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Complementary & alternative medicine for women.

It was bad enough when Jennifer Tilofi* was diagnosed with rheumatoid arthritis six years ago at age 31; but when, after nearly four years of treatment with some pretty toxic drugs, she felt no better, she knew something had to change.

"My liver enzymes were intermittently elevated (a sign of potential liver problems), and the kidney specialist I saw told me the medicine I was on would eventually harm my kidneys," she recalled. She knew she couldn't just stop taking the large doses of Advil, methotrexate and rituxan (Remicade)--if she did, her joints could become permanently damaged. Plus, she needed the medications for pain. So she started looking outside conventional medicine for relief.

That's how she found Victoria Maizes, MD, executive director of the University of Arizona's Program in Integrative Medicine. Ms. Tilofi, a physical therapist from Longwood, FL, wrote a "pitiful" e-mail begging the integrative medicine specialist to see her, even though the doctor's Web site said she didn't treat out-of-state patients. Dr. Maizes relented, and Ms. Tilofi flew out to meet her.

It took just one visit to know that this doctor was different from any other. For one, even before Ms. Tilofi met with Dr. Maizes, she had to write an essay describing the physical, emotional and spiritual aspects of her life. That essay, as well as the hour-plus initial visit Dr. Maizes conducted, led to a plethora of new treatment options designed to complement, not replace, the Western medicines Ms. Tilofi already took. These included daily doses of the anti-inflammatory supplements fish oil and primrose oil; an anti-inflammatory diet primarily devoid of wheat and sugar and high in vegetables and fish; meditation for stress relief; and craniosacral therapy, in which light touch and massage are used to relieve pain and emotional tension. The insight she gained during her sessions with Dr. Maizes, and a greater understanding of how stress worsens her disease, also led Ms. Tilofi to switch jobs.

Two years later, Ms. Tilofi uses far less medication than before she added the alternative therapies. Instead of monthly Remicade infusions, today she gets one every seven weeks. She's no longer taking methotrexate, and instead of the 24 grams a day of liquid Advil and the pain pills she took every night, she only takes Advil as needed for pain--rarely.

Ms. Tilofi is part of a growing trend in this country for people to seek care outside the conventional health care system. In 2002, about 62 percent of American adults--including 40 percent of women--used some sort of complementary and alternative medicine (CAM), everything from prayer to deep breathing to chiropractic, yoga, massage and nutritional approaches. (1) Even if you take prayer out of the picture, one out of three people in the United States still used some form of CAM. (2) And most paid for it themselves, since much is not covered by insurance. By the late 1990s, Americans were spending an estimated $270 billion a year out of pocket for CAM therapies, about as much as they spent on conventional medical approaches. (3)

The use of CAM appears to cross not only gender, but also age, racial and ethnic boundaries. An AARP telephone survey of more than 1,500 adults ages 50 and older conducted in late 2006 found that nearly two out of three reported using some form of CAM [See Ages & Stages on page 6]. (4) If you include prayer in the definition of CAM, about 60 percent of Asians and Latinos, and 71 percent of African Americans use CAM. (5,6) Even kids are using it. A recently published study found that more than 30 percent of American children 18 and younger take some form of dietary supplements, mostly multivitamins and/or multiminerals. (7)

Talk to Your Doctor

But here's the hitch: Patients don't tell their health care providers about their use of CAM. In one study of 1,013 parents and caregivers, researchers found that while 12 percent of the children were using some form of CAM, only a third of their parents told the doctor. (8) National studies find the same thing: about 60 percent of those using CAM say they've never discussed it with their doctors. (9)

Given that many of the herbs, supplements and other CAM treatments people turn to could have potentially dangerous interactions with conventional therapies, particularly pharmaceutical medications, that's a problem. "People who are using CAM need to talk to their health care providers," said Richard Nahin, PhD, the Senior Advisor for Scientific Coordination at the National Center for Complementary and Alternative Medicine (NCCAM). Integrative medicine--the use of both conventional and CAM approaches--doesn't mean parallel health care approaches, he said. "It means doing everything together." This is particularly important since understanding patients' CAM practices could provide valuable insight into their values, lifestyles and health beliefs, all of which are important in providing quality health care. (10)

Patients cite a variety of reasons for not sharing their CAM use with their doctors: The doctor doesn't ask, they don't know if they should bring it up, there isn't enough time during the office visit. (4) Many don't believe it's important that their doctors know; some think it isn't any of their doctor's business, and still others think their doctor wouldn't understand.

In addition, nearly 40 percent of patients with a serious medical condition (cancer, coronary artery disease or diabetes) said they don't tell their doctor because they don't think their physician "would approve." (9)

In fact, studies of doctors find they rarely ask their patients about CAM, even though most suspect patients are using it. One study found that more than half of physicians did not have a positive attitude about CAM when they talked to their patients about it, and most felt uncomfortable during the discussions. Not surprisingly, the more physicians knew about CAM options, the more comfortable they felt discussing it with their patients. (11)

Ironically, notes Dr. Maizes, "Most patients say they want their physician to know about this."

The first step in starting that conversation is examining your relationship with your doctor. "I have patients come in and say, 'I love my doctor; but he sure doesn't know about this,'" she says. "If you love your doctor, then your doctor loves you, and you can say, 'I'm using this, and here is how it helps me.'" If your doctor criticizes or shames you, she says, it may be time to find a new doctor.

Ms. Tilofi has seen both sides. Her rheumatologist, while "tolerant" of her use of CAM, doesn't believe it's the reason behind Ms. Tilofi's improvement. Rheumatoid arthritis often goes into remission, and her doctor believes that's what's happened to Ms. Tilofi. The fact that it coincided with the lifestyle changes Ms. Tilofi made and the supplements she takes is just coincidental, the doctor told her. But Ms. Tilofi's primary care physician "has been super interested." She asks questions, delves into the specifics of the treatments and "just gets it," said Ms. Tilofi.

One of the biggest challenges Theiry Raby, MD, who directs the Center for Integrative Medicine at Northwestern Memorial Hospital in Chicago, faced when she started the center 11 years ago, was suspicion from other doctors. She made a point to involve referring or primary care physicians in patients' treatment, insisting that all her staff--even nutritionists--write a note to the referring physician after every patient interaction. Slowly and surely, she said, the center gained credibility. One major reason? "Physicians see patients get better."

Not One or the Other: Understanding Integrative Medicine

Most people who use CAM don't choose it instead of conventional medicine. Like Ms. Tilofi, they choose it in addition to conventional medicine in what has come to be known as integrative medicine. Dr. Raby defines integrative medicine as: "A healthy balance between conventional and alternative medicine." That means if you have an infection, you might receive an antibiotic along with a probiotic to replace the good bacteria the antibiotic wipes out, and herbs or a prescription for yoga to strengthen your immune system. If you break your leg, you get surgery, but you may also receive acupuncture, as well as a prescription for bone-building minerals and vitamins like calcium, magnesium and vitamin D.

Although a relatively new concept, integrative medicine is catching on. Today, the Consortium of Academic Health Centers for Integrative Medicine, devoted to training medical students, residents and physicians in CAM and integrative medicine, boasts 38 members, including such prestigious schools as Albert Einstein College of Medicine and Columbia University in New York, Harvard Medical School, Yale Medical School and the University of Pennsylvania Medical School. All also offer integrative medicine programs for patients.

Many integrate CAM with oncology. For instance, Dr. Maizes sees many women with metastatic breast cancer. She doesn't try to take the place of the women's oncologists; instead, she recommends therapies to strengthen her breast cancer patients' immune systems and help combat the fatigue and other side effects of chemotherapy, as well as reduce risk factors that could stimulate the growth of cancer cells.

For instance, she warns women away from alcohol, which can increase estrogen levels--a potent fuel for cancer cells. She also recommends melatonin, which some studies suggest may increase survival, and mushrooms and the herb astragalus to strengthen the immune system (typically suppressed during chemotherapy) and help prevent infection. If women are receiving the chemotherapy taxol, she adds glutamine or alpha lipoic acid, potent antioxidants that tend to get depleted with taxol therapy. And she teaches her patients mind/body practices to help minimize the stress that comes from coping with a chronic form of cancer: the constant doctor appointments, tests, and, most stressful of all, waiting.

It's something breast cancer patients of all stages apparently crave. A survey of 105 women diagnosed with breast cancer found that 64 percent used vitamins and minerals, and a third regularly used antioxidants, herbs and health foods. Nearly half (40 percent) regularly used prayer and spiritual healing, while 37 percent used support groups and 21 percent used humor or laughter therapy as part of their healing treatment. All are considered CAM. (12)

The use of CAM is so prevalent in cancer patients that in September the American College of Chest Physicians (ACCP) became the first professional oncology organization in the United States to formally provide recommendations on the use of CAM during cancer treatment. While the AACP guidelines note that some herbal remedies may interfere with chemotherapy, they add that other therapies, such as acupuncture, may help with pain and other symptoms. (13)

Most oncologists, however, feel differently about CAM than their patients. While they agree that CAM can help relieve symptoms and side effects of treatment, they are less likely than their patients to expect that CAM improves immunity or quality of life, cures disease or prolongs life. (14)

Empowering the Patient

The women Dr. Raby sees usually find her after they become frustrated with what modern medicine has to offer. They tend to be educated, between the ages of 25 and 52, and want to share in a relationship with their physician. Her goal is to empower them to care for themselves instead of dictating to them what they should do for their health. "We do whatever we need to do as long as it is safe," she said. Many women she sees have chronic conditions like fibromyalgia, rheumatoid arthritis, multiple sclerosis, depression, anxiety, irritable bowel syndrome (IBS) or chronic fatigue syndrome, conditions in which Western medicine can only go so far.

So, for instance, when she treats women with IBS, she focuses on stress, which often triggers symptoms: "What is the core of their stress and what are their coping mechanisms?" Often, she finds, women internalize stress, which then manifests itself as migraines, reflux, back pain and headaches. Western medicine, she said, tends to compartmentalize the mind and the body; alternative medicine views them as one and the same. "Every aspect of your life has an impact on your body," she reminds her patients.

But Dr. Raby, a board-certified internist, always keeps one foot firmly planted in Western medicine. That woman with IBS? Dr. Raby will also run tests to make sure she doesn't have something more serious like ulcerative colitis or Crohn's disease.

To help women learn to undo the damaging effects of stress on their bodies, she refers them to a clinical psychologist, has them learn guided imagery or self-hypnosis or recommends biofeedback. She may suggest journaling, yoga or tai chi, sometimes just meditation or prayer. "You figure out what is right for them," she said. "The person in front of me may have the exact same symptoms as the one next to me, but you individualize care."

For more information on this and other women's health and lifestyle topics, visit www.healthywomen.org, or call toll-free: 1-877-986-0472.

*Not her real name

Resources

American Association of Acupuncture and Oriental Medicine

866-455-7999

www.aaaomonline.org

Association for Applied Psychophysiology and Biofeedback

800-477-8892

www.aapb.org

American Naturopathic Medical Association

702-897-7053

www.anma.com

American Association of Naturopathic Physicians

866-538-2267

www.naturopathic.org

Consortium of Academic Health Centers for Integrative Medicine

612-624-9166

www.imconsortium.org/cahcim/home.html

National Center for Complementary and Alternative Medicine

888-644-6226

www.nccam.nih.gov

References

1 Upchurch DM, Chyu L, Greendale GA, et al. Complementary and alternative medicine use among American women: findings from The National Health Interview Survey, 2002. J Women's Health (Larchmt). Jan-Feb 2007;16(1):102-113.

2 Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. May 27 2004(343):1-19.

3 Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. JAMA. 1998;280:1569.

4 AARP and NCCAM. Complementary and Alternative Medicine: What People 50 and Older Are Using and Discussing with Their Physicians. AARP. Washington, DC. 2007.

5 Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. May 27, 2004(343):1-19.

6 Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med. Jan-Feb 2005;11(1):42-49.

7 Picciano, MF et al., Arch Pediatr Adolesc Med. 2007; 161(10):978-985.

8 Sawni-Sikand A, Schubiner H, Thomas RL. Use of complementary/alternative therapies among children in primary care pediatrics. Ambul Pediatr. Mar-Apr 2002;2(2):99-103.

9 Eisenberg DM, Kessler RC, Van Rompay MI, et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Ann Intern Med. Sep 4, 2001;135(5):344-351.

10 Pappas 5, Perlman A. Complementary and alternative medicine. The importance of doctor-patient communication. Med Clin North Am. Jan 2002;86(1):1-10.

11 Corbin Winslow L, Shapiro H. Physicians Want Education About Complementary and Alternative Medicine to Enhance Communication With Their Patients. Arch Intern Med. May 27, 2002;162(10):1176-1181.

12 Lengacher CA, Bennett MP, Kip KE, et al. Frequency of use of complementary and alternative medicine in women with breast cancer. Oncol Nurs Forum. Nov-Dec 2002;29(10):1445-1452.

13 Cassileth BR, Deng GE, Gomez JE, Johnstone PAS, Kumar N, Vickers AJ. Complementary Therapies and Integrative Oncology in Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition). Chest. 2007;132(3_suppl):3405-354.

14 Richardson MA, Masse LC, Nanny K, Sanders C. Discrepant views of oncologists and cancer patients on complementary/alternative medicine. Support Care Cancer. Nov 2004;12(11):797-804.

15 Eisenberg DM, Cohen MH, Hrbek A, Grayzell, Van Rompay MI, Cooper RA. Credentialing complementary and alternative medical providers. Ann Intern Med. Dec 17, 2002;137(12):965-73.
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Publication:National Women's Health Report
Date:Nov 1, 2007
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