Research Database -
International Updates

Women's Health

Issue 93

YOUNUS and colleagues, London Regional Cancer Centre, Ontario, Canada, Jawaid.younus@lrcc.on.ca, write about the mind control of menopause.
Background: The objectives of this clinical trial were to assess the effect of hypnosis on hot flushes and overall quality of life; and also the effect of hypnosis on fatigue.
Methods: 14 women, 4 of them suffering from breast cancer, all with symptoms of hot flushes, were treated with 4 hour-long sessions of hypnosis at weekly intervals. The same therapist conducted all sessions. Patients recorded frequency, duration, and severity of hot flushes. The QLQ-C30 and Brief Fatigue Inventory were used to measure quality of life and fatigue.
Results: The frequency, duration and severity of hot flushes were all significantly reduced by hypnosis (p = 0.0001). Overall quality of life was also improved (p = 0.05). Patients slept better (p = 0.012) and felt less fatigued (p = 0.017).
Conclusions: Hypnosis appears to be a most promising intervention for dealing with hot flushes, with a potential for improving insomnia and general quality of life.
Younus J, Simpson I, Collins A, Wang X. Mind control of menopause. Women’s Health Issues 13 (2): 74-78, Mar-Apr 2003.

Issue 92

GIRMAN and co-workers, Continuum Center for Health and Healing, New York, NY 10016, USA, review (101 references) an integrative medicine approach to premenstrual syndrome.
Abstract: Complementary and alternative medical (CAM ) therapies are widely used by women suffering from pre-menstrual syndrome (PMS). The authors have searched for all clinical applications of CAM to PMS and a related disorder, pre-menstrual dysphoric disorder (PMDD), since 1966 on Medline. For many of the therapies that are widely used, conclusive evidence is lacking. For others, such as the use of some herbal and nutritional approaches, exercise, and the use of mind-body approaches, there is substantial evidence for efficacy.
Girman A, Lee R, Kligler B. An integrative medicine approach to premenstrual syndrome. American Journal of Obstetrics and Gynecology 188 (5 Suppl): S56-S65, May 2003.

PONGROJPAW and CHIAMCHANYA, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand, report on the efficacy of ginger in the prevention of post-operative nausea and vomiting after gynecological laparoscopy.
Background: This randomized controlled trial was designed to test the efficacy of ginger in the prevention of post-laparoscopy nausea and vomiting.
Methods: 80 women who underwent outpatient laparoscopic surgery were randomly allocated to study or placebo group. The study group received 2 capsules containing 0.5 g of powdered ginger one hour before the surgery. The placebo group received placebo capsules. Visual analogue nausea scores (VANS) were recorded 2, 4, and 24 hours post surgery. Vomiting was also recorded.
Results: In the study group, 12 women (30%) suffered from nausea, as compared to 23 (57%) in the placebo group. The VANS was lower in the study group at 2 and 4 hours (p = 0.05), while at 24 hours there was no difference. Incidence and frequency of vomiting was lower in the study group but not to a statistically significant degree.
Conclusions: From these results, it appears that ginger is effective as a preventive agent for post-operative nausea.
Pongrojpaw D, Chiamchanya C. The efficacy of ginger in prevention of post-operative nausea and vomiting after outpatient gynecological laparoscopy. Journal of the Medical Association of Thailand 86 (3): 244-250, Mar 2003.

Issue 91

ALKAISSI and co-workers, Department of Anaesthesiology and Intensive Care, University Hospital in Linkoeping, Linkoeping, Sweden, have found that P6 acupressure may relieve nausea and vomiting after gynaecological surgery.
Background: The aim of the study was to investigate the effect of sensory stimulation of the P6 point on postoperative nausea and vomiting in the everyday clinical steeing.
Methods: 410 women undergoing general anaesthesia for elective gynaecological surgery were included in this prospective, consecutive, randomized, multicentre, placebo-controlled, double-blinded trial. One group (135 women) was given bilateral P6 acupressure, a second group (139 women) was given similar pressure on non-acupressure points, a third group (136 women) served as a no-treatment control. Nausea, vomiting, pain, and satisfaction with the treatment were recorded. Results were analyzed by logistic regression.
Results: No nausea, vomiting or rescue medication was more frequent in the acupressure group than in the no-treatment group (p = 0.02). The incidence of nausea and vomiting was 46% in the no-treatment group, 38% in the placebo group, and 33% in the acupressure group. When considering cases of vaginal surgery separately, the decrease in nausea and vomiting was from 36% to 20% (p = 0.017). The corresponding decrease from 59% to 55% in women who had had laparoscopic surgery was not statistically significant.
Conclusions: P6 acupressure is a noinvasive method that may have a place as prophylactic antiemetic therapy during gynaecological surgery, particularly in cases of vaginal surgery.
Alkaissi A, Evertsson K, Johnsson VA, Ofenbartl L, Kalman S. P6 acupressure may relieve nausea and vomiting after gynaecological surgery: an effectiveness study in 410 women. Canadian Journal of Anaesthesia 49 (10): 1034-1039, Dec 2002.

DICKERSON and co-workers, Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina 29406, USA, macfarll@musc.edu, review (36 references) the premenstrual syndrome.
Abstract: Premenstrual syndrome is a common cyclical disorder among young and middle-aged women. It is characterized by emotional and physical symptoms that occur during the luteinizing phase of the menstrual cycle. Although the aetiology remains uncertain, research suggests that altered regulation of neurohormones and neurotransmitters is involved. Many symptoms can occur, including depression, mood lability, abdominal pain, breast tenderness, headache, and fatigue. Women with mild symptoms should be instructed about lifestyle changes such as healthy diet, sodium and caffeine restriction, exercise, and stress reduction. Supportive strategies such as the use of a symptom diary may be helpful. In women with moderate symptoms, treatment includes both medication and lifestyle changes. Dietary supplements such as calcium and evening
primrose oil may offer modest benefit. Antidepressants of the selective serotonin uptake inhibitor class are the most effective pharmacological intervention at this time. Prostaglandin inhibitors and diuretics may offer some relief. Only weak evidence supports the use of gonadotropin- releasing hormone agonists, androgenic hormones, oestrogen, progesterone, or other psychotropics, and their use is limited by side effects.
Dickerson LM, Mazyck PJ, Hunter MH. Premenstrual syndrome. American Family Physician 67 (8): 1743-1752, Apr 2003.

Issue 90

HABEK and co-workers, Department of Gynecology and Obstetrics, Health Centre, Bjelovar, Croatia, dubravko.habek@bj.hinet.hr, report on a trial of acupuncture in the treatment of premenstrual syndrome.
Results: In this randomized placebo-controlled trial of acupuncture versus sham acupuncture, two groups of women took part in two groups. More than 60% of them suffered from PMS symptoms. Some women in the treatment group stopped having them after one treatment, others after four treatments. Overall, there was a statistically significant reduction in PMS symptoms with the acupuncture treatment as compared to baseline (p = 0.001), whereas for the sham treatment it was insignificant (p > 0.05). The success rate for acupuncture in treating PMS symptoms was 77.8%; for the sham treatment it was 5.9%.
Conclusions: The results from this study are encouraging, and acupuncture should be suggested to patients suffering from PMS as a possible treatment.
Habek D, Habek JC, Barbir A. Using acupuncture to treat premenstrual syndrome. Archives of Gynecology and Obstetrics 267 (1): 23-26, Nov 2002.

Issue 86

KRONENBERG and co-workers, Rosenthal Center for Complementary and Alternative Medicine, College of Physicians and Surgeons, Columbia university, 630 West 168th Street, Box 75, New York, NY 10032, USA, review (58 references) the randomized controlled trials of complementary and alternative medicine for menopausal symptoms.

Background: Women use CAM therapies, especially soy bean products and herbs, for menopausal symptoms. A number of randomized controlled trials have evaluated the safety and efficacy of these medicines.

Methods: Searches of Medline and the Alternative and Complementary Database of the British Library (AMED) were conducted, and the authors’ own clinical files were consulted. Search terms were hot flush, menopause, climacteric combined with phytoestrogens, alternative medicine, herbal medicine, traditional medicine, Traditional Chinese Medicine, Ayurveda, naturopathy, chiropractic, osteopathy, massage, yoga, relaxation therapy, homeopathy, aromatherapy, and therapeutic touch.

Results: 29 randomized controlled trials of CAM therapies were identified. Of these, 12 dealt with soy or soy extracts, 10 with herbs, and 7 with other CAM therapies. Soy seems to show modest benefit for hot flushes, but existing studies are inconclusive. Isoflavone preparations are less effective than soy foods. Black cohosh may be effective, but the lack of reliable long-term safety data precludes recommendation for prolonged use. Dong quai, evening primrose oil, a Chinese herb mixture, vitamin E, and acupuncture do not affect hot flushes, and two trials have shown that red clover has no effect.

Conclusions: Black cohosh and foods that contain phytoestrogens show promise for the treatment of menopausal symptoms, especially hot flushes. Other therapies are not at this time supported by controlled trials. Long-term safety data of isoflavones are needed.

Kronenerg F, Fugh-Berman A, et al. Complementary and alternative medicine for menopausal symptoms: a review of randomized, controlled trials. Annals of Internal Medicine 137 (10): 805—813, Mar 2002.

Comment: Women using natural approaches to treat menopausal symptoms will be highly interested in seeing further research regarding the efficacy of the many products touted for these symptoms.

Issue 85

KEATING and CHEZ, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FLA, USA, advocate Ginger syrup as an antiemetic in early pregnancy.

Background: Ginger has been used to ameliorate symptoms of nausea. A beverage containing ginger in a syrup may be easier to consume than a capsule or solid food. This study was carried out in order to determine if ginger syrup is an effective remedy for nausea and vomiting in the first trimester of pregnancy.

Methods: Double-blinded, placebo-controlled, randomized clinical trial of 26 women in the first trimester of pregnancy. They ingested 1 tablespoon of ginger syrup or placebo diluted with water 4 times daily. Duration and severity of nausea and vomiting over a 2-week period were measured on a 10-point scale.

Results: After 9 days, 10 of 13 (77%) of women receiving ginger had at least a 4-point improvement on the nausea scale. Only 2 of the 10 (20%) of placebo subjects had the same improvement. Conversely, no woman in the ginger group but 7 (70%) in the placebo group had less than a 2-point improvement on the nausea scale. 8 of 12 (67%) women in the ginger group who had been vomiting daily before treatment stopped by day 6. Only 2 of the 10 women in the placebo group who were vomiting daily (20%) stopped by day 6.

Conclusions: The ingestion of 1 gram of ginger in syrup may be useful in some patients experiencing nausea and vomiting in the first trimester of pregnancy.

Comments: Ginger is widely used for alleviation of nausea in early pregnancy; however, its use in pregnancy was contra-indicated (on theoretical safety grounds) by a prominent UK researcher because of the lack of randomized controlled trials (RCTs) demonstrating its lack of toxicity for pregnant women. Additionally, any treatment at all, even massage or reflexology, of any pregnant women in her first trimester was contraindicated (again, on grounds that if anything happened to the foetus, the practitioner could be sued), according to a recent article in guidelines published in an article in a journal of a leading UK association! I guess that, on safety grounds, pregnant women should just suffer, which appears to go counter to the entire ethic of helping women using natural, non-drug treatments. We appear to be living in a Kafka-esque society. I long for the return of common sense and good practice.

Issue 84

KORCZYNSKI, II Kliniki Ginekologii Instututu Ginekologii I Poloznictwa Akademii Medyczney, 94-029 lodz, ul. Wilenska 37, reviews (23 references) the benefits and risks of routine episiotomy during the second stage of labour.

Methods: Literature review.

Results: Perineal trauma complications as well as perinatal outcomes are discussed. The risk of stress incontinence and sexual dysfunction is described. New techniques to improve perinatal outcomes and prevention of post partum incontinence are introduced.

Conclusions: Routine episiotomy gives poor effects in most cases. Perineal massage during pregnancy and waterbirth are promising methods to avoid episiotomy and improve the quality of life for post partum women.

Korczynski J. Routine episiotomy in modern obstetrics. Is it necessary? Przeglad Lekasrki 59 (2): 95-97, 2002.

Comment: The rates for Caesarean section and procedures such as episiotomy are rising, despite the mounting body of clinical literature showing that more conservative methods produce both better outcomes and improve the quality of life following childbirth.

TAYLOR and colleagues, Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, 94143-0606, USA, Diana.Taylor@nursing.ucsf.edu, measured the therapeutic effect of an acupressure brief in dysmenorrhea.

Methods: The acupressure brief (the Relief Brief) is fitted with latex foam pads exerting pressure on lower abdominal and lower back Chinese acupressure points known to relieve painful periods. The trial was randomized and controlled against conventional treatment for dysmenorrhea. 58 women were randomized into treatment and control groups. Pain intensity and worst pain, analgesic medication use, and adverse effects were measured at baseline and at two post-treatment menses.

Results: The consumption of analgesic medication dropped to one-third of baseline in the treatment group whilst remaining constant in the control group. 90% of women wearing the Relief Brief experienced at least 25% decrease in menstrual pain compared to 7% of women in the control group.

Conclusions: An acupressure brief is a safe and extremely efficient nonpharmacological treatment for painful periods. It may also serve as an adjuvant to analgesic medication in more severe cases of dysmenorrhea.

Taylor D, Miaskowski C, Kohn J. A randomized clinical trial of the effectiveness of an acupressure device (relief brief) for managing symptoms of dysmenorrhea. The Journal of Alternative and Complementary Medicine 8 (3): 357-370, Jun 2002.

WILLIAMSON and co-workers, School of Complementary Health, Exeter, UK, conducted a randomized controlled trial of reflexology for menopausal women.

Background: Clinical observations suggest that reflexology may be helpful for menopausal women, particularly in the relief of psychological symptoms.

Methods: 76 women presenting with menopausal symptoms were randomized to receive nine sessions of either reflexology or non-specific foot massage over a period of 19 weeks. The Women’s Health Questionnaire (primarily the subscores for anxiety and depression) and the severity and frequency of flushes and night-sweats were measured.

Results: Anxiety and depression scores fell in both groups to between 50% and 70% of baseline values, with a clear time effect but no significant difference between treatment and control groups. Similar changes were found for severity of hot flushes and night sweats.

Conclusions: Reflexology could not be shown to be more effective than non-specific foot massage in relieving menopausal symptoms.

Comment – Jan Williamson: Both groups – treatment and control – in this study experienced improvements in psychological symptoms during the menopause. Therefore, the study highlights the beneficial effects which can be achieved by therapies which work on the feet. Research into complementary therapies is sparse and even more so into reflexology in particular. Thus, when studies are undertaken , the focus needs to be on the scientific rigour of the study. However this study does show the problem of devising an appropriate placebo control trial of reflexology. Future studies may benefit from the lessons gained here by avoiding attempts at blinding, eliminating the complication of non-specific effects, perhaps by using a ‘waiting group’ for instance.

Issue 80

PROCTOR and colleagues, Department of Obstetrics and Gynaecology, National Women’s Hospital, Claude Road, Epsom, Auckland, New Zealand, 1003, E: m.proctor@auckland.ac.nz, reviewed (42 references) published reports of randomized controlled trials (RCTs) investigating the effectiveness of transcutaneous electrical nerve stimulation (TENS) or acupuncture for treating primary dysmenorrhoea (painful periods).
Background: Conventional treatment of dysmenorrhoea usually consists of either non-steroidal anti-inflammatory drugs (NSAIDs) or the oral contraceptive pill, both of which can result in unwanted side effects. There is therefore potential for an effective non-pharmacological treatment. Both TENS and acupuncture have been shown to be effective for relieving pain in a number of conditions.
Methods: RCTs comparing TENS and/or acupuncture with each other, placebo, no treatment or medical treatment of primary dysmenorrhoea were identified by searching the following sources: the Cochrane Menstrual Disorders and Subfertility Group Register of controlled trials (CCTR; Cochrane Library Issue 3, 2001); MEDLINE; EMBASE; CINAHL; Bio extracts; PsychLIT; SPORTDiscus; the Cochrane Complementary Medicine Field’s Register of controlled trials (CISCOM); the UK National Research Register; the Clinical Trial Register; the citation lists of review articles and publications of included trials; and contact with the first or corresponding author of included trial publications. Data were analysed using meta-analysis where possible or were reported as descriptive data. Outcome measures analysed were: pain relief, adverse events, adjunctive use of analgesics and absence from work or school.
Results: Nine RCTs met the predetermined inclusion criteria: seven involving TENS, one involving acupuncture and one involving both treatments. The analyses revealed that high-frequency TENS was more effective at relieving pain than placebo TENS. Low-frequency TENS appeared to be no more effective than placebo. However, data were inconclusive with regard to whether high-frequency TENS was more effective than low-frequency TENS. In one small but well-designed study, acupuncture was found to be significantly more effective at relieving pain than placebo acupuncture or no treatment.
Conclusion: High-frequency TENS appears to be effective for relieving pain of primary dysmenorrhoea. One trial of high-frequency TENS reported some minor adverse events – these require further study. Data regarding the effectiveness of low-frequency TENS were inconclusive. The results of just one small trial of acupuncture indicated that this intervention may be effective in relieving pain of primary dysmenorrhoea and deserve confirmation in larger studies.
Proctor ML et al. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea. The Cochrane Database of Systematic Reviews 2002 (1): CD002123.

LIMOSIN and ADES, Service de Psychiatrie du Professeur Rouillon, Hopital Albert-Chenevier, 40, rue de Mesly, 94000 Creteil, France reviewed (47 references) the diagnosis, prevalence, causes and treatment of premenstrual disorder.
Background: Premenstrual syndrome has undergone frequent investigation in many different types of study, but findings have been inconclusive, leading to many doctors becoming disinterested in the issue. In recent years, however, psychiatrists have taken an interest in this area, recognizing that anxiety and mood changes can impair social skills and cause functional disability. Severe symptoms can affect many areas of life and therefore should be treated. In 1983, a conference of the US National Institutes of Mental Health (NIMH) led to the proposal of the first diagnostic criteria for premenstrual syndrome. Successful diagnosis required prospective daily assessment of symptoms. In 1987, diagnostic criteria for Late Luteal Phase Dysphoric Disorder were defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, Third Edition-Revised (DSM III-R). In 1994, with the publication of DSM-IV (DSM, Fourth Edition), this disorder retained the same diagnostic criteria but was renamed Premenstrual Dysphoric Disorder.
Discussion: Diagnostic criteria: Because of different diagnostic criteria used in different studies and differing populations investigated, prevalence rates of premenstrual syndrome reported in the literature vary widely. However, the most relevant criteria are probably 1) functional impairment (e.g. symptoms resulting in avoidance of social activities) and 2) seeking medical help or treatment. Lifetime prevalence rates: In reports that defined the syndrome based on one or several symptoms, lifetime prevalence rates were estimated to be between 75 and 85%. Reports that required ‘medical care request’ to be a criterion estimated lifetime prevalence rates to be between 10 and 15%. Finally, those requiring ‘social activities interruption’ to be a criterion estimated rates to be between 2 and 5%. Assessment: The best method of assessing this complex and changing disorder is to use a self-questionnaire, which enables a distinction to be made between isolated symptoms and a severe disabling disorder. Other psychiatric disorders or symptoms: Premenstrual syndrome may be associated with an increased risk of major (clinical) depression. The premenstrual period may also be a risk period for increased frequency or severity of symptoms of coexisting psychiatric disorders (e.g. obsessive-compulsive disorder, alcoholism, schizophrenia) or higher rates of suicide attempts. Causes: The most popular culprit of the disorder is dysregulation of the brain chemical serotonin, with evidence linking this molecule with expression of anger and irritation, depressive symptoms and certain food cravings. Moreover, oestrogens can enhance the activity of serotonin, and there is some evidence for an altered response to d-fenfluramine (a drug that mimics serotonin’s activities) in women with premenstrual dysphoric disorder. Psychoanalytic theories broadly describe a ‘femininity complex’, which has variously been thought to involve ambivalence towards pregnancy, coveting of men’s perceived advantages in political, social and cultural arenas, the woman’s personal, social and cultural history, and the mother-daughter relationship.
Treatments: Regardless of the cause, if symptoms are severe and disabling, treatment is justified. Early pharmacological treatments were based on hormones – progesterone or the contraceptive pill – but neither has proven to be effective. More recently, a range of psychoactive drugs has been investigated, including the newer antidepressants (specific serotonin reuptake inhibitors [SSRIs] such as clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline and citalopram; and a selective noradrenaline reuptake inhibitor [SNRI], maprotiline); and benzodiazepines (tranquillizers) (e.g. alprazolam). SSRIs, prescribed intermittently, appear to be the most effective pharmacological treatment to date. Non-drug approaches that can be helpful include psychological support, psychotherapy and relaxation techniques.
Conclusion: The diagnostic criteria set out in the DSM make premenstrual syndrome appear a generalized and homogeneous disorder. However, it remains a complex and many-faceted condition and can affect different individuals in vastly different ways. For many years, premenstrual syndrome was viewed as a physical disorder and remained untreated. Today, however, physicians are coming to recognize that psychiatric symptoms can be severe, resulting in functional and quality-of-life impairment, and therefore justify medical intervention. To distinguish isolated mild complaints from a severe disabling disorder, the standardized prospective auto-assessment method should be used. The most effective medical treatments to date appear to be intermittent SSRIs.
Limosin F, Ades J. (Psychiatric and psychological aspects of premenstrual syndrome.) L’Encephale 27 (6): 501-8. Nov-Dec 2001.
Comment: Isn’t is amazing that if you ask psychiatrists to review the literature regarding PMS, they will concentrate on psychiatric and psychoactive drugs as the prime treatment vehicles, rather than even considering the potentially therapeutic benefits which can be obtained using nutritional, herbal, or Chinese Medical approaches? I especially draw your attention to the above description of the ‘femininity complex!’

Issue 78

MEHL, Program in Integrative Medicine of the University of Arizona in Tucson, Texas, USA, evaluated non-drug and non-surgical (ND/NS) therapies (which included traditional Chinese medicine, body therapies and guided imagery) for treating women with uterine fibroids.
Background:Increasingly, women with uterine fibroids are keen to find alternatives to conventional therapies. It is therefore important to investigate what alternatives are effective and also whether they are cost-effective.
Methods: 74 menstruating women aged 24 to 45 years with uterine fibroids received either experimental treatment (n=37, ND/NS group) or conventional treatment (n=37, matched control group) for up to 6 months. The experimental programme consisted of weekly traditional Chinese medicine, somatic therapy, bodywork and guided imagery. Patients were evaluated on fibroid size, changes in troublesome symptoms and treatment satisfaction.
Results:In 22 patients in the ND/NS group, fibroids shrank and stopped growing, compared with three in the control group. Cost of treatment in the ND/NS group averaged US $3800 per patient, which was significantly higher than for patients in the standard care group. ND/NS and standard treatment were equally effective in reducing bothersome symptoms of fibroids. Patient satisfaction was significantly higher in the ND/NS group than in the control group.
Conclusion:The results confirm that effective alternatives to conventional treatments exist for treating uterine fibroids. The financial costs are higher, but patient satisfaction is also greater.
Mehl ML. Complementary medicine treatment of uterine fibroids: a pilot study. Alternative Therapies in Health and Medicine 8 (2): 34-6, 38-40, 42, 44-6. Mar-Apr 2002.

SMITH and colleagues, Department of Obstetrics Gynaecology, Adelaide University, Adelaide, Australia, evaluated acupuncture for the relief of nausea and vomiting in early pregnancy.
Methods: In a single-blind, randomized, controlled trial, 593 women less than 14 weeks’ pregnant and experiencing symptoms of nausea and vomiting received 1) traditional acupuncture, 2) pericardium (P6) acupuncture, 3) sham acupuncture or 4) no acupuncture. They received treatment once a week for 4 weeks.
Results: The traditional acupuncture group reported less nausea throughout the trial and less dry retching from week 3 compared with the no acupuncture group. The P6 acupuncture group reported less nausea from week 2 and less dry retching from week 3 compared with the no acupuncture group. The sham acupuncture group reported less nausea and dry retching from week 3 compared with the no acupuncture group. There were no differences between the groups with regard to vomiting.
Conclusion: Acupuncture was effective for relieving nausea and dry retching in early pregnancy. Some women showed a time-related placebo effect.
Smith C et al. Acupuncture to treat nausea and vomiting in early pregnancy: a randomized controlled trial. Birth 29 (1): 1-9. Mar 2002.

GRIFFITHS, Southern Cross University, Australia reported on a case of dysmenorrhoea successfully treated with traditional Chinese medicine, involving acupuncture and herbal therapy.
Methods: A woman with dysmenorrhoea (painful periods) received acupuncture treatment 1 week before the onset of her period, for three menstrual cycles, and a Chinese herbal medicine for 6 months.
Results: During the 6-month treatment period, the woman’s overall health improved dramatically to the point were she was completely pain free. This had a significant effect on her lifestyle such that she felt confident enough to go on a foreign holiday, which she would not have contemplated previously. Follow-up in the intervening period since treatment has revealed that the woman has not needed to seek any further treatment.
Conclusion: In this single case report, a programme of acupuncture and Chinese herbal medicine was extremely effective in treating dysmenorrhoea.
Griffiths V. Traditional Chinese medicine: a case of dysmenorrhoea. The Australian Journal of Holistic Nursing 7 (1): 42-3. April 2000.
Comment: There is huge scope for the application of complementary treatment modalities to the myriad problems affecting women of all age groups, as illustrated by the above research results.

Issue 77

OLSEN and SECHER, Maternal Nutrition Group, Danish Epidemiology Science Centre, Statens Serum Instutut, Artillerivej 5, DK-2300 Copenhagen S, Denmark, sfo@ssi.dk, explored whether low intake of fish in pregnant women was related to the occurrence of premature birth.
Methods: 8,729 pregnant women were involved in a prospective study in Aarhus, Denmark. The women’s dietary habits during pregnancy, particularly in relation to their consumption of seafood, were documented. From these data, the women were divided into 4 broad groups: 1) no fish consumption; 2) low fish consumption; 3) medium fish consumption; 4) high fish consumption (consuming fish as a hot meal and an open sandwich with fish at least once a week). Outcome measures of the study were the occurrence of preterm delivery and low birth weight.
Results: The occurrence of premature birth differed significantly across the 4 groups of women, ranging from 7.1% in the no fish consumption group to 1.9% in the high consumption group. In the zero fish consumption group, the adjusted odds for having a premature birth were increased 3.6-fold in comparison with the high consumption group. The dose-response relationship (quantified maternal fish intake: occurrence of premature birth) was calculated to operate in the range from zero intake up to an intake of 15 g of fish or 0.15 g n-3 fatty acids daily. Risk estimates for low birth weight were similar to those for premature birth.
Conclusion: Women who consume little or no fish (or n-3 fatty acids from other sources) are at increased risk of having a premature birth and a low birth weight baby. In such women, dietary supplementation with small amounts of n-3 fatty acids – as fish or fish oil – may help protect them against these risks.
Olsen SF, Secher NJ. Low consumption of seafood in early pregnancy as a risk factor for preterm delivery: prospective cohort study. British Medical Journal 324 (7335): 447. Feb 2002.

Issue 76

KIERNAN, Cayuga Community College, Auburn, NJ, USA, jkiernan@ computer-connection.net, examined the subjective effects of therapeutic touch during home visits in women following childbirth.
Methods: 5 women who had recently given birth received therapeutic touch during home visits during a 2-month period. The visits, which were audiotaped and transcribed, focused on postpartum problems and concerns. Data were coded and categorized, and were analysed for associations between categories.
Results: From the women’s experiences, 5 main themes were identified: ‘feeling relaxed’, ‘feeling open’, ‘feeling cared for’, ‘feeling connected’ and ‘feeling sceptical’.
Conclusion: The home visits resulted in the experience of many positive emotions for both the women and the researchers carrying out the visits, which included feelings of mutual caring. It is not certain whether the visits per se, the interaction, or the therapeutic touch was responsible for the particular experiences encountered.
Kiernan J. The experience of Therapeutic Touch in the lives of five postpartum women. The American Journal of Maternal Child Nursing 27 (1): 47-53. Jan-Feb 2002.

WERNTOFT and DYKES, Department of Nursing, Unit of Caring Sciences, Lund University, Lund, Sweden, elisabet.werntoft@omv.lu.se, investigated the potential of acupressure to relieve nausea and vomiting in normal healthy pregnant women.
Methods: This randomized, placebo-controlled pilot study included 60 healthy women with a normal pregnancy and experiencing nausea and vomiting of pregnancy (NVP). The women were assigned to 1 of 3 treatment groups: 1) acupressure (at the Neiguan point, P6), 2) placebo (acupressure at a placebo point), or 3) control (no treatment).
Results: In women receiving acupressure, NVP was significantly reduced compared with women receiving placebo or no treatment. At Day 1 after the start of treatment, relief from NVP occurred in both the acupressure and the placebo groups; relief lasted only for 6 days in the placebo group, but was still apparent after 14 days in the acupressure group.
Conclusion: The results indicate that it is possible to significantly reduce NVP in healthy women with a normal pregnancy by applying acupressure at P6.
Werntoft E, Dykes AK. Effect of acupressure on nausea and vomiting during pregnancy. A randomized, placebo-controlled, pilot study. The Journal of Reproductive Medicine 46 (9): 835-9. Sep 2001.

SLOTNICK, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Suite 310, Hofheimer Hall, 825 Fairfax Avenue, Norfolk, VA 23507, USA, slotnirn@evms.edu, evaluated the safety and effectiveness of acustimulation at P6 to relieve nausea and vomiting associated with early pregnancy.
Background: Current pharmacological treatments for nausea in early pregnancy can be inconsistent or ineffective, cause unwanted side effects, or be associated with a risk of teratogenicity.
Methods: 41 women in early pregnancy and experiencing nausea and vomiting of pregnancy received acustimulation at point P6 with an acustimulation device. Patients self-rated severity of nausea pre-treatment, relief from nausea post-treatment and effectiveness of the device on scales of 1-5 (5 represented ‘most severe and debilitating nausea’, ‘significant or complete relief’ and ‘very easy to use’, respectively). Newborns were evaluated for congenital abnormalities.
Results: The average pre-treatment nausea severity score was 4.2; average post-treatment effectiveness was rated 4.2; the average score for device ease of use was 4.3. No congenital abnormalities were detected in the newborns.
Conclusion: Acustimulation of P6 for relieving nausea in early pregnancy may offer a useful alternative to pharmacological treatments.
Slotnick RN. Safe, successful nausea suppression in early pregnancy with P-6 acustimulation. The Journal of Reproductive Medicine 46 (9): 811-4. Sep 2001.

Issue 75

MCCANDLISH, National Perinatal Epidemiology Unit, Institute of Health Sciences, Headington, Oxford, UK, reviewed (49 references) the management of perineal care and trauma in routine midwifery practice.
Discussion: The author explored two aspects of perineal care: 1) management of the perineum at the end of the second stage of labour; and 2) management and repair of injuries to the perineum. Management techniques examined included episiotomy, massage, sutures, and prevention and control of complications of labour. The author highlights techniques based on clinical evidence and those that are not evidence-based and treatment outcomes.
Conclusion: Some aspects of perineal management and repair have been researched and there is reliable evidence on which to base practice. However, there remains a considerable and urgent need for collaborative clinical research in this area. Midwives need to be aware of this and actively pursue the furtherance of such knowledge.
McCandlish R. Perinatal trauma: prevention and treatment. Journal of Midwifery and Women’s Health 46 (6): 396-401. Nov-Dec 2001.

Issue 73

MUSLIMATUN and colleagues, SEAMEO TROPMED Regional Center for Community Nutrition, University of Indonesia, Jakarta, Indonesia, investigated whether retinol and iron variables in breast milk and in serum postpartum were enhanced more with weekly vitamin A and iron supplementation during pregnancy than with weekly iron supplementation.
Background: Studies on the effect of vitamin A and iron supplementation during pregnancy on maternal iron and vitamin A status postpartum are scarce.
Methods: In this randomized, controlled clinical trial, 88 pregnant women received a weekly supplement of iron (120 mg Fe as FeSO(4)) and folic acid (500 g), and another 82 received the same amount of iron and folic acid plus vitamin A (4,800 retinol equivalents (RE)).
Results: Transitional milk (4-7 days postpartum) had higher (p<0.001) concentrations of retinol and iron than mature milk (3 months postpartum). Compared with the weekly iron + folate group, the women who received the additional weekly vitamin A supplementation had a greater (p<0.05) concentration of retinol in transitional milk (as mol/L) and in mature milk (as mol/g fat). Serum retinol concentration at approximately 4 months postpartum did not differ significantly between the two groups; however, the vitamin A-supplemented group had significantly fewer (p<0.01) subjects with serum retinol concentrations 0.70 mol/L. Iron status and concentrations of iron in transitional and mature milk did not differ between the groups.
Conclusions: Weekly vitamin A and iron [plus folate] supplementation during pregnancy enhanced concentrations of retinol in breast milk, but not in serum, by approximately 4 months postpartum. No positive effects were observed on iron status and iron concentration in breast milk.
Muslimatun S et al. Weekly vitamin A and iron supplementation during pregnancy increases vitamin A concentration of breast milk but not iron status in Indonesian lactating women. The Journal of Nutrition 131 (10): 2664-9. Oct 2001.

EWIES, Department of Gynaecology, Leicester University, UK, aymanewies@hotmail.com, reviewed (45 references) available research into some of the more common alternative therapies used by women to treat menopausal symptoms.
Background: Extensive evidence indicates that the benefits of hormone replacement therapy (HRT) outweigh the risks. However, many women and health care providers remain concerned about safety and side effects. Many patients favour alternative therapies. In the USA, menopausal women spent more than $600 million in 1999 on such therapies. This article critically appraises some of the most commonly used alternative therapies.
Discussion: Calcium, vitamin D, exercise, stress reduction and different dietary and life style adaptations may enhance quality of life in menopausal women who do or don’t take HRT. These items have potential for being effective and safe. Other alternative therapies have undergone only limited, if any, clinical research. Health care providers need to be aware of the lack of conclusive evidence available for certain alternative therapies when addressing patients’ questions and concerns. The evidence base will increase in the coming years. Eventually, the greater number of available treatment choices should allow individualization of treatment. But until prospective studies with prolonged follow-up are conducted to evaluate the benefits and risks of different alternative therapies, HRT, which is better studied, will remain the treatment of choice, and ‘one size fits all’ will continue to describe the management plan for most peri- and postmenopausal women at least for the immediate future.
Learning objectives: After reading this article, the reader will be able to summarize the alternatives to HRT, describe the effects of phytoestrogens on menopausal symptoms, and explain the origin and clinical use of the more common herbal remedies.
Ewies AA. A comprehensive approach to the menopause: so far, one size should fit all. Obstetrical and Gynecological Survey 56 (10): 642-9. Oct 2001.

Comment: The agenda and point of view underlying this review (supportive of HRT) is evident and plain to see.

KOMESAROFF and colleagues, Baker Medical Research Institute, PO Box 6492, St Kilda Central, Melbourne 8008, Victoria, Australia, investigated the efficacy and safety of a externally applied cream containing an extract of wild yam (Dioscorea villosa) for treating troublesome menopausal symptoms in women.
Background: Many women seek alternatives to hormonal therapies for managing menopausal symptoms. Currently popular treatments include extracts of wild yam (Dioscorea villosa), which are applied externally as cream. These preparations are known to contain steroidal saponins, including diosgenin, which has been claimed to influence endogenous steroidogenesis.
Methods: This double-blind, placebo-controlled, randomized, cross-over design clinical trial involved 23 [otherwise] healthy women (average age 53.51.1 years) suffering troublesome menopausal symptoms. At the start of the study, the average time since their last period was 4.30.9 years; average body mass index was 27.30.8; cholesterol level was 5.70.2 mmol/L; follicle-stimulating hormone (FSH) level was 74.25.1 IU/L; oestradiol levels were undetectable in the majority of cases. Subjects entered a 4-week baseline study period, followed by treatment with a wild yam cream or matching placebo cream for 3 months. [Subjects were then crossed over to the alternative treatment for a further 3 months.] Subjects completed diaries [of symptoms] over the baseline period and for 1 week of each month thereafter. Blood and saliva samples were collected at baseline and at 3 and 6 months for measurement of lipids and hormones.
Results: After 3 months of either active treatment or placebo, no significant side effects had been reported, and there were no significant changes in weight, systolic or diastolic blood pressure, or levels of total serum cholesterol, triglyceride, high-density lipoprotein (HDL) cholesterol, FSH, glucose, oestradiol, or serum or salivary progesterone. Symptom scores revealed a minor effect of both placebo and active cream on diurnal flushing number and severity, and total non-flushing symptom scores, and on nocturnal sweating after placebo. There were no statistically significant differences on symptoms scores between placebo and active creams.
Conclusions: Short-term treatment of troublesome menopausal symptoms in women with a topical wild yam extract was free from side effects, but appeared to have little effect on menopausal symptoms. The results emphasize the importance of careful study of treatments for menopausal symptoms if women are to be adequately informed about the choices available to them.
Komesaroff PA et al. Effects of wild yam extract on menopausal symptoms, lipids and sex hormones in healthy menopausal women. Climacteric 4 (2): 144-50. Jun 2001.

Comment: It is vitally important that further studies with these types of products be conducted, as well as with products containing Natural Progesterone.

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IBRAHIM and colleagues reviewed (48 references) the literature for alternative therapies for treatment of menopausal symptoms.
Background: Fewer than one in three women choose to take hormone replacement therapy (HRT), due to lack of confidence in the espoused benefits and the significant array of associated side effects. Alternatives to conventional HRT have become more accessible and acceptable to many women. Physicians now face the challenges of how to advise patients about alternative medicine and how to determine which therapies may be safe and effective.
Ibrahim SA et al. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Use of botanicals for management of menopausal symptoms. Obstetrics and Gynecology 97 (6): Suppl 1-11. Jun 2001.

TIAN and colleagues, Maternity and Child Health Institute, Changqing 400013, China studied the effect of a Chinese herbal medicine for replenishing Kidney combined with acupuncture in treating anovulation and infertility, and the relationship between the medicine’s ovulation-inducing effect and endometrial levels of estradiol receptors (ER) and progesterone receptors (PR).
Methods: 29 patients were treated with Kidney-replenishing medicine combined with acupuncture for 1 to 3 months. Endometrial ER and PR levels were measured by immunohistochemistry. Patients were grouped according to PR levels into either a ‘PR-positive’ group or a ‘mild PR- positive’ group.
Results: 15 patients in the ‘PR-positive’ group completed treatment for 45 [menstrual] cycles. Among these, 40 cycles showed ovulation, the ovulation rate 88.9%. 10 of 14 cases who were previously infertile became pregnant, pregnancy rate 71.4%. 11 patients in the ‘mild PR-positive’ group, 9 of whom were previously infertile, completed treatment for 33 cycles. Of these, 10 cycles showed ovulation (ovulation rate 30.3%) and 2 of the previously infertile 9 patients became pregnant (pregnancy rate 22.2%). The differences between the ‘PR-positive’ and the ‘mild PR-positive’ groups were significant (p<0.01).
Conclusion: A Chinese herbal medicine for replenishing Kidney combined with acupuncture treatment, as applied in this study, was successful for treating infertility due to anovulation in 12 of 26 patients who completed treatment for between 33 and 45 menstrual cycles. The combined treatment was particularly effective in patients (10 out of 15) who initially had high endometrial PR levels.
Tian D et al. (Study on relationship between ovulation inducing effect of drug-acupuncture and endometrial contents of estradiol receptor and progesterone receptor.) Zhongguo Zhong Xi Yi Jie He Za Zhi 18 (4): 225-6. Apr 1998.
Comment: The results of the above research are highly interesting and hopefully will be followed up by clinicians internationally.

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TSUI and colleagues, Department of Clinical Pharmacy, University of California, San Francisco, CA 94143, USA, examined the usage patterns of dietary supplements during pregnancy.
Methods: A survey was distributed to pregnant women touring the University of California San Francisco Birthing Center or receiving care at the university’s Women’s Health Clinic between November 1999 and March 2000.
Results: 150 surveys were completed. 20 women (13%) used dietary supplements during pregnancy. The most common products were: echinacea (8.9%), pregnancy tea (8.9%) and ginger (6.7%). The most common reasons for starting or discontinuing use of dietary supplements were to relieve nausea and vomiting (25%) and avoid potential harm to the fetus (25%). All side effects were mild. They included gastrointestinal discomfort with elderberry (n=1); taste disturbance with echinacea (n=1); and intestinal gas with borage seed oil (n=1). Most patients (75%) informed their primary care provider of their use of dietary supplements.
Conclusion: There is low usage of dietary supplements among pregnant women. However, usage is a concern because of lack of safety data. Most patients use dietary supplements to relieve gastrointestinal symptoms. Most disclose their usage to their primary care provider.
Tsui B et al. A survey of dietary supplement use during pregnancy at an academic medical center. American Journal of Obstetrics and Gynecology 185 (2): 433-7. Aug 2001.

TANAKA, Departments of Obstetrics and Gynaecology, Osaka City University Medical School, Osaka, Japan, examined the therapeutic effects of several Japanese herbal medicines on menopausal symptoms induced by gonadotropin-releasing hormone (GRH) in women with endometriosis, adenomyosis or leiomyoma.
Results: 17 of the 22 patients studied showed menopausal symptoms. The following Japanese herbal remedies were administered to 13 of the 17 symptomatic patients: Toki-shakuyaku-san, Shakuyaku-kanzo-to, Keishi-bukuryo-gan, Kami-shoyo-san, Tokaku-joki-to or Keishi-to. Efficacy was observed in all 13 patients. 11 patients with hot flashes received Toki-shakuyaki-san and all experienced some relief; 4 experienced total relief. 3 patients with severe shoulder stiffness received Shakuyaku-kanzo-to and were completely relieved of symptoms. No significant changes in serum oestradiol levels were detected after treatment with the Japanese herbal medicines.
Conclusion: The results indicate that Japanese herbal medicines can be recommended for menopausal symptoms induced by GRH agonists without a negative effect on serum oestradiol levels.
Tanaka T. Effects of herbal medicines on menopausal symptoms induced by gonadotropin- releasing hormone agonist therapy. Clinical and Experimental Obstetrics and Gynecology 28 (1): 20-3. 2001.

CLAUSEN and colleagues, Department of Obstetrics and Gynecology, Aker University Hospital, Oslo, Norway, torun.clausen@ioks.uio.no, investigated whether diet in the first half of pregnancy is associated with the risk for pre-eclampsia.
Background: Pre-eclampsia is associated with high body mass index (BMI), insulin resistance and hypertriglyceridaemia.
Methods: In this prospective, population-based, cohort study, 3,133 women (83% response rate) completed a quantitative food frequency questionnaire investigating their dietary intake early in the second trimester of pregnancy.
Results: 85 of the women developed pre-eclampsia. The adjusted odds ratio (OR) for pre-eclampsia was 3.7 (95% confidence interval [CI], 1.5-8.9) for energy intake of >3,350 kcal/day compared with 2,000 kcal/day. The adjusted OR for pre-eclampsia was 3.6 (95% CI, 1.3-9.8) for sucrose intake (% of total energy) of >25% compared with 8.5%, and was 2.6 (95% CI, 1.3-5.4) for polyunsaturated fatty acids (PUFAs) intake (% of total energy) of >7.5% compared with 5.2%. Other energy-providing nutrients were not associated with the risk for pre-eclampsia.
Conclusion: The findings suggest that high intakes of energy, sucrose and PUFAs independently increase the risk for pre-eclampsia.
Clausen T et al. High intake of energy, sucrose, and polyunsaturated fatty acids is associated with increased risk of preeclampsia. American Journal of Obstetrics and Gynecology 185 (2): 451-8. Aug 2001.

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