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Homoeopathic treatment during the menopause
Homoeopathic treatment during the menopause Tessa Katz Nurses and midwives may not be directly involved in treating menopausal patients, nevertheless they are in a unique position to offer support and advice to patients concerned about the menopause. Many women want to know about ways of dealing with uncomfortable symptoms and fears associated with going through the menopause. Homoeopathic treatment is one form of therapy which can be used during the menopause, which takes into account both the physical symptoms and the emotional responses. Homoeopathic treatment can be used as an alternative to treatment with hormone replacement therapy (HRT), or alongside HRT, in the management of menopausal symptoms. As well as exploring homoeopathic approaches to the treatment of menopausal symptoms, the current trend of promoting HRT is questioned in this article.
This jigsaw puzzle of symptoms serves to indicate how fragmented our understanding of the changes occurring during the menopause really is. There are no known risks of using homoeopathic medicines, and the benefits are appreciated by a growing number of women... Tessa Katz Bsc, MBChB, MFHom, DRCOG, Royal London Homoeopathic Hospital, Great Orrnond Street, London WC I N 3HR, UK
(Requests for offprints to
TK)
INTRODUCTION Hormone replacement therapy (HRT) is currently being promoted as safe and effective for use in the treatment of menopausal symptoms, but there is controversy surrounding the safety of long-term HRT, and many women are experiencing unwanted side-effects. More and more women are turning to alternative ways of dealing with the symptoms experienced during the climacteric. This is illustrated by the number of books appearing on the 'natural' way to treat the menopause (Ojeda 1993, Melville 1992, Doress & Siegal 1989, Greenwood 1990). There are marked differences in the way individual women experience the menopause. This is taken into account when prescribing homoeopathic remedies. Conventionally, symptoms are separated into menstrual disturbances, bone mass deficiencies, cardiovascular abnormalities, hot flushes, and general problems with well-being. This jigsaw puzzle of symptoms serves to indicate how fragmented our understanding of the changes occurring during the menopause really is. The use of HRT relies on the idea that the menopause is an hormonal deficiency disease. There is still controversy about labelling the menopause as an 'oestrogen deficiency disease'. Symptoms may not be due to a reduction of oestrogen alone, and the previous psychological state of t~he woman may have an important part to play in how the symptoms are experienced.
The disease label implies that this is an illness to be treated. One may wonder why a normal reproductive ageing process in women is being labelled as a disease at all. In the conventional treatment of the menopause with HRT, improvement in menopausal symptoms is juggled with the possible increased risk of endometrial and breast cancer caused by long-term use of HRT. Long-term hormonal treatment implies long-term medical supervision, and possible diagnostic intervention. There are no known risks of using homoeopathic medicines, and the benefits are appreciated by a growing number of women attending the Royal London Homoeopathic Hospital's women's clinic and private homoeopaths. Nurses and midwives will have encountered patients who are confused about the menopause, its implications, and management. This article will highlight some of the symptoms, controversies about management, and homoeopathic treatment.
SYMPTOMS The climacteric period may extend for many years on either side of the time of actual cessation of menses. Symptoms may go virtually unnoticed by some women, but up to 30% of women will experience
ComplementaryTheropiesin Nursing& Midwifery (1997) 3, 46-50 9 1997PearsonProfessionalLtcl
47
Homoeopathic treatment during the menopause
Flushes may begin gradually, but typically they are experienced as an explosion of heat with sweating, feelings of irritation, anxiety or panic.
marked flushing and sweating during the menopause. Follicle stimulating hormone (FSH) changes can occur from about the age of 35 years, before any changes in menstrual pattern are evident, and before changes in oestradiol concentration occur (Reyes 1977). The increase in FSH is as a response to degenerating oocytes, despite normal menses. In 18% of women, the mean length of the premenopausal period is 4-5 years. 4% of women may experience pre-menopause for more than 9 years. Various combinations of hormonal patterns of FSH, luteinizing hormone (LH), and oestradiol can be observed during this period (Iles 1989). The post-menopausal state is regarded as 12 months after menses have ceased. Median menopause age is 50-51 (Treloar 1981). Typical temporary effects include irregular and/or heavy bleeding, flushing, sweating, and vaginal dryness. These may severely affect well-being. Increased sweating may be the first sign of the climacteric.
Irregular bleeding Beyond 45 years of age, the cycle may become erratic. There may still be luteinization of follicles with a low concentration of progesterone, but usually persisting follicles continue to produce oestrogen unopposed by progesterone, therefore causing unopposed thickening of the endometrial lining, and erratic and heavy bleeding.
Hot flushes Flushes may begin gradually, but typically they are experienced as an explosion of heat with sweating, feelings of irritation, anxiety or panic. Vasomotor disturbances are present in 41% of women over 39 years of age, despite regular cycles; in 85% of women at the menopause; and, in 57%, 10 years after the menopause (Oldenhave 1993). Severe flushes occur in 3% of women with regular cycles, 30% around the menopause, and 7% 10 years post-menopause. Flushes may range from 5 to 50 per day. They are more common after bilateral salpingo-oopherectomy, and after hysterectomy despite ovarian conservation, than with normally occurring menopause. The cause of flushing is not clearly understood. It is related to a change in hypothalamic function in response to ovarian feedback. Flushing is preceded by a spike of luteinizing hormone releasing hormone (LHRH) and not associated with changes in oestradiol concentration. There is a complex interaction of hormones in the hypothalamic-pituitary-adrenal axis associated with hot flushes. Flushes still occur after the removal of the pituitary gland. Oestrogen deficiency alone does not explain the incidence of hot flushes. Flushes are accompanied by cardiovascular changes, increased heart rate, and hand-blood flow, which decrease after the flush. Electro-encephalograph has shown seizure-like activity with flushes.
The associated tenseness, tiredness, irritability, headache, muscle and joint pains, and depression can mimic an agitated depressed state.
Vaginal dryness Vaginal dryness occurs in 16% of regularly menstruating women above the age of 39 years, 40-45% 4-10years after the menopause. 55% of women do not report this symptom (Oldenhave 1991). It is more common in women who have had a hysterectomy.
PERMANENT EFFECTS Oesteoporosis Bone loss occurs with ageing, leading to a low skeletal mass and increased risk of fractures. During a woman's lifetime, 50% of bone loss occurs from the spine, and 30% from cortical bone (Cummings 1989). Obviously, falls and trauma are important causes of fractures in osteoporotic bones. Genetic profile, calcium intake, and weight-bearing physical activity profoundly influence the height of peak bone mass, i.e. bone strength (Oldenhave 1994). Recent studies have examined the role of intake of excess protein and acid-forming foods in the promotion of osteoporosis, due to their effect of leaching calcium from bone (Sebastian et al 1994). The number of hot flushes experienced, and the extent of sweating, may predict a greater risk of osteoporosis (Te Velde 1994). The cause of the imbalance between bone resorbtion and formation leading to bone mass loss in menopausal women is not clear.
Ischaemic heart disease There is an increased prevalence of myocardial infarction, atherosclerosis, and alteration in lipid profile in women after the menopause. Administration of oestrogen lowers the risk of post-menopausal coronary artery disease, but this effect may be reduced by the combination of oestrogen and progesterone, which is now used in HRT. Perhaps the climacteric should be viewed as a dynamic and temporary adjustment process of the hypothalamus and other central nervous system centres, only initially triggered by defective feedback from ovaries.
C O N V E N T I O N A L MANAGEMENT OF THE MENOPAUSE: BENEFITS A N D RISKS No large-scale randomized study evaluating the benefits and risks of long-term unopposed oestrogen
48
Half of women prescribed HRT stop within 6 months, and 80% do so without telling their general practitioner.
In provoking the patient's own healing process, homoeopathic treatment can improve general well-being and reduce the symptoms associated with the menopause.
Complementary Therapiesin Nursing & Midwifery
treatment or long-term combined oestrogen and progesterone treatment has ever been published (Te Velde 1994). Most data come from observational studies. Therefore, it is entirely possible that the reported benefits of long-term hormonal treatment are attributable to the lack of similarity between users and non-users. The long-term users of HRT tend to be white, upper middle-class, and lean, and naturally at a decreased risk of developing cardiovascular disease (CVD), and perhaps osteoporosis (Barrett-Connor 1991, Cauley 1990, Barrett-Connor 1989). The vast majority of observational studies have evaluated the long-term effects of oestrogen-only therapy. HRT is usually now prescribed in combination to decrease the risk of endometrial cancer. It is significant to realize that treatment with HRT still increases the risk of endometrial cancer despite the addition of progesterone. The risk of breast cancer is increased with oestrogen therapy long-term, but may be increased further by the combination with progesterone. There is an increased relative risk of breast cancer by 1,3 for long-term (>15 years) use of oestrogen (Steinberg 199 l). This relative risk increases to 1,6 with combination therapy (Persson 1992). Moreover, it is possible that oestrogens were more often withheld from women at risk of breast cancer than from control groups, thus the moderately increased risk of breast cancer reported may underestimate the extent of the problem (Bergkvist 1988). Combination therapy decreases the benefit of oestrogen on cardiovascular disease and increases the risk of breast cancer. Whereas oestrogen beneficially alters lipids and affects vessel walls, progesterone may do the opposite. Women with pre-existing CVD may benefit from HRT, but women with no risk for CVD show minimal increased benefit. Hip fracture is only minimally reduced by longterm treatment. Long-term treatment used for 10 years post-menopausally offers some protection against fracture up to the age of 75 years, but not after, when most fractures occur (Felson 1993). Regular exercise and stopping smoking tend to prevent osteoporosis (Law 1991). There is as yet no unbiased epidemiological data on the effects of long-term hormonal treatment and there are many unanswered questions (Box 1).
9 How is it that synthetic oestrogens used in the oral contraceptive pill increase the risk of CVD, yet 'natural' oestrogens in HRT do the opposite? 9 What is the best way to take HRT? It is increasingly being individually tailored due to the side-effects. 9 What is patient compliance like on HRT?
Half of women prescribed HRT stop within 6 months, and 80% do so without telling their general practitioner. The negative impact of being labelled as sick, the possibility of unexpected vaginal bleeding, and the fear of cancer, possibly contributes to the low compliance rate of women on HRT. Bearing all these questions in mind, the ways in which the homoeopathic approach differs from conventional treatment will be examined.
HOMOEOPATHIC APPROACHES TO TREATING THE SYMPTOMS ASSOCIATED W I T H MENOPAUSE With a little bit of knowledge about homoeopathy, nurses can suggest homoeopathic treatment to help women going through the menopause. One of the principles of homoeopathic treatment is the acceptance of the individual's experience of the menopause. Individualization is essential in order to find the appropriate homoeopathic remedy which matches the patient in all respects. The main concept of homoeopathy is that 'like can cure like'. Thus a substance that can provoke symptoms in a healthy patient can be used homoeopathically to treat the same symptoms in a diseased patient. For example, consuming too much cayenne pepper (Capsicum) can cause a flushed, hot face in healthy individuals, and thus is one of the remedies used homoeopathically to treat hot flushes. Homoeopaths have observed that what a substance can provoke, it can also cure. This principle has been known to medicine for many years. In provoking the patient's own healing process, homoeopathic treatment can improve general weUbeing and reduce the symptoms associated with the menopause. Since the remedies are made of extremely low doses of substance, there are no known harmful side-effects. There are a number of useful remedies for menopausal symptoms. The commonest remedies used include: lachesis mutans, graphites, murex, manganum, sepia, amyl nitrosum, crotalis cascavallis, capsicum, calcarea arsenicum, pulsatilla, cimicifuga, sulphur, and sulphuric acid. Some of these remedies have been discussed in previous articles (Katz 1994). Only five of them will be briefly discussed here, although there are approximately 100 homoeopathic remedies which may be useful for the menopause (Schrooyens 1993). The above are only brief descriptions of some useful remedies for treating menopausal symptoms. Further details of the remedies can be obtained from Homoeopathic Materia Medicas(J H Clarke, Boericke) The dosages (or potencies as they are called by homoeopaths) depend on how severe the symptoms are and on how generally healthy the patients are. Usually, high potencies (above 200C, i.e. more
Homoeopathic treatment during the menopause
As nurses, time can be spent with patients exploring their individual responses to the menopause, and they can suggest homoeopathic remedies which seem to match the process that the patient may be experiencing.
9 Useful for hot flushes, headaches,and emotional symptoms related to the menopause. 9 The flushes are associated with facial redness, pulsations felt all over the body, throbbing sensations in the head, and tachycardia and a choking feeling. The flushes may be accompanied by marked anxiety, as if something might happen, restlessness, and a marked desire for fresh air. Flushesworse for any emotion. The flushes may be associated with smacking of the lips. 9 The skin may feel cold and clammy after flushing. 9 Generally, the patient feels weak. Cannot tolerate heat, has to open windows even in cold weather.
Calcarea arsenicum is useful for overweight women with menopausal symptoms and headaches.The person needing Calcarea arsenicum may feel very depressed and anxious about the future, worse at night and in the dark, and better for company. The anxiety is associated with palpitations. There may be insomnia worse after 03:00 h with restlessnessand sweating. The patient usually feels the cold more, and feels worse for exertion.
9 Like Calcarea arsenicum, the patient needing graphites tends to be overweight, and feels sluggish. She may be timid and indecisive, worrying about the consequences of any decision. Graphites patients tend to take offence easily, and worry over seemingly minor problems. They may be depressed, and weep with music. They dislike mental exertion, and find concentrating difficult, becoming restless when they have to concentrate. 9 They may have a weak memory for recent events. 9 They are chilly but worse for becoming overheated, and worse in the morning on waking. 9 Libido tends to be low. 9 Hot flushes may be preceded by chilliness.
9 Murex may be useful in excessive bleeding pre-menopausally. Patients needing murex often feel more sexually aroused at the time of the menopause, and very sensitive to touch. They have symptoms of prolapse and dryness of genitalia. Murex is useful for pre-menopausal depression, possibly associated with hypochondriasis. Patients prefer to be left alone when depressed, and may find it difficult to find the right words when expressing themselves. They feel weak and tired, but feel worse on lying down. 9 All symptoms tend to be worse at menopause.
highly diluted, but more strongly 'energized' or shaken) are used in people whose basic vitality is high, and low potencies (below 30C) in people weakened by chronic pathological disorders. However, the use of different potencies appears to be less important than finding the appropriate remedy that closely matches the patients symptomatology. Therefore, it is advisable to use a 30 C potency
49
9 Sulphur is a very useful remedy for hot flushes associated with marked sweating. The patients may feel a rush of blood to their heads worse at night in bed. The person generally feels worse for any heat, and pains may be burning. The temperament of the patient needing sulphur is angry and argumentative, worse in the morning, with an empty sensation at about I 1:00h. They may crave sweets, fatty foods and alcohol. 9 They may be untidy in appearance, and tend to talk a lot about their own theories on many subjects.
of a remedy that fits the person as closely as is possible at the beginning of one's homoeopathic practice. The above remedies can be given in 30 C potency daily and stopped when a response is noted.
CONCLUSION
From experience at the Royal London Homoeopathic Hospital Women's Clinic in the UK, about 70% of patients feel a definite improvement in menopausal symptoms whilst using homoeopathic medicines, about 25% get some benefit, and 5% notice no change in their symptoms. Alongside the homoeopathic remedies, advice is usually given to patients to stop smoking, to increase weight-bearing exercises, and to decrease protein or acid-forming foods in their diets. Most of the patients seen at the homoeopathic clinic have tried HRT, and are either unhappy with taking possibly harmful medication daily, or have suffered intolerable side-effects. Some of the patients use homoeopathic treatments alongside HRT. The homoeopathic approach involves exploring the woman's feelings about the menopause and what it represents to her. Each consultation focuses on the patient's individual responses and aims to find a medication that takes all the issues, emotional and physical, into account. Even conventional practitioners are realizing the need to individualize their approaches to suit the needs of the particular patient, even with respect to HRT. As nurses, time can be spent with patients exploring their individual responses to the menopause, and they can suggest homoeopathic remedies which seem to match the process that the patient may be experiencing. There is so much controversy surrounding the use of HRT, that alternative, safer approaches to the treatment of the menopause need to be examined and researched. Homoeopathy represents one of these therapeutic alternatives.
REFERENCES
Barrett-ConnorE 1991 Postrnenopausaloestrogenand prevention bias. Annals of Internal Medicine 115: 455456
50 ComplementaryTherapies in Nursing & Midwifery Barrett-Connor E, Winfard D, Crique M 1989 Postmenopausal oestrogen use and heart disease risk factors in the 1980s. Journal of American Medical Association 261: 2095-2100 Bawdon F 1994 HRT - the myths exploded. What doctors don't tell you 4 (9): 1-3 Bergkvist L, Persson I, Adami H, Schairer C 1988 Risk factors for breast and endometrial cancer in a cohort of women treated with menopausal oestrogens. International Journal of Epidemiology 17: 732-737. Boericke W 1987 Homoeopathic materia medica. Homoeopathic Book Service, London Canley J et al 1990 Prevalence and determinants of oestrogen replacement therapy in elderly women. American Journal of Obstetrics and Gynecology 163: 1438-1444 Clarke J H 1990 Dictionary of practical materia medica. Jain Publishers, India Cummings S R, Black D, Rubin S 1989 Lifetime risks of hip, Colles' or vertebral fracture and coronary heart disease among white postmenopausal women. Annals of Internal Medicine 149:2445-2448 Doress P, Siegal D 1989 Ourselves growing older. Fontana, USA Felson D et al 1993 The effect of postmenopausal oestrogen therapy on bone density in elderly women. New England Journal of Medicine 329:1141-1146 Greenwood S 1990 Menopause the natural way, Optima Iles S, Gath D 1989 Psychological problems and uterine bleeding. Clinical Obstetrics and Gynecology 168: 772-780 Law M, Wald N, Meade T W 1991 Strategies for prevention of osteoporosis and hip fracture. British Medical Journal 303:453--459
Lomax P, Schonbaum E 1993 Postmenopausal hot flushes and their management. Pharmacology and Therapeutics 57:347-358 Melville A 1992 Natural hormonal health. Thorsons Ojeda L 1993 Menopause without medicine. Thorsons Oldenhave A, Netelenbos C 1994 Pathogenesis of climacteric complaints: ready for the change? Lancet 343:649~53 Oldenhave A 1991 Well-being and sexuality in the climacteric: a survey based on 6622 women aged 39 to 60 years in the Dutch municipality of Ede, (dissertation) Excelsior, Leidschendam Oldenhave A, Jaszmann L, Haspels A A, Everaerd W 1993 Impact of climacterium on well-being: a survey based on 5213 women 39 to 60 years old. American Journal of Obstetrics and Gynecology 168:772-780 Persson I, Yuen J, Bergkvist L, Adami H et al 1992 Combined oestrogen-progesterone replacement and breast cancer risk. Lancet 340:1044 Reyes F, Winter J, Faiman C 1977 Pituitary ovarian relationships preceding the menopause. American Journal of Obstetrics and Gynecology 129:557-564 Sebastian A et al 1994 Improved mineral balance and skeletal metabolism in postmenopansal women treated with potassium bicarbonate. New England Journal of Medicine 330:1776-1781 Steinberg K, Thacker S, Smith S e t al 1991 A meta-analysis of the effect of oestrogen replacement therapy on the risk of breast cancer. Journal of American Medical Association 265:1985-1990 Te Velde E, van Leusden H 1994 Hormonal treatment for the climacteric: alleviation of symptoms and prevention of postmenopausal disease. Lancet 343:654-657 Treloar A E 1981 Menstrual cyclicity and the premenopause. Maturitas 3:249-264
This jigsaw puzzle of symptoms serves to indicate how fragmented our understanding of the changes occurring during the menopause really is. There are no known risks of using homoeopathic medicines, and the benefits are appreciated by a growing number of women... Tessa Katz Bsc, MBChB, MFHom, DRCOG, Royal London Homoeopathic Hospital, Great Orrnond Street, London WC I N 3HR, UK
(Requests for offprints to
TK)
INTRODUCTION Hormone replacement therapy (HRT) is currently being promoted as safe and effective for use in the treatment of menopausal symptoms, but there is controversy surrounding the safety of long-term HRT, and many women are experiencing unwanted side-effects. More and more women are turning to alternative ways of dealing with the symptoms experienced during the climacteric. This is illustrated by the number of books appearing on the 'natural' way to treat the menopause (Ojeda 1993, Melville 1992, Doress & Siegal 1989, Greenwood 1990). There are marked differences in the way individual women experience the menopause. This is taken into account when prescribing homoeopathic remedies. Conventionally, symptoms are separated into menstrual disturbances, bone mass deficiencies, cardiovascular abnormalities, hot flushes, and general problems with well-being. This jigsaw puzzle of symptoms serves to indicate how fragmented our understanding of the changes occurring during the menopause really is. The use of HRT relies on the idea that the menopause is an hormonal deficiency disease. There is still controversy about labelling the menopause as an 'oestrogen deficiency disease'. Symptoms may not be due to a reduction of oestrogen alone, and the previous psychological state of t~he woman may have an important part to play in how the symptoms are experienced.
The disease label implies that this is an illness to be treated. One may wonder why a normal reproductive ageing process in women is being labelled as a disease at all. In the conventional treatment of the menopause with HRT, improvement in menopausal symptoms is juggled with the possible increased risk of endometrial and breast cancer caused by long-term use of HRT. Long-term hormonal treatment implies long-term medical supervision, and possible diagnostic intervention. There are no known risks of using homoeopathic medicines, and the benefits are appreciated by a growing number of women attending the Royal London Homoeopathic Hospital's women's clinic and private homoeopaths. Nurses and midwives will have encountered patients who are confused about the menopause, its implications, and management. This article will highlight some of the symptoms, controversies about management, and homoeopathic treatment.
SYMPTOMS The climacteric period may extend for many years on either side of the time of actual cessation of menses. Symptoms may go virtually unnoticed by some women, but up to 30% of women will experience
ComplementaryTheropiesin Nursing& Midwifery (1997) 3, 46-50 9 1997PearsonProfessionalLtcl
47
Homoeopathic treatment during the menopause
Flushes may begin gradually, but typically they are experienced as an explosion of heat with sweating, feelings of irritation, anxiety or panic.
marked flushing and sweating during the menopause. Follicle stimulating hormone (FSH) changes can occur from about the age of 35 years, before any changes in menstrual pattern are evident, and before changes in oestradiol concentration occur (Reyes 1977). The increase in FSH is as a response to degenerating oocytes, despite normal menses. In 18% of women, the mean length of the premenopausal period is 4-5 years. 4% of women may experience pre-menopause for more than 9 years. Various combinations of hormonal patterns of FSH, luteinizing hormone (LH), and oestradiol can be observed during this period (Iles 1989). The post-menopausal state is regarded as 12 months after menses have ceased. Median menopause age is 50-51 (Treloar 1981). Typical temporary effects include irregular and/or heavy bleeding, flushing, sweating, and vaginal dryness. These may severely affect well-being. Increased sweating may be the first sign of the climacteric.
Irregular bleeding Beyond 45 years of age, the cycle may become erratic. There may still be luteinization of follicles with a low concentration of progesterone, but usually persisting follicles continue to produce oestrogen unopposed by progesterone, therefore causing unopposed thickening of the endometrial lining, and erratic and heavy bleeding.
Hot flushes Flushes may begin gradually, but typically they are experienced as an explosion of heat with sweating, feelings of irritation, anxiety or panic. Vasomotor disturbances are present in 41% of women over 39 years of age, despite regular cycles; in 85% of women at the menopause; and, in 57%, 10 years after the menopause (Oldenhave 1993). Severe flushes occur in 3% of women with regular cycles, 30% around the menopause, and 7% 10 years post-menopause. Flushes may range from 5 to 50 per day. They are more common after bilateral salpingo-oopherectomy, and after hysterectomy despite ovarian conservation, than with normally occurring menopause. The cause of flushing is not clearly understood. It is related to a change in hypothalamic function in response to ovarian feedback. Flushing is preceded by a spike of luteinizing hormone releasing hormone (LHRH) and not associated with changes in oestradiol concentration. There is a complex interaction of hormones in the hypothalamic-pituitary-adrenal axis associated with hot flushes. Flushes still occur after the removal of the pituitary gland. Oestrogen deficiency alone does not explain the incidence of hot flushes. Flushes are accompanied by cardiovascular changes, increased heart rate, and hand-blood flow, which decrease after the flush. Electro-encephalograph has shown seizure-like activity with flushes.
The associated tenseness, tiredness, irritability, headache, muscle and joint pains, and depression can mimic an agitated depressed state.
Vaginal dryness Vaginal dryness occurs in 16% of regularly menstruating women above the age of 39 years, 40-45% 4-10years after the menopause. 55% of women do not report this symptom (Oldenhave 1991). It is more common in women who have had a hysterectomy.
PERMANENT EFFECTS Oesteoporosis Bone loss occurs with ageing, leading to a low skeletal mass and increased risk of fractures. During a woman's lifetime, 50% of bone loss occurs from the spine, and 30% from cortical bone (Cummings 1989). Obviously, falls and trauma are important causes of fractures in osteoporotic bones. Genetic profile, calcium intake, and weight-bearing physical activity profoundly influence the height of peak bone mass, i.e. bone strength (Oldenhave 1994). Recent studies have examined the role of intake of excess protein and acid-forming foods in the promotion of osteoporosis, due to their effect of leaching calcium from bone (Sebastian et al 1994). The number of hot flushes experienced, and the extent of sweating, may predict a greater risk of osteoporosis (Te Velde 1994). The cause of the imbalance between bone resorbtion and formation leading to bone mass loss in menopausal women is not clear.
Ischaemic heart disease There is an increased prevalence of myocardial infarction, atherosclerosis, and alteration in lipid profile in women after the menopause. Administration of oestrogen lowers the risk of post-menopausal coronary artery disease, but this effect may be reduced by the combination of oestrogen and progesterone, which is now used in HRT. Perhaps the climacteric should be viewed as a dynamic and temporary adjustment process of the hypothalamus and other central nervous system centres, only initially triggered by defective feedback from ovaries.
C O N V E N T I O N A L MANAGEMENT OF THE MENOPAUSE: BENEFITS A N D RISKS No large-scale randomized study evaluating the benefits and risks of long-term unopposed oestrogen
48
Half of women prescribed HRT stop within 6 months, and 80% do so without telling their general practitioner.
In provoking the patient's own healing process, homoeopathic treatment can improve general well-being and reduce the symptoms associated with the menopause.
Complementary Therapiesin Nursing & Midwifery
treatment or long-term combined oestrogen and progesterone treatment has ever been published (Te Velde 1994). Most data come from observational studies. Therefore, it is entirely possible that the reported benefits of long-term hormonal treatment are attributable to the lack of similarity between users and non-users. The long-term users of HRT tend to be white, upper middle-class, and lean, and naturally at a decreased risk of developing cardiovascular disease (CVD), and perhaps osteoporosis (Barrett-Connor 1991, Cauley 1990, Barrett-Connor 1989). The vast majority of observational studies have evaluated the long-term effects of oestrogen-only therapy. HRT is usually now prescribed in combination to decrease the risk of endometrial cancer. It is significant to realize that treatment with HRT still increases the risk of endometrial cancer despite the addition of progesterone. The risk of breast cancer is increased with oestrogen therapy long-term, but may be increased further by the combination with progesterone. There is an increased relative risk of breast cancer by 1,3 for long-term (>15 years) use of oestrogen (Steinberg 199 l). This relative risk increases to 1,6 with combination therapy (Persson 1992). Moreover, it is possible that oestrogens were more often withheld from women at risk of breast cancer than from control groups, thus the moderately increased risk of breast cancer reported may underestimate the extent of the problem (Bergkvist 1988). Combination therapy decreases the benefit of oestrogen on cardiovascular disease and increases the risk of breast cancer. Whereas oestrogen beneficially alters lipids and affects vessel walls, progesterone may do the opposite. Women with pre-existing CVD may benefit from HRT, but women with no risk for CVD show minimal increased benefit. Hip fracture is only minimally reduced by longterm treatment. Long-term treatment used for 10 years post-menopausally offers some protection against fracture up to the age of 75 years, but not after, when most fractures occur (Felson 1993). Regular exercise and stopping smoking tend to prevent osteoporosis (Law 1991). There is as yet no unbiased epidemiological data on the effects of long-term hormonal treatment and there are many unanswered questions (Box 1).
9 How is it that synthetic oestrogens used in the oral contraceptive pill increase the risk of CVD, yet 'natural' oestrogens in HRT do the opposite? 9 What is the best way to take HRT? It is increasingly being individually tailored due to the side-effects. 9 What is patient compliance like on HRT?
Half of women prescribed HRT stop within 6 months, and 80% do so without telling their general practitioner. The negative impact of being labelled as sick, the possibility of unexpected vaginal bleeding, and the fear of cancer, possibly contributes to the low compliance rate of women on HRT. Bearing all these questions in mind, the ways in which the homoeopathic approach differs from conventional treatment will be examined.
HOMOEOPATHIC APPROACHES TO TREATING THE SYMPTOMS ASSOCIATED W I T H MENOPAUSE With a little bit of knowledge about homoeopathy, nurses can suggest homoeopathic treatment to help women going through the menopause. One of the principles of homoeopathic treatment is the acceptance of the individual's experience of the menopause. Individualization is essential in order to find the appropriate homoeopathic remedy which matches the patient in all respects. The main concept of homoeopathy is that 'like can cure like'. Thus a substance that can provoke symptoms in a healthy patient can be used homoeopathically to treat the same symptoms in a diseased patient. For example, consuming too much cayenne pepper (Capsicum) can cause a flushed, hot face in healthy individuals, and thus is one of the remedies used homoeopathically to treat hot flushes. Homoeopaths have observed that what a substance can provoke, it can also cure. This principle has been known to medicine for many years. In provoking the patient's own healing process, homoeopathic treatment can improve general weUbeing and reduce the symptoms associated with the menopause. Since the remedies are made of extremely low doses of substance, there are no known harmful side-effects. There are a number of useful remedies for menopausal symptoms. The commonest remedies used include: lachesis mutans, graphites, murex, manganum, sepia, amyl nitrosum, crotalis cascavallis, capsicum, calcarea arsenicum, pulsatilla, cimicifuga, sulphur, and sulphuric acid. Some of these remedies have been discussed in previous articles (Katz 1994). Only five of them will be briefly discussed here, although there are approximately 100 homoeopathic remedies which may be useful for the menopause (Schrooyens 1993). The above are only brief descriptions of some useful remedies for treating menopausal symptoms. Further details of the remedies can be obtained from Homoeopathic Materia Medicas(J H Clarke, Boericke) The dosages (or potencies as they are called by homoeopaths) depend on how severe the symptoms are and on how generally healthy the patients are. Usually, high potencies (above 200C, i.e. more
Homoeopathic treatment during the menopause
As nurses, time can be spent with patients exploring their individual responses to the menopause, and they can suggest homoeopathic remedies which seem to match the process that the patient may be experiencing.
9 Useful for hot flushes, headaches,and emotional symptoms related to the menopause. 9 The flushes are associated with facial redness, pulsations felt all over the body, throbbing sensations in the head, and tachycardia and a choking feeling. The flushes may be accompanied by marked anxiety, as if something might happen, restlessness, and a marked desire for fresh air. Flushesworse for any emotion. The flushes may be associated with smacking of the lips. 9 The skin may feel cold and clammy after flushing. 9 Generally, the patient feels weak. Cannot tolerate heat, has to open windows even in cold weather.
Calcarea arsenicum is useful for overweight women with menopausal symptoms and headaches.The person needing Calcarea arsenicum may feel very depressed and anxious about the future, worse at night and in the dark, and better for company. The anxiety is associated with palpitations. There may be insomnia worse after 03:00 h with restlessnessand sweating. The patient usually feels the cold more, and feels worse for exertion.
9 Like Calcarea arsenicum, the patient needing graphites tends to be overweight, and feels sluggish. She may be timid and indecisive, worrying about the consequences of any decision. Graphites patients tend to take offence easily, and worry over seemingly minor problems. They may be depressed, and weep with music. They dislike mental exertion, and find concentrating difficult, becoming restless when they have to concentrate. 9 They may have a weak memory for recent events. 9 They are chilly but worse for becoming overheated, and worse in the morning on waking. 9 Libido tends to be low. 9 Hot flushes may be preceded by chilliness.
9 Murex may be useful in excessive bleeding pre-menopausally. Patients needing murex often feel more sexually aroused at the time of the menopause, and very sensitive to touch. They have symptoms of prolapse and dryness of genitalia. Murex is useful for pre-menopausal depression, possibly associated with hypochondriasis. Patients prefer to be left alone when depressed, and may find it difficult to find the right words when expressing themselves. They feel weak and tired, but feel worse on lying down. 9 All symptoms tend to be worse at menopause.
highly diluted, but more strongly 'energized' or shaken) are used in people whose basic vitality is high, and low potencies (below 30C) in people weakened by chronic pathological disorders. However, the use of different potencies appears to be less important than finding the appropriate remedy that closely matches the patients symptomatology. Therefore, it is advisable to use a 30 C potency
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9 Sulphur is a very useful remedy for hot flushes associated with marked sweating. The patients may feel a rush of blood to their heads worse at night in bed. The person generally feels worse for any heat, and pains may be burning. The temperament of the patient needing sulphur is angry and argumentative, worse in the morning, with an empty sensation at about I 1:00h. They may crave sweets, fatty foods and alcohol. 9 They may be untidy in appearance, and tend to talk a lot about their own theories on many subjects.
of a remedy that fits the person as closely as is possible at the beginning of one's homoeopathic practice. The above remedies can be given in 30 C potency daily and stopped when a response is noted.
CONCLUSION
From experience at the Royal London Homoeopathic Hospital Women's Clinic in the UK, about 70% of patients feel a definite improvement in menopausal symptoms whilst using homoeopathic medicines, about 25% get some benefit, and 5% notice no change in their symptoms. Alongside the homoeopathic remedies, advice is usually given to patients to stop smoking, to increase weight-bearing exercises, and to decrease protein or acid-forming foods in their diets. Most of the patients seen at the homoeopathic clinic have tried HRT, and are either unhappy with taking possibly harmful medication daily, or have suffered intolerable side-effects. Some of the patients use homoeopathic treatments alongside HRT. The homoeopathic approach involves exploring the woman's feelings about the menopause and what it represents to her. Each consultation focuses on the patient's individual responses and aims to find a medication that takes all the issues, emotional and physical, into account. Even conventional practitioners are realizing the need to individualize their approaches to suit the needs of the particular patient, even with respect to HRT. As nurses, time can be spent with patients exploring their individual responses to the menopause, and they can suggest homoeopathic remedies which seem to match the process that the patient may be experiencing. There is so much controversy surrounding the use of HRT, that alternative, safer approaches to the treatment of the menopause need to be examined and researched. Homoeopathy represents one of these therapeutic alternatives.
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