil, MD, Steven Strauss, MD, David Eisenberg, MD, Dennis Awang, PhD, and most especially the late Varro Tyler, PhD. My sincerest gratitude to Joseph Fins, MD, medical ethicist and physician, whose critical mind, uncompromising integrity, and unwavering friendship were invaluable as we co-wrote our minority state- ment for the White House Commission on Complementary and Alternative Medicine Policy. I would also like to express my deepest appreciation to Marc Micozzi, MD, PhD and the folks at Elsevier Publishing, without whom this book would never have made it to print. A special thank-you goes to Viola Gutierrez, my delightful and infatigable assistant, who manages both my office and home with unerring aptitude; Jim Carnazzo, for his loving friendship; and most importantly, my children, Mekoce and Kiara, who are my most wondrous teachers and most delightful companions. Thank you for your patience, love, understanding, and support. Tieraona Low Dog, MD June 2004 ix SECTION One Current Concerns About Women’s Health The use of complementary/alternative medicine (CAM) and integrative medicine is widespread and on the increase among American adults, especially women. This fact underscores the importance of com- municating with patients about CAM and integrative medicine. The results of a recent survey showed that two thirds of adults claimed use of CAM by the age of 33 years. The use of CAM is most widespread among post–baby boomers (7 of 10), with only 5 of 10 baby boomers and 3 of 10 preboomers turning to CAM. These trends may represent an openness to CAM on the part of baby boomers that relates more to the management of medical conditions more common among older Americans than to lifelong attitudes inclusive of “holistic” healing among younger Americans. Two thirds of health maintenance organizations offered at least one type of alternative therapy as of 1999, with acupuncture, massage, and nutritional therapy the modalities most likely to be covered. The best predictor of CAM use is higher education, perhaps reflecting a greater amount of disposable income, as well as knowledge, awareness, and attitudes about CAM. Regional variations are quite consistent, with one half to two thirds of respondents from such diverse areas as South Carolina, Northern California, Florida, and Oregon indicating that they use CAM. As many as half of all patients who use CAM do not tell their physicians that they are doing so, indicating that much work on the integration of CAM into the continuum of care remains to be done (see Chapter 1). A high proportion of adults with cancer—80% or more, according to the findings of several surveys—use CAM. In one study, 40% of CAM users abandoned conventional care after turning to CAM. As many as 74% of patients with breast cancer said they used CAM, despite the relative effectiveness of conventional care. CAM use is also common among patients with neurologic diseases, psychiatric disorders, physical disabilities, psoriasis, and diabetes, among other ailments. The range of CAM modalities is reflected by the topics covered in this book. In addition to the management of medical conditions, CAM therapies have gained increasing attention in the prevention of chronic disease. Although CAM is often considered a means of achieving a healthy lifestyle and preventing disease, much evidence exists to support the effectiveness of CAM in treatment. Increasing numbers of clinical trials of CAM are being conducted, whereas prevention trials are larger, longer, more costly, more complex, and, ultimately, rarer. Obesity is increasingly recognized as a major contributor to chronic medical conditions and as a source of morbidity and mortality. Losing or managing weight is an important means of preventing disease. Controversy over the safety of ephedra has clouded the issue of herbal remedies in weight loss and has motivated efforts by Congress to enforce regulatory actions against all dietary supplements (see Chapter 2). The role of dietary supplements in optimal health is increasingly recognized. A 2003 article by Fairfield and Fletcher1,2 documented the importance of nutrition and provided clear substantiation of the role of 2 SECTION ONE Current Concerns About Women’s Health dietary supplementation in light of the typical American diet and the nutrient composition of foods. The use of dietary supplements is already prevalent among older Americans, especially women. References 1.Fairfield RH, Fletcher KM: Vitamins for chronic disease prevention in adults: scientific review, JAMA287:3116, 2002. 2.Fletcher RH, Fairfield KM: Vitamins for chronic disease prevention in adults: clinical applications, JAMA 287:3127, 2002. CHAPTER 1 Communicating with Patients About Complementary and Integrative Medicine This book is designed to serve as a bridge between two great bodies of knowledge. On one side is traditional Western medicine, with its basis in biomedical science. On the other is complementary/alternative medicine (CAM), with its emphasis on the whole person, often in subtle but profound ways that we are now only beginning to under- stand. Like any bridge, the one between these two approaches requires a firm foundation on each side of the span. The two forms of medicine share certain fundamental strengths: an internally consistent theoretical basis, extensive empirical evidence, and observable results. Beyond those broad commonalities lie differences in the specifics of philosophy, conceptual framework, techniques, and, sometimes, even objectives. Together the two great bodies of medical knowledge provide a vast array of healing possibilities. Whereas 80% of the world’s population is confined to the limited range of health care options offered by local cultures, Americans have the unique and historical opportunity to integrate the best of the old and new healing practices of the Americas, Europe, Asia, Africa, the Middle East, and elsewhere. In modern health care we have discovered that these different practices are not mutu- ally exclusive and, indeed, they work well together. Eastern and Western systems, ancient techniques, and new therapies—all can be evaluated, selected, and combined in ways that greatly extend the spectrum of healing for an individual and for society. As exciting as these choices are, knowing how or when to start making them is not simple. What criteria should be used to evaluate alternative/complementary therapies? When is it time to rely on traditional Western care? What about homeopathic remedies for insomnia or acupuncture treatments for chronic pain? Can St. John’s wort and Prozac be used at the same time? Should you undergo therapeutic touch before, during, or after 3 4 SECTION ONE Current Concerns About Women’s Health surgery? How can you design a lifestyle or care plan that comfortably combines conven- tional and alternative/complementary treatments? This book will guide you through the process of understanding alternative/comple- mentary therapies and how they can be successfully integrated with traditional Western care. It will help you learn how to draw on a larger repertoire of healing therapies and sys- tems to get the full benefit of all the resources available from the world health community. Many people in the world rely on ethnomedicine, in which a local healer who has an ongo- ing relationship with the patient uses traditional methods to address the whole individual, encouraging the patient to take an active role in the healing process. These indigenous approaches—some of which are highly sophisticated systems that have been used effec- tively for centuries or even millennia—have often been dismissed by the conventional Western medical community as primitive. Throughout the first half of the 20th century, cultural biases made it increasingly difficult for Americans to appreciate the richness of other health care traditions. We were appropriately impressed by advances in surgery, antibiotics, and other lifesaving technologies developed by the medical-scientific commu- nity. Western medicine seemed to be leaving everyone else behind. Then, in 1972, while in Peking covering President Richard Nixon’s visit, New York Timesreporter James Reston underwent an emergency appendectomy. Reston’s Chinese physicians used acupuncture for anesthesia during surgery and afterward for pain control, with excellent results. This became front-page news, introducing millions of Americans to the potential benefits of this ancient practice and launching a scientific and social debate that has continued to grow for three decades. WHAT IS COMPLEMENTARY/ALTERNATIVE MEDICINE? Broadly speaking, CAM is any therapy that is outside the American medical mainstream but is practiced by a significant number of people with observable results. Mainstream American medicine, or conventional Western care, can be defined as the allopathic approach—that is, the one used by physicians who hold MD degrees. It is also known as biomedicine because of its firm foundations in the hard science of biology. The term alternative medicinebecame part of the English language in the 1960s, when acupuncture and other Asian therapies first became known to mainstream Americans, who viewed them as an alternative, rather than as an adjunct, to conventional treatment. Many people, especially physicians, took exception to the term because of its exclusive, “either/or” connotation. A more accurate term, complementary,was adopted by some to describe those alternative therapies that were being used in conjunction with traditional Western medi- cine. As a means of combining this more accurate term with the more widely recognized original, the phrase complementary and alternative medicinewas coined, then shortened to the acronym CAM. More recently, the term integrative medicine was coined, implying an active, conscious effort by patient and physician to incorporate alternative and allopathic treatments in a cohesive approach. In this book, the terms alternative, complementary,and CAMare used interchangeably to describe the therapies and systems drawn from other tra- ditions that are now being used in conjunction with mainstream Western medicine. The plural term alternative medicines is used to emphasize that CAM is not a monolithic field but one that comprises many distinct traditions and approaches. The following criteria