Complementary and Alternative Medicine Use for Menopausal Complaints 11

COMPLEMENTARY AND ALTERNATIVE MEDICINE

USE AND THE MENOPAUSAL TRANSITION:

THE EFFECT OF A CHINESE HERBAL FORMULA

ON VASOMOTOR SYMPTOMS

AND BONE TURNOVER

Corinne Patching van der Sluijs, B.Sc, B.Hlth Sc, Dip Ed

This thesis is submitted for the degree of Doctor of Philosophy, University of Western Sydney Centre for Complementary Medicine Research

November 2007

CERTIFICATION

The work presented in this thesis is, to the best of my knowledge and belief, original

except as acknowledged in the text. I hereby declare that I have not submitted this

material, either in full or in part, for a degree at this or any other institution.

Corinne Patching van der Sluijs

iii

DEDICATION

To Byron Edward Patching

Without your loving support and patience, this work would not have been possible

And

To our two beautiful young children who entered the world during this time

Micah Robert (1st January 2005)

Grace Elisabeth (23rd June 2006)

ACKNOWLEDGEMENTS

I wish to take this opportunity to express my sincere thanks to the many people who supported and assisted me during this research project; without whose help this thesis would not have eventuated. I am grateful to the many survey respondents and clinical trial participants who graciously gave their time to take part in this research. Thank you to the general practice clinics, the menopause clinics, the New South Wales Government and the

University of Western Sydney who gave permission to allow for the distribution of the questionnaire.

To my principal supervisor Professor Alan Bensoussan, I am extremely grateful for your guidance, expertise, patience and understanding throughout this journey; and to my co- supervisors Drs Smita Shah and Liwan Liyanage who encouraged and supported me during this time. I am grateful for the assistance and support of Dr Rod Baber and staff at the Royal

North Shore Menopause Clinic, Professors Felix Wong and Markus Seibel. In addition, I wish to acknowledge the support of Professor Seibel and the ANZAC Research Centre for providing the bone marker assay kits and for testing the samples. Sungwon Chang, I am grateful for your statistical guidance and assistance. Your support has been invaluable. I wish to also sincerely thank practitioners Nadine Licht, Christine Guirguis and Tuyet Tran for your considerable help in consulting trial participants.

I am grateful for financial support and the PhD scholarship granted to me by the University of Western Sydney. I also wish to thank staff at CompleMED for their ongoing support for this project. Finally, I would like to express my sincere gratitude for the financial and technical assistance received from Global Therapeutics for the clinical trial.

ABSTRACT

Although Hormone Therapy (HT) is the most effective treatment for alleviating menopausal vasomotor symptoms and reducing bone loss, many women are reluctant to take this treatment due to side effects and concerns about safety.

Epidemiological studies suggest that a significant proportion of women use

Complementary and Alternative Medicine (CAM) therapies to alleviate vasomotor symptoms and improve quality of life. Anecdotal and clinical evidence indicate a number of CAM therapies, such as herbal medicine, may be effective in alleviating symptoms and modulating bone metabolism. Hence, in the context of concerns over the safety of HT and the extensive history of the clinical use of herbal medicine, this thesis investigated issues pertinent to CAM use and the menopausal transition.

The aims of this thesis were to:

• Examine the nature and extent of CAM use by women transitioning through

menopause

• Evaluate the effectiveness of a herbal formula containing Chinese herbs and

Cimicifuga racemosa for alleviating vasomotor symptoms, improving quality

of life and modulating bone turnover markers.

From July 2003 until July 2004 the Women’s Health during Midlife Survey recruited

1,296 women aged 45-65 who were symptomatic when transitioning through menopause or asymptomatic but taking menopause specific treatments. A validated

19-item survey instrument assessed the use of CAM modalities and menopause

vi specific products. The instrument was completed voluntarily and anonymously by women recruited from three strata; menopause clinics, clinics of general practice and government agencies.

Approximately 54% of respondents had visited a CAM practitioner and/or used a

CAM product during the previous 12 months. The most popular practitioners were the naturopath (7.2%) and acupuncturist (4.8%), while soy (25.4%) and evening primrose oil (EPO, 18.4%) were the most popular products. Massage and chiropractic were considered the most effective therapies, while phytoestrogen tablets and EPO were the most efficacious products. Although 26.4% of respondents indicated their doctor asked about CAM use, 71% of CAM users said they informed their physician about using CAM. Of the 60% of women using pharmaceutical medicines, 62.5% reported using a CAM product during the preceding 12 months.

The survey results confirm the continued popularity of CAM use amongst women transitioning through menopause. A number of treatments were perceived to be effective in relieving symptoms. However, communication between medical practitioners and patients about CAM use is inadequate, and given the high use of pharmaceutical medicines this oversight may unnecessarily expose women to drug- herb interactions.

A randomised, double-blind, placebo controlled clinical trial was conducted to evaluate the effectiveness of a herbal formula derived from two traditional Chinese herbal formulae with the addition of Cimicifuga in alleviating vasomotor symptoms.

The trial recruited 93 healthy women who reported at least six vasomotor symptoms

vii per day. After a four week baseline period, women were randomly allocated to receive either herbal treatment or identical looking placebo tablets for 16 weeks.

During the trial women recorded the number and severity of their flushes on a Daily

Flush Diary, and at each monthly consultation two quality of life scales were completed. Forty nine eligible trial women were entered into a pilot study to assess the effect of the formula on bone turnover markers; bone specific alkaline phosphatase and deoxypyridinoline (corrected for creatinine).

The herbal formula was found to be no more effective than placebo in reducing the frequency of flushing and the composite hot flush score or in improving quality of life. The pilot study found the formula had no effect on bone turnover markers after

16 weeks of treatment. Therefore, this formula cannot be recommended as a treatment for vasomotor symptoms and is unlikely to have any long term effect on bone.

The use of CAM during the menopausal transition is very popular. Although this thesis found the current herbal formula to be an ineffective treatment, the scientific evaluation of potential CAM therapies is imperative so that health care professionals and consumers can make informed decisions concerning treatment options for the alleviation of symptoms.

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TABLE OF CONTENTS CERTIFICATION II

DEDICATION III

ACKNOWLEDGEMENTS IV

ABSTRACT V

TABLE OF CONTENTS VIII

LIST OF FIGURES XIII

LIST OF TABLES XIV

LIST OF ABREVIATIONS XVI

LIST OF APPENDICES XVIII

CHAPTER 1 INTRODUCTION 1 1.1 General Background to the Study 1

1.2 Aim and Scope 5

1.3 Significance of the Study 8

1.4 Thesis Overview 9

SECTION ONE

COMPLEMENTARY AND ALTERNATIVE MEDICINE USE FOR MENOPAUSAL COMPLAINTS 11

CHAPTER 2 CAM AND THE MENOPAUSAL TRANSITION 12 2.1 Introduction 12

2.2 Defining CAM 13

2.3 Economic Impact of CAM 15

2.4 The CAM Consumer 19

2.5 CAM Use and the Menopausal Transition 23

2.6 CAM Use by Middle Aged Women 32

2.7 Summary and Conclusions 42

CHAPTER 3 SURVEY: RESEARCH DESIGN 44 3.1 Introduction 44

3.2 Study Objectives 45

3.3 Participants and Setting 46

3.4 Survey Instrument 49

3.5 Statistical Analyses 53

3.6 Summary 54

CHAPTER 4 SURVEY: RESULTS 56 4.1 Introduction 56

4.2 Survey Instrument Reliability 57

4.3 Demographics and Health Characteristics 57

4.4 Use of CAM 62

4.5 Use of Pharmaceuticals 69

4.6 Determinants of CAM Use 71

4.7 Discussion 72

CHAPTER 5 SURVEY: DISCUSSION AND CONCLUSIONS 75 5.1 Introduction 75

5.2 CAM Use by Women Aged 45-65 75

5.3 CAM and Pharmaceutical Use 80

5.4 Determinants of CAM Use 81

5.5 Methodological Considerations 83

5.6 Conclusions 86

SECTION TWO

THE EFFECT OF FF-01 ON VASOMOTOR SYMPTOMS AND BONE TURNOVER 87

CHAPTER 6 MENOPAUSE AND VASOMOTOR SYMPTOMS 88 6.1 Introduction 88

6.2 A Definition of the Menopause 89

6.3 Epidemiology of the Menopause 92

6.4 Changes during the Menopausal Transition 94

6.5 Symptoms of the Menopause 99

6.6 Pharmacological Treatments for Vasomotor Symptoms 116

6.7 Summary and Conclusion 124

CHAPTER 7 CHINESE HERBAL MEDICINE FOR VASOMOTOR SYMPTOMS 126 7.1 Introduction 126

7.2 TCM and Menopause 127

7.3 Systematic Review on CHM for Vasomotor Symptoms 131

7.4 Discussion and Conclusions 153

CHAPTER 8 TRIAL FORMULA: FF-01 155 8.1 Introduction 155

8.2 FF-01: the Clinical Trial Formula 156

8.3 Constituent Herbs of the Formula 158

8.4 CHM Pharmacological Research 189

8.5 Summary and Conclusions 191

CHAPTER 9 MENOPAUSE AND BONE METABOLISM 193 9.1 Introduction 193

9.2 Definition of Osteoporosis 194

9.3 Risk Factors for Osteoporosis 195

9.4 Burden of Osteoporotic Fractures 196

9.5 Skeletal Changes Associated with Menopause 198

9.6 Biochemical Markers of Bone Turnover 199

9.7 Pharmacological Treatments for Osteoporosis 203

9.8 The Effect of Herbs on Bone Metabolism 217

9.9 Summary and Conclusions 222

CHAPTER 10 TRIAL: RESEARCH DESIGN 225 10.1 Introduction 225

10.2 Study Aims and Outcomes 226

10.3 Legal Requirements 227

10.4 Subject Recruitment 228

10.5 Treatment Schedules 230

10.6 Trial Protocol 232

10.7 Participant Evaluation 236

10.8 Subject Restrictions 242

10.9 Compliance 244

10.10 Pilot Study: FF-01 on Bone Turnover Markers 245

10.11 Statistical Analyses 247

10.12 Summary 247

CHAPTER 11 TRIAL: RESULTS 250 11.1 Introduction 250

11.2 Recruitment 251

11.3 Baseline Characteristics 252

11.4 Reliability and Validity of Outcome Measures 254

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11.5 Results 257

11.6 Compliance 261

11.7 Adverse Events 263

11.8 Success of Blinding 264

11.9 FF-01 and Bone Turnover 265

11.10 Discussion 266

CHAPTER 12 TRIAL: DISCUSSION AND CONCLUSIONS 268 12.1 Introduction 268

12.2 Clinical Effect of FF-01 268

12.3 Trial Outcomes in Comparison to Other Studies 270

12.4 Action of FF-01 271

12.5 Strengths of the Study 274

12.6 Limitations of the Study 278

12.7 Formula Tolerability 282

12.8 Summary and Conclusions 284

CHAPTER 13 GENERAL CONCLUSIONS 286 13.1 Overview 286

13.2 Major Findings and Their Implications 288

13.3 Limitations of the Research 292

13.4 Conclusions 294

13.5 Future Research Directions 295

REFERENCES 297

APPENDICES 353

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LIST OF FIGURES

Figure 4.1: Total CAM use during the past year by recruitment group 63

Figure 4.2: Perceived effectiveness of CAM practitioners on overall symptoms 66

Figure 4.3: Perceived effectiveness of CAM products on overall symptoms 67

Figure 4.4: Sources of advice about CAM use 68

Figure 7.1: Selection of papers for CHM systematic review 133

Figure 8.1: Selection of papers for Cimicifuga systematic review 160

Figure 11.1: Flow of participants through the trial stages 252

Figure 11.2: Mean weekly hot flush scores for the ITT population 258

xiv

LIST OF TABLES

Table 2.1: Summary of surveys assessing CAM use during the menopausal transition 34

Table 2.2: Comparison of survey methodologies according to seven benchmark measures 38

Table 4.1: Demographic characteristics and medicine use of participants by total sample and recruitment group 59

Table 4.2: Symptomatology and health status of participants by total sample and recruitment group 60

Table 4.3: Mean scores (standard deviations) and ANOVA for symptoms and health status on a six point scale by recruitment group 61

Table 4.4: Mean scores (standard deviations) and ANOVA for symptoms and health status on a six point scale by CAM users and non-users 64

Table 4.5: Most commonly used pharmaceutical agents by drug category 70

Table 4.6: Maximum likelihood estimates of the logistic regression function for predicting CAM use 71

Table 4.7: Misclassification matrix for the logistic regression model 72

Table 6.1: Medical conditions and chemical agents that cause abnormal sweating 106

Table 7.1: Characteristics of CHM studies included in the systematic review 134

Table 7.2: Comparison of trial methodologies on CHM for vasomotor symptoms according to ten benchmark measures 148

Table 8.1: Details of FF-01 158

Table 8.2: Characteristics of Cimicifuga trials included in the systematic review 161

Table 8.3: Comparison of trial methodologies on Cimicifuga racemosa for vasomotor symptoms according to ten benchmark measures 163

Table 9.1: Risk factors for osteoporotic fractures 196

Table 10.1: Clinical trial inclusion and exclusion criteria 230

Table 10.2: Extraction details for FF-01 231

Table 10.3: Data collection schedule for the monthly consultations 236

Table 10.4: Minimum washout times for medications affecting bone metabolism 245

Table 11.1: Baseline characteristics of trial participant population 253

Table 11.2: Test re-test correlation for secondary outcome measures 256

Table 11.3: Changes from baseline to end of treatment in daily mean hot flush number and score for ITT and per protocol populations 258

Table 11.4: Changes from baseline to end of treatment in quality of life scale scores for ITT population 259

Table 11.5: Changes from baseline to end of treatment in quality of life scale scores for per protocol population 260

Table 11.6: Changes from end of treatment to follow-up in primary and secondary outcomes by intervention group 261

Table 11.7: Frequency of adverse events reported by intervention group 264

Table 11.8: Changes in BAP and DPD between herbal and placebo groups from baseline to end of treatment and end of treatment to follow-up 265

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LIST OF ABREVIATIONS

AHS Area Health Service

BAP bone specific alkaline phosphatase

BMD bone mass density

BMI body mass index

CAM complementary and alternative medicine

CHD coronary heart disease

CHM Chinese herbal medicine

CI confidence interval

CNS central nervous system

CVD cardio-vascular disease

DHM Douglas Hanly Moir

DNA deoxyribonucleic acid

DPD deoxypyridinoline

ED50 drug dose pharmacologically effective for 50% of the population

EPO evening primrose oil

FDA Food and Drug Administration

FSH follicle stimulating hormone

GnRH gonadotrophin releasing hormone

HERS Heart and Estrogen/progestin Replacement Study

HFRDI scale hot flush related daily interference scale

HT hormone therapy

ITT intention to treat

IU international units

xvii

LH luteinising hormone

MWS Million Women Study

NSW New South Wales

OR odds ratio

PBS Pharmaceutical Benefits Scheme

RCT randomised controlled trial mRNA messenger ribonucleic acid

RR relative risk

SERM selective estrogen receptor modulator

TCM traditional Chinese medicine

TGA Therapeutic Goods Administration

TNF-α tumour necrosis factor alpha

UWS University of Western Sydney

WHI Women’s Health Initiative Study/ies

WHO World Health Organisation

xviii

LIST OF APPENDICES

Appendix I Women’s Health during Mid-life Survey Covering Letter 354

Appendix II Women’s Health during Mid-life Questionnaire 355

Appendix III Trial Information Sheet 363

Appendix IV Trial Consent Form 365

Appendix V Trial Registration and Eligibility Form 366

Appendix VI Trial Case Report Form: Initial Consultation 368

Appendix VII Daily Flush Diary 370

Appendix VIII Greene Climacteric Scale 372

Appendix IX Hot Flush Related Daily Interference Scale 373

Appendix X Trial Randomisation Form 374

Appendix XI Trial Week 12 Case Report Form 375

Appendix XII Certificates of Analysis for FF-01 377

Appendix XIII Publication of Women’s Health during Midlife Survey 388

CHAPTER 1 INTRODUCTION

1.1 General Background to the Study

Menopause occurs naturally at about 51 years of age1 and refers to the permanent cessation of menses due to a loss of ovarian follicular activity in the absence of related pathology.2 The years surrounding the menopause are a natural transition which prepares the body for a period in life where reproduction is no longer possible.

Menopause is determined retrospectively after 12 months of amenorrhoea following the final menstrual period.2 Although women transitioning through menopause may report a range of symptoms,3 a clear distinction must be made between symptoms directly attributable to a loss in ovarian function and those that are due to aging or to social and environmental stresses occurring during this stage of life.2 The World

Health Organisation (WHO) in its 1996 report on the menopause concluded that symptoms directly related to the menopausal transition are; vasomotor symptoms

(which includes hot flushes and night sweats), urogenital atrophy and menstrual irregularities.2

Vasomotor symptoms are thermoregulatory disturbances that result in a sudden transient sensation of warmth in the face, neck and chest and may be accompanied by skin flushing, perspiration, anxiety and increased pulse rate. Vasomotor symptoms may vary in severity from mild warmth to profuse sweating, be occasional or frequent and can last from seconds to an hour, although the average length of time is three minutes.4, 5

The prevalence of vasomotor symptoms seems to be common amongst women of

European origin.4 Approximately 62% of Australian women experience vasomotor disturbance6 while 39% report these symptoms to be troublesome.7 Vasomotor symptoms may interfere with work and leisure activities and disrupt sleep.

Disturbed sleep can lead to fatigue, depressed mood and wellbeing.8 Therefore, it is not surprising that vasomotor symptoms are one of the main complaints for which women seek medical treatment during the menopause.4

Although vasomotor symptoms are characteristic of the menopausal transition, acceleration in bone loss over and above that attributable to aging also typically occurs during this stage in life, unbeknownst to many women. During the premenopausal years, bone remodelling which involves the processes of bone resorption and formation is more or less balanced resulting in little or no net bone loss. However, due to the postmenopausal decline in oestrogen production these two processes become uncoupled resulting in increased rates of bone resorption. If a woman’s peak bone mass is low at the beginning of menopause, this increased bone loss may eventually lead to thinning of the bones (osteoporosis) and an associated

3 increased risk of fracture. Osteoporotic fractures are a major cause of morbidity and mortality in women,9 with the cost of treatment estimated to be $1.9 billion annually.10 Due to an aging population, the treatment of osteoporotic fractures will continue to impose a considerable strain on the healthcare system.11

Since the advent of hormone therapy (HT), women are often prescribed oestrogen and/or progesterone for the alleviation of vasomotor symptoms and/or to prevent or treat osteoporosis.12 However, a significant number of women discontinue treatment,13 due to side effects such as bloating, breast tenderness and breakthrough bleeding,14 or because of concerns about increased health risks such as cancer.15 The unfavourable results reported by several large clinical studies on HT during 2002-

200315, 16 has led many doctors and their patients to reconsider its use.17 Although long-term use is necessary for the treatment and prevention of osteoporosis, HT is now generally recommended for the short-term alleviation of acute symptoms.18

These concerns have generated an interest in the search for safer and effective alternative treatments for menopausal complaints.

Significant numbers of women in industrialised countries are now seeking and using complementary and alternative medical (CAM) treatments specifically for the alleviation of menopausal symptoms and to improve quality of life.19-22 Although a number of overseas studies have investigated the popularity of CAM use during the menopausal transition, only one Australian research group has reported on the extent of CAM use in an Australian setting.23 To date, no comprehensive work has examined the perceived effectiveness of CAM, pharmaceutical use and communication with medical practitioners in relation to menopause.

Popular CAM treatments for menopausal symptoms include herbal products such as red clover (Trifolium pratense), black cohosh (Cimicifuga racemosa) and soy

(Glycine max); practitioner centred modalities such as acupuncture, naturopathy and herbal medicine; and self help approaches that include relaxation and stress management.20, 22 There is some evidence from clinical trials to suggest that phytoestrogens isolated from soy24 and the herb Cimicifuga25, 26 may help alleviate vasomotor symptoms.

Another CAM treatment option is Traditional Chinese Medicine (TCM), the oldest health care system in the world. TCM theory incorporates a whole body view to health and aging, so a cluster of related symptoms can be treated using a suitable herbal formula. Anecdotal evidence supports the use of Chinese herbal medicine

(CHM) for the alleviation of vasomotor symptoms, although few rigorous clinical trials have been undertaken to substantiate these claims. Of the clinical studies that have been conducted, many have been plagued by poor research design resulting in questionable findings.27-32 CHM has a long history of use for the treatment of bone disorders and preliminary evidence is emerging for its beneficial affect on bone metabolism in both bone cell cultures and animal models of osteoporosis.33-38

However, there is a lack of methodologically sound clinical trials that confirm any beneficial effect of herbal medicine in modulating bone metabolism. Therefore, the evaluation of an effective and safe herbal formula to alleviate menopausal vasomotor symptoms and beneficially affect bone metabolism is warranted.

Thus, in order to determine the popularity, benefits and receptiveness of CAM interventions for menopause, this thesis will first examine the extent of CAM use by

Australian symptomatic women transitioning through menopause. Understanding issues related to the extent of CAM use and its perceived effectiveness may help to determine the likely reception of a new CAM treatment by women and medical practitioners. This thesis then evaluates the effectiveness of a herbal formula (FF-

01) for the alleviation of menopausal vasomotor symptoms and modulation of bone metabolism. Given the problems associated with long-term HT use, an effective treatment that can both alleviate symptoms and be beneficial to bones would be highly desirable to take during this period of hormonal change.

1.2 Aim and Scope

1.2.1 Aim

This thesis has two related aims:

1. To determine the nature and extent of CAM use amongst women, 45-65

years, who are symptomatic when transitioning through menopause or

asymptomatic but taking menopause specific treatments (HT and/or CAM).

2. To scientifically evaluate the effectiveness of FF-01 in easing the menopausal

transition by assessing changes in vasomotor symptoms, quality of life and

bone metabolism.

1.2.2 Scope: limitations and assumptions

A number of limitations and assumptions have been made in order to contain the scope of this thesis within the research aims. Although a number of studies have attributed a variety of symptoms to the menopause, many of these complaints may in fact be due to aging or to the stresses of everyday life. However, the one set of symptoms that typically occur during this phase in life and reflect the hormonal changes of menopause are hot flushes and night sweats. These symptoms are often the most troublesome, leading to the search for an effective treatment. Furthermore, a number of secondary symptoms such as sleeplessness, fatigue, irritability and depressed mood may occur as a result of disruption to sleep caused by night sweats.

Therefore, this thesis will primarily investigate the treatment of vasomotor symptoms.

Many external factors may influence the menopausal transition and how it is perceived, whether it is a positive or negative experience. These include social, cultural, psychological and stereotypical influences that may impact how a woman approaches this transitional time. For example, Japanese women report fewer menopausal symptoms than Caucasian women39 and Asian women living in

Australia note a lower prevalence of symptoms and a shorter perimenopause than

Australian born women.40 These differences may be due to cultural and physiological differences, the discussion of which is beyond the scope of this thesis.

A large range of CAM treatments are available and utilised by women to improve health during the menopausal transition. In order to contain the scope of the literature review, the first section of the thesis will briefly discuss the most popular

CAMs for menopausal complaints. The second part of this thesis evaluates the clinical effectiveness of a Chinese herbal formula, which also contains the Western herb Cimicifuga, for the alleviation of vasomotor symptoms. Therefore, the literature will be searched for published clinical trials that assess the efficacy of

Chinese herbal medical formulae and Cimicifuga for menopausal vasomotor symptoms. These studies will be systematically reviewed to evaluate their methodological rigor in order to assess the quality of the clinical evidence.

The scientific assessment of the effectiveness of the formula will be carried out by a double-blinded randomised clinical trial comparing herbal treatment effects against placebo. The herbal formula tested in this study is a modified version to one that has been on the market for several years and is loosely based on two Chinese herbal formulae. However, since all women in the treatment group will be given the same formula, this thesis will not be an examination of the application of Chinese medicine treatment principles. TCM theory recognises that the manifestation of a disease may differ between individuals due to the interplay of unique environmental factors and metabolic requirements. Due to these unique differences, two people presenting with the same complaint, for example menopausal hot flushes, may also exhibit a range of different accompanying signs and symptoms. Since the TCM diagnostic process considers variations in signs and symptoms, two patients may be diagnosed differently and their treatment will be tailored to suit the individual.

A final limitation impacting on the scope of this study concerns the measurements of bone turnover. Biochemical markers indicating bone formation and resorption are useful in evaluating therapies for preventing bone loss however; they are not suitable

8 for establishing a diagnosis of osteoporosis. Therefore, the assessment of the herbal formula’s influence on bone markers will be a pilot study and if warranted further long-term clinical trials with a larger sample size will be needed to determine the formula’s treatment effects on bone density and safety before any claim can be made regarding osteoporosis.

Several assumptions have been made in this thesis. Since a modified version of the trial formulation had been on the market for several years with anecdotal reports of efficacy, it was assumed the formula being assessed would also be effective in alleviating menopausal flushing and improving quality of life. The formula contains a number of herbs that have some scientific evidence for their beneficial effect on bone; therefore it was assumed that the formula would have a modulating effect on bone metabolism.

1.3 Significance of the Study

The findings of this thesis would be of great interest to health care professionals, both conventional and complementary, and symptomatic women transitioning through menopause. The results of the survey will add to the current knowledge about the trends in CAM use, especially within an Australian context. CAM practices considered effective by women respondents may warrant further research to establish efficacy and safety. This study investigates issues that are an important aspect of ongoing patient care, particularly in regard to patients who consume both conventional and complementary medicines.

Due to the current unease over the long term use of HT, both practitioners and patients are searching for safer and effective treatment options to improve quality of life. Therefore, good quality evidence regarding the effectiveness of CAM interventions is imperative for professionals and consumers to be able to make informed decisions concerning effective treatment options for the alleviation of symptoms. A methodologically sound and carefully executed clinical trial will determine the effectiveness of the formula FF-01.

1.4 Thesis Overview

This thesis comprises of two main studies and is divided into two sections. The first covers the survey on CAM use by symptomatic women aged 45-65 transitioning through menopause. The second section describes a randomised double blind clinical trial evaluating the effectiveness of a herbal formula in alleviating menopausal vasomotor symptoms and modulating bone turnover markers.

The Women’s Health during Midlife Survey is detailed in the first section. Chapter

2 examines the use of CAM both generally and specifically in relation to menopausal symptoms and quality of life. This chapter aims to set the broad context of the thesis by defining CAM, outlining the popularity of CAM use during the menopausal transition and describing women who are most likely to use CAM. The chapter also outlines popular CAM treatments used for menopausal complaints. Subsequent chapters describe the survey research design, results and discussion of the findings.

The second section focuses on the effect of FF-01 on vasomotor flushing, quality of life and bone metabolism. Chapters 6, 7 and 8 provide the necessary background information regarding the menopausal transition, with specific emphasis on vasomotor flushing and changes in bone metabolism. Further discussion includes medical and CAM interventions for vasomotor symptoms and postmenopausal bone loss and relevant research conducted on the herbs comprising the formula. The protocol for both the trial and pilot study will then be detailed, followed by the results, discussion and conclusions from these studies. Finally, Chapter 13 presents the key findings and conclusions of this thesis.

SECTION ONE Complementary and Alternative Medicine Use for Menopausal Complaints

CHAPTER 2 CAM AND THE MENOPAUSAL TRANSITION

2.1 Introduction

The use of CAM in industrialised countries is a growing phenomenon. CAM is predominately used to treat a range of non-life threatening ailments and to improve quality of life. Overseas surveys indicate that a significant number of CAM users are middle aged women who use alternative treatments to alleviate menopausal complaints.

The purpose of this chapter is to define CAM and discuss the trends in CAM use with specific reference to the use of alternative treatments during the menopausal transition. A review of studies investigating CAM use during the menopausal transition will be undertaken in order to examine which methodological issues influence the wide range of usage rates reported by the various authors. The extent

13 of research on this subject from an Australian context will also be noted in this chapter. Issues and findings raised in this chapter will be taken into consideration in the design of the protocol for the Women’s Health during Midlife Survey.

2.2 Defining CAM

CAM is a blanket term encompassing a range of diverse therapies and diagnostic approaches that generally lie outside the politically dominant health care system. A large number of diverse CAM therapies are currently available in Australia, including complex health care systems incorporating their own theories and practice

(e.g. TCM or Ayurveda), mind-body interventions (e.g. patient support groups, meditation, prayer, creative arts), biologically based therapies (e.g. herbs, diet, nutritional supplements) and the use of energy fields (e.g. Reiki, therapeutic touch).

The administration of CAM therapies ranges from self-care techniques and herbal/vitamin supplements to those requiring consultations with specialised practitioners.

The boundary delineating complementary and orthodox medicine is constantly moving, as therapies once considered complementary are gradually integrated into mainstream medical care. The integration of a CAM therapy may occur due to an acceptance of supporting scientific evidence, clinical experience of use and changes in societal attitudes.41 Therefore, CAM therapies considered as mainstream medical practices may differ between countries. For example, osteopaths have the same status as medical doctors in the United States (US)42, 43 whereas in China, TCM is integrated with western medicine at every level of health care.44-46

As CAM evolves, definitions of CAM that require a set of criteria or conditions to be met run the risk of dating and no longer holding true to the current situation.

Eisenberg and colleagues47 defined CAM therapies “as medical interventions not taught widely at US medical schools or generally available at US hospitals.”

However, CAM is now taught at over 60% of US medical schools48, 49 and the first four year residency programme in holistic medicine commenced in 2004.50 CAM treatments are also being offered within hospital settings in the US51 and Australia.

An Australian example is the Brownes Dairy Cancer Support Centre at Sir Charles

Gairdner Hospital in Perth. Furthermore, significant numbers of Australian general practitioners are personally using CAM and supplements, regard CAM as companion products to pharmaceuticals, refer patients to medical and non-medical CAM practitioners and are interested in further training in CAM.52, 53

The wide range of disciplines included under the CAM umbrella and the evolving nature of the industry makes an all encompassing definition incorporating the myriad of differences between therapies difficult. In 1995 the Panel on Definition and

Description met and proposed a definition of CAM for use by the US Office of

Alternative Medicine. This definition also prescribes a set of descriptive parameters for research in the area of CAM.54

The Panel defines CAM on page 50 as following:

CAM is a broad domain of healing resources that encompasses all

health systems, modalities, and practices and their accompanying

theories and beliefs, other than those intrinsic to the politically

dominant health system of a particular society or culture in a given

historical period. CAM includes all such practices and ideas self-

defined by their users as preventing or treating illness or promoting

health and wellbeing. Boundaries within CAM and between the CAM

domain and the domain of the dominant system are not always sharp

or fixed. 54

The above definition has been adopted by the Cochrane Collaboration and will also be applied throughout this thesis when discussing CAM and issues relating to CAM.

2.3 Economic Impact of CAM

2.3.1 Trends in CAM use

CAM is now widely used in many countries and is making a significant impact on the world economy. In developing countries, local traditional medicines continue to be primarily utilised to meet basic health care needs. The WHO reports that 80% of the populations of African member states use traditional medicines for primary health care, while in China TCM accounts for nearly 40% of all health care. In Latin

America, approximately 71% of the Chilean population and 40% in Columbia seek

16 traditional medicinal care.46 Traditional medicines are commonly used in these countries because they are easily accessible, cheap and can therefore cater for the general health needs of vast numbers of people.

In many industrialised countries, the use of CAM has increased in popularity.55

National surveys report the percentage of the population who used CAM over a 12 month period ranges from 20% in the United Kingdom,56 42.1% in the US,57 to 76% in Japan58 and Singapore.59 Survey results also suggest a wide range in the extent of

CAM use even within the same country. For example, US national surveys on CAM prevalence range from 8.3%60 to 42%.57 The variations between survey outcomes may be due to differences in the operational definition of CAM, the number of therapies included in the analyses, whether or not self medication and/or consultations with practitioners were considered and methods used in implementing the survey. Therefore, caution must be exercised when interpreting and making comparisons between studies.

Despite the aforementioned problems, consecutively conducted population surveys indicate that the prevalence of CAM use by the general public has increased over time. In a number of studies, MacLennan and colleagues61-63 found that the use of

CAM in South Australia during the previous 12 months rose from 48.5% in 1993 to

52.1% by 2000,61, 62 although no significant increase was found in a follow-up study conducted in 2004.63 A similar trend has been documented in the US. A follow-up study by Eisenberg and co-workers57 noted an increase in the use of CAM from

33.8% in 199047 to 42.1% in 1997.57

Kessler and colleagues55 investigated long term trends in CAM use in the US over three age cohorts, respondents born; before 1945, between 1945-1964 and those born

1965-1979. Approximately three out of ten respondents of the pre-baby boom, five out of 10 of the baby-boom and seven out of ten of the post-baby boom cohorts reported using a CAM therapy by 33 years of age. The authors conclude that the use of CAM therapies by a large proportion of the study participants is due to a secular trend that began during the 1950s and is therefore, not a passing fad of a fringe section of the population or of a particular generation. The popularity of CAM use represents a shift in consumer demands that are likely to continue growing with time.55

2.3.2 Growth of the CAM industry

The increased consumer demand for CAM has impacted greatly on the global market for herbal medicines. By the year 2000, this market was estimated to be worth

US$60 billion.46 As an example of the rate in growth; the market for Chinese herbal medicines had been increasing in value by approximately 8% since 1994 and was estimated to be US$23 billion in 2002.64 The largest consumer for Chinese medicines was Europe (35%) particularly Germany, while North America comprised

15% of the demand. Although China’s domestic market accounts for 10% of sales, growth in demand was increasing at a rate of about 22% per year.64

Information about the specific size of the Australian CAM market is difficult to find and estimate due to various factors. Firstly, the Australian Bureau of Statistics does not account for a separate CAM sector when compiling market data regarding

18 medicines and therapies. Furthermore, many CAM companies are not publicly listed so information about product sales is difficult to access. Finally, no single body exists to collect and analyse information about the industry, its growth and economical impact.65

An indication about the size of the industry can still be gleaned from several alternative indicators. The Australian Self Medication industry reported that pharmacy sales of dietary supplements had increased by 13.04% during the 12 months preceding December 2004; a further 4.55% increase occurred during 2005.66

However, these figures do not include supplements sold through supermarkets, health food stores and direct company sales. Mayne Consumer Products, which recently acquired five vitamin and supplement companies, increased its sales revenue by 17% during 2005. Mayne distributes over 500 health products to more than 3500 health food stores and pharmacies throughout Australia.67 Blackmores

Limited (a publicly listed CAM company) reported a 15.5% increase in sales during

2005, with the preceding year recording a 22% increase.68 Blackmores is another large supplier and distributor of dietary and herbal supplements to Australian supermarkets, pharmacy chains and health food stores. Finally, the Expert

Committee on Complementary Medicines in the Health System reported that the annual retail turnover of CAM products was estimated to be approximately AU$800 million, with an additional 20% of Australian product being exported overseas.65

In order to quantify the total financial outlay to CAM (including products and practitioner visits) made by the Australian public, MacLennan and co-workers62 extrapolated estimated costs incurred by respondents from a South Australian survey

19 to the Australian population. The total expenditure on alternative therapies was estimated to be AU$2.3 billion during 2000, which was calculated to be nearly four times the amount which the public pays for pharmaceutical medications.62 However,

Donohoe69 contends that this is an unfair comparison between the total turnover of

CAM products and services with out-of-pocket expenditure of drugs on the

Pharmaceutical Benefits Scheme (PBS).69 The PBS provides Medicare-eligible persons access to drugs made affordable by a significant financial contribution by the

Australian Commonwealth Government. Since the total expenditure of conventional medicine (products and services) was calculated to be AU$60.779 billion for 2000-

2001,70 the total expenditure of CAM is actually only 3.8% of the total medical expenditure.

By 2004 the total extrapolated costs had decreased by 21.7% to AU$1.8 billion, although the use of CAM had not significantly decreased during the previous 12 months.63 The introduction of the Goods and Services Tax in 2000 increased the costs of CAMs by 10%, however pharmaceutical products were unaffected and continue to be subsidised by the PBS. This additional 10% cost may have contributed to slowing the growth in CAM use between the years 2000 to 2004.62, 63

2.4 The CAM Consumer

Since the 1960s there has been an increasing awareness and a change in perceptions towards health, with the embracing of a holistic integration of mind and body, an interest in self care and a personal responsibility for well-being.71, 72 This trend may be due in part to a loss of faith in conventional medicine with its increasing costs and

20 risk of adverse effects,73 and a dissatisfaction with the medical encounter as doctors spend less time with patients74 and display less compassion during a consultation.75

A number of studies have found that CAM users are more likely to subscribe to a set of values that support a “post-modernist” approach to health which includes a holistic view of health, a belief in natural remedies, individual responsibility for well-being and a belief in the effectiveness and underlying philosophy of CAM alternatives.76-79

Several studies have supported the notion that CAM users are more critical, sceptical and dissatisfied with conventional medicine.80-82 CAM users may be more concerned about the adverse effects of pharmaceuticals83-85 and perceive CAM remedies to be associated with lower health risks,79, 85 thereby supporting their belief that natural plant based products are better than artificial drugs86 and their use can lead to improved health.87 In addition, CAM users may appreciate the unhurried approach offered by CAM providers74, 88 and a feeling of control over one’s health that is espoused by many CAM philosophies.89, 90

Research has also suggested that CAM users are not necessarily a homogenous consumer group who subscribe to a similar set of values and beliefs or who have a dissatisfaction or distrust of conventional medicine. CAM may be utilised for more pragmatic reasons. Many patients are using CAM in conjunction with conventional medicine57, 63 and CAM users may be no more discontent with conventional medicine than CAM non-users.76, 91 A random household telephone survey conducted by Eisenberg and colleagues91 reported that 79% of respondents who saw a medical doctor and CAM practitioner during the previous 12 months believed the

21 combination to be superior to either one seen alone. When asked about perceived confidence in CAM providers and/or doctors, the responses were similarly high for both (81% and 77% respectively).91 A further study noted that of the 54% of respondents who were highly satisfied with conventional care, 39% used CAM, while of the 9% reporting dissatisfaction 40% were CAM users.76

The concurrent use of CAM and conventional medicine to treat illness may indicate that CAM is being used as a complement to conventional care in an attempt to ensure that specific health care needs are met60, 92-96 and as an assertion of personal control over health.97-99 This may be especially true of chronic conditions such as diabetes100, 101 and cancer,92 which do not respond as well to conventional treatments.102 However, many people display a considerable amount of autonomy over their health and often make lifestyle changes when faced with a medical crisis such as beginning an exercise programme, making dietary changes or taking vitamins and/or over-the-counter pharmaceuticals.94 An integrated approach to health care is not necessarily a new phenomenon but given the increased choice that faces today’s consumers the combinations of therapies used may certainly be new.

Patients also tailor their choice of CAM use depending on their condition. Certain

CAM modalities are commonly used for particular conditions, such as chiropractic for back pain and relaxation techniques or massage for stress.57, 76, 93 However, patients also use a range of therapies for the same condition.92, 103-105 A survey of

453 cancer outpatients at the University of Texas revealed that 83.3% used at least one CAM modality. Of CAM users, 12.9% had used one modality, 62.4% had used

2-6 and 24.7% had used seven or more modalities. Furthermore, 88% of patients combined CAM with conventional therapy; 76.6% used herbs along with pharmaceuticals. Nevertheless, only 64.1% of herb users discussed CAM use with their doctor.105

This high use of multiple therapies may increase the potential for deleterious drug- herb interactions.106-109 This situation may be further compounded by the fact that few patients inform their medical practitioner of their CAM use110-112 unless directly asked.85 One of the main reasons patients cited for not disclosing CAM use was a concern about a negative response from their practitioner.111

In conclusion, CAM users do not seem to have out rightly rejected conventional medicine or to share an all encompassing set of beliefs; indeed patients may be selecting therapies that they believe will best satisfy their medical needs.

Furthermore, many CAM users recognise that both CAM and conventional treatments have certain strengths and limitations and may be best utilised in combination to achieve a desired therapeutic outcome.94

2.4.1 Who uses CAM?

Consumers of CAM tend to be female,57, 62, 76, 113-116 middle-aged,57, 116, 117 well- educated57, 62, 76, 116, 118 and earn higher incomes119 than non-users. CAM users tend to report poorer health status76 and often use treatments predominately to improve quality of life115, 120 or to relieve the symptoms of a range of co-morbid, non-

23 threatening health problems.57, 121 These conditions are often rheumatological and neurological in nature,122 such as arthritis,104, 123 chronic pain57, 76, 124 and anxiety related disorders.57, 76, 93

CAM use surveys have consistently found that women use CAM significantly more often than men.57, 76, 113-116 This trend is not surprising as women in general are more likely to access medical care and tend to suffer more from chronic conditions.125

Women often use CAM therapies for a range of gynaecological conditions126 such as premenstrual syndrome,127, 128 cancer,129-131 pregnancy132, 133 and menopausal complaints.19, 20, 22, 134-136

2.5 CAM Use and the Menopausal Transition

2.5.1 The menopausal transition

Menopause occurs naturally at around 51 years of age and refers to the permanent cessation of menses1 due to a loss of ovarian follicular activity in the absence of related pathology. The menopausal status can only be determined retrospectively after 12 months of amenorrhoea following the final menstrual period.2 Although menopausal women have reported a range of symptoms,3 complaints that can be directly attributed to the menopausal transition are; vasomotor symptoms, urogenital atrophy and menstrual irregularities.2

Vasomotor symptoms are the most characteristic symptom of the menopausal transition. These are thermoregulatory disturbances that result in a sudden transient

24 sensation of warmth in the face, neck and chest and may be accompanied by skin flushing, perspiration, anxiety and increased pulse rate. Vasomotor symptoms may occur during the day or night (night sweats), and vary in severity from mild warmth to profuse sweating, be occasional or frequent and can last from seconds to an hour, although the average length of time is three minutes.4, 5

The prevalence of vasomotor flushing experienced by naturally menopausal women varies between different ethnic or cultural groups, but seems to be more prevalent amongst women of European origin. Approximately 82% of women in the US report these symptoms,137 compared to 10% of South East Asian women.138

Although 62% of Australian women report experiencing vasomotor flushing,6 a significant proportion (39%) consider these symptoms to be troublesome.7

Furthermore, Kronenberg4 notes that 10-20% of women find these symptoms to be virtually intolerable. Flushing occurring at night can disturb sleep thereby causing fatigue, depressed mood and decreased quality of life.8 Therefore, it is not surprising that vasomotor symptoms are one of the main complaints for which women seek medical treatment, such as HT.4

2.5.2 Concerns about hormone therapy

Clinical studies have demonstrated HT to be very effective in controlling vasomotor symptoms.139, 140 However, women may be reluctant to take or continue taking HT due to side effects14, 140, 141 and concerns about safety.142-145

HT safety has been a topical issue due to the publication of two major studies. On

May 31, 2002, the oestrogen plus progestin arm of The Women’s Health Initiative

(WHI) study was prematurely terminated because interim analyses revealed that adverse events outweighed the benefits of therapy. HT treatment increased the rates of breast cancer, coronary heart disease, stroke and pulmonary embolism. These findings are inconsistent with the requirements of an intervention used for the primary prevention of chronic disease.16 A subsequent paper concluded that oestrogen plus progestin did not offer cardiac protection and may increase the risk of coronary heart disease (CHD) in healthy postmenopausal women.146 In February

2004 the oestrogen-alone arm of the WHI was also prematurely stopped as preliminary data found no overall benefit for chronic disease prevention in women with hysterectomy.147 The WHI study was the first randomised double-blind clinical trial to test the health benefits and risks of combined oestrogen and progesterone

(PremproTM) on healthy post-menopausal women.

The second major study to alert the public about the safety of HT was the Million

Women Study (MWS), a cohort study of 1,084,110 women aged 50-64 years. This research concluded that current and recent HT use not only increases the incident risk of breast cancer (relative risk (RR), 1.66) but also breast cancer mortality (RR

1.22).15

The impact on the prescribing of HT was immediate. Following the publication of the WHI results, a decline in the use of oestrogen replacement therapy was reported.

148-152 In addition, numerous editorials and opinion articles appeared in medical journals calling for caution in promoting the long term use and the prescription of

26 high doses of HT, and to consider life style changes as a safer alternative to improve health.153-160 As a result of these findings, The US Preventative Services Task Force revised their recommendations concerning HT and suggested against the routine use of HT for the prevention of chronic disease.161 The Food and Drug Administration

(FDA) now requires warning labels on all oestrogen products.162 In Europe,

Germany and the Netherlands plan to restrict the use of HT only to women suffering acute menopausal symptoms, using the lowest dose possible for the shortest time,163 while the European Drug Agency is re-examining the risk-benefits of HT.164

In the light of these findings and events, it is of no surprise that women are seeking and using alternative treatments for menopausal complaints.20, 23, 165 The following section considers some popular alternative therapies and summarises the available evidence for their effectiveness in alleviating symptoms.

2.5.3 Popular CAM treatments for menopausal symptoms

Women use a range of CAM therapies for the alleviation of menopausal complaints.

The following section briefly outlines the commonly used therapies and some of the evidence for their effectiveness in relieving symptoms. Since this thesis also assesses the efficacy of a Chinese herbal formula with the addition of Cimicifuga racemosa, a thorough assessment of the clinical evidence on CHM formulae and

Cimicifuga for the alleviation of vasomotor symptoms will be undertaken in the form of systematic reviews which are reported in Chapters 7 and 8.

2.5.3.1 Herbal therapies

Several popular herbs have some clinical evidence for the alleviation of vasomotor symptoms. These include soy (Glycine max),166-168 Trifolium pratense (red clover)169 and Cimicifuga.170-172

The increased intake of phytoestrogens is a popular form of self treatment for menopausal symptoms.20, 136 Phytoestrogens are plant compounds structurally or functionally similar to mammalian oestrogens, synthetic oestrogens and anti- oestrogens such as tamoxifen.173, 174 Phytoestrogens include isoflavones, lignans and coumestans.175 Isoflavones are the most ubiquitous and are found in high concentrations in leguminous plants, especially soy, clover and alfalfa.176

Epidemiological studies suggest that the regular consumption of phytoestrogens may afford numerous health benefits. Asian women who typically consume a high phytoestrogenic diet have significantly lower rates of menopausal symptoms,177-179 cardiovascular disease,180-182 breast cancer,183-186 endometrial cancer187 and improved bone mass density.188-190 Such women consume approximately 25-40mg isoflavones per day,191, 192 while the average daily intake by a Western woman is less than

2mg.193, 194 However, it is important to note that other factors such as lifestyle, social-cultural and morphological differences between Asian and Western populations may have confounding influences or provide alternative explanations for these observations.195

In response to the epidemiological observations regarding phytoestrogens, a number of clinical trials were conducted to scientifically assess the efficacy of soy and

Trifolium isoflavones in improving menopausal health outcomes. The results of these trials have been mixed. A systematic review by Huntley and Ernst24 that included ten well designed trials on soy for the treatment of perimenopausal symptoms listed five that recorded positive167, 168, 196, 197 or promising198 outcomes.

Despite variation in trial methodologies, the authors conclude there is some evidence for soy in reducing menopausal symptoms.24 A recently conducted review of the literature which included six systematic reviews and the meta-analysis of 25 randomised controlled trials on phytoestrogens concluded that phytoestrogens may be beneficial to women presenting with mild to moderate vasomotor symptoms in early natural postmenopause.199

Many of the Trifolium clinical studies used the proprietary medicine Promensil

(Novogen Ltd, North Ryde, Australia). Only two double blind randomly controlled trials demonstrated a superior effect of Promensil over placebo in reducing menopausal symptoms including hot flushing,169, 200 while two smaller studies201, 202 and one larger trial203 recorded no significant improvement in symptoms. A meta- analysis of five randomised controlled trials indicated a marginally significant effect of Trifolium isoflavones for the alleviation of vasomotor symptoms in menopausal women, weighted mean difference of -1.5 hot flushes daily (95% Confidence

Interval (CI) -2.94-0.03; p=0.05). The authors conclude that it is unclear if this effect is clinically relevant. Although there were no apparent adverse events with short term use of Trifolium isoflavones, the safety with long-term administration has not been established.204 Further well designed clinical trials on Trifolium with adequately powered sample sizes may be needed.

A number of products containing concentrated phytoestrogens isolated from soy and/or Trifolium are now available, for example Phytolife (Blackmores). However, the long-term safety of these products has not been adequately determined.

Therefore, as a preventative measure it may be prudent to incorporate a realistic and modest amount of soy products into the diet.

Cimicifuga may be one of the most promising herbal treatments for the alleviation of menopausal vasomotor symptoms. The herb is native to eastern North America and was traditionally used for general malaise, rheumatism, sore throat and women’s complaints such as menstrual cramps, amenorrhoea, easing labour and for menopausal symptoms.205 In 1989 the German Commission E (an expert panel commissioned by the German government to address herbal products) approved

Cimicifuga for the treatment of menopausal complaints.206

A number of clinical studies have demonstrated improvements in menopausal symptoms with Cimicifuga. Most of these studies assessed the German proprietary medicine Remifemin (Shaper & Brummer, GmbH & Co KG, Salzgitter). Although, many studies have a number of design issues,207-210 cumulative evidence points to

Remifemin as having minimal toxicity211-213 and conferring some relief for menopausal vasomotor symptoms.172, 210, 214

Various multi-herb preparations for menopausal symptoms are now available on the

Australian market, often containing Cimicifuga, soy and/or Trifolium. Menocalm

(Herbal Creations Pty Ltd) and Meno-eze (Naturopathica) are examples of such products. The effects of these formulae may be due to the summation of the many

30 pharmacologically active components215 found in the constituent herbs of the formula. Although a number of herbal formulae have recently been subjected to clinical evaluation with varying outcomes,216-223 a large number have not been investigated for their supposed superior efficacy over single herb preparations.224

Several popular herbal remedies subjected to clinical research were found to be ineffective in alleviating menopausal symptoms. These include Evening Primrose

Oil (EPO, from Oenothera biennis),225 wild yam (Dioscorea villosa) cream226 and the Chinese herb dang gui (Angelica sinensis) administered as a single herb.227 It is worthwhile to note that Angelica is always given as part of a traditional Chinese medical formula and inappropriate prescribing may cause symptoms such as hot flushing, red face, sweating, insomnia and irritability due to its warming nature.

Therefore, understanding the theory and application of a CAM modality is important to maximise the effectiveness of a treatment and minimise potential side-effects.

2.5.3.2 Other CAM modalities

A number of externally applied CAM modalities have been found to be effective in alleviating menopausal vasomotor symptoms and improving quality of life. These include several relaxation practices228-231 and acupuncture.232-235

Hot flushing and the stress response both involve increased arousal of the sympathetic nervous system,4 therefore it is hypothesised that relaxation techniques may reduce sympathetic activation and reduce the frequency of hot flushing.229 The results of four small studies of short duration (less than ten weeks) suggest that

31 relaxation training, such as muscle relaxation and breathing techniques, can reduce vasomotor symptoms.228-231 Further beneficial changes included lowered heart rate, blood pressure and breathing rate; and brain waves consistent with reduced mental arousal.229

A review of the literature found a number of small clinical studies demonstrating acupuncture to be of benefit in alleviating vasomotor flushing,232, 233, 235, 236 although one study concluded that acupuncture offered no symptomatic relief.237 The alleviation of vasomotor symptoms by acupuncture may occur via several pathways.

Since treatment with acupuncture has been found to stimulate β-endorphin production and activity,238-241 it has been proposed that acupuncture may ameliorate

233, 242 vasomotor symptoms via a pathway involving β-endorphin. β-endorphin is an

243, 244 endogenous opioid which plays a role in thermoregulation. Plasma levels of β- endorphin have been noted to be significantly lower before the onset of a vasomotor episode in highly symptomatic women.245 The occurrence of hot flushing is associated with a significant and rapid rise in the plasma levels of calcitonin gene- related peptide, a potent vasodilating neuropeptide.246 Acupuncture has been demonstrated to increase the urinary excretion of calcitonin gene-related peptide.242

Therefore, there appears to be at least two pathways by which acupuncture modulates vasomotor symptoms and further research is necessary to elucidate the exact mechanisms of action. Larger well designed randomised placebo controlled trials are needed to substantiate the treatment effect of acupuncture on vasomotor symptoms and quality of life.

In conclusion, a number of CAM therapies may be of some benefit in reducing menopausal symptoms. However, the evidence regarding individual herbs is not conclusive and many herbal formulae currently on the market lack clinical evidence regarding efficacy. Research on externally applied CAM modalities suggests a psychological component to vasomotor symptoms that may be influenced by non- pharmacological methods and behavioural techniques. Further studies with larger sample sizes are warranted to determine the full extent of the clinical efficacy of these therapies.

2.6 CAM Use by Middle Aged Women

The following review was based on the retrieval of studies determining the use of

CAM by women transitioning through menopause. Searches were conducted on computerised databases including; MEDLINE accessed via the World Wide Net,

CINAHL, Cochrane Library and the journal databases; Science Direct, Blackwell

Synergy and Ovid covering the time since their inception until April 2006. The search terms included “complementary”, “alternative”, “traditional”, “herbal”,

“medicine”, “survey”, “use”, “menopause”, “perimenopause”, “women” and combinations of these terms. Reference lists of retrieved articles were also searched for relevant studies. Articles were included if they were in English, referred to use within industrialised countries and were published between 1980 to April 2006.

Surveys of middle aged women indicate that significant numbers are using various

CAM treatments for the alleviation of menopausal symptoms and to improve quality of life. Table 2.1 outlines the retrieved survey articles. These studies indicate that

33 the most commonly used products were dietary supplements such as vitamins, minerals and soy,20-23, 136, 247 while relaxation methods and massage were popular practitioner based therapies.20, 21 CAM users were more symptomatic than non- users,22, 135 more likely suffering from menopausal symptoms23, 135 and sleep disturbances.20 Many women claimed they favoured natural20 and safe136 approaches to managing menopause. CAM users generally found their therapies of choice to be very efficacious.20, 136 Significant numbers of women used more than one CAM product19, 136 and/or used CAM along with conventional medicine,22 including HT20 and over-the-counter pharmaceuticals.136 However, between 53.6%135 and 70%136 of women did not report CAM use to their medical provider. Finally, women tended to obtain information about CAM from the media or friends and relatives, rather than from health care providers.136, 247

Table 2.1: Summary of surveys assessing CAM use during the menopausal transition

Reference Year Country Sample CAM use Recruitment Age Therapies considered Prevalence of CAM use size recall time methods Visits Product Visits & Product Mantyranta et al 1989 Finland 1,308 Used product Postal survey 45-64 Supplements: 11% 199719 National for menopause Calcium Bee products Essential fatty acids Food supplements Minerals Vitamins Others (herbs & homeopathic) Keenan et al 1997- USA 2,602 Used at least 3 Telephone =/>45 Acupuncture 1% 46% 200322 1998 Florida months for random digit Body work Minnesota menopause dialling Chiropractic Tennessee Dietary supplements Exercise Herbal medicine Homeopathy Mind-body techniques Naturopathy Self help Soy products TCM Cherrington et al 1998- USA 833 Various time Various 30-65 Acupuncture 7.6% 31% 33% 2003134 1999 Alabama frames Random digit Chiropractic Texas depending on dialling Curandera New Mexico hysterectomy Public health Diet/exercise South Carolina status and clinics and Herbs symptoms community Herbal medicine warranting sites Meditation hysterectomy Public sites Medicine man or woman Postal Over the counter remedies Pharmacist Prayer Relaxation Root doctor Vitamins

34 35

Table 2.1: Continued

Reference Year Country Sample CAM use Recruitment Age Therapies considered Prevalence of CAM use size recall time methods Visits Product Visits & Product Vashisht et al 1999 England 200 Ever used Written 30-76 Acupuncture 68.5% 2001247 Menopause clinic at questionnaire Chinese herbs Chelsea and completed Homeopathy Westminster Hospital prior to Hypnosis consultation Massage Reflexology Spiritual healing Products included: Black cohosh Dong quai Evening primrose oil Gingko Natural progesterone cream Phytoestrogens Vitamins Wild yam Kam et al 2002248 2000 USA 100 Therapies tried Written 59.6- Dietary supplements 48% San Francisco women’s for menopause questionnaire 47.8 Exercise health conference Dietary modification Newton et al Not USA 886 Ever used Telephone 45-65 Acupuncture Not 37% 76.1% 200220 stated Washington state, Currently use survey Chiropractic stated enrolled in the Group Currently use Dietary soy products Health Co-operative for menopause Herbal medicine (providers of medical Herbal, naturopathic care) Homeopathy Massage & body work Naturopathy Relaxation Gingrich & Not USA 40 Not stated Self 40-65 Herbs included: 67.5% Fogel249 stated Southeast health food administered Black cohosh grocery, major herbal questionnaire Dong quai supplier Evening primrose oil Gingko Ginseng Hops Kava St John’s Wort Valerian

Table 2.1: Continued

Reference Year Country Sample CAM use Recruitment Age Therapies considered Prevalence of CAM use size recall time methods Visits Product Visits & Product Dailey et al Not USA 397 6 months Written 40-55 Gingko biloba 24.9% 2003135 stated 8 primary care centres, questionnaire Ginseng Michigan Phytoestrogens (in black cohosh and soy) St John’s wort Mahady et al Not USA 500 Current use Face-to-face 40-60 Botanical dietary supplements 79% 2003136 stated Clinics at University of interview Illinois, Chicago

Bair et al 2002 21 Not Study of Women’s 3307 Previous 12 Completed a 42-52 Herbs or herbal remedies 48.5% stated Health Across the months survey Special diets or nutritional remedies Nation Psychological methods 7 sites in US, Physical methods community based Folk medicine or TCM cohorts Gollschewski et 2001 South East 886 Ever use Postal 47-67 Unspecified CAM products 82.5% al 2004 23 Queensland Use over questionnaire Herbal therapies previous Women Wild yam cream month for selected at Tropical progesterone cream dietary random from Dong quai supplements 2001 electoral Black cohosh role Vitamin E Evening primrose oil Ginseng Red clover Healthy eating Nutritional supplements Phytoestrogen supplements Phytoestrogens consumed in diet

2.6.1 A comparison of survey methodologies on CAM use

CAM prevalence studies of middle-aged women suggest use ranges from 11% in

Finland19 to 85.2% in South East Queensland, Australia.23 The large range in usage may be due to a number of methodological differences such as the; operational definition of CAM, number of therapies considered, time frame for CAM use recall, inclusion of provider services and/or self care therapies and the use of convenience samples. Therefore, care is required when interpreting and comparing the findings of various studies. Table 2.2 compares the survey methodologies against seven benchmark measures as a summary stop-go analysis. These benchmark measures were identified from the literature to be important in order to determine reliable estimates of CAM use.250 Red signifies the measure was not completed nor was it clearly stated in the report, yellow signifies the measure was completed in part and green indicates the measure was completed in full or was stated clearly. Only two of the 11 published studies covered four or more of the benchmark measures. Most protocols failed to include a sample size calculation or test the validity and reliability of the survey instrument.

Table 2.2: Comparison of survey methodologies according to seven benchmark measures

Benchmark measures

First author and Sample size Sampling techniques Sample population Questionnaire tested Includes twelve Defines CAM or Analyses includes date calculation clearly stated clearly defined for validity and month recall justifies chosen product and presented reliability CAM practitioner

Mantyranta, 199719

Keenan, 200322

Cherrington, 2003134

Vashisht, 2001247

Kam, 2002248

Newton, 200220

Gingrich, 2003249

Dailey, 2003135

Mahady, 2003136

Bair, 2002165

Gollschewski, 2004 23

Present survey

Red- not stated or not clearly stated Yellow- stated or completed in part Green- clearly stated

The diversity and number of therapies included in a study’s operational definition of

CAM can influence the magnitude of the findings. Many authors provided a list of therapies that were surveyed without an explanation for their inclusion. This is especially true of practises that could be considered part of a healthy or general lifestyle rather than as a CAM modality. These included self help,22 pharmacist,134 relaxation,20, 134 exercise248 and healthy eating.23 Considering these practices as

CAM may inflate the results.20, 23 Relaxation, exercise and healthy eating are generally part of a good lifestyle and are often the first changes made when a person wishes to improve health. Conventional medicine also advocates these interventions if a woman wishes to stay and remain well. Several of these practices are important components of complex CAM health care systems (e.g. TCM or Ayurveda); therefore, unless they are clearly defined as such it may not be appropriate to include them as part of CAM. This aspect highlights the difficulty in applying and agreeing to a comprehensive CAM definition. The lack of a concrete definition of CAM may result in the inclusion of a large variety of therapies in surveys.

Time frames for the recall of CAM use in surveys ranges from lifetime use,23, 247 current use136 to “used product for menopause”.19, 248 Studies that assessed the once in a lifetime use of CAM therapies report a much higher prevalence rate20, 23 than those that recall use over shorter time periods.21, 22 The majority of national CAM surveys used a time frame of twelve months, 20, 21, 47, 56-58, 62, 113, 120, 121, 124, 250 but this time period was used by only one CAM study on midlife women.21 A time period of

12 months is likely to generate reliable recall of use and may even serve as a reference point for future comparative work.250

A number of studies relied on convenience samples that are not necessarily typical of the general population.20, 135, 136, 247-249 Such samples included women visiting; a menopause clinic,247 medical clinics,136 a health fair,248 a health food/herbal grocery249 and women enrolled at a Group Health Co-operative.20 Several of these studies reported CAM use to be significantly higher136, 247, 249 than more general population studies.22, 134 These results suggest that CAM use amongst certain groups of women with specific needs or lifestyles are higher than the general population.

For example, women who present at menopause clinics report a greater number of life stresses and symptoms.251 Therefore, in a bid to improve quality of life, these women are more likely to be prescribed HT and/or try CAM treatments.247 Although the authors of these studies state that the results can not be extrapolated to the general population due to sampling biases, this research demonstrates that CAM use may be more prevalent amongst women with particular needs or interests.

The stop-go analysis (Table 2.2) demonstrated that surveys varied greatly in design approaches and a number of design benchmarks could be improved for ease of comparison between survey results. Improvements could include: conducting sample size calculations, validating survey instruments, defining CAM or explaining the choice of CAM modalities and including whenever feasible both product and practitioner use. Nevertheless, the results of these studies demonstrate that the use of

CAM amongst menopausal women is very popular. Greater consistency between survey approaches is needed if one wishes to compare results and monitor trends in

CAM use.

2.6.2 The Women’s Health during Mid life Survey

The literature search revealed that only one comprehensive study investigating CAM use amongst menopausal women had been conducted in Australia, South East

Queensland.23 This study investigated the prevalence and types of CAM used and explored associations between CAM use and menopausal symptoms. For statistical analyses CAM was divided into four groups; 1) unspecified CAM medications 2) herbal therapies 3) phytoestrogens and 4) nutrition and supplements. As discussed previously, this study included lifestyle approaches (healthy eating) as part of CAM and considered ever use of therapies, which may have contributed to the high rates of

CAM use. The study also included “tropical progesterone cream”, a hormonal product, which should not be considered as CAM.

Given the safety concerns over the long term use of HT and the search for alternative treatments for menopausal symptoms, especially vasomotor, a comprehensive study investigating the prevalence of CAM use and the perceived effectiveness of these treatments was considered timely. The results of such a study would inform health care practitioners and menopausal women of treatments considered to be effective by users and of CAM use trends within the community. The results may also provide insight into future investigative work on the most effective treatments. Since most of the research on CAM use has been conducted overseas with only one study undertaken locally, the outcomes of this survey would be especially relevant to

Australian practitioners and women. Therefore, it was proposed that a comprehensive Australian study investigating the prevalence of CAM use and CAM related issues be undertaken amongst women aged 45-65 transitioning through menopause who were symptomatic or asymptomatic but taking menopause specific

42 treatments (HT and/or CAM). In addition this study aims to identify other important issues regarding CAM use that were not considered by Gollschewski and colleagues.23 These include the perceived effectiveness of CAM treatments, determinants for CAM use, use of pharmaceutical medications and the extent of communication between patients and medical practitioners about CAM. Finally, this study was planned to take into account the methodological issues raised in this literature review in order to improve reliability of the results.

2.7 Summary and Conclusions

CAM constitutes a significant part of the health care economies of many industrialised nations. Various overseas prevalence studies suggest that some of the highest consumers of CAM are middle aged women, who seek a range of therapies to alleviate menopausal symptoms and improve quality of life. Evidence suggests that a number of these therapies have some modest evidence to attest to their benefit in reducing menopausal vasomotor symptoms and improving quality of life. Most of the research investigating the use of CAM by women transitioning through menopause has been conducted overseas, therefore it was considered timely that a local study was conducted addressing issues pertaining to women residing in

Sydney.

An extensive review of the studies examining the prevalence of CAM use by women during menopause identified a number of methodological issues that may account for the large reported range in CAM usage. These issues were considered carefully and

43 incorporated as far as practicable into the protocol for the Women’s Health during

Mid-life Study in order to generate reliable outcomes. These included:

• A sample size calculation based on reported estimates

• A clear description of the sampling techniques

• A clear definition of the sample population

• A 12 month period of recall

• The use of a validated and reliable measurement instrument

• A justification of the chosen CAM modalities

• Analyses of both CAM practitioners and product use

The following chapter outlines the research design of the Women’s Health during

Mid-life Survey which investigated the use of CAM and CAM related issues concerning Australian women transitioning through menopause.

CHAPTER 3 SURVEY: RESEARCH DESIGN*

3.1 Introduction

The preceding chapter identified a paucity of research on the use of CAM and CAM related issues amongst Australian women. Given the concern over the safety of HT, it was considered timely to investigate the use and perceived effectiveness of alternative therapies from an Australian perspective amongst a cross section of women transitioning through menopause. From July 2003 until July 2004 the

Women’s Health during Midlife survey recruited 1,296 eligible women from three strata; Sydney menopause clinics, general practice clinics and government agencies who completed a voluntary and anonymous written or electronic 19 item questionnaire. The following chapter outlines the research design of this study.

* The survey covered by Chapters 3, 4 and 5 has been published in Menopause 2007: 14(3): 397-403. Refer to Appendix XIII

3.2 Study Objectives

3.2.1 Research questions

The broad research questions were:

• What is the extent of CAM use amongst women aged 45-65 who were

symptomatic or asymptomatic but taking menopause specific treatments (HT

and/or CAM)?

• How do these women rate the effectiveness of CAM for the alleviation of

symptoms?

3.2.2 Objectives

The objectives of the study were to:

• Determine the extent of CAM use amongst women aged 45-65 who were

symptomatic or asymptomatic but taking menopause specific treatments (HT

and/or CAM).

• Identify the most commonly used CAM therapies for the alleviation of

menopausal symptoms.

• Determine the perceived effectiveness of CAM therapies to alleviate

symptoms.

• Identify where women obtain advice about CAM.

• Identify if HT and other prescription medications are also being used.

3.3 Participants and Setting

Recruitment of participants occurred from July 2003 until July 2004. Women were considered eligible if they were literate in English, aged between 45-65 years, transitioning through menopause and were symptomatic or asymptomatic but taking menopause specific treatments (HT and/or CAM). Questionnaires were excluded if less than 80% was completed.

Survey participants were recruited from three specialist menopause clinics, eleven general practice clinics and government agencies. Drawing from three recruitment strata provided access to a wider representation of women, from those with nil to significant menopausal concerns, who may have been accessing conventional or

CAM interventions. Although these strata are essentially three convenience samples and lessen the generalisibility of our results, nevertheless they provide a better understanding of trends within the community than any one of the three strata considered in isolation. These concerns and other limitations that affected the design of the research protocol will be discussed in section 5.3.

All women aged 45 to 65 years attending menopause and general practice clinics during the designated survey period were invited by the clinic nurse or receptionist to complete the voluntary and anonymous questionnaire prior to their appointment.

The completed questionnaire was placed in an envelope provided, then sealed and returned to the nurse or receptionist. Questionnaires were collected from the clinics once a fortnight. Women from the government agencies, which included the New

South Wales (NSW) public service sector and the University of Western Sydney

(UWS), were recruited via the circulation of an invitation email with a link to an

47 electronic version of the questionnaire. A PDF copy was also attached with instructions for completion and its return by mail for those who were not connected to the internet. Consent to take part in the study was given on return of the completed instrument to the receptionist or when the sent button on the completed electronic version was pressed.

Ethics approvals were obtained from UWS, Western Sydney Area Health Service

(Westmead Hospital), South Western Sydney Area Health Service (Royal Hospital for Women) and Northern Sydney Health (Royal North Shore Hospital). Permission and support was also granted from the Co-ordinator General of the NSW government for the distribution of the questionnaire.

3.3.1 Menopause and general practice clinics

The three outpatient menopause clinics were each affiliated with a major Sydney hospital, and associated with one of three Sydney Area Health Services (AHS). The collaborating hospitals were; Royal Hospital for Women, Royal North Shore and

Westmead. The directors of each clinic were contacted and provisional permission was granted. An ethics application to the corresponding hospital committee was made in conjunction with the directors before the study commenced.

The menopause clinics and AHS were located north, south and west of Sydney.

These locations allowed for a wider geographical spread for the recruitment of women from both menopause and general practice clinics. A total of ten general practice clinics in three AHS, with an additional clinic in the south east of Sydney,

48 took part in the study. Clinics were selected at random from the Yellow Pages telephone directory by choosing every fifth clinic that corresponded to the AHS included in the study. An additional method for selecting clinics included the recommendation of another clinic by a participating clinic (snowballing). The clinic was contacted by telephone and a meeting was arranged with the chief investigator

(CP) to present the study package. Permission to commence the study was granted by the head doctor or the clinic manager.

Recruiters from each of the menopause and general practice clinics were briefed in detail by the chief investigator and given a detailed outline on how to administer the questionnaire. Advertisements about the study were displayed at participating clinics.

3.3.2 Government agencies

The third stratum included women from two large institutions: the NSW

Government and UWS. The Premiers Department at the NSW government circulated an explanatory email containing a link to the electronic questionnaire on

3rd May 2004 with reminders on the 6th and 26th May to the following lists:

• Chief Executive Officers

• Agencies

• Spokeswomen and women liaison officers

• Premiers Department Staff

An explanatory email and the electronic questionnaire were circulated on June 3rd

2004 to UWS staff on the following lists:

• UWS colleges

• Human resources

• Information technology

• Corporate services

3.4 Survey Instrument

Development of the 19 item self administered survey instrument was based on an extensive literature review of published studies on general CAM use and use by menopausal women. The questionnaire was divided into three sections entitled;

“Your health”, “Your use of treatments during menopause” and “Your background”

(refer to Appendix 1 and II for covering letter and survey questionnaire).

The first section enquired about general health status,252 use of HT and prescription medication, menopausal status and symptoms experienced during the previous 12 months.253 The menstrual status of respondents was recorded as their last “natural” menstrual period occurring either more than 12 months ago, during the last 2–11 months or last/current month. A “natural” menstrual period was one not caused by

HT or other treatments. Symptom severities were recorded on a scale from 0 (not bothered at all) to 6 (extremely bothered).

The second section included questions about CAM use and the perceived effectiveness of these therapies for the alleviation of complaints. Respondents were asked if they had consulted any of six categories of CAM practitioners and/or used any number of nine popular CAM menopause products during the previous 12 months. Practitioners included herbalist, nutritionist/dietician, naturopath, acupuncturist, Chinese herbal practitioner and homeopath, while CAM products included soy food products, soy or phytoestrogens capsules, Remifemin, Promensil,

Menocalm, Cimicifuga, Meno-eze, Angelica sinensis and EPO. Space was provided for respondents to include additional therapists and products. The modalities chosen were all popular therapies used by menopausal women as agreed by an expert panel.

Furthermore, since this study assessed the use of pharmaceuticals and CAM, the chosen modalities all included the prescribing of ingested remedies. Acupuncture was included because it is a component of TCM along with Chinese herbal medicine.

The products listed were all commonly sold at Sydney health food stores, supermarkets and pharmacies. Non-users of CAM were defined as women who had not used any CAM treatments during the previous 12 months. For each practitioner and CAM product, women were asked to rate the effectiveness of the therapy on a scale from 0 (not effective at all) to 6 (excellent effect). Respondents were also asked where they obtained advice about CAM and whether there had been any communication with their medical practitioner about CAM use. The final section covered basic demographics such as age, education, employment status,254 postcode of habitation, marital status, country of birth and the main language spoken at home.

3.4.1 Reliability and validity

Reliability and validity are important issues relating to reliable and valid measurement instruments. Reliability refers to the consistency of measurement.

Does the instrument produce consistent results with repeated administrations under similar conditions? Validity suggests an instrument is true or correct, and includes aspects of face and content validity. Face validity addresses the appropriateness and precision of questions, while content validity assesses if the questionnaire adequately covers the objectives being investigated. Therefore, the objective was to develop a survey instrument that demonstrated internal validity by accurately and reliably assessing the research objectives.255, 256 Establishing internal validity is particularly important when designing a new questionnaire, as validation benchmarks do not exist.

3.4.1.1 Reliability

Reliability was assessed by administering the questionnaire to a separate second cohort of thirty-two eligible participants, and then re-administering the instrument to the same cohort two weeks later. The Wilcoxon Sign test was applied to assess reliability by matching the before and after answers of the test-retest.

3.4.1.2 Face and content validity

The scientific community was called upon to determine the face validity of the items, by assessing if the questions accurately measured the constructs. During the design stage, a panel of specialist physicians, CAM practitioners, psychologists and a

52 statistician were consulted to review the face and content validity by examining the relevance, content and wording of the questionnaire. Variables and input criteria were defined in collaboration with the statistician. A focus group and pilot study were also carried out to further determine the questionnaire’s validity.

Following drafting of the instrument, a focus group of eight women was conducted to review the questionnaire. All women who took part in the focus group met the recruitment criteria. These women were asked if the questions were relevant, offensive, difficult to comprehend or confusing. From the feedback received, the questions and instructions were edited to ease comprehension, reduce ambiguity and increase compliance in answering items as requested.

Following ethics committee approval, a pilot study was conducted. Twenty-four eligible women were recruited from two community groups and a menopause clinic

(Westmead). Feedback was obtained about the comprehension of items and time for completion. The women took on average ten minutes to complete the survey. Any questions that were omitted or incompletely answered were analysed. The wording and layout of these questions and/or their instructions were further revised to improve completeness and accuracy of responses and then sent to health professionals for comment on face validity. The pilot study data were entered into a prepared Access database. A preliminary statistical analysis was undertaken to ensure that data was correctly coded and all objectives could be assessed.

3.5 Statistical Analyses

The sample size calculation was based on previous overseas studies that determined

CAM use by women specifically for menopausal symptoms to be conservatively at least 15%.19, 20 Therefore, in order to determine whether a similar rate of CAM use existed amongst our sample, the minimum sample size (n) was calculated so that the estimated proportion lay within 5% (or ±2.5% ) of the true percentage value within a

95% confidence interval. To allow for a 95% confidence band to lie within ±2.5% the sample size was determined to be 784. The calculation is as follows:

⎛⎞ PP1 n ⎜⎟()(− ) ==⎜⎟2 ⎜⎟L ⎝⎠()1.96

⎛⎞ .15 .85 n ⎜⎟()() 784 ==⎜⎟2 ⎜⎟.025 ⎝⎠()1.96

Although the sample size was calculated to be 784, the minimum sample size was rounded to 800. Since this cross-sectional study recruited women from three strata of the community, a minimum of 270 women would need to be recruited from each in order to attain a sample size of approximately 800.

The Statistical Package for Social Sciences (SPSS version 12.0.1, Chicago, Ill, USA) software was used for all data analyses. Descriptive statistics identified CAM use, perceived effectiveness of treatments, pharmaceutical use, menopausal symptomatology, sources of information, CAM use for other conditions and

54 demographic details. Symptom scores were collapsed to create three categories: 0-1 none, 2-4 moderate, 5-6 severe. Likewise, perceived effectiveness scores for both practitioners and products were collapsed to produce the following three categories: not effective 0-1, moderately effective 2-4 and very effective 5-6. The perceived effectiveness was then calculated separately for each modality and product by adding up the scores for each category and calculating the percentages. Ratio data was analysed using ANOVA while Chi-squared analyses were used to determine differences between groups for discrete variables. Univariate analyses (Chi-squared) were undertaken to determine variables most likely to best predict CAM use. These variables were entered into a multivariate logistic regression model to determine the best predictors for CAM use. The statistical significance was set at 0.05.

3.6 Summary

The research protocol was planned by taking into account issues raised in the literature review in order to increase the reliability of the results.

• The survey instrument was rigorously tested both for internal validity and

reliability. Internal validity included face and content and required the

revision of the instrument by a panel of professionals. Reliability involved

the test-retesting of the instrument on a sample of eligible women over a two

week time interval.

• All CAM modalities included in the study fall under the definition proposed

by the Panel on Definition and Description54 and involve an ingestible

component to treatment, a factor that may be important to better understand

the impact of pharmaceutical and CAM use.

• Before commencing the study, the sample size was calculated to determine

the minimum number of women to be recruited. This calculation was based

on the results of previous CAM use studies.

• The study investigates the use of CAM by menopausal women over 12

months, a time frame consistent with most general CAM surveys.

In essence, the three recruitment strata described in the protocol are convenience samples; nevertheless we believe that drawing women from these three strata will provide access to a wider representation of women, than any one stratum considered alone. Although this method of sampling may limit the generalisibility of the results, they may give a better understanding of the trends within the community that we are investigating.

CHAPTER 4 SURVEY: RESULTS

4.1 Introduction

The following chapter reports on the results of the Women’s Health during Midlife

Survey based on the completed questionnaires of 1,296 women. The results indicate that a significant number of women who took part in the survey used a range of

CAMs to alleviate symptoms and improve quality of life during the previous 12 months. A number of modalities were considered by respondents to be good to very good at improving overall symptoms. Further analyses included; the extent of pharmaceutical drug use, communication with general practitioners and where women obtain advice about CAM.

4.2 Survey Instrument Reliability

The Wilcoxon Sign Test was used to test the reliability of the questionnaire by matching the before and after answers of the test-retest. The answers to 17 out of 74 variables were misjudged by over 10%. Of these, seven variable answers were misjudged by less than 20%. When the overall effect on the total outcome was determined by considering the over and under estimation of all answers between the before and after testing at the 10% significance level, only four variables were considered to be significantly different. Therefore, 70 of the 74 variables were found to be highly reliable at the 10% significance level.

4.3 Demographics and Health Characteristics

A total of 1,356 surveys were collected of which 1,296 eligible surveys were included in the final analyses. Respondents were excluded if they fell outside the age range (n=37), completed less than 80% of the questionnaire (n=7) or were asymptomatic and not taking treatments specifically for menopausal symptoms

(n=16).

Basic demographics, symptoms and health status for the total sample and recruitment groups are presented on Tables 4.1 and 4.2. The three groups differed in mean age

2 (F(2, 1264)=52.27; p=0), educational background (χ =64.4 df =2; p=0), occupation

2 2 (χ =101.04 df=4; p=0), menstrual status (χ =86.9 df =4; p=0) and severity of menopausal symptoms. More women attending menopause clinics were menopausal

(76.6%) compared to general practice clinics (70.1%) and government agencies

(52.9%). Significantly more women at menopause clinics reported having severe hot

2 2 flushes (χ =16.6 df =4; p=0.002), night sweats (χ =21.7 df =4; p=0), sleeping

2 2 difficulties (χ =18.0 df =4; p=0.001) and dry vagina (χ =37.0 df =4; p=0). There were no significant differences in symptom severity between general practice clinic and government agency respondents. Sleep difficulties were rated as the most troublesome complaint by respondents.

Table 4.3 presents the mean scores and standard deviations of symptoms by recruitment group (refer to Appendix II for questionnaire scale). Except for menstrual irregularities and bladder infections, menopause clinic recruits scored significantly higher for all symptoms. There was no significant difference between the groups for scores of irregular menses (F(2, 1281) =0.61; p=0.501), however slightly more general practice women scored bladder problems as a higher concern

(mean=0.64, SD=1.491) although there was no significant differences between the three groups (F(2, 1276) =11.381; p=0).

Most women considered their general health to be good or excellent, although menopause clinic recruits reported their overall health status to be slightly worse than the other two groups of women. When compared to a year ago, most women rated their health status as the same or better with no significant differences between

2 recruitment groups (χ =4.806 df = 4; p=0.31).

Table 4.1: Demographic characteristics and medicine use of participants by total sample and recruitment group (values expressed as numbers (valid percentages) unless stated otherwise)

Characteristic Total Sample Menopause General Government (n=1296) Clinics Practice Agencies Statistic p-value (n=306) Clinics (n=723) (n=267) Age, mean±SD 52.5±5.08 54.0±5.20 54.1±5.41 51.3±4.5 52.27* <0.001* df = 2, 1264

Country of birth Australia/NZ** 939 (73.3) 208 (68.2) 188 (71.8) 543 (76.1) 7.14 0.03 Other 342 (26.7) 97 (31.8) 74 (28.2) 171 (23.9) df=2

Main language spoken English 1205 (95.4) 288 (95.4) 234 (94.0) 683 (95.9) 1.60 Other 58 (4.6) 14 (4.6) 15 (6.0) 29 (4.1) df=2 0.45

Marital status Partner 899 (70.3) 200 (65.6) 186 (71.3) 513 (72.1) 4.43 0.11 No partner 379 (29.7) 105 (34.4) 75 (28.7) 199 (27.9) df=2

Education Tertiary 603 (47.3) 126 (42.3) 74 (28.2) 403 (56.3) 64.37 <0.001 Non-tertiary 673 (52.7) 172 (57.7) 188 (71.8) 313 (43.7) df=2

Occupation Professional 648 (50.5) 134 (44.1) 85 (32.6) 429 (59.7) 101.04 <0.001 Non- 560 (43.6) 133 (43.8) 148 (56.7) 279 (38.9) df=4 professional Not employed 75 (5.8) 37 (12.2) 28 (10.7) 10 (1.4)

Used HT Yes 421 (32.6) 209 (68.3) 74 (27.7) 138 (19.2) 239.68 <0.001 No 872 (67.4) 97 (31.7) 193 (72.3) 582 (80.8) df=2

Used CAM Yes 697 (53.8) 184 (60.1) 132 (49.4) 381 (52.7) 7.33 0.03 No 599 (46.2) 122 (39.9) 135 (50.6) 342 (47.3) df=2

Used pharmaceuticals Yes 774 (59.9) 219 (72.3) 194 (72.4) 361 (50.0) 66.885 <0.001 No 518 (40.1) 84 (27.7) 73 (27.3) 361 (50.0) df=2

Last menses >12 months 795 (62.0) 229 (76.6) 185 (70.1) 381 (52.9) 86.898 <0.001 2-11 months 182 (14.2) 47 (15.7) 34 (12.9) 104 (14.0) df=4 last month 306 (23.9) 23 (7.7) 45 (17.0) 238 (33.1) *ANOVA (ratio data) **New Zealand

Table 4.2: Symptomatology and health status of participants by total sample and recruitment group (values expressed as numbers (valid percentages) unless stated otherwise)

Characteristic Total Menopause General Government Sample Clinics Practice Agencies Statistic p-value (n=1296) (n=306) Clinics (n=723) (n=267)

Menopausal symptoms

Hot flushes None 648 (50.6) 129 (42.3) 134 (51.1) 385 (53.9) 16.63 0.002 Moderate 394 (30.8) 99 (32.5) 87 (33.2) 208 (29.1) df=4 Severe 239 (18.7) 77 (25.2) 41 (15.6) 121 (16.9)

Night sweats None 667 (52.4) 128 (42.2) 140 (52.8) 399 (56.6) 21.71 <0.001 Moderate 401 (31.5) 106 (35.0) 83 (31.3) 212 (30.1) df=4 Severe 205 (16.1) 303 (22.8) 42 (15.8) 94 (13.3)

Difficulty sleeping None 443 (34.5) 79 (26.0) 97 (36.6) 267 (37.3) 18.00 0.001 Moderate 506 (39.4) 130 (42.8) 91 (34.3) 285 (39.9) df=4 Severe 335 (26.1) 95 (31.3) 77 (29.1) 163 (22.8)

Irregular menses None 1037 (80.8) 242 (80.4) 220 (83.0) 575 (80.1) 3.74 0.44 Moderate 158 (12.3) 33 (11.0) 32 (12.1) 93 (13.0) df=4 Severe 89 (6.9) 26 ( 8.6) 13 (4.9) 50 (7.0)

Vaginal dryness None 831 (64.8) 156 (51.3) 171 (65.3) 504 (70.4) 37.02 <0.001 Moderate 301 (23.5) 94 (30.9) 57 (21.8) 150 (20.9) df=4 Severe 150 (11.7) 54 (17.8) 34 (13.0) 62 (8.7)

Health status

Present Poor 26 (2.0) 9 (3.0) 6 (2.3) 11 (1.5) 8.82 0.07 Good 695 (53.8) 177 (58.0) 150 (56.4) 368 (51.0) df=4 Excellent 573 (44.2) 119 (39.0) 110 (41.4) 343 (47.5)

A year ago Worse 72 (5.6) 20 (6.6) 18 (6.8) 34 (4.7) 4.81 0.31 No change 791 (61.3) 192 (63.0) 151 (56.8) 448 (62.2) df=4 Better 428 (33.2) 93 (30.5) 97 (36.5) 238 (33.1)

Table 4.3: Mean scores (standard deviations) and ANOVA for symptoms and health status on a six point scale by recruitment group

Menopause General Government Characteristic Clinics Practice Agencies ANOVA p-value Mean (±SD) Clinics Mean (±SD) F-ratio (df) Mean (±SD)

Menopausal Symptoms

Hot flush 2.53 (2.199) 1.99 (2.005) 1.92 (2.084) F(2, 1278)=9.38 <0.001

Night sweat 2.45 (2.165) 1.96 (2.058) 1.79 (1.981) F(2, 1270)=11.19 <0.001

Heart beats 1.79 (1.877) 1.60 (1.814) 1.35 (1.735) F(2, 1279)=6.88 <0.001 strong/quick Tense 2.99 (1.927) 2.59 (1.986) 2.29 (1.873) F(2, 1284)=14.58 <0.001

Difficulty 3.09 (2.035) 2.78 (2.208) 2.60 (2.023) F(2, 1281)=5.90 <0.001 sleeping Panic attacks 1.56 (1.942) 1.26 (1.745) 1.01 (1.645) F(2,1281)=11.08 <0.001

Mood 2.64 (2.087) 2.08 (1.933) 1.93 (1.837) F(2, 1274)=14.61 <0.001

Dizziness 1.59 (1.790) 1.45 (1.751) 1.04 (1.537) F(2, 1280)=14.43 <0.001

Headache 2.39 (2.022) 1.90 (1.862) 1.83 (1.830) F(2, 1279)=9.56 <0.001

Pain 2.74 (1.988) 2.91 (1.991) 2.34 (2.001) F(2, 1287)=9.42 <0.001

Crawling under 1.27 (1.942) 1.16 (1.794) .73 (1.493) F(2, 1287)=13.87 <0.001 skin Breathing 1.03 (1.609) 1.02 (1.618) .73 (1.443) F(2, 1287)=5.71 <0.001 difficulties Menstrual .84 (1.707) .70 (1.489) .83 (1.631) F(2, 1281)=.69 0.5 irregularities Bladder .59 (1.350) .64 (1.491) .30 (.919) F(2, 1276)=11.38 <0.001 infections Vaginal dryness 2.00 (2.096) 1.42 (2.002) 1.17 (1.777) F(2, 1279)=20.36 <0.001

Health Status

Present 5.11 (1.293) 5.08 (1.264) 5.29 (1.153) F(2, 1290)=4.17 0.02

A year ago 4.66 (1.429) 4.83 (1.484) 4.87 (1.345) F(2, 1288)=2.56 0.08

4.4 Use of CAM

More than one in two women visited a CAM practitioner and/or used a CAM product during the past year for the alleviation of symptoms (Table 4.1). Of this total, 20.3% consulted CAM practitioners, 48.7% used CAM products, while 15.2% had used both therapists and products. Menopause clinic respondents were more likely to have visited a CAM practitioner (25.2%) or used a CAM product (53.6%) than women from general practice clinics (17.2%, 43.8% respectively) or government agencies (19.4%, 48.4% respectively) (Figure 4.1). Overall, the three most commonly visited practitioners were the naturopath (7.2%), acupuncturist

(4.8%) and herbalist (4.6%), while the three most popular products were soy

(25.4%), EPO (18.4%) and Remifemin/Cimicifuga (12.0%). Twelve percent of respondents had consulted at least one practitioner (mean=0.33, SD=0.78; range 0-6 practitioners), while 8.3% consulted two or more therapists. Of those women using

CAM products, 25.2% had used at least one product (mean=0.92, SD=1.30; range 0-

9 products), while 23.7% had used two or more products. CAM users scored all symptoms, as significantly more severe (at the 5% significance level) than non-users, except bladder infections (F(1,1277)=3.07; p=0.08) (refer to Table 4.4). One quarter of respondents (25.3%) also reported using CAM for health conditions other than menopausal symptoms. Approximately one in five women was using CAM for menopause and for other health conditions not related to menopausal complaints.

Figure 4.1: Total CAM use during the past year by recruitment group

Used at least one practitioner and/or any CAM product

Used at least one menopause product CAM use CAM

Visited at least one practitioner

0% 10% 20% 30% 40% 50% 60% 70% Percent

Menopause clinics General practice clinics Government agencies

Table 4.4: Mean scores (standard deviations) and ANOVA for symptoms and health status on a six point scale by CAM users and non-users

Characteristic CAM user CAM non-user ANOVA p-value Mean (±SD) Mean (±SD) F-ratio (df)

Menopausal Symptoms

Hot flush 2.53 (2.201) 1.56 (1.866) 71.96 (1, 1279) <0.001

Night sweats 2.37 (2.145) 1.53 (1.856) 55.36 (1, 1271) <0.001

Heart beats strong/quick 1.69 (1.892) 1.30 (1.651) 14.82 (1, 1280) <0.001

Tense 2.76 (1.932) 2.23 (1.888) 24.99 (1, 1285) <0.001

Sleeping difficulties 3.04 (2.075) 2.42 (2.021) 29.13 (1, 1282) <0.001

Panic attacks 1.41 (1.862) .94 (1.585) 22.62 (1, 1282) <0.001

Mood 2.36 (1.966) 1.86 (1.874) 21.47 (1, 1275) <0.001

Dizziness 1.43 (1.754) 1.06 (1.527) 16.02 (1, 1281) <0.001

Headache 2.12 (1.930) 1.82 (1.845) 8.24 (1, 1280) 0.004 Pain 2.74 (2.014) 2.33 (1.983) 13.28 (1, 1288) <0.001

Crawling under the skin 1.15 (1.838) .70 (1.462) 22.80 (1, 1288) <0.001

Breathing difficulties 1.00 (1.625) .70 (1.386) 12.35 (1, 1288) <0.001

Menstrual irregularities .93 (1.738) .66 (1.460) 9.50 (1, 1282) 0.002 Bladder infections .49 (1.247) .38 (1.084) 3.07 (1, 1277) 0.08 Vaginal dryness 1.65 (2.004) 1.15 (1.809) 22.26 (1, 1280) <0.001

Health Status

Present 5.23 (1.215) 5.17 (1.212) .91 (1, 1291) 0.34 A year ago 4.84 (1.415) 4.79 (1.376) .41 (1, 1289) 0.522

4.4.1 Effectiveness of CAM treatments

Figures 4.2 and 4.3 present the perceived effectiveness of practitioners and products for overall alleviation of symptoms. Ninety four percent of respondents who consulted a massage therapist considered the treatment moderately to very effective in alleviating menopausal symptoms. Chiropractic intervention was considered to be the next most effective therapy (90%), while the nutrition was rated third (86.4%).

The three most effective CAM products were phytoestrogen tablets (72.6%), EPO

(66.3%) and Cimicifuga (63.7%). Overall, 59.5% of respondents found at least one practitioner or product to be very effective in improving symptoms.

4.4.2 Sources of CAM advice

Women sought advice about CAM from a wide variety of sources (Figure 4.4), with the most popular being magazines (21.0%), friends (20.7%), general practitioners

(19.5%), books (16.3%) and health food shop assistants (14.7%). Only one in five women who used CAM had been referred to these treatments by medical practitioners.

Figure 4.2: Perceived effectiveness of CAM practitioners on overall symptoms

Chinese Herbalist 35% 45% 21%

Herbalist 35% 38% 27%

Homeopath 22% 39% 39%

Naturopath 22% 47% 31%

Acupuncturist 16% 54% 30% Practitioners Nutritionist 14% 66% 21%

Chiropractor 10% 50% 40%

Massage Therapist 6% 27% 67%

0% 20% 40% 60% 80% 100% Percent Not Effective Moderately Effective Very Effective

Figure 4.3: Perceived effectiveness of CAM products on overall symptoms

Menocalm 54% 23% 23%

Promensil 52% 43% 5%

Meno-eze 47% 43% 10%

Soy products 39% 49% 12%

Angelica 39% 42% 20% Product Remifemin 39% 32% 29%

Cimicifuga 36% 38% 26%

Evening primrose oil 34% 48% 18%

Phytoestrogen tablets 28% 45% 28%

0% 20% 40% 60% 80% 100% Percent

Not Effective Moderately Effective Very Effective

Figure 4.4: Sources of advice about CAM use

Magazines 21%

Friend 21%

General Practitioner 20%

Books 16%

Newspapers 15%

Health Food Shop Assitant 15%

Naturopath 12%

Chemist 11%

Internet 9% Source of Advice of Source

Television 9%

Spouse 9%

Chiropractor 8%

Traditional Chinese Medical Practitioner 8%

Herbalist 5%

0% 5% 10% 15% 20% 25% Percent

4.4.3 Communication with physicians

Of respondents who were CAM users, 70.4% reported informing their doctor about

CAM use. However, only 26.4% of women noted their doctor had specifically enquired about their use of CAM. Respondents from specialist menopause clinics were significantly more likely to tell their doctor about CAM use than general

2 practice and government agency respondents (χ =11.0, df =2; p=0.03). There was no significant difference between recruitment groups in terms of medical practitioner

2 enquiry about CAM use (χ =2.05, df =2; p=0.34).

4.5 Use of Pharmaceuticals

Sixty percent of respondents reported that they currently used prescription or over- the-counter pharmaceuticals (mean=1.24, SD=1.51; range 0-9), with 30.6% taking two or more pharmaceuticals. Table 4.5 presents the ten most commonly used pharmaceutical agents by drug category taken by survey participants. The top three drug categories included HT (22.6%), anti-hypertensive agents (17.6%) and nonsteroidal anti-inflammatories and analgesics (10.7%). During the past 12 months, one third of women (32.6%) reported using HT. Menopause clinic women were 3.5 times more likely to have taken HT during the past year than women from government agencies and were 2.5 times more likely than general practice recruits.

Of the women currently taking pharmaceuticals, 28.9% had also used CAM products during the past 12 months. There was no significant difference (p=0.48) in the

70 overall use of pharmaceuticals amongst CAM product users (60.8%) and non-users

(58.8%). However, CAM non-users were significantly (5% significance level) more likely to use two or more pharmaceuticals (34.2%) than CAM users (27.6%).

Table 4.5: Most commonly used pharmaceutical agents by drug category

Pharmaceutical Category No. % Range of Drugs Taken Gonadal hormones* 0-4 1 or more 293 22.6

Anti-hypertensive agents 0-3 1 or more 228 17.6

Beta-adrenergic blocking agents 0-1 1 or more 37 2.8

Bronchodilators, aerosols, inhalants 0-3 1 or more 106 8.2

Anti-depressants 0-1 1 or more 128 9.9

Hyperacidity, reflux, ulcers 0-1 1 or more 82 6.3

Hypolipaedemic agents 0-2 1 or more 101 7.8

NSAIDS and analgesics 0-3 1 or more 139 10.7

Hypoglycaemic agents 0-3 1 or more 50 3.9

Thyroid hormones, anti-thyroid agents 0-1 1 or more 56 4.3

* Category does not include contraceptives

4.6 Determinants of CAM Use

Variables covering basic demographics (age, marital status, occupation, country of birth and language spoken), health status, current CAM use for other conditions, menopausal symptoms, sources of advice about CAM and HT use were explored to seek predictors of CAM use using logistic regression (Table 4.6). Of these variables, a combination of nine predictors (independent variables) was selected based on their individual association for CAM use (dependent variable). However, because these nine variables explained only 23% of the variation (R2), we also applied the Correct

Classification Rate (CCR) method (Table 4.7) to explain the model’s goodness of fit.

Ideally this value should be close to one. Using the CCR model, 67.76% of CAM users were correctly classified, hence the logistic regression model is reasonably well supported.

Table 4.6: Maximum likelihood estimates of the logistic regression function for predicting CAM use

Exp(β) Coefficient (β) S.E. (Odds Ratio) 95.0% C.I. Present health status 0.12 0.05 1.12 (1.01,1.25) Hot flush severity 0.70 0.13 2.01 (1.55,2.60) CAM used for other health conditions 0.80 0.16 2.24 (1.64,3.05) HT use 0.41 0.14 1.51 (1.15,1.98) Advice from physician 0.46 0.17 1.58 (1.13,2.21) Advice from naturopath 1.39 0.26 4.03 (2.44,6.64) Advice from health food store attendant 0.55 0.20 1.73 (1.16,2.57) Advice from books 0.66 0.20 1.93 (1.32,2.84) Advice from magazines 0.59 0.17 1.80 (1.29,2.51) Constant -1.71 0.32 0.18 2 Note: Hosmer-Lemeshow goodness of fit for the model, χ2 = 8.99, df = 8 (p= 0.34) Nagelkerke R = 0.23

Table 4.7: Misclassification matrix for the logistic regression model

Predicted (%) Correct CAM Non User CAM User Classification Observed CAM Non User 386 174 68.93 CAM User 218 438 66.77 Overall (%) 67.76 Estimate of Correct Classification Rate = 0.6776; Estimate of Misclassification Rate = 0.3224 Estimate of Standard Error of Misclassification Rate = 0.0134

The most significant factors associated with CAM use were present health status, severity of hot flushing, whether CAM was being used for other conditions and sources of CAM advice. From Table 4.6 it can be seen that for each additional unit increase in hot flush severity, the odds of using CAM increase by 70%. As indicated by the Odds Ratio, a woman who receives advice from a naturopath is four times

(95% CI 2.44-6.64) more likely to use CAM than one who does not receive such advice.

4.7 Discussion

The findings of this survey again highlight the popularity of CAM use amongst certain sections of the community. This comprehensive survey found that CAM use was very popular amongst women aged 45-65 transitioning through menopause and who were symptomatic or asymptomatic but taking menopause specific treatments.

Approximately 54% of surveyed women indicated they had used at least one CAM modality during the past year, with more than twice as many women using a CAM product than consulting a CAM practitioner. Additional use of soy was the most popular method of self treatment, a trend also noted by previous studies.20, 136 The use of soy has become mainstream, with soy being added to foods such as baked goods.257, 258

A number of therapies were regarded as moderately to very effective by women respondents. CAM practitioners were generally rated more highly than products used for self medication, with massage and chiropractic rated the most effective.

Stressful situations have been noted to aggravate symptoms such as vasomotor symptoms,4 therefore therapies that generate a feeling of relaxation and wellbeing

(e.g. massage) may be particularly beneficial. The most effective product was phytoestrogen tablets. Some evidence suggests soy phytoestrogens and red clover isoflavones have mild-to-moderate level of efficacy for the alleviation of vasomotor symptoms. Our results indicate that 28% of women found commercial phytoestrogens to be an effective treatment.

Women obtained advice about the use of CAM from a broad range of sources, with the most popular being magazines and friends. These sources cannot be assured for reliable dissemination of correct and current information. Although general practitioners are increasingly becoming interested in CAM and are often consulted about their use, many do not have a good understanding of the wide variety of CAM modalities available.

Two thirds of respondents reported they were currently using prescription or over- the-counter pharmaceuticals. Approximately one third of women currently taking pharmaceuticals had also used a CAM product during the past 12 months. However, the way in which the questionnaire was structured did not allow us to identify those respondents concurrently using pharmaceuticals and CAM products. Nevertheless, our results indicate that the use of both pharmaceuticals and CAM is high and their

74 concurrent use increases the risk of drug-herb interactions. These results highlight the need for correct information regarding the safe use of all medications to be readily available.

To our knowledge, this is the largest study conducted in Sydney which examines the use of CAM by women for the alleviation of menopausal complaints. In order to achieve a wide representation of women, our sample was recruited from three diverse strata; specialist menopause clinics, clinics of general practice and government agencies. Therefore, the generalisibility of these results to the general population may be somewhat limited. Nevertheless this exploratory survey confirms the findings of other epidemiological studies that CAM use for menopausal complaints is very popular. The following chapter discusses the main findings of this study and their implications in greater detail.

CHAPTER 5 SURVEY: DISCUSSION AND CONCLUSIONS

5.1 Introduction

The following chapter discusses the findings of the Women’s Health during Mid-life

Survey by highlighting their importance in the context of the research aims and objectives. The discussion also explores the relevance of these findings to the practice of both medicine and complementary medicine. The final section identifies biases and protocol limitations that may impact on the generalisation of the results.

5.2 CAM Use by Women Aged 45-65

Our study found that 53.8% of surveyed women aged 45-65 years used at least one

CAM modality during the previous year to alleviate menopausal symptoms. These findings are comparable to those of several overseas studies.21, 22 However, as discussed previously (section 2.6.1) differences in study approaches have contributed

76 to the observed variation in prevalence data on CAM use. The use of convenience samples,136, 247, 249 the inclusion of lifestyle factors23 and a variety of time frames for

CAM use20, 23, 247 may result in higher prevalence rates than compared to the general population. These methodological variations make comparisons between study results cumbersome.

In addition to these considerations, relevant events occurring at the time the research is conducted should also be taken into account when analysing the results, as these events may influence the decision-making behaviours that are being measured. Our study was conducted not long after the widespread publication of the WHI results, which caused discussion and dissemination of information by various media about the use of alternative therapies for menopausal symptoms. A decline in the use of

HT was noted in Australia during the years 2003-2004;259 although no comparative study investigating the impact of the WHI results on the use of CAM has been undertaken.

5.2.1 Demographics and health characteristics

Our study sampled women from three recruitment strata; specialist menopause clinics, general practice clinics and government agencies. These may essentially be considered as three convenience samples; therefore generalisations of the results to the general population must be made with caution. The strengths and limitations of this study will be discussed further in section 5.5.

As can be seen from Table 4.1, there were several significant differences between the three recruitment groups. Government agency women were younger, completed a higher level of education and were more likely to be professionally employed than the other two strata. Our analyses also demonstrated that women attending menopause clinics were the most symptomatic and were more likely to access conventional and/or CAM interventions. Previous studies have confirmed that women attending specialist menopause clinics report a greater number of symptoms than the general population251, 260 and are more likely to be prescribed medical treatment.247 Government agency women, who represented those not specifically seeking medical treatment at the time of recruitment, were the least symptomatic and least likely to be using HT, although many had tried CAM.

5.2.2 CAM use and effectiveness of treatments

The use and self prescribing of CAM products was far more popular (33.5%) than consulting a practitioner (5.1%). This finding was consistent with other studies which found self medication with CAM products to account for the largest section of the CAM market.57, 62, 76, 115 All menopause specific products listed on the questionnaire could easily be purchased at supermarkets, pharmacies and health food stores around Sydney and represented a lower financial outlay than consulting a practitioner.

Phytoestrogens, EPO and Cimicifuga were regarded as the most effective products.

The use of soy is particularly popular amongst menopausal women,20 as it involves a simple lifestyle change. Epidemiological research has suggested that the inclusion of

78 soy products in the diet can reduce the severity of vasomotor symptoms.177-179 There is modest evidence from clinical trials to suggest that phytoestrogens isolated from soy may alleviate menopausal symptoms.24, 167, 168, 198, 261-264 A recently conducted meta-analysis of isoflavone therapy derived from either soy or Trifolium for vasomotor symptoms concluded that supplementation may confer a slight to modest reduction in symptoms especially in women experiencing a greater number of flushes per day.265 Some evidence also suggests that Cimicifuga may provide some symptomatic relief for menopausal women.25, 26, 266 A full review of studies investigating the effectiveness of black cohosh for vasomotor symptoms is presented in Chapter 8. Although EPO was a popular supplement amongst respondents, little evidence exists for its overall benefit in alleviating menopausal flushing. However, one clinical study found a significant reduction in the maximum mean number of night time flushes ( p < 0.05) with EPO supplementation.225 With the exception of

EPO, it would appear that patients are not simply utilising CAM in a random fashion, but are responding to their needs by selecting CAM interventions supported by some scientific evidence. Furthermore, approximately one in five women used

CAM for menopausal and other health complaints and hence may be perceived as repeat rather than one time users of CAM. Therefore a significant number of women are not experimental users of CAM, but rather use CAM for the treatment of a number of health concerns.

Massage therapy was rated as the most effective therapy with chiropractic the second, a finding similar to that of another large US study.20 However, it was not possible to illicit which therapy was the most effective in reducing a particular symptom due to the way in which questions regarding symptomatology and CAM

79 use were structured. Nevertheless, the most common symptoms troubling respondents using massage and chiropractic were being tense, sleeping difficulties and pain; symptoms often associated with stress. Menopausal symptoms, such as hot flushing may be induced by stress267 resulting in an increased arousal of the sympathetic nervous system268 and raised cortisol levels.4 Massage has been noted to decrease cortisol and increase serotonin and dopamine levels,269 reduce blood pressure270, 271 and heart rate.272 Chiropractic has been found to be effective for relieving pain273 and stress related conditions such as migraine headaches.274

Although relaxation techniques may be beneficial in reducing menopausal symptoms229-231 no research has been conducted on the direct effect of massage and chiropractic on symptoms such as hot flushing. Since women rated massage and chiropractic so highly, further research on the effect of these therapies on menopausal complaints is warranted.

5.2.3 Sources of CAM advice

Respondents tended to seek advice about CAM use primarily from media and friends rather than health professionals, a finding consistent with previous surveys.120, 136, 247

This trend is of concern as many women are relying on advice from sources that may lack credibility or persons that do not have adequate medical or scientific training.275,

276 Products may also be recommended that contain inconsistent levels of active constituents,275, 277, 278 which when used concurrently with pharmaceuticals may increase the possibility of drug-herb interactions due to an uncertainty regarding the concentration of pharmacologically active ingredients.

The general practitioner was the third most cited source of CAM advice. However, many doctors do not have an adequate background or training in CAM to be able to fully inform their patients of the large range of options available. A significant number of medical practitioners have indicated that they are very open to learning more about CAM and their increasing acceptance of CAM is reflected by a greater willingness to refer patients to both medical and non-medical CAM practitioners.53,

279, 280 There is now widespread acceptance by the Australian medical community of a number of CAM modalities, especially acupuncture, meditation and chiropractic.279, 281 Furthermore, significant numbers of doctors personally use supplements53 and regard these as companion products to pharmaceuticals.52 An increasing acceptance of CAM has also been demonstrated by pharmacists282 and nurses.283

5.3 CAM and Pharmaceutical Use

Our study highlights that a significant proportion of respondents may be using CAM products in conjunction with pharmaceuticals. Of the 59.9% of respondents currently using pharmaceuticals, 62.5% reported taking a CAM product over the past year without therapist consultation. The concurrent use of CAM and pharmaceuticals increases the potential for drug-herb interactions.106, 108, 284

Warfarin is the most common drug with documented evidence to cause herb-drug interactions, while Hypericum perforatum (St John’s Wort) is the most common herb.284 Three respondents noted they were taking warfarin, with one indicating she

81 had seen a herbalist and nutritionist during the past 12 months. Three women who had taken Hypericum over the past 12 months were taking pharmaceuticals at the time of the study. These included an analgesic, HT and thyroid medication.

Interactions with Hypericum have been particularly noted with the concurrent use of antidepressants and cyclosporine.284

Therefore, it is imperative that health professionals discuss and record the use of

CAM with patients as part of a routine medical assessment. Despite this, only a quarter of participants reported that their general practitioner enquired about CAM use. Furthermore, women attending menopause clinics indicated that specialist clinicians were just as unlikely to ask about their use of CAM. The omission of documentation about CAM use while taking a medical history has been reported to commonly occur amongst hospital medical staff.285 Monitoring pharmaceutical drug and CAM use is an important aspect of ongoing patient care, which should be undertaken by all practitioners involved in the shared care of a patient. There is also an onus on CAM practitioners to be more active in the care of patients who wish to integrate conventional and CAM practices by consulting openly with other medical practitioners on the best treatment outcomes.286

5.4 Determinants of CAM Use

Studies that investigated CAM use suggest consumers to be middle-aged,57, 116, 117 well-educated,57, 62, 76, 116, 118 earn higher incomes57, 119 and report poorer health76 than non-users. However, recent research specifically profiling women CAM users indicate that the predominant determinants of CAM use are poorer health95 and

82 greater symptomatology.95, 287 A recent study investigating the association between

CAM and conventional medicine use in midlife women found that those who reported poorer health, as determined by the number of co-morbidities, menopausal symptoms and health related quality of life measures, were more likely to report continuous CAM use.165 The results of our analyses reflect these findings by indicating that the most significant factors determining CAM use were health status, severity of hot flushing, sources of CAM advice and whether CAM was currently being used for other health related conditions.

These results suggest a change in usage patterns amongst menopausal women that may have been instigated by recent publications of the unfavourable and contentious results of several large clinical studies on HT.15, 16, 288 The dissemination of these findings resulted in a noticeable decline in the prescription and use of HT amongst women.17, 149, 150, 289 Furthermore, following these publications, articles about CAM therapies for menopausal symptoms appeared regularly in various media and these possibly increased the awareness of CAM amongst the public and encouraged women to try these alternative treatments. These events may also reflect a change in attitude amongst menopausal women who no longer see this stage in life as a medical condition but as a natural phase that can be managed by non-medical means.

The use of alternative treatments and the implementation of lifestyle changes may indicate Australians are taking a more active role in the management of health and wellbeing. Easy access to information via the internet and various media along with the growth in advertising and marketing of CAM has increased public awareness and exposure to treatments that would otherwise not have been considered. As CAM

83 becomes more mainstream, the characteristic differences between consumers and non-consumers will lessen,290, 291 suggesting that consumers predominately initiate the use of CAM to alleviate troublesome symptoms and improve quality of life.

5.5 Methodological Considerations

This study specifically investigated CAM use amongst symptomatic women transitioning through menopause or those who were asymptomatic but taking menopause specific treatments. In order to achieve a wide representation of women, our sample was drawn from three recruitment strata: women attending specialist menopause clinics, those attending general practice clinics for a range of health related conditions and those who may or may not have been seeking medical attention (government agencies). We therefore recruited women with varying degrees of menopausal concerns who may have been accessing conventional or

CAM interventions. Due to the varied representation of symptomatic menopausal women we believe this survey generates a better understanding of trends within the community in addition to understanding the variations between the three strata groups considered.

However, it would be difficult to generalise these findings to the whole community of menopausal women aged 45-65 years. As with all voluntary surveys, there may have been a bias by participants in choosing to complete the questionnaire. While all patients attending clinics were invited, those interested in CAM may have been more likely to participate. Therefore, it may be argued that this study generated higher

CAM usage estimates than the general population. In contrast, the exclusion of

84 potential participants who could not communicate in English may have reduced estimates of CAM use. CAM usage, for example, in Asian communities is known to be high.59 Due to the large number of clinics involved in recruitment and the lack of access to information regarding the numbers of eligible women employed at government agencies we were unable to determine an accurate response rate from some of the services and an overall response rate. Therefore, due to these aforementioned limitations it is difficult to generalise the findings of this exploratory survey to all menopausal women aged 45-65 years living in Sydney.

We must acknowledge certain resource limitations which impacted on the protocol and influenced the way in which participants were recruited. The ideal method to ensure random sampling and accuracy in data collection was considered to be random digit telephone dialling using computer-assisted telephone interviewing

(CATI). However, the financial outlay for out-sourcing this task was beyond the university grant approved for the study. Furthermore, since we were selecting women aged 45-65, a large number of households would have had to be called to attain our sample size. This would have increased the cost of the study. With the rising popularity of mobile telephones, random digit dialling may lead to biases due to the exclusion of women who no longer rely on a land telephone line. Calling eligible women using telephone listings such as the “white pages” was another option considered. Again the financial outlay and manpower needed to carry out the task was considered too prohibitive.292 This method of recruitment can also lead to bias as not everyone has a telephone or is listed in the telephone directory.293

We therefore decided to use convenience sampling from various sections of the community in order to ease recruitment while at the same time widening the representation of the final sample. Since we were considering symptomatic menopausal women, our main criteria to ensure a broad sampling cross section was access to medical care; specialist care, general care and requiring no medical care at the time of survey completion. A self explanatory written questionnaire was considered the most suitable method of surveying participants and information gathering. The questionnaires could be given to consecutive eligible women who attended the clinics and be completed while waiting for an appointment or online if employed via the agencies. Written questionnaires and electronic print-outs served as hard copies and information was entered into the computer at a later date.

Despite these limitations, we believe a number of key strengths allow the results of this study to give valuable insight into the use and effectiveness of CAM by menopausal women for the relief of symptoms. The strengths of this study included a large and diverse sample size, 12 months usage data consistent with most general

CAM surveys, a validated and reliable survey instrument and the exploration of use and perceived effectiveness of both CAM practitioners and menopause specific products. The protocol for this study was compared with past published work as outlined on Table 2.2. This Stop-Go chart lists nine bench-mark measures identified from the literature considered to be important to determine reliable estimates of

CAM use.250 As can be seen from the table, our study protocol covered all eight measures.

5.6 Conclusions

This study provides further insight into the continuing popularity of CAM use amongst women transitioning through menopause. The widespread dissemination of relevant information through the media following the publication of several large studies on HT may have made CAM more accessible to those who would not have previously considered using such alternatives. There appears to be some correlation between the CAM interventions selected by patients and the extent of basic scientific evidence to support that use. Women predominately obtain advice about CAM from sources that lack credibility or from persons that do not have adequate medical or scientific training. The use of pharmaceutical drugs by this group of women is high.

However, communication levels between doctors and their patients regarding CAM use remains substantially lower than the significant proportion of women who use

CAM and do so in conjunction with pharmaceuticals. Such lack of communication may expose patients to unnecessary deleterious drug-herb interactions.

SECTION TWO The Effect of FF-01 on Vasomotor Symptoms and Bone Turnover

CHAPTER 6 MENOPAUSE AND VASOMOTOR SYMPTOMS

6.1 Introduction

The menopausal transition is a period of hormonal change, heralding in a new phase of life where a woman is longer able to conceive and bear children. Menopause may occur naturally, surgically or as a secondary consequence to the treatment of cancer.

Natural menopause may only be determined retrospectively after 12 months of amenorrhoea. However, this definition has not always been consistently applied in the literature with some authors using various interpretations of the term

“menopause”. This has made comparisons between the outcomes of research difficult.

Vasomotor symptoms, which include hot flushes and night sweats, are characteristic of the menopausal transition and occur due to a decline in ovarian function. The prevalence of these symptoms may vary across cultures, but are generally more

89 common amongst women of European origin. For a significant number of women, vasomotor symptoms may impact negatively on quality of life and warrant the need for treatment. Until recently, HT was the preferred treatment for the alleviation of these symptoms; however concern over the long term safe use of HT has resulted in a significant decrease in the prescribing of this medication. Although a number of other treatments are available, their efficacy and safety have not been fully substantiated.

The focus of this chapter is to examine in detail the menopausal transition and symptomatology. In order to limit misunderstandings regarding terminology relating to this transitional period, definitions as proposed by the WHO are outlined and will be adopted in this thesis. The menopausal transition will then be discussed covering epidemiology, endocrinology and symptomatology. Since vasomotor symptoms are the most typical and troublesome of menopausal symptoms and often lead to the seeking of treatment, the aetiology and factors relating to these symptoms will be examined. A range of pharmacological treatments for vasomotor symptoms are presented and critiqued. Many of these options have inherent risks associated with their use; therefore, the search for a safer, effective alternative is suggested.

6.2 A Definition of the Menopause

The word “menopause” is derived from two Latin words, mensis meaning “month” and pausis signifying “to stop” and was first coined by the French physician

Gardanne in 1821.294, 295 The term refers to the permanent cessation of the monthly menses due to an age related decline in ovarian function. The menopause occurs

90 after a transitional period in which the ability to conceive and bear children gradually declines until reproductive capability ends. Menopause may occur naturally, due to the surgical removal of the ovaries296 or as a consequence of medical treatment such as chemotherapy for breast cancer.297, 298

In the past, terms used to describe changes occurring around the time of menopause have not been consistently defined and applied in the literature. This has made comparisons between various study outcomes difficult.299 Therefore, in order to adopt a unified definition for the menopause and the encompassing transitional years, the WHO2, 300 has proposed the following terminology:

• Pre-menopause refers to the reproductive years before menopause.

• Natural menopause is the permanent cessation of menses due to a loss of

ovarian follicular activity in the absence of related pathology. This event is

determined retrospectively after 12 months of amenorrhoea following the

final menstrual period.

• Peri-menopause is the time period when endocrinological, biological and

clinical features of menopause first begin and concludes 12 months following

the final menstrual period. The climacteric is an infrequently used term

which refers to the time of decreasing ovarian function, associated menstrual

irregularities and vasomotor symptoms. Throughout this thesis the term peri-

menopause will be used instead of “climacteric”.

• The menopausal transition refers to the time of menstrual variability that

occurs before the final menstrual period.

• Induced menopause is the cessation of menses which occurs after surgical

removal of both ovaries (with or without hysterectomy) or due to the

medically induced destruction of ovarian function (e.g. chemotherapy or

radiation).

• The postmenopausal period is the time following the final menstrual period

irrespective of whether menopause was natural or induced.

Despite attempts by the WHO in standardising terminology, there still exists some ambiguity over when some of the above time periods begin and end. Prior301 notes that women in their final year of peri-menopause are also postmenopausal causing some uncertainty as to whether or not this year should be included within the perimenopausal period. This can only be determined retrospectively 12 months later.

Although the definition may not be precise enough for some comparative research, authors may overcome confusion by clearly indicating in which period this year is to be considered. Furthermore, because menopause is determined retrospectively as 12 months cessation of menses, a period greater than one year may be required to determine with certainty the occurrence of the final menstrual period. This is necessary as a certain number of women may continue to have another period even when 360 days have elapsed. Wallace and colleagues302 determined that 10.5% of women aged 45-49 and 4.5% of women aged 53 and over were likely to have another period after 360 days of amenorrhoea. Nevertheless for the purpose of this research, the WHO definitions noted above will be used unless otherwise stated.

6.3 Epidemiology of the Menopause

The average age for natural menopause in developed countries is approximately 51 years1, 303-308 with a standard deviation of two years.306 By 55 years of age, 96% of women have reached menopause.303 The menopausal transition ranges from 0-10 years with an average duration of four years.4, 303, 305

A number of factors that may influence the timing of menopause have been investigated. Besides advancing age, an association between smoking and an earlier menopausal age has consistently been observed in a large number of studies irrespective of the methodology employed.1, 305, 307-320 The median age of menopause occurred 1-2 years earlier in current smokers than non-smokers.1, 305, 307-309, 311, 312, 314,

316-320 Current smokers also tended to have an earlier and shorter perimenopause than non-smokers.305, 321 Only one study found no relationship between smoking and an earlier menopausal age.304 However, these researchers grouped ex-smokers together with current smokers and for their analyses compared the outcomes with never smokers. Since the menopausal age of non-recent ex-smokers has been found to be closer to that of non-smokers than current-smokers,312, 318, 320 the grouping together of these women would in effect reduce any significant difference in menopausal age between smokers and non-smokers. The studies that found a positive association between smoking and an earlier age of natural menopause analysed ex-smokers together with non-smokers or considered ex-smokers as a separate group. A similar age between never smokers and current smokers312, 318, 322 may suggest a short-term effect of smoking on age at menopause.

A review and reanalysis by Midgette and colleagues323 of the results of studies published prior to 1990 on the association between smoking and age of natural menopause demonstrated an increasing risk of being post-menopausal with a greater number of cigarettes smoked. Inconsistencies between some studies to show a dose- response to smoking and age of menopause may reflect errors in recalling the number of cigarettes smoked in self reports1, 323 and differences in defining menopausal status.323

The small amount of research undertaken on the relationship between passive smoking and menopausal age suggests an age decreasing effect.324 Cooper and colleagues325 observed that both active and passive smoking but not former smoking was associated with elevated serum follicle stimulating hormone (FSH) in women aged 38-49 years. Elevated FSH levels are an early marker of approaching menopause and this noted effect may indicate a shorter duration of the transitional period before menopause.325 However, a subsequent study found no difference in menopausal age amongst passive smokers compared to never-smokers.312 More research is needed to prove or disprove any association between passive smoking and menopausal age.

The disjointed and conflicting findings of other potential risk factors with age at menopause may reflect confounding with each other, confounding on the effect of smoking or confounding which was not sufficiently controlled.1, 317 Numerous studies have found that nulliparous women tend to experience menopause earlier than parous women.304, 308, 311, 314-316, 326, 327 However, parity may be confounded with marital status and both of these variables may in fact be a measure of socio-

94 economic status.317 Dvornyk and colleagues326 found that nulliparous women were at a greater risk for surgical menopause thereby lowering the menopausal age for these women. Other variables that may impact on the age of menopause such as weight,318, 319 education,304, 311, 315, 317 marital status,311, 317 alcohol intake,309, 310, 313-315,

319, 328 socioeconomic status,304, 315 age at menarche304, 327 and irregular menses316, 327 show varying consistencies and are unlikely to have a large impact on menopausal age.

In conclusion, besides advancing age and smoking no other factor seems to have an independent effect on the age of natural menopause.306 Both cross-sectional and case-controlled data demonstrate that smoking is associated with an earlier menopause and was not confounded by factors such as parity, weight and socioeconomic status.314

6.4 Changes during the Menopausal Transition

6.4.1 Physiological changes

During the reproductive years, a non-pregnant woman experiences monthly cyclical changes within her ovaries and uterus in preparation for the implantation of a fertilised ovum. Throughout these years, there is a gradual loss of primordial follicles (non-growing premature follicles) from a finite ovarian pool. By the age of menopause, very few follicles remain in the ovaries.

At 20 weeks gestational age the ovaries of a foetus contain their peak number of primordial follicles, estimated to be around 6.8 million.329 However, this number drops dramatically so that by birth the ovaries contain approximately 733,000 follicles330 and by the age of seven only some 300,000 remain.329 Each month after puberty a number of follicles begin to develop. However, only one, the dominant follicle, matures to release an ovum for fertilisation. The other follicles not selected for maturation die by atresia. Over the next three decades the number of primordial follicles steadily decreases,331 until a critical threshold of approximately 25,000 is reached. This threshold has been estimated to occur at about 38 years of age.332

After this age, follicular loss occurs more than two-fold so that by the age of menopause, some 1000 follicles remain in the ovaries.332, 333 The complete loss of follicles occurs sometime after menopause.

A break in menstrual regularity is a common marker of approaching menopause and heralds the beginning of the menopausal transition.2 The median age for entry into the menopausal transition is 45.5 years and the transition lasts between 2-7 years.303

Approximately 10-15 years before menopause, the length of the menstrual cycle gradually decreases due to a shortening of the follicular phase.334, 335 As the follicle number reaches a critically low level, menstrual cycles become irregular and are more likely to be anovulatory.303 Oligomenorrhoea may occur during anovulatory cycles because the endometrium sheds less frequently303 and circulating oestrogen is unopposed by progesterone.335 Eventually anovulation occurs more frequently and oestrogen production by the ovaries becomes negligible resulting in amenorrhoea.

6.4.2 Hormonal changes

The monthly ovarian and uterine cycles are influenced by a number of regulatory hormones secreted by the hypothalamus, anterior pituitary and ovaries.

Gonadotrophin releasing hormone (GnRH) secreted by the hypothalamus ultimately controls this hormonal interplay by stimulating the release of FSH and luteinising hormone (LH) by the anterior pituitary gland. The combined action of FSH and LH on follicular cells causes the follicle to mature and subsequently secrete oestradiol.

Ovulation occurs following a mid-cycle surge in LH and a subsequent less pronounced peak in FSH secretion.336 LH also stimulates the formation of the corpus luteum from the remnants of the ovulated follicle and the secretion of a number of hormones.

The main ovarian hormones that control maturation of the follicle are grouped into two classes: the steroid hormones, which include oestradiol and progesterone, and the regulatory peptide hormones, inhibin and activin.337, 338 Squamous epithelial cells which envelop each follicle (granulosa cells) secrete oestradiol339 and the peptide hormones340 during follicular development while the corpus luteum secretes progesterone341 and inhibin342 during the luteal phase of the cycle. Inhibin inhibits the production and secretion of FSH while activin stimulates the release of FSH.343

The regulation of LH secretion occurs predominately by negative feedback of the steroid hormones.338

One of the earliest endocrinological changes that occur at the onset of the menopausal transition is an increase in serum FSH without an accompanying rise in

LH.344-348 This uncoupled rise in serum FSH without LH is termed a “monotropic” rise, and may occur even when a woman is menstruating regularly.346, 348 This monotropic increase in FSH is first apparent at around 39 years of age,349 an age which coincides with the accelerated loss of follicles.332 By 48-50 years, serum FSH levels may be three times greater than in women aged 23-35.349 A rise in FSH predominately occurs during the mid-follicular and post-ovulatory phases of the menstrual cycle. Contrary to FSH, LH concentrations do not rise significantly until after the age of 45349 alongside a fall in ovarian hormone secretion350 and increased levels of GnRH. One year post-menopause, serum FSH may be 13 times higher than follicular phase levels of younger women, while LH increases three fold.336, 347

However, it must be noted that although there is an overall increase in serum FSH with a subsequent rise in LH during the perimenopausal years, hormonal levels can fluctuate widely during this time.351 Hormonal levels may range from those characteristic of ovulatory cycles occurring in younger pre-menopausal women to sudden transient surges in FSH and LH typical of post-menopausal women.352-356

With advancing post-menopausal age, elevated levels of serum gonadotrophins slowly decrease347 as their response to GnRH gradually declines.

The disproportionate increase in FSH compared to LH may be due to the decreased secretion of the inhibin hormones A and B.357 The inhibins are involved in directing follicular development and suppressing the secretion of FSH by the pituitary.358

Inhibin A is produced by the dominant follicle and corpus luteum while inhibin B is secreted by early small antral follicles.359 Once the number of ovarian follicles fall

98 below a certain threshold, the amount of inhibin produced and secreted by the remaining follicles is insufficient to regulate and restrain the secretion of FSH and so

FSH levels begins to rise.360-362 This decrease in inhibin and subsequent rise in FSH is first apparent during the early follicular phase when neither a dominant follicle nor corpus luteum is present to secrete inhibin A. The monotropic increase in FSH accelerates follicular development and depletion.363 As menopause approaches, the serum levels of inhibin become undetectable.364

After the menopause, the source and nature of the oestrogens change. Oestradiol, the most potent of this class of hormones, is the predominant hormone in circulation during the reproductive years. A significant quantity of the less potent oestrone is also present. With the advent of the peri-menopausal years, oestradiol levels begin to fluctuate widely,350 and by the final menstrual period serum oestradiol will have decreased by approximately 90% of premenopausal levels due to the continued loss of ovarian follicles.350, 365 The dominant post-menopausal oestrogen is oestrone and is synthesised primarily in adipose tissue via the conversion of adrenal androgen precursors, particularly androstenedione.366-369 The small amount of oestradiol present in the circulation after menopause is produced by the peripheral conversion of oestrone to oestradiol.370

Throughout the reproductive years, the main source of progesterone was the corpus luteum. However, during the menopausal transition, anovulatory cycles with their absence of a corpus luteum become increasingly common; consequently there is no luteal-phase rise in serum progesterone.371 A lack in detectable levels of progesterone is a feature of the postmenopausal period.355

The menopausal transition is a time of widely fluctuating hormonal levels,356, 372 therefore measurement of these hormones to determine menopausal status is not generally useful. Endocrine markers have little predictive value of the possibility of further ovulatory cycles due to irregular maturation of ovarian follicles which may or may not result in ovulation. Elevated follicular stage FSH demonstrates a decline in ovarian function, but FSH levels cannot predict when the final menstrual period will occur.350, 365, 372 In fact no sharp hormonal changes have been documented to occur at the final menstrual period355 so it is not possible to distinguish transient amenorrhoea and amenorrhoea which follows menopause. Therefore, menopause can not really be determined until at least a year after the cessation of menses. It is not until several years following the final menstrual period that serum hormonal levels stabilise.338, 347

6.5 Symptoms of the Menopause

Clinic and patient based studies conducted during the 1960s and 1970s initially supported the notion that women transitioning through menopause were highly symptomatic, experiencing a broad range of diffuse symptoms and consequently were high users of health care resources.373, 374 However, many of these studies were restricted to convenience samples of self-selected women who actively sought treatment for health related issues and were under the care of gynaecologists and/or psychiatrists.374-377 Although information can be obtained quickly and cheaply from women attending clinics, these findings may not be extrapolated to the general population. Evidence suggests that treatment users differ significantly from non-

100 users.251, 378 Matthews and colleagues379 found that perimenopausal women who use

HT tend to be more determined in seeking treatment than non users and postmenopausal hormone users scored higher on measures of depressive symptoms than women not taking treatment. Furthermore, Ballinger380 noted that women who were referred to a gynaecological outpatient clinic tended to be more depressed and had excessive concerns over bodily functions compared to women in the general population.

Researchers reporting on menopausal symptomatology used a range of instruments to analyse prevalence and severity, thereby making comparisons between study outcomes problematic. Examples of such instruments include those developed by

Kupperman and co-workers,381, 382 Neugarten and Kraines379, 383 and Greene,253, 384,

385 while some authors developed their own.386 Several of these instruments were lists of between one to 30 diverse symptoms. The long lists seem to imply that any symptom presented by a middle-aged woman could be attributed to menopause.387

Instruments varied from undifferentiated lists as in the Blatt index388 to those that grouped symptoms into sub-categories using factor analyses, such as the Greene

Climacteric Scale.253

Comparisons between the outcomes of research on symptomatology is further complicated due to the inconsistent classification of certain symptoms between the various lists.387 For example “feeling tired” was categorised as “psychological” by

Greene389 and “psychosomatic” by Neugarten and Kraines.383 To illustrate the arbitrary nature of the list developed by Neugarten and Kraines, Kaufert387 notes that only nine of the 28 symptoms listed were found to discriminate between menopausal

101 and adolescent women. Therefore, it may be concluded that many symptoms in this list, and also in others, are common not only to the menopausal transition but also to other stages in life. This debate regarding which symptoms are characteristically due to the hormonal changes occurring at menopause and which are not has complicated the task in selecting symptoms to be investigated in research.387

6.5.1 Psychological distress and symptom reporting

For most women, menopause does not seem to lead to enhanced psychological distress373, 379, 390, 391 or depression.384, 385, 392, 393 Studies have suggested no correlation between depressed mood and changes in gonadotrophins.394, 395 A longitudinal study conducted over six years on 354 Australian middle-aged women by Dennerstein and colleagues395 concluded that women experienced a reduction in depressive mood during the midlife years. The investigators found that negative mood decreased over time and that there was no direct link between menopausal status, FSH, oestradiol or inhibin levels, age or education and negative mood level.

They suggested that psychosocial and lifestyle factors, along with health experience may have more of an effect on mood than endocrinological changes occurring during the menopausal transition. The authors suggest the menopausal transition may have an indirect effect in amplifying the effect of some of these variables.

A number of studies have demonstrated that women who suffer from depression during the menopausal transition are more likely to have had a history of depression or depressed mood.260, 396-398 A depressed woman feels less in control, vulnerable and/or helpless when faced with life changes and challenges and thereby view

102 present and new events with a negative outlook.399 Depression may negatively influence other health related behaviours resulting in poor dietary habits, lack of exercise, increased smoking and alcohol consumption and interfere with social relationships. Such behavioural changes can increase the likelihood of other health problems.

A significant number of studies demonstrate that attitude and expectations about the menopause affect a woman’s psychological experience and hence symptom reporting during this time.7, 400-404 Expecting negative symptoms and a troublesome menopause may lead to a self-fulfilling prophecy7, 405 with greater incidences of symptom reporting. For the menopausal women of Puebla, Mexico, there is a high value placed on external appearance and family responsibilities. Consequently, menopause is viewed in a negative light resulting in a greater frequency of symptom reporting.406

Although socio-cultural factors impacting on the menopausal experience are beyond the scope of this thesis, it is interesting to note that in cultures where a woman’s status increases with age, women report fewer symptoms at the menopause. For example, Indian women of the Rajput caste no longer wear a veil over the face and are given certain privileges; they also report very few menopausal symptoms. Indian women in Mexico who become heads of their married son’s families also suffer few symptoms.407 The WHO “Report on the Menopause in the 1990’s” also notes that when the menopausal experience of women in developing nations is described, the focus tends to be on the positive aspects of the transition such as freedom from childbearing and raising children and freedom from cultural restrictions that limit

103 menstruating women from certain social and religious customs, such as entering temples during the time of menses.2 This experience contrasts that of Western culture where aging and wisdom is ignored or held with little esteem, while youth and beauty is valued and to be retained for as long as possible.407 Western women tend to report a high degree of menopause related symptomatology. Therefore, it may be argued that the health and psychological well being of women transitioning through menopause may reflect the value attributed to women, in particular the social status given to elderly women.2

6.5.2 Which symptoms are specific to menopause?

In order to determine which symptoms are specific to menopause, a distinction must be made between symptoms directly attributable to a loss in ovarian function with those due to aging. Woods and Mitchell408 examined the published evidence of 12 longitudinal studies to answer this question and concluded that only vasomotor symptoms, vaginal dryness and sleep disturbances significantly increased in prevalence during the menopausal transition. How long these symptoms persisted post-menopause is unclear due to a lack of follow-up data.408

In their 1996 report on the menopause, the WHO concluded that vasomotor symptoms, urogenital atrophy and irregular menses during the perimenopause are the only symptoms characteristic of the menopausal transition and occur due to a loss in ovarian function. Other complaints often attributed to the menopausal syndrome, such as tingling, headache, dizziness, fatigue, sleep disturbances, depression, fluid retention, backache and difficulty in concentration, are not specific to the menopause

104 and may be psychological or socio-cultural in origin.2 It was found that many of these symptoms were not highly correlated with menopausal status, but were strongly correlated with each other.2 These symptoms also occurred at other stages in life and were often associated with “premenstrual syndrome”.387 Nevertheless, the

WHO report concluded that a number of symptoms such as fatigue, sleep disturbances, depression and difficulty in concentrating may also occur as secondary phenomena in women suffering severe vasomotor symptoms.2 For this subset of women, vasomotor symptoms result in a substantially decreased quality of life and for whom finding a safe and effective treatment regime is warranted.390

An interesting study conducted by van Hall and colleagues409 demonstrated that many symptoms often attributed to the endocrinological changes at menopause are also commonly experienced by men of a similar age. The authors analysed data from health interviews of 8,679 women and men aged 25-75 from randomly selected

General Practices in the Netherlands. Apart from vasomotor symptoms, none of the other complaints that are usually regarded as menopausal were any more common in men than in women during the perimenopausal period. It was concluded that psychosomatic symptoms attributed to the menopausal transition are neither gender nor age specific and consequently a hormonal cause for these complaints is unlikely.409 Therefore, it may be concluded that vasomotor symptoms are the primary symptom characteristic of the menopausal transition. Since these symptoms may impact negatively on quality of life for a significant number of women, vasomotor symptoms and their treatment will be considered in greater detail.

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6.5.3 Vasomotor symptoms

Vasomotor symptoms are thermoregulatory disturbances that result in sudden transient and recurrent sensations of intense heat affecting the scalp, face, neck and chest. These sensations are often accompanied by sweating, anxiety, skin clamminess, red skin blotching and palpitations.4, 410, 411 Vasomotor symptoms may sometimes be followed by chills as the core body temperature drops due to vasodilation of surface blood vessels and perspiration. Shivering raises the core body temperature back to normal. Sweating, which mostly occurs on the face, neck and chest but rarely the lower extremities, is particularly bothersome as sweat soaked clothes or bed sheets may need to be changed.4 Vasomotor symptoms generally last from 1-5 minutes with a small percentage of women reporting a time longer than six minutes.4 These symptoms may continue for one to more than 11 years,137 although on average they last for four years.4 Approximately 10-15% of women may experience flushing for more than 15 years.4, 137, 385 There is no evidence to suggest that the physiology of night sweats differs from that of daytime hot flushes.4

An extensive survey of 501 women conducted by Kronenberg4 found that 87% of women experiencing vasomotor symptoms had daily flushes, with one third of these women suffering more than ten per day. Women rated the intensity of their flushing from moderate to severe, with 26% of naturally menopausal women rating their flushing as severe. Approximately 42% of naturally menopausal women had a premonition before a hot flush, often describing this “aura” as a sense of anxiety.

During a hot flush, women have described that they feel “irritated, annoyed or frustrated” and at times felt a “sense of panic, a feeling of suffocation”. Around 50% of women who experienced vasomotor symptoms reported symptoms beginning

106 before the menopause when cycles were regular or becoming irregular, while most of the remaining women experienced these symptoms within the year following the final menstrual period.4 Other research groups have corroborated this observation; vasomotor symptoms most commonly occur during the late perimenopause and 1-2 years postmenopause.305, 392

The sudden initiation of menopause as a consequence of oophorectomy, radiation or chemotherapy may cause a rapid and severe onset of vasomotor symptoms.296, 298, 412,

413 Approximately 90% of women who undergo surgical menopause experience flushing.137, 412 Hot flushes are also a prominent side effect of tamoxifen, a pharmacological treatment for breast cancer.414, 415 Other conditions may also cause hot flushing, such as systemic diseases, emotions and reactions to alcohol, drugs or food additives (refer to Table 6.1). It is important for physicians to rule out these probable causes when making a diagnosis in order to facilitate appropriate treatment.416, 417

Table 6.1: Medical conditions and chemical agents that cause abnormal sweating.416, 417

Conditions causing abnormal sweating Primary hyperhidrosis Anxiety Emotional flushing (blushing) Secondary hyperhidrosis Carcinoid Syndrome Systemic mast cell disease Renal cell carcinoma Pancreatic islet cell tumours Medullary carcinoma Thyrotoxicosis of the thyroid Acromegaly Diabetes Neurological lesions Spinal chord injury High fever Phaeochromocytoma Alcohol and drug abuse Obesity Food additives and eating Medications e.g. niacin, tamoxifen

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6.5.3.1 Prevalence of vasomotor symptoms

The prevalence of menopausal vasomotor symptoms varies considerably across different cultures, although they seem to be more common amongst European and

North American women.2 The prevalence of hot flushing in naturally menopausal women has been reported to be non existent amongst Mayan women,418 35% of mainland Chinese women,419 26% amongst Japanese women,420 between 58%421 to

82%137 of US women and approximately 40%7 to 83%422 of Australian women.

The exact reasons for differences in symptom reporting are not known. Perhaps these variations reflect methodological inconsistencies such as discordant definitions for menopausal status,299 an inaccurate recollection of symptoms or the use of a variety of terms to describe vasomotor symptoms, such as hot flush, night sweats, sweating, flushing4 or day sweats,423 which may cause duplication of symptoms if these are listed on the same measurement instrument.392, 423-425 Furthermore, comparisons between studies may be difficult due to the use of convenience versus community based populations. Nevertheless, despite these issues there is evidence to suggest there are differences in the prevalence of vasomotor symptoms across certain racial groups.426, 427 This may be due to cultural practices, such as the dietary consumption of phytoestrogens. Japanese women who consume a high phytoestrogen rich diet tend to experience fewer vasomotor episodes compared to their Western counterparts whose diets tend to be low in phytoestrogens.177, 179

Furthermore, it has been suggested that women in developing countries experience vasomotor flushing similarly to Western women; however these symptoms are perceived differently as their cultures discourage the reporting of symptoms that are

108 regarded as non-life threatening. The under-funded and financially stretched

Government health care services of developing nations are primarily focussed on maternal health and child care, therefore complaints that only impact on quality of life are considered of low medical priority.2 Thus women generally do not seek treatment for seemingly trivial symptoms, if they indeed live long enough to reach menopause.

6.5.3.2 Vasomotor symptoms and quality of life

Approximately 39% of women who experience vasomotor episodes find these symptoms particularly troublesome.7 Numerous studies have suggested that severe vasomotor symptoms may have detrimental effects on work, social life, sleep and quality of life.8, 428-436 Vasomotor symptoms may lead to the exacerbation of other complaints that are sub-clinically present or may worsen existing symptoms, such as the aggravation of depression, insomnia and joint pain.433 Disrupted sleep due to night sweats can significantly worsen mood and increase anxiety and daytime drowsiness.437, 438 Campbell and Whitehead439 termed this phenomenon the “domino effect” where the presence of vasomotor symptoms leads to the occurrence of other related secondary symptoms. The alleviation of vasomotor symptoms often improves these accompanying symptoms.

Although disrupted sleep may also be due to advancing age and psychosocial factors,392, 440 epidemiological studies have indicated that women with night time flushing were more likely to report sleep disturbances305, 392 compared to asymptomatic women of a similar age and menopausal status. Erlik and colleagues8

109 objectively measured hot flushes, as indicated by skin temperature and resistance, while simultaneously assessing sleep by polygraphic techniques. Of the 47 measured flushing episodes, 45 were associated with waking episodes. Furthermore, severe night time vasomotor symptoms may disrupt sleep to such an extent that the affected woman needs to get out of bed to change sweat soaked clothes and bedding.441

Polysomnographic studies have indicated that women with night sweats have lower sleep efficiency (percentage of time sleeping), more awakenings and sleep stage changes than asymptomatic women.442, 443 Administration of oestrogen improves vasomotor symptoms and consequently decreases the number of waking episodes,444-

446 improves sleep efficiency,445 shortens the latency for onset of sleep446, 447 and increases the period of rapid eye movement sleep.444, 447 The alleviation of vasomotor symptoms was the most important predictive factor for the beneficial effect of oestrogen on disturbed sleep.446

A significant number of women experience vasomotor symptoms severe enough to have a detrimental affect on quality of life. These women often seek treatment in a bid to alleviate flushing and consequently note an improvement in secondary symptoms. HT is the most efficacious treatment for the alleviation of vasomotor symptoms,139 however recent concerns regarding the safety of this medication has led to a search for safer, viable options.

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6.5.3.3 Factors affecting the frequency of flushing

A number of factors affecting the prevalence of vasomotor symptoms have been identified and investigated. Two recent reviews of the literature found cigarette smoking to be the main factor associated with a greater incidence of flushing.448, 449

However, evidence concerning Body Mass Index (BMI) increasing the prevalence of flushing is mixed.

Many studies have demonstrated a greater prevalence of vasomotor symptom reporting amongst smokers compared to non-smokers.402, 421, 431, 450-455 Some evidence also suggests that passive smoking causes an increase in the number of hot flushes.426

The exact mechanism of how nicotine enhances vasomotor symptoms is not known, however it is likely that smoking affects oestrogen metabolism. Smokers tend to have lower levels of unbound biologically active oestradiol456 and a lower concentration of urinary oestrogen457 than non-smokers. Smoking may act in a number of ways to alter oestrogen metabolism.448 Smoking may cause an acceleration in the destruction of primordial oocytes within the ovaries,458, 459 leading to reduced levels of circulating oestradiol. Enhanced hepatic drug metabolism stimulated by smoking460 could lead to greater rates of oestrogen clearance by the liver resulting in lower serum levels of oestrogen.456, 461 Nicotine and other chemicals have been found to inhibit aromatase which catalyses the conversion of androstenedione to oestrogen in a dose-dependent manner,12 thereby further reducing oestrogen levels. Since vasomotor symptom aetiology is subject in part to oestrogen withdrawal, any interference with oestrogen metabolism may lead to a detrimental

111 effect on symptom reporting. Alternatively it has been suggested that the thermogenic effect of nicotine462 may precipitate flushing in symptomatic women who are smokers.463

Research conducted to date is inconclusive on whether BMI has any effect on the reporting of hot flushing. Some studies suggest that thin women experience more vasomotor symptoms,382, 464-466 while others indicate heavier women report more flushing.453, 467-470 However, there may be a significant interaction between decreasing BMI and smoking. Schwingal and colleagues found that thin women who smoked during the premenopausal period were more likely to experience hot flushing.466

The physiology of adiposity can support an increased risk of vasomotor symptoms in either thin or large women. Since the conversion of androgens to oestrogens occurs in adipose tissue,366, 368 it was suggested that overweight menopausal women experience fewer vasomotor symptoms because of increased levels of circulating oestrogens.368, 471, 472 However, adipose tissue is also the site for the production of leptin and tumour necrosis factor-α (ΤΝF-α), which may impair ovarian oestrogen secretion.473 Leptin can also influence thermoregulation,474 thereby increasing the risk for flushing in women with a higher BMI. The conclusions of two reviews investigating an association between BMI and the frequency of vasomotor symptoms were inconclusive; one suggested a higher BMI leads to more symptom reporting,449 while the other found the available evidence was inconclusive.448 Therefore, more research is needed to assess correlations between flushing, BMI and the impact of leptin and TNF-α on circulating oestrogen levels.

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A number of other hot flush triggers were reported by women who participated in the survey conducted by Kronenberg.4 These included stressful or emotional situations

(59%), ambient temperature (44%) and confined spaces (38%). A small number of women reported caffeine (17%) and alcohol (20%) exacerbated their symptoms.

Research has suggested that ambient temperature475 and stressful situations267 may have a significant impact on the frequency and intensity of hot flushes. However, the results from a number of studies investigating alcohol consumption and vasomotor symptom prevalence are inconclusive.426, 466, 468 Moderate alcohol consumption, of one drink or less per day, does not seem to increase the number of vasomotor symptoms in symptomatic women.449 There does not seem to be any significant association between vasomotor symptom prevalence and socioeconomic status, age, parity and number of pregnancies.4, 466

The amount of physical exercise undertaken does not have an effect on vasomotor symptoms. Most of the published studies found no beneficial effect of exercise on vasomotor symptoms,476-481 while a few authors reported a reduction in symptom reporting with exercise.482-484 However, there may be an interaction between exercise and increased psychological wellbeing. Although Thurston and colleagues476 found no significant association between exercise and a decrease in vasomotor symptoms for their entire sample, an exploratory analysis revealed that physical activity may reduce the risk of vasomotor symptoms among women with a history of major depression.

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6.5.3.4 Aetiology of vasomotor symptoms

The pathophysiology of vasomotor symptoms has not been fully elucidated. The oldest hypothesis suggests hot flushing is associated with a dysfunction of the thermoregulatory centre due to diminishing levels of oestrogen. The thermoregulatory nucleus, located in the medial preoptic area of the hypothalamus, has been identified as the key site for temperature regulation.485 The maintenance of core body temperature within narrow limits (the neutral zone) is regulated by the dissipation of heat via peripheral blood flow to the skin.486 The thermoregulatory responses of sweating and shivering do not occur when core body temperature is within the neutral zone. However, when core body temperature is outside this zone, sweating lowers core body temperature when the upper threshold of the neutral zone is reached, while shivering raises core body temperature to within limits of the neutral zone.486 It has been hypothesised that during the premenopausal years, the thermoregulatory zone is broad and adaptable, however at menopause this zone is narrowed due to a lowering of the upper threshold.487, 488 Consequently, a small increase in core body temperature, such as that preceding a vasomotor episode,489-491 causes a rise in skin temperature491-494 due to increased peripheral blood flow492, 494 and sweating as evidenced by increased skin conductance.495 These thermoregulatory responses reduce body temperature to within the neutral zone.

There is little doubt that oestrogen has a major role in the aetiology of vasomotor symptoms. This hypothesis is supported by the observation that flushing commonly occurs during the time of hormonal change preceding and immediately after the menopause. The rapid onset of vasomotor symptoms with sudden oestrogen withdrawal due to oophorectomy296, 412 and the alleviation of these symptoms with

114 the administration of oestrogen therapy139 further supports the causal role of oestrogen withdrawal. How a decrease in oestrogen leads to hot flushing is unknown, as there are no differences in plasma levels of oestrogen between symptomatic and asymptomatic women.489, 496 Furthermore, prepubertal girls who have low levels of serum oestrogen do not experience hot flushing. Therefore, it may be concluded that oestrogen withdrawal is necessary for the occurrence of vasomotor symptoms but oestrogen is not the only factor involved in their aetiology.

LH was suggested to be involved in the triggering of vasomotor symptoms, as it was observed that an increase in LH often corresponded to a vasomotor episode.497, 498

However, not all hot flushes are accompanied by a pulse in LH.498 Subsequently, it was discovered that women with hypothalamic amenorrhoea had increases in LH but no corresponding hot flushes and women with isolated gonadotrophin deficiency experienced hot flushes without an increase of LH.499 Conversely, vasomotor symptoms still occur in women who do not secrete LH due to a hypophysectomy4, 500 or in women with pituitary insufficiency.501 Suppression of LH secretion with

GnRH agonists does not cause a reduction in vasomotor symptoms,497, 502 while increasing the levels of LH by stimulating GnRH release does not result in hot flushing.503 Therefore, a correlation between LH pulses and hot flushing does not explain the aetiology of vasomotor symptoms.

Noradrenaline may play a pivotal role in the aetiology of hot flushing, as the neurotransmitter is thought to be involved in lowering the thermoregulatory set point

504 505, 506 and in causing peripheral vasodilation partially via α2-adrenergic receptors.

Even though plasma noradrenaline does not increase before or during a hot flush,492,

115

497 levels of the noradrenaline metabolite 3-methoxy-4-hydroxy-phenylglycol

(MHPG) does increase.491 Freedman463 suggests that elevated brain noradrenaline may be involved in triggering vasomotor symptoms in symptomatic women, as

MHPG, which originates from the brain, increases significantly following hot flushing.491 Freedman and associates507 demonstrated that clonidine reduces central adrenergic activity causing a significant decrease in vasomotor episodes, while

508 yohimbe, an α2-adrenergic antagonist which elevates MHPG plasma levels and brain noradrenaline, precipitates flushing in symptomatic women. Freedman463 further notes that most brain α2-receptors are inhibitory presynaptic receptors; however in symptomatic women there seems to be a deficit in this inhibitory function. Oestrogen is able to modulate brain adrenergic receptors,509 therefore a decrease in oestrogen levels occurring at menopause may be involved with this deficit in inhibitory functioning.463 Furthermore, Freedman463 suggests that brain noradrenaline causes a narrowing of the thermoneutral zone in symptomatic postmenopausal women as the administration of clonidine increases the sweating threshold in these women.510 Oestrogen was found to reduce flushing by increasing the sweating threshold, however the mechanism by which this occurs is unknown.511

The neurotransmitter, serotonin has also been suggested to be involved in the mechanism of vasomotor symptoms. Gonzales and Carrillo512 observed a direct relationship between serum serotonin and oestradiol levels, with a reduction in both occurring due to suppression in ovarian function with aging. Oestrogen withdrawal is associated with up-regulation of serotonin receptors in the hypothalamus.513 The serotonin receptor 2A was shown to mediate heat loss mechanisms. Internal or external stimuli such as anxiety, ambient temperature, caffeine or alcohol cause an

116 increased release in serotonin which activates the sensitised serotonin receptors.

This causes a disturbance of the thermoregulatory system within the hypothalamus which in turn activates mechanisms to cool the body, such as vasodilation which increases blood flow to the skin to facilitate heat loss. This response may trigger a vasomotor episode.514

Two other biochemical candidates have been suggested to precipitate vasomotor symptoms; calcitonin gene-related peptide242 and neuropeptide Y.515 These two agents are associated with peripheral vasodilation, and levels increase significantly in the event of a vasomotor episode.515 However, it is not known if these are indeed triggers or if they are merely produced in response to a hot flush.516

To conclude, the aetiology of vasomotor symptoms is complex and most likely involves numerous mediators and metabolic pathways. As yet the exact mechanisms have not been elucidated however; it seems likely that oestrogen withdrawal impacts on noradrenaline release which ultimately results in a decrease in the sweating threshold and an up-regulation of serotonin 2A receptors precipitating a hot flush in susceptible women.

6.6 Pharmacological Treatments for Vasomotor Symptoms

6.6.1 Hormone therapy

HT is the most effective treatment for the alleviation of severe vasomotor symptoms.

A systematic review of double-blind randomised, placebo-controlled trials of oral

HT for at least three months duration concluded that HT was highly effective in

117 alleviating vasomotor symptoms, with a 77% reduction in frequency of flushing

(95% CI 58.2-87.5) and a significant reduction in symptom severity (OR 0.13, 95%

CI 0.08-0.22) when compared to placebo.139 A range of oral517, 518 and transdermal519-521 oestrogens and combination oestrogen plus progestagen preparations522-524 have been demonstrated to be significantly superior to placebo in reducing vasomotor symptoms.

HT may be administered orally, transdermally (as gel, patch, implant, injection or intranasal spray) or transmucosally (as vaginal ring, tablet, cream or pessary).

Unopposed oestrogen is only prescribed to women without a uterus, while women with a uterus are administered oestrogen in combination with a progestagen to prevent endometrial hyperplasia and cancer.288, 525-528 The risk of endometrial cancer was found to remain elevated for many years after stopping oestrogen therapy;529 15 years after cessation of therapy the relative risk was estimated to be as high as 5.8

(95% CI 2.0-17.0).530 Progestagens can be taken continuously or sequentially. A sequential regimen involves taking a progestagen for 10-14 days per 28 day cycle; however this usually causes a monthly menses. To avoid bleeding, a low dose progestagen may be taken continuously along with oestrogen. Unfortunately, many women will continue to have breakthrough bleeding. Any abnormal bleeding that occurs while taking HT requires investigation, as this regimen is still associated with an increased risk of endometrial cancer after a duration of five years.531, 532

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6.6.1.1 The downside of HT

A significant number of women who initiate HT do not continue with treatment. Of women who receive a HT prescription, approximately 35-40% will not return for a refill and between 76-81% of women will cease therapy within three years.533 Side effects such as breakthrough bleeding,13, 140, 534-537 breast tenderness,14, 140 bloating and weight gain14, 535 and concerns about safety535, 536 often lead to discontinuation with therapy. However, troublesome vasomotor symptoms frequently return with the cessation of therapy538-540 resulting in approximately 25% of women resuming treatment.541 The alleviation of vasomotor symptoms and osteoporosis prevention were the main reasons given by current users for initiation of HT.536

Many women initiated HT for the prevention of chronic conditions such as cardiovascular disease (CVD). This decision was based on evidence from observational studies which suggested a 30-50% reduction in CVD amongst HT users.542, 543 However, due to the completion of several long-term randomised controlled trials (RCT) it became apparent that this evidence was not as robust as first thought. A recent re-analysis of previously conducted RCTs and good quality observational studies that supported HT for CVD indicated that the apparent benefits of HT reflected confounding by socio-economic and lifestyle factors such as alcohol consumption and exercise. Therefore, women who chose to take HT tended to have lower risks for CVD and led healthier lives than women not using HT.544 In addition to socio-economic differences between users and non-users, Col and Pauker545 contend that selection of participants for observational studies may have been biased

119 due to an under-reporting of CVD events amongst HT users. These reasons may account for a reduced rate of CVD reported by HT users. Selection biases that may have occurred in observational studies are virtually eliminated in RCTs16, 546-548 suggesting a more robust level of evidence.

The publication of the results from two large RCTs changed the nature and course of

HT prescribing for the prevention of chronic diseases. The Heart and

Estrogen/Progestin Replacement Study (HERS) was the first RCT to investigate if conjugated oestrogens and medroxyprogesterone acetate reduced the risk of CHD events. The authors concluded that among 2,763 postmenopausal women with CHD there was no significant decrease in rates of primary or secondary cardiovascular events among HT users compared to placebo. During the first year the hormone group experienced more CHD events, although this risk decreased over years 3-5 of the trial. However, the decreased rates did not persist during additional years of follow-up. The authors concluded that after 6.8 years, HT did not reduce the risk of cardiovascular events and that HT should not be used to reduce the risk for CHD in women with this condition.549

The WHI trials of oestrogen plus progestin and oestrogen only were designed to assess the risks and health benefits of HT on the incidence of cardiovascular events in healthy postmenopausal women. Both arms were terminated early as the risks exceeded benefits in taking HT. The oestrogen plus progestin arm enrolled 16,608 women aged 50-79 with an intact uterus. Over an average period of 5.2 years there was an increased risk of CHD, breast cancer, stroke and pulmonary embolism.16 The elevated risk of CHD was most evident during the first year.146 The authors

120 conclude that the risk-benefit profile of HT is not consistent with requirements of a treatment for the prevention of chronic disease and should not be initiated or continued for the prevention of CHD.16 No overall benefit in disease prevention was found with conjugated equine oestrogens in women with prior hysterectomy.

Oestrogen conferred an increased risk of stroke, decreased hip fracture rate but did not affect the incidence of CHD over an average of 6.8 years.147 Subsequent WHI reports found that HT caused an increased risk of cardiovascular disease,146 stroke,550 dementia,551, 552 thromboembolism, 16 ovarian cancer553 and breast cancer.554 The

HERS investigators found an increased rate of venous thromboembolism555 and biliary tract surgery amongst HT users.556

The results from a number of observational studies and RCTs indicate that HT increases the risk of breast cancer554, 557-559 in particular amongst those who consume alcohol.560-562 The risk of breast cancer increases with duration of HT use.557 A large

United Kingdom observational study of 1,084,110 women aged 50-64 who underwent routine mammography (MWS) found current users of HT were more likely than never users to develop breast cancer (adjusted RR 1.66 [95% CI 1.58-

1.75], p<0.0001) and to die from it (1.22 [1.00-1.48], p=0.05). The incidence of breast cancer was significantly increased for current users of oestrogen alone (1.30

[1.21-1.40], p<0.0001), oestrogen and progestagen preparations (2.00 [1.88-2.12], p<0.0001) and the synthetic steroid tibolone (1.45 [1.25-1.68], p<0.0001). This risk was greater for current users of oestrogen and progestagen than for other preparations.15 The higher rate of breast cancer with the use of combined HT may be due to an increase in breast tissue density563-567 which reduces the sensitivity of mammographic screening568 leading to an oversight of existing cancers. In addition,

121 oestrogens may stimulate mitotic activity and accelerate the development of tumours.569, 570 As with the WHI, the publication of this study caused a flurry of letters and comments to a variety of journals attempting to temper alarm by outlining the shortcomings of the study.571-573 Although there were a number of limitations to the MWS, such as short follow-up, non-blinding of histologists574 and recruitment biases,572 the accumulated evidence to date suggests an increased risk of breast cancer amongst HT users.

6.6.1.2 Consequences of the WHI

The dispensing of HT products peaked in 2000.575 However in the year following the widespread publication of the WHI results, there was a dramatic decrease in the use of HT.17, 148, 151, 259, 289, 576 In 2003 the FDA revised the labelling of HT products to reflect the increased risks with their use as reported by the WHI. In addition, new guidelines for the prescribing of HT were published recommending the lowest dose for the shortest duration to alleviate symptoms.162 Likewise, a number of position papers were published suggesting that for each patient the risks and benefits of taking HT should be determined before prescribing the minimum dose necessary for the shortest period of time.161, 577, 578 Due to these events, the years 2002-2003 saw a shift from mainly positive attitudes regarding HT to largely negative, and this was reflected by a corresponding decrease in the prescribing of hormones.579

However, there is some good news. Since 2002 epidemiologists observed a dramatic reduction in the incidence of breast cancer, which directly corresponded with the declining use of HT. Initial data from the US National Cancer Institute’s

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Surveillance, Epidemiology and End Results registries showed an overall 6.7% decline in the rate of invasive breast cancer between the years 2001 and 2003. The steepest decrease of 11.8% occurred amongst women aged 50-69 and was most evident in those with oestrogen-receptor-positive tumours,580 which stop growing once deprived of hormones. Large drops in breast cancer rates where also reported amongst Kaiser Permanente’s Northern California medical centres members.581

Such dramatic declines in breast cancer had never been observed in a single year and were temporally consistent with substantial decreases in the use of HT during this time.582 Similar declines in breast cancer with HT use were also observed in

Germany583 and New Zealand.584 Although these observations do not establish a cause-and-effect relationship, they strongly suggest a link between the use of gonadal hormones and an increased risk of breast cancer.585 With the mounting evidence suggesting a link between HT and cancer, it is not surprising that women are seeking safer alternative treatments for the alleviation of symptoms and to improve quality of life. Herbal medicines and supplements, although not entirely free of adverse effects, generally have a better safety profile than prescription only pharmaceuticals such as HT. However, the efficacy of herbal medicines is often unsubstantiated and research is needed to determine their therapeutic benefit.

6.6.1.3 Bio-identical hormones

Natural or bio-identical hormones are combinations of certain steroid hormones compounded to suit the individual woman and are believed to be safer and more effective than synthetic hormones.586 The preparations may include various dosages and combinations of the following: dehydroepiandrosterone sulphate, pregnenolone,

123 testosterone, progesterone, oestrone, oestradiol and oestriol. The amounts prescribed are often based on hormonal concentrations found in saliva. However, there is little evidence proving the efficacy and safety of such products or if they offer any further advantages over synthetic hormones.587

6.6.2 Non-hormonal medications

A number of alternative agents to HT have been investigated for their effectiveness in alleviating vasomotor symptoms. Anecdotal evidence suggests that some antidepressants were able to alleviate hot flushing, including venlafaxine a serotonin/noradrenaline reuptake inhibitor and the selective serotonin reuptake inhibitors paroxetine and fluoxetine. Since serotonin is presumed to have a role in modulating the hypothalamic thermoregulatory centre, it was surmised that these antidepressants could relieve vasomotor symptoms.588 Clinical studies indicate that venlafaxine may be somewhat effective in reducing vasomotor symptoms.589-592

Side effects of treatment include nausea, decreased appetite, dry mouth, insomnia and constipation. Paroxetine593, 594 and fluoxetine595 have also demonstrated a modest effect in alleviating vasomotor symptoms in clinical studies.

Clonidine, an α-adrenergic agonist that reduces vascular reactivity, was initially indicated for the treatment of hypertension. Clonidine raises the sweating threshold in women with vasomotor symptoms,510 by reducing hypothalamic noradrenaline levels.463, 491 A number of clinical studies have demonstrated superiority of clonidine compared to placebo in reducing vasomotor symptoms.596-602 Side effects with treatment may include dry mouth, postural hypotension, fatigue and constipation.

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Gabapentin is structurally similar to gamma-aminobutyric acid and is prescribed as an anticonvulsant. Although a small RCT demonstrated a significant reduction in hot flushing compared to placebo,603 larger trials are needed to determine long term efficacy and safety. Fatigue, dizziness and peripheral oedema were reported side effects. The drug’s mechanism of action on vasomotor symptoms is unclear.

6.7 Summary and Conclusion

Menopause is the permanent cessation of menses due to a loss in ovarian function, and heralds in a new phase of life where reproduction is no longer possible. This event is preceded by a period of hormonal change and re-equilibrium. Due to widely fluctuating hormonal levels, the use of endocrine markers to determine menopausal status is not useful. Therefore, menopause is determined retrospectively after 12 months of amenorrhoea following the final menstrual period.

Menopausal women were at one time thought to be highly symptomatic, however epidemiological studies have indicated that many of these symptoms are not specific to the menopausal transition and are therefore, not a consequence of ovarian aging.

Epidemiological research has strongly suggested that vasomotor symptoms are temporarily and significantly related to the menopausal transition and gradually abate with time as hormonal levels reach a new equilibrium. In some women, vasomotor symptoms may severely impact on quality of life and give rise to a host of secondary symptoms.

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The days of long-term prescribing of HT for vasomotor symptoms and the prevention of chronic degenerative conditions are over. A number of large, well conducted clinical studies concluded that the risk-benefit profile of HT does not justify its long-term prophylactic use for the prevention of ill health. Although HT is very effective for the alleviation of vasomotor symptoms, a significant proportion of women are reluctant to take a treatment that is associated with serious risks. A number of alternative non-hormonal pharmacological treatments are available, however the research conducted suggest varying levels of efficacy. These agents are also associated with significant side effects and their long-term safety has not been substantiated. Therefore, due to the concerns about the safety of HT and the efficacy and safety of non-hormonal treatments, the verification of a safe and effective non- pharmacological remedy for the alleviation of vasomotor symptoms is necessary and timely.

The following chapter examines published clinical research on the effectiveness of

Chinese herbal formulae for the alleviation of vasomotor symptoms. The trial methodologies and outcomes of papers retrieved from both English and Chinese language journals will be analysed and discussed in detail.

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CHAPTER 7 CHINESE HERBAL MEDICINE FOR VASOMOTOR SYMPTOMS*

7.1 Introduction

TCM has a long history of use throughout China and Asia. Anecdotal evidence suggests that CHM is effective in treating menopausal complaints, and clinical work conducted in China suggests many formulae are highly efficacious. However, a literature search and comprehensive review of published clinical research assessing the effectiveness of Chinese herbal medicine for the alleviation of vasomotor symptoms has never been conducted. Therefore, the following chapter examines the methodological rigor of RCTs published in both Chinese and English language journals to evaluate the clinical evidence that may or may not support the effectiveness of CHM. This chapter also gives a brief introduction to TCM theory

* This chapter has been submitted to a relevant journal for publication.

127 relating to aging and menopause along with basic theoretical approaches for the treatment of vasomotor symptoms.

7.2 TCM and Menopause

TCM is a comprehensive, holistic oriental healing art that incorporates its own theories of health and disease. Perfect health is a state when the forces and processes within the body are in a state of dynamic balance. Illness occurs when these processes become uncoupled resulting in a loss of balance and disharmony.

Sustained or severe physical, psychological or environmental stress can lead to internal disharmony resulting in externally manifested signs and symptoms.

Herbal medicine involves the boiling and ingesting of an individualised formula designed according to the patient’s presenting signs and symptoms. TCM diagnosis is based on the grouping of relevant signs and symptoms relating to the disorder in question, the general state of health of the individual and external environmental influences. Several groups of related signs and symptoms may be generated for a defined medical condition and each symptom group is known as a “syndrome complex” or “pattern of disharmony”. Because signs and symptoms theoretically relate to each other, a pattern of disharmony not only constitutes a Chinese medical diagnosis, but is also an explanation of the internal disharmony within the body. The diagnosis will ultimately guide a TCM practitioner in their choice of treatment.

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The theory of TCM recognises that the manifestation of a disease may differ between individuals due to the interplay of unique environmental factors and metabolic requirements. Therefore, because of these unique differences, two people presenting with the same complaint, for example menopausal hot flushes, may exhibit a range of different accompanying signs and symptoms. Since the TCM diagnostic process considers the whole person along with variations in signs and symptoms, both individuals may be diagnosed with a different pattern of disharmony and be given an individualised formula.

7.2.1 TCM theory of menopause and aging

Menopause is referred to in Chinese as “geng nian qi” or “the time of change” an alternative term is “jue jing” meaning “menopause”. The menopausal syndrome is a recent addition to modern TCM gynaecological resource books,604 and reflects a

Western influence on the practice of TCM. Ancient TCM texts make limited reference to the menopause, as menopause was seen as part of the continuum of aging.

According to TCM physiology, aging reflects a gradual decline in the vital energy

(or Qi) of two or more Organ* systems, in particular the Kidneys. The Kidneys store the constitutional energy (Jing) inherited from the parents at conception, and this energy is gradually depleted throughout the lifespan. Growth, development,

* TCM is primarily concerned with the functional activity of Organs, not anatomy and physiology. An Organ consists of a functional network including corresponding meridian, tissue, emotion, body function and sense organ.

129 reproductive capacity and aging are regulated by Kidney Qi. The Kidneys also govern the bones, teeth, ears and hair. Therefore, with an age related decrease in

Jing, the bones weaken and become brittle; hearing declines and the hair turns grey and thins.

Growth, development and aging are described in women in terms of seven year cycles. At seven years of age the Kidney Qi is strong and the permanent teeth erupt and grow; at 14 years the Kidneys have matured, there is an abundance of Blood and the menses begin to flow. Around 35 years of age the meridians (energetic pathways) leading to the face begin to decline and wrinkles appear. By the age of

49, the Kidney Qi has declined, the digestive processes have weakened and consequently less Blood is produced every 28 days to provide an excess for discharge as menses. Eventually the monthly flow of blood ceases.605 These developmental stages correspond to several endocrinological changes discussed previously. At around 38 years the loss of primordial follicles accelerates to more than two-fold,332, 333 which roughly corresponds to the TCM age of 35 when the signs of aging become noticeable. The average age for natural menopause occurs at about 51 years,1, 303, 305 an age approximating that observed by the ancient Chinese scholars.

The Kidneys are the foundation of Yin and Yang within the body. Yin and Yang are two opposing but complementary functions that balance and support each other. The

Kidney Yin aspect pertains to the functions of providing foundational structure, moisture and nourishment needed for birth, growth and reproduction, while Kidney

Yang is the heat or driving force required for all physiological processes. In health,

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Yin and Yang processes complement each other and are in dynamic balance. With an age related decline in Jing, transformations between Kidney Yin and Yang may be disturbed if the relative balance between them are upset. If Yin is depleted more rapidly than Yang, symptoms of relative Yang excess manifest such as hot flushing, palpitations, insomnia, thirst and dryness. However, if Yang declines more rapidly a relative excess of Yin predominates resulting in symptoms such as fatigue, oedema, depression and feeling cold. Since the Kidneys are the physiological foundation of

Yin and Yang and of the other Organs, a pathology manifesting in the Kidneys will eventually lead to dysfunctions within the other Organs of the body.606

Hot flushes occur essentially due to a deficiency in Yin resulting in a rising of Yang to the upper parts of the body. Yang which pertains to heat, fire and upward movement is no longer effectively balanced and anchored by the moistening, cooling and structural aspect of Yin. This results in a swift upwards movement of heat to the chest and head causing flushing, sweating and irritability associated with vasomotor symptoms. Menopausal vasomotor symptoms are primarily diagnosed as a deficiency of Kidney Qi, in particular Yin.607

Since Kidney Yin deficiency is the root cause for vasomotor symptoms and hence the predominant diagnosis, treatment would involve herbal formulae that tonify the

Kidneys, especially the Yin aspect. Herbs would be chosen to nourish the Kidneys, clear Heat, moisten dryness and nourish Yin.

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7.3 Systematic Review on CHM for Vasomotor Symptoms

Modern text-books on TCM gynaecology report on the effectiveness of Chinese herbal medicine in reducing menopausal hot flushing604, 608, 609 and present case histories demonstrating positive outcomes608 with minimal risks.610 A literature search of clinical work was conducted to search for evidence that may or may not support the effectiveness of Chinese herbal medicine in alleviating vasomotor symptoms. The following section examines and evaluates the robustness of this clinical research.

Studies included in the systematic review needed to meet the following broad criteria:

• Randomised clinical trials that assessed the efficacy of Chinese herbal

formulae for the alleviation of vasomotor symptoms, flushing, sweating or

tidal fever. Clinical studies were considered if they included the assessment

of a Chinese herbal formula versus placebo, HT, another Chinese herbal

formula or no treatment for menopausal syndrome.

• Assessed healthy women transitioning through menopause.

Studies were excluded if they were:

• Non-parallel in design.

• Did not include a reference to the treatment of vasomotor symptoms,

flushing, tidal fever or night sweating.

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A thorough search of MEDLINE, Cumulative Index to Nursing and Allied Health

Literature (CINAHL), EMBASE and the Cochrane Central Register of Controlled

Trial databases from inception until April 2006 was conducted using the search terms: “menopause”, “climacteric”, “hot flush/flash”, “vasomotor symptoms”,

“Chinese herbal medicine”, “traditional Chinese medicine”, “herbal medicine”,

“randomised controlled trial”, “controlled clinical trial”, “clinical trial” and combinations of these terms. Reference lists from retrieved articles were also searched for appropriate studies. This search resulted in the inclusion of seven studies, two in Chinese language.

The Online TCM Database611 was searched for studies conducted in China from

1984 until 2005. This database contained over 10,000 journals. The terms used for searching included; “clinical trial”, “geng nian qi”, “jue jing”, “menopause”, “hot flushing”, “sweating”, “night sweating”, “tidal fever”, “yin deficiency” and “Kidney

Yin deficiency”. This search resulted in 15 studies which were translated into

English. In total 22 clinical trials are included in this systematic review. Figure 7.1 gives an outline of the identification and selection of relevant research papers for this systematic review. An overview of the studies, including design, interventions and outcomes are summarised on Table 7.1.

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Figure 7.1: Selection of papers for CHM systematic review

253 potentially relevant references on Chinese herbal medicine screened 228 irrelevant references excluded (did not consider vasomotor symptoms, narrative reviews, pharmacological studies)

25 reports reviewed

3 reports excluded (did not include a flushing or sweating component)

22 studies included in review

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Table 7.1: Characteristics of CHM studies included in the systematic review

First author Design Sample Recruitment Participants Intervention Placebo Outcomes and date size and setting Lin HQ, 2000612 Randomised, open, 200 Inpatients and Women 45-55 years, Sea buckthorn fruit granules Mi huan Herbal formula far parallel group, positive (100 active; outpatients disease course of 3 Mi huan tablet (undefined) superior than mi huan, control 100 control) months-2 years Oryzanol Oryzanol oryzanol and diazepam 8 weeks duration Diazepam Diazepam (93% vs. 48%, p<0.01) Vitamin E Vitamin E Guo L, 1999613 Open, parallel group, 103 Not reported Women 42-61 years Oestradiol 5mg once/month Oryzanol 60mg Herbs plus oestradiol far positive control (57; 46) experiencing Sheng mu li 24g Stilboestrol more efficacious than Duration of herbal menopausal symptoms, Shu di huang 15g 0.125g 3 stilboestrol treatment not reported, average length of Shan yao 10g times/day 78.9% cured compared to two months duration of disease was 4 years Shan zhu yu 10g 19.6% reported cure rate HT Fu ling 10g with HT Dang gui 10g (p<0.01) Tu si zi 10g Sha yuan ji li 10g Suan zao ren 10g Chai hu 10g Zhi gan cao 3g Gou qi zi 2g Taken as water extract once/day Gao JR, Open, parallel group, 150 Outpatients Healthy symptomatic Yin deficiency Premarin Herbal formulae as 2002614 positive control (60 Yin def; university teachers Ji ju di huang wan 10g three 0.625mg effective as HT in Duration 3 months 40 Yang def; aged 38-62 years times/day reducing symptoms 50 HT) Yang deficiency measured by the Er xian tang twice/day Kupperman Index Total effective rate 88.3% vs. 75% vs. 90% Yuan XF, Randomised, open, 115 Not reported Women aged 40-61 Group 1 (integrated treatment) Group 3 Herbal + drug treatment 2003615 parallel group (55 integrated; years, with menopausal Dan shen 15g (control) far more efficacious Duration not reported 30 oryzanol; complaints including Dang gui 15g Vitamin C two Total effectiveness rate 30 control) hot flushing, sweating, Chi shao 9g tablets 3 Herb/oryzanol 91%, irritability, insomnia and Bai shao 9g times/day oryzanol 67%, control palpitations Mai men dong 9g Dose not reported 40% Suan zao ren 9g (p<0.01 herb/oryzanol vs. Huang lian 3g control, p<0.05 oryzanol Zhi zi 9g vs. control) Taken as water extract twice/day Oryzanol 60mg Group 2 Oryzanol 60mg

134

135

Table 7.1: Continued

First author Design Sample Recruitment Participants Intervention Placebo Outcomes and date size and setting Mao JQ, 2003616 Open, parallel group, 99 Outpatients Women 38-56 years, Tu si zi 12g Geng ming kang Herbal formula far more positive control (56; 43) perimenopausal Yin yang huo 12g 3x/day efficacious 40 days duration symptoms with or Ba qian tian 12g (undefined) (93% vs. 70%, p<0.05) without flushing Chao bai shao yao 12g Oryzanol 9mg Bai he 12g Vitamin B 60mg Sheng di huang 15g Shu di huang 15g Shan yao 15g Shan zhu yu 15g Suan zao ren 15g Zhi mu 10g Huang bai 10g Modified, as decoction once/day Huang SX, Randomised, open, 60 Outpatients Women, 42-46 years Bai he 30g Oryzanol 600mg Herbal formula far more 2003617 parallel group (30; 30) duration of symptoms 5 Shu di huang 20g Vitamin E 300mg efficacious 2 months duration months-4 years Shan zhu yu 12g Vitamin D 200mg (93% vs. 67%, p<0.01) Huang jing 15g Dan shen 15g Long gu 30g Zheng zhu mu 30g Fu xiao mai 30g Da zao 15g Gu he 15g Gan cao 5g Taken as extract, once/day Chen LX, Open, parallel group, 94 Outpatients Women 35-57 years, Sheng di huang 15g Fu fu chun Herbal formula far more 2003618 positive control, (56; 38) duration of symptoms 3 Dang gui 15g capsule, dosage efficacious 2 months duration months-8 years. Sha shen 12g not stated (89.3% vs. 68.42%, Menopausal symptoms Gou qi zi 15g (undefined) p<0.05) including flushing, Mai men dong 12g insomnia, internal heat, Chuan jian zi 10g oedema, irritability. Bai shao Modified, as extract, dose not stated

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136

Table 7.1: Continued

First author Design Sample Recruitment Participants Intervention Placebo Outcomes and date size and setting Yang XF, Open, parallel group, 103 Outpatients Women 43-56 years, Chai hu 12g Oestradiol Herbal formula more 2003619 positive control (69; 34) disease duration 2 Huang qin 12g 5mg/month effective than HT 2 months duration months-4 years. Ban xia 10g Oryzanol 60mg (94.2% vs. 52.9%, Symptoms included hot Dang shen 10g Vitamin B 60mg p<0.05) flushing, dizziness, Gui zhi 12g insomnia, irritability, Bai shao 12g oedema, chest Huang lian 10g tightness Yin yang huo 10g Shu di huang 15g Gan cao 10g Modified, given as extract, daily dose not given Yang HH, Randomised, open, 60 Outpatients Women, 45-50 years, KD Yin deficiency Stilboestrol Herbal formula more 2003620 parallel group, positive (30; 30) disease duration 3-10 Shu di huang 20g 0.5mg/day effective than HT control years with diagnoses of Shan yao 20g Or Duration of herbal Kidney Yin or Yang Zhi shou wu 15g Ethinylestradiol treatment not reported, deficiency, Liver and Gui ban 15g 50μg/day 3 weeks duration for Kidney Yin deficiency Gou qi zi 15g HT or Kidney Yin and Yang Shan zhu yu 15g deficiency Fu ling 15g Shi gan cao 9g Kidney Yang deficiency Dang shen 15 g Bai zhu 15g Gan jiang 15g Gou qi zi 15g Fu zi 15g Rou gui 15g Du zhong 15g Tu si zi 15g LV and KD Yin deficiency Zuo gui wan Er shi wan Tian ma Gui ban Yu jin KD Yin and Yang deficiency Er xian tang Er zhi wan Dose and formula type not reported

136

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Table 7.1: Continued

First author Design Sample Recruitment Participants Intervention Control Outcomes and date size and setting Tang SJ, Randomised, open, 68 Outpatients Women with Sheng di huang 15g Premarin Herbs have similar 2003621 parallel group, positive (34; 34) menopausal symptoms, Shu di huang 15g 0.0625mg/day effectiveness to HT control 45-55 years, duration Bai shao 15g from 5th day (88.2% herbal vs. 91.2% 3 months duration of symptoms 3 months- Shan yao 15g menses for 28 HT, p<0.05) 2 years Huang jing 15g days Sheng long gu 15g Progesterone Sheng mu li 15g 6mg/day from 15th Shan zhu yu 10g day menses for 4 Chai hu 10g days Yu jin 10g Qing pi 10g Gui zhi 3g Jing jie 3g Formula as granules once/day Liang RN, Non-randomised, 61 Outpatients Women older than 40 Shu di huang 24g Oryzanol 60mg Herbal formula far more 2003622 open, parallel group, (36; 25) years or who have had Shan zhu yu 9g efficacious positive control oophorectomy, peri or Ze xie 9g Total effective rate 88.9% 3 months duration postmenopausal, with Mu dan pi 9g vs. 44% (p<0.01) symptoms of hot Shan yao 12g flushing and sweating Dan shen 15g 4 tablets twice/day Li Q, 2003623 Randomised, open, 50 Outpatients Women aged 40-56 Huai niu xi Li wei ai Both formulae highly parallel group, positive (30; 20) years, experiencing Bai shao (undefined) one efficacious control symptoms for 3 Tian men dong tablet/day. (90% vs. 95%, p<0.05) Duration 30 days. months-2 years Xuan shen Dose not reported Yin chen hao Chuan jian zi Fu xiao mai Gui ban Mu li Dai zhu shi Gan cao Doses of herbs not reported. Water extract, 200ml twice/day

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138

Table 7.1: Continued

First author Design Sample Recruitment Participants Intervention Control Outcomes and date size and setting Lu YP, 2003624 Randomised, open, 260 Outpatients Women aged 36-56 Sheng di huang 20g Oestradiol 5mg Herbal formula more parallel group, positive (130; 130) years, suffering Yin yang huo 20g once/month effective than HT and control predominately peri- Nu zhen zi 20g Diazepam diazepam Duration of one month menopause stage Huang jing 15g 5mg/night (93% vs. 61%, p<0.01) psychological Shan yao 15g symptoms Shan yu rou 15g Mu dan pi 10g Ze xie 10g Xi lian cao 9g Zi cao 6g Chai hu 12g Modified if required, as water extract twice/day Lin WC, 2003625 Open, parallel group, 96 Not reported Women aged 40-60 Tian men dong 10g Geng nian shu Herbal formula more positive control (58: 38) years with menopause Mai men dong 10g (undefined, effective than diazepam 30 days duration symptoms for 3 Shan zhu yu 10g dosage not and Geng nian shu months-12 years. Suan zao ren10g stated) (94.8% vs. 86.9%, Symptoms included hot Sheng di huang 15g Diazepam 2.5- p<0.01) flushing, sweating and Long gu 15g 5mg irritability. Mu li 15g Oryzanol (no Huai shan yao 15g dose) Fu sheng 15g Vitamin B6 Dan shen 15g 600mg Yuan zhi 6g Vitamin E 300mg Wu wei zi 6g Decoction twice/day Lu QB, 199128 Open, parallel group 170 Hospital Women aged 40-60 Sheng di huang 20g Healthy controls, Two formulae more 8 weeks duration (120 Geng outpatient clinic, years, with yin Mu dan pi 10g nothing given effective, total efficacy nian xin; city treatment deficiency, excess fire Chao suan zao ren 10g was 89.2% 20 Geng nian centre and/or heart meridian Zhu fu ling 10g an; symptoms Gou teng 10g 30 healthy Healthy controls were Lian zi xin 1.5g controls) same age range but Duan zi bei chi 15g and etc not symptomatic, Entire formula not reported recruited from women’s One group given decoction (xin), health census other given tablets (an)

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139

Table 7.1: Continued

First author Design Sample Recruitment Participants Intervention Control Outcomes and date size and setting Wang DZ, Open, parallel group, 271 Not described Women aged over 40 Huang lian 3g Herbal positive control Herbal formulae far more 199429 positive control. Only (46 water or surgical menopause, Mai men dong 9g (undefined) efficacious than placebo those receiving tablets extract; 90 peri or menopausal Bai shao 9g (80-91% vs. 48.6%) were randomly glycerol with symptoms Zao ren 9g and etc allocated to treatment extract; 98 including sweating, hot Entire formula not reported. group tablets; 37 flushes Extract twice/day Duration 30 days undefined Glycerol extract 35ml twice/day control) Herbal tablets 6/day Herbal control /day Exact dosages not reported Luan YQ, Randomised, double- 66 Not reported Women aged 40-60 Kun tai capsule 0.5g tablet, Oestradiol 0.5mg Herbal formula as 2004626 blind, positive control (33; 30) years, no menses for 3 dose not reported tablet, dose not effective as HT in Duration 3 months months, 3 or more (not defined) reported reducing Kupperman vasomotor episodes Index per day, FSH >40mIU/L Total effective rate 51.5% and oestradiol <30μg/L vs. 66.7% (p>0.05) Both treatments increased serum oestrogen Chen LC, Randomised, open, 38 Outpatients from Non-hysterectomised Dang gui 4g Premelle 0.625mg Both treatments 2003627 positive control (24; 14) a Taipei hospital healthy women aged Cang zhu 4g medroxy-progesterone significantly reduced the Duration 16 weeks 45-65 years, with no Bai shao 4g acetate 2.5mg prevalence and severity of menses for previous 6 Chai hu 4g symptoms as measured months, no use HT Fu ling 4g by the Greene scale; no over previous 6 months Gan cao 2g significant differences experiencing Mud an pi 2.5g between groups climacteric complaints Zhi zi 2.g Sheng jiang 4g Bo he 2g Extracted to 7g extract and prepared as 12g powder and 4g taken 3 times/day

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Table 7.1: Continued

First author Design Sample Recruitment Participants Intervention Placebo Outcomes and date size and setting Pan B, 200432 Open study, 34 Climacteric clinics Women average age Received one or two of the Oestrogens Herbal formulae improved participants self (18; 16) 50.6 for herbal group following standardised 0.625mg/day symptoms selected treatment and 52.7 years for HT formulae: or No comparisons made group, positive control group. A list of 10 Gui zhi fu ling wan Transdermal oestradiol between herbal climacteric complaints Dang gui shao yao san 0.72mg once for 2 treatments and HT recorded symptom Jia wei shao yao san days severity before and Taken as granules 3 times/day Medroxyprogesterone after treatment Dosages not stated acetate 2.5mg/day or Chlormadinone acetate 2mg twice/day Hirata JD, Double blind, 71 Participants Healthy women, no Root of Angelica sinensis Placebo of No significant differences 1997227 randomised, placebo- (35; 36) recruited via menses for 6 months, standardised to 0.5mg/kg ferulic maltodextrin and oil of between groups controlled radio, television, aged 44.5-59.6 years acid by HPLC with added oil of orange. Made to look Duration 24 weeks newspaper and with at least 14 hot orange to disguise aroma and taste identical to magazine flushes of any severity active infomercials per week or more than 5 moderate-severe events per week Wiklund IK, Double blind 384 Women recruited Healthy women aged Ginseng capsules containing Identical looking No significant difference 1999628 randomised placebo (193; 191) by newspaper 45-65 years, no HT use 100mg standardised ginseng placebo capsules between placebo and control advertisements during previous 2 extract, 2 capsules/day active groups in reducing Duration 16 weeks months, no menses for vasomotor symptoms 6 months, with 6 episodes flushing at least 3 days over past 7 days Davis SR, Randomised double- 55 Recruited through Non-Asian women Shu di huang 15g Placebo of cornstarch No significant difference 200130 blind placebo (28; 27) Jean Hailes aged 45-70 years, with Shan zhu yu 10g and bitter taste between groups in controlled parallel Foundation amenorrhoea > 12 Shan yao 12g enhancer reduction of vasomotor group clinical trial. newsletter, and months and FSH Ze xie 8g symptoms (p=0.09) Duration 12 weeks various media >25IU/L with at least 14 Mu dan pi 8g hot flushes or night Fu shen 12g sweats per week Chen pi 5g Di gu pi 20g He huan pi 15g Suan zao ren 10g Han lian cao 1 Nu zhen zi 10g One sachet twice/day

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7.3.1 Factors affecting the comparison of trials

The ability to compare the outcomes of trials on Chinese herbal medicine was hampered by a number of factors. These were:

• Inconsistent menopausal status of trial subjects

• Varying severity levels of vasomotor symptoms

• Product variability with no chemical standardisation.

7.3.1.1 Inconsistent menopausal status of trial subjects

As discussed previously, lack of an adoption of a standard definition for the menopause and terminology referring to the transitional years has led to trial authors devising their own inclusion criteria for the menopause. This makes comparisons between outcomes difficult as the menopausal status of trial subjects is varied resulting in heterogeneous treatment groups. Menopausal eligibility criteria of the

22 trials included:

30 • Amenorrhoea of 12 months or more

227, 627, 628 • Amenorrhoea of at least six months

626 • Amenorrhoea of at least three months

614 • Menopausal status defined by measures of FSH, LH and oestradiol

• The remaining studies did not describe the menopausal status of the

participants. Instead an age range or a list of symptoms was given. These

studies selected for premenopausal, perimenopausal and postmenopausal

women resulting in heterogeneous treatment groups.

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Hormonal levels fluctuate widely during the perimenopausal years356, 372 and their use in determining menopausal status are not generally useful.351 Due to fluctuating hormone levels, women may spontaneously experience a relatively normal menses after a time of amenorrhoea. Vasomotor symptoms may also occur erratically during this time. Consequently, perimenopausal women have been noted to contribute to a higher placebo response to vasomotor treatment than women suffering vasomotor symptoms during the postmenopausal stages.5 This phenomenon may mask the true efficacy of a treatment being assessed.

7.3.1.2 Varying severity levels of vasomotor symptoms

A range of vasomotor symptom severities were listed as inclusion criteria of the clinical trials selected for this review including:

30 • At least 14 or more vasomotor symptoms per week of any severity

• Greater than five moderate to severe events per week or 14 or more events of

any severity227

628 • Six episodes of hot flushes during at least three days over the past week

• The remaining studies did not state the number of vasomotor symptoms.

Messina and Hughes629 analysed the data sets from 13 parallel design clinical trials on soy foods and isoflavone supplements and found that there was a statistically significant (p=0.01) relationship between initial hot flush frequency and treatment efficacy. The authors found that most trials with positive outcomes recruited subjects with at least five or more vasomotor symptoms per day.168, 169, 198, 261, 262

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The U.S. Food and Drug Administration recommends that subjects must have a minimum of seven moderate to severe vasomotor episodes per day or 49 per week at baseline to be included in trials assessing HT for the alleviation of vasomotor symptoms.630 However, it may be difficult to enrol women who are experiencing numerous severe vasomotor symptoms into clinical trials of herbal medicines whose efficacy is unsubstantiated or not as effective as HT. Hence, the inclusion of women into a clinical trial with at least 5-6 moderate vasomotor symptoms per day at baseline may be a necessary compromise in order to evaluate the effectiveness of a herbal treatment.

7.3.1.3 Product variability with no chemical standardisation

The concentration of active constituents contained within a herbal product depends on the plant type, growing conditions, time of harvest, storage, processing and extraction methods. Because of the aforementioned reasons, different herbal batches and manufactured products may vary considerably in the concentration of marker compounds277, 278 and as a result herbal preparations may demonstrate variable chemical activity.277

To reduce variability between batches of plant material and manufactured products, manufacturers are now producing standardised herbal extracts which contain a specific amount of an identified active constituent.631 For example Cimicifuga may be standardised to contain not less than 2.5% triterpene glycosides calculated as 27- deoxyactein. However, when active constituents are not known, a chromatographic

“fingerprint” of the plant can be used to compare batches in an attempt to reduce

144 their variability.122 Standardisation of plant material can ensure correct identification of the plant species and provide some measure of quality assurance so that preparations are manufactured to deliver an appropriate dose of a known quantifiable active compound.632, 633

Of the retrieved clinical trials, two reported the use of standardised herbal extracts.227, 628 However, Hirata and colleagues227 were the only authors to describe their extract in detail; dang gui extract standardised to 0.5mg/kg of ferulic acid by high-performance liquid chromatography. Due to the wide variety in quality and content of herbal medicines tested in clinical trials, the CONSORT Group have suggested that trialists describe the characteristics of their product in detail and provide evidence of qualitative testing.634

The quality of herbal products may also be influenced by the inadvertent or deliberate substitution of herbs in a formula. Such an admission may result in serious consequences, such as the eighty cases of renal failure that occurred after the ingestion of a herbal preparation administered by a Belgian slimming clinic adulterated with the herb Aristolochia fangchi. A detailed analysis of the formula identified the nephrotoxin aristolochic acid in a herbal batch labelled Stephania tetrandra, intimating possible substitution with A. fangchi.635 Adulteration of

Chinese herbal products with pharmaceuticals such as anti-diabetic drugs,636 synthetic anorexics637 and other substances638 has also been reported. Such contamination of herbal products can lead to adverse events and mask the true effectiveness of a herbal treatment.

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An Australian clinical trial conducted in Melbourne reported that a Chinese herbal formula administered to 28 postmenopausal women was no more effective than placebo (n=28) in reducing the severity of hot flushing.30 However, this study illustrates the need for identification of the herbs comprising an administered trial formula. The master’s thesis submitted by Chen639 noted that two of the twelve herbs in the formula were substituted with others deemed to be the “best alternatives”. It was not known which herbs were substituted and what the substitutes were. This is a serious protocol deviation and a potentially dangerous practice as discussed previously.635 Therefore, the formula stated in the Australian

Medical Journal report was not the same formula tested and so the claim that “the formula is no more effective than the placebo” cannot be made.

7.3.2 Quality of the clinical evidence

The articles were evaluated to determine the quality of the evidence regarding the effectiveness of CHM in alleviating menopausal vasomotor symptoms. The primary aim was to assess the methodological rigor of the trials so that the design, conduct and analyses minimised or avoided biases when comparing treatment outcomes.640

The ten key criteria used to evaluate the robustness of the clinical trials were based on a scale published by Jadad and co-workers641 and item listed in the CONSORT statement for the reporting of RCTs.642

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The points considered were:

• Clearly stated objectives and hypotheses

• Clearly listed inclusion and exclusion criteria describing the study

population

• Detailed method of subject recruitment. The referral or self-selection of

participants may affect the external validity of the trial

• A calculation to determine and justify sample size

• A randomised study that provides a clear description of the randomisation

procedure

• Inclusion of a comparison placebo or positive control group

• Blinding of trial subjects and investigators to treatment allocation (double-

blind) to reduce bias

• The success of binding is checked and reported

• Appropriate statistical calculations which match the original trial objectives

• Clear description of the herbal and placebo treatment characteristics along

with dose, route of administration and duration of treatment.

Table 7.2 presents a summary of the studies according to the preceding key points which form ten benchmark measures in the form of a stop-go analysis. Green indicates the criterion was adequately addressed, while red signifies the criterion was not covered in adequate detail or was omitted. As can be seen from the chart, most studies conducted in China did not adequately cover the key methodological benchmarks, with the best reports only covering two of the ten criteria.614, 621, 626

Most trials published in English language journals addressed significantly more key points.

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The 22 retrieved clinical studies were published between 1991 and 2004. The total number of participants included in the studies was 2,605. The average sample size was 53 and the size ranged from 14 to 193 subjects. Only two studies justified sample size with an appropriate calculation.30, 628 A number of studies were published by one author without the acknowledgement of any other forms of assistance.614-616, 620, 625 This is unusual as clinical trials are labour intensive and often require the input from a various experts.

The scales used to assess quality of life included the Greene scale,627 Kupperman

Index227, 617, 626, 628 or a self devised symptom list.32 Five studies30, 32, 227, 626, 628 included an assessment of the effectiveness of herbal treatment on alleviating vasomotor symptoms measured either as a component on the quality of life scale or as a separate outcome measure. The remaining trials included vasomotor symptoms along with other menopausal symptoms and no baseline or post-treatment measures were given. An overall assessment of the efficacy of herbal treatment was given as an effectiveness rating which was presented as a percentage. Therefore, the effectiveness of Chinese herbal medicine for the alleviation of vasomotor symptoms cannot really be evaluated from these studies.

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Table 7.2: Comparison of trial methodologies on CHM for vasomotor symptoms according to ten benchmark measures

Benchmark measures

First author and Clear Clear Recruitment Sample size Randomised Randomisation Double Blinding Appropriate Treatments date objectives inclusion and described calculated participants procedure blind checked statistical clearly exclusion described analyses described criteria

Lin HQ 2000612

Guo L 1999613

Gao JR 2002614

Yuan XF 2003615

Mao JQ 2003616

Huang SX 2003617

Chen LX 2003618

Yang XF 2003619

Yang HH, 2003620

Tang SJ, 2003621

Liang RN, 2003622

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149

Table 7.2: Continued

First author and Clear Inclusion and Recruitment Sample size Randomised Randomisation Double Blinding Appropriate Treatments date objectives exclusion described calculated participants procedure blind checked statistical clearly criteria described analyses described

Li Q, 2003623

Lu YP, 2003624

Lin WC, 2003625

Lu QB, 199128

Wang DZ, 199429

Luan YQ, 2004626

Chen LC, 2003627

Pan B, 200432

Hirata JD, 1997227

Wiklund IK, 1999628

Davis SR, 200130

Present study

Red: not stated or not clearly stated Yellow: stated and not completed or completed in part Green: clearly stated

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Two studies assessed the efficacy of single herbs227, 628 while the others evaluated a range of herbal formulae. Ninety five percent of the trials did not report on the characterisation or standardisation of the herbal formula. In three studies the herbal formula was modified depending on the presenting signs and symptoms of the subject.618, 619 An inert placebo was included in four studies,29, 30, 227, 628 however only Hirata and colleagues227 gave details about the placebo formulation. Five studies used a herbal formula as a positive control without providing details of the herbs included.28, 612, 616, 618 The efficacy of these control formulae had not been evaluated. In two studies617, 622 oryzanol was given as the control, while in five studies oryzanol was taken in conjunction with other positive control substances.612,

613, 616, 619, 625 Oryzanol, a mixture of fats derived from rice bran oil, may have some therapeutic effect on menopausal complaints643 and therefore cannot be considered an inert substance. Oestrogens were used as a positive control in nine studies.32, 613,

614, 619-621, 624, 626, 627 Placebos are not commonly used in clinical research conducted in China, as the Chinese believe it is unethical to withhold potentially beneficial treatments in place of a placebo.44

Most studies did not present baseline demographics or measures. Baseline demographics were described in 27% of the reports,30, 32, 227, 626-628 while three studies incorporated a baseline period before the commencement of the treatment phase.30,

627, 628 Therefore, most statistical analyses did not include comparisons between baseline and end of treatment phase results.

Fifteen reports mentioned randomisation but only two described the randomisation procedure in detail.30, 227 As a number of studies had equal numbers in all treatment

151 groups it is unlikely that randomisation of subjects had occurred.612, 617, 620, 621, 623, 624

Furthermore, the success of randomisation was not checked in most studies that mentioned participants were randomised as comparisons between baseline demographics of the intervention groups were not reported or discussed. Four reports mentioned the trial was double blinded30, 227, 626, 628 but not one study measured the success of blinding.

Adverse events30, 227, 623, 626-628 and withdrawals30, 227, 626-628 were infrequently reported by trialists, implying that the majority of trials conducted on Chinese herbs included treatments with minimal side effects and subjects who completed all trial requirements. Compliance with trial medication was calculated and reported in one study.227

Trials conducted in China often used rudimentary statistics and results were expressed as an overall effectiveness as a percentage with p values (refer to Table

7.1). No statistical comparisons were made between treatment groups. All trials conducted by Chinese research groups reported positive outcomes. Twelve studies found the herbal formula to be highly efficacious, while seven32, 614, 620, 621, 624, 626, 627 reported similar or superior efficacy of herbs compared to HT. Such remarkable findings may indicate flaws in methodology and a bias towards publishing trials with positive outcomes.644 The three trials published in English language journals which compared a herb or formula to a placebo reported no significant differences between treatment and placebo groups in reducing vasomotor symptoms. Finally, only one study628 indicated that analyses were conducted on an intention-to-treat (ITT) basis.

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7.3.3 Systematic review conclusion

The majority of clinical work conducted in China on the use of CHM for the alleviation of vasomotor symptoms lacks methodological rigor resulting in biased results suggesting highly efficacious treatments with a similar or superior effect to

HT. Most of the reviewed trials did not assess the effect of treatment on vasomotor symptoms as a separate component but gave an overall effectiveness rating of the herbal treatment for a range of symptoms. The stop-go analysis (Table 7.2) highlights the numerous design flaws inherent in the protocols of the trials evaluated.

All studies conducted in China failed to address more than two of the ten key points regarding methodological rigor, while four of the five papers published in English language journals covered five or more of the key points.

Therefore, it can be concluded that the scientific evidence supporting anecdotal reports of highly efficacious Chinese herbal treatments for the alleviation of hot flushing is lacking. Hence, in the context of concerns over the safety of HT, the extensive history of CHM use and the lack of supporting clinical research for the efficacy of CHM treatment, it was considered important that a rigorous clinical study on the treatment of vasomotor symptoms with a Chinese herbal formula be undertaken. A safe and effective therapy would offer a valuable treatment option for women experiencing menopausal symptoms. The following clinical trial evaluating the effectiveness of FF-01 was planned in accordance with accepted scientific guidelines as outlined in the CONSORT statement642 to ensure sound methodology.

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7.4 Discussion and Conclusions

This chapter examined the clinical research conducted on CHM for the alleviation of vasomotor symptoms. The review concluded that the overall quality of this research is poor. Clinical trials conducted by Chinese research groups reported CHM to be highly efficacious, even when HT was used as a positive control. Such outcomes not only indicate major methodological flaws but also suggest a bias towards the publication of positive results. Published reports in Chinese language journals on

CHM for the treatment of menopausal complaints tend to be brief and fail to include detailed descriptions of randomisation and blinding procedures. Rudimentary statistics were conducted without adequate comparisons between treatment groups.

Clinical trials conducted in China often did not include placebo control groups; but incorporated HT or other herbal formulae as positive controls. A number of reports did not define the treatment formula or herbal positive control used in the study.

Such major oversights in research design leads to findings that are highly questionable.

The review raised a number of methodological issues which may impact on the rigor of the study and hence affect the quality of the outcomes. The issues raised in the review were:

• Clearly stated objectives and hypotheses

• Clear inclusion and exclusion criteria to ensure the selection of participants

of a similar menopausal status and at least a moderate severity of symptoms.

Baseline comparisons between the groups to determine if randomisation

produced similar treatment groups.

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• A detailed description of the recruitment process, whether participants were

referred or self-selected.

• A sample size calculation to ensure adequate power of the study.

• Randomisation of trial participants to treatment allocation with a clear

description of this process in the report.

• A placebo control group to take into account any placebo effects due to

treatment. The placebo group should receive a similar looking and tasting

tablet as the herbal treatment group.

• Double blinding of participants and practitioners to reduce any bias. The

success of blinding should be checked during the trial.

• The use of appropriate statistical analyses to compare the effects of treatment

with placebo.

The protocol for the present clinical trial assessing the effectiveness of FF-01 in alleviating vasomotor symptoms addresses these points in order to ensure sound methodology and the reporting of valid outcomes. The following chapter examines the herbal formula FF-01 in detail. The scientific evidence confirming the herbs’ traditional uses will be reviewed.

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CHAPTER 8 TRIAL FORMULA: FF-01

8.1 Introduction

FF-01 is based on two traditional Chinese herbal formulae with the addition of the

Western herb Cimicifuga racemosa. The formula is similar to one currently on the market which has good anecdotal evidence suggesting a potential treatment for the alleviation of vasomotor symptoms. Cimicifuga is included as the principal herb for the alleviation of these symptoms. The remaining herbs clear Heat and nourish Yin.

The following chapter examines the pharmacological and clinical research substantiating the traditional uses of the herbs that comprise FF-01. A systematic review evaluating the clinical evidence for the alleviation of vasomotor symptoms with Cimicifuga is also presented in this chapter.

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8.2 FF-01: the Clinical Trial Formula

FF-01 was specifically formulated by the sponsor of the trial (Global Therapeutics) to alleviate vasomotor symptoms. The clinical trial formula was not listed with the

Therapeutic Goods Administration (TGA). A similar formula to FF-01, which is listed with the TGA, had been on the market for a number of years with good anecdotal evidence suggesting relief of vasomotor symptoms and improvement in quality of life. This formula had been a top seller over a number of years for the sponsor. Adverse reactions reported by women were mild and self-resolving, therefore no significant risks were associated with the use of this product. Due to the anecdotal evidence attesting to the effectiveness of this formula in relieving symptoms and because of good safety reports, a RCT was planned to scientifically evaluate the efficacy of a similar product, FF-01. The two traditional Chinese formulae Er xian tang and Zhi bai di huang wan were the basis for the design of FF-

01 (refer to Table 8.1).

Zhi bai di huang wan is based on the classic Yin tonic formula Liu wei di huang wan and includes two additional herbs to increase the cooling properties of the formula.

Zhi bai di huang wan is indicated for Yin deficiency with Heat, night sweats, dry mouth and tongue, sore and weak lower back, hearing problems, a red tongue with little coat and a rapid thin pulse. The Kidneys are located in the lower back and are said to govern the bones. Therefore, if the Kidneys are deficient there will be weakness and pain in the lumbar area and spine. A deficiency of Kidney Yin entails a lack of Jing and Blood to nourish the associated sensory organ, the ears. This manifests as tinnitus and a decline in hearing. Additional signs of Yin deficiency with internal Heat are a red dry tongue and a thin (lacks blood volume) rapid

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(signifies Heat) pulse. Rehmannia glutinosa (Sheng di huang), the principal herb of the formula, is a strong Kidney tonic and nourishes the Yin and Jing. However, due to its inherent nourishing properties, Rehmannia tends to be rich, heavy and cloying in nature and must be counterbalanced by herbs that move Qi to prevent stagnation and disruption to digestion.645

Er xian tang was developed at Shu Gang Hospital in Shanghai604 and is indicated for conditions where the Kidney Yin and Yang are both deficient in addition to internal

Fire caused by Yin deficiency. The formula has also been used to treat vasomotor symptoms. Yang deficiency causes symptoms such as fatigue, depression and urinary frequency. The principal herbs of the formula, Curculigo orchioides (Xian mao) and Epimedium sagittatum (Yin yang huo), are powerful Kidney tonics which strengthen Yang. To a lesser extent, Epimedium also tonifies the Kidney Yin.

Besides balancing the warming nature of Curculigo and Epimedium, Phellodendron amurense (Huang bai) and Anemarrhena asphodeloides (Zhi mu) also nourish

Kidney Yin and drain Fire.645

Zizyphus spinosa (Suan zao ren) and Cimicifuga are the final two herbs of the formula. Zizyphus was included to calm the Spirit, ease irritability and reduce insomnia. Clinical studies have demonstrated some efficacy in the use of Cimicifuga for the alleviation of vasomotor symptoms.172, 210, 214 Therefore, this herb was included principally for providing symptomatic relief. In terms of Chinese herbal energetics, Ross646 suggests that Cimicifuga primarily tonifies Kidney Yin and clears

Heat due to Yin deficiency, indications for use in the treatment of vasomotor symptoms.

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Table 8.1: Details of FF-01

Herb name Part used Amount Latin Chinese/common (mg) name Cimicifuga racemosa Black cohosh Root and Rhizome 350

Rehmannia Sheng di huang Root 400 glutinosa (uncured) Epimedium Yin yang huo Leaf 400 sagittatum

Curculigo orchioides Xian mao Root 375

Phellodendron Huang bai Bark 325 amurense

Anemarrhena Zhi mu Root 400 asphodeloides Asparagus lucidus Tian men dong Root 400

Zizyphus spinosa Suan zao ren Seed 500

The following section reviews the individual herbs of the formula in greater detail, including pharmacological and clinical studies. Cimicifuga is discussed in greater detail and includes a systematic review evaluating the clinical research investigating the herb’s potential as a treatment for the alleviation of vasomotor symptoms.

8.3 Constituent Herbs of the Formula

8.3.1 Cimicifuga racemosa [L] Nutt

Cimicifuga racemosa, a herb native to eastern North America, has been traditionally indicated for general malaise, rheumatism, sore throat, menstrual cramps, amenorrhea and to ease labour.205 The herb was also used as an insect repellent due to its unpleasant smell. This use is reflected in the genus name Cimicifuga which originates from the Latin cimex a type of insect and fugare to put to flight.647

Recently the herb was reclassified to Actea racemosa following deoxyribonucleic

159 acid (DNA) sequence mapping and morphological studies.648 However, due to delays in accepting or rejecting this change in the medical, botanical and herbal literature the name Cimicifuga racemosa will be retained in this thesis.205 In 1989 the German Commission E (an expert panel commissioned by the German

Government to address herbal products) approved Cimicifuga for the alleviation of menopausal complaints, in particular vasomotor symptoms.206

Cimicifuga contains a number of cycloarctane triterpene glycosides including actein,

26-deoxyactein and 27-deoxyactein (formally 23-epi-26-deoxyactein).649 Aromatic acids include fukiic acid, piscidic acid,650 caffeic acid, ferulic acid, isoferulic acid, fukinolic acid, dehydrocimicifugic acid A and B.651 The herb also contains tannins, resins, volatile oils, fatty acids, starches and sucrose.205

8.3.1.1 Systematic review on clinical studies for vasomotor symptoms

Clinical studies conducted on Cimicifuga have demonstrated some efficacy for the alleviation of vasomotor symptoms. Most of these studies assessed the German proprietary medicine Remifemin (Shaper & Brummer, GmbH & Co KG, Salzgitter) and include a number of uncontrolled observational studies that suggest a highly efficacious product.208, 209, 266, 652, 653 Remifemin is a dried isopropanol extract (40% by volume) of the roots and rhizomes of Cimicifuga. The product is standardised to contain 1mg triterpenes per 20mg extract, calculated as 26-deoxyactein. A 60% ethanol extract was originally formulated, and this complicates the analysis of earlier clinical research.

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To determine the quality of clinical research conducted on Cimicifuga, a literature search of MEDLINE, CINAHL, EMBASE and the Cochrane Central Register of

Controlled Trial databases from inception until December 2006 was conducted.

Search terms and combinations included “menopause”, “climacteric”, “hot flush/flash”, “vasomotor symptoms”, “Cimicifuga racemosa”, “Actea racemosa”,

“Black Cohosh”, “randomised controlled trial”, “controlled clinical trial”, “clinical trial” and combinations of these terms. Reference lists from retrieved articles were also searched for appropriate studies. Articles in German were translated into

English. Clinical studies were included if they met the following criteria:

• Evaluated the efficacy of Cimicifuga for the alleviation of vasomotor

symptoms as either the primary or secondary outcome measure

• Assessed healthy women transitioning through menopause.

Figure 8.1 outlines the identification and selection of the 12 research papers for this review. The methodologies, interventions and results are summarised on Table 8.2.

The key points identified and listed in 7.3.2 were used to evaluate the quality of trials conducted on Cimicifuga. Table 8.3 assesses the methodological quality of the 12 trials as a stop-go analysis. Design rigor has improved since the 1980s with later studies addressing five or more of the ten key criteria.

557 potentially relevant references on Cimicifuga screened 533 irrelevant references excluded (duplicates, reviews, considered herbal formulae, pharmacological studies)

24 reports reviewed

12 reports excluded (not RCTs)

12 RCTs included in review

Figure 8.1: Selection of papers for Cimicifuga systematic review

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Table 8.2: Characteristics of Cimicifuga studies included in the systematic review

First author and Design Sample size Recruitment Participants Intervention Control Outcomes date and setting Warnecke, Open, parallel group, 60 Gynaecology Women aged 45-60 40 drops 0.6mg conjugated All treatments improved 1985654 positive control, 12 weeks (20 herb; 20 practice years with no or irregular Remifemin twice oestrogen/day climacteric symptoms; Remifemin duration oestrogen; 20 menses and climacteric daily caused greatest improvement in diazepam) symptoms Diazepam 2mg/day Kupperman Index and psychological symptoms and stimulated vaginal epithelium. No statistical data reported. Stoll, 1987210 Double-blind, placebo and 80 Not reported Women aged 46-58 4 tablets 0.625mg conjugated Remifemin significantly improved positive controlled, (30 herb; 30 years with 3 or more Remifemin daily oestrogen symptoms measured by the parallel group oestrogen; 20 vasomotor (each containing Kupperman Index (<15) and Duration 12 weeks placebo) symptoms/day and one 2mg herb) Placebo HAMA (p>0.01) other symptom Lehmann- Open, positive controlled 53 University medical Hysterectomised women Remifemin 4mg Oestriol lmg Improvements in all treatment Willenbrock, Duration 2 weeks (group clinic aged less than 40 years groups (p<0.01) on modified 1988655 allocations not with 1 intact ovary and Conjugated Kupperman Index. No significant reported) climacteric symptoms oestrogens 1.25mg differences between treatment groups. Oestrogen-gestagen sequential therapy dose not give Jacobson, Randomised, double- 85 Breast cancer Non pregnant breast 2 tablets daily Placebo (not Both groups experienced 2001656 blind, placebo controlled (42; 43) clinics cancer survivors over 18 (dose and reported) reduction in hot flushing and trial years of age who formulation not menopausal symptoms. No Duration 60 days completed primary reported) statistical difference between therapy at least 2 months groups (p>0.86) before trial and experiencing hot flushing (no number reported) Some taking tamoxifen Liske, 2002170 Randomised, double blind 149 Not reported Healthy peri and post Standard dose None Reduction in symptoms in both parallel group study of (74 standard menopausal women 39mg crude groups as measured by the different dosages dose; 75 high Multicentre study aged 42-60 with a herb/day Kupperman Index and depression Duration 12 weeks with dose) Kupperman Index score High dose scale. No significant differences option to continue for 24 of at least 20 or more 127.3mg crude between doses (p = 0.73) weeks herb/day

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Table 8.2: Continued

First author and Design Sample size Recruitment Participants Intervention Control Outcomes date and setting Wuttke, 2003172 Double-blind, randomised, 62 Not reported Healthy women aged 40- 2 tablets Menofem 0.6mg conjugated Herb equipotent to oestrogen and placebo and positive (20 herb; 22 60 years, last menses daily (corresponds oestrogens superior to placebo in reducing controlled oestrogen; 20 Multicentre study months previous, at least to 40mg herb) climacteric symptoms as Duration 12 weeks placebo) 3 hot flushes daily Matching placebo measured by the Menopause Rating Scale (p=0.05) Munoz, 2003214 Open, parallel group 136 Mastology Unit of Breast cancer survivors 2 tablets Menofem Tamoxifen 20mg Herb significantly reduced severe Duration 12 months (90; 46) a Medical Clinic aged 35-52 years, with daily (corresponds hot flushing in women taking regular menses to 40mg herb) tamoxifen (p>0.01) Tamoxifen 20mg Frei-Kleiner, Randomised, placebo- 122 Recruited via 12 Healthy peri or early 1 capsule/day 1 capsule/day Superiority of herb for symptoms 200526 controlled, double-blind, (81; 41) gynaecology menopausal women (equivalent to (identical placebo, of moderate intensity (p=0.018), parallel group practices and 2 aged 45-60 years with at average 42mg described) no superiority of herb in ITT Duration 12 weeks university least 3 hot flushes per crude herb) population menopause day with at least one centres functioning ovary Nappi, 2005657 Randomised, open, 64 2 University Women aged 45-55 Remifemin Transdermal Herb and HT significantly reduced positive controlled study (32; 32) Departments of years, with no menses 40mg/day oestradiol number of vasomotor symptoms Duration 3 months Obstetrics and for previous 6 months 25μg/week (p<0.001) and reduced anxiety Gynaecology and at least 5 hot flushes Dihydrogesterone (p<0.001) and depression per day 10mg for last 12 (p<0.001) days of 3 month oestradiol treatment Osmers, 200525 Randomised, double- 304 24 medical clinics Women with no menses 1 tablet Remifemin Matching placebo Herb significantly reduced hot blind, placebo controlled specialising in of a least 6 months, (corresponding to flushes (p = 0.007) and clinically Duration 12 weeks gynaecology climacteric complaints of 40 mg herb) reduced symptoms as recorded at least greater than 0.4 on the Menopause Rating Scale in at least 3 items on the (p=0.027) Menopause Rating Scale Pockaj, 2006658 Randomised, double- 132 North Central Women experiencing at 1 tablet containing Placebo 1 tablet/day No significant difference between blind, placebo controlled, Cancer Treatment least 14 hot flushes per 20mg herb treatment groups for hot flush crossover trial Group week for at least 1 month (standardised to score and frequency Duration two 4 week without clinically evident contain 1mg periods malignant disease triterpene glycoside, 27- deoxyactein) Newton, 2006659 Randomised, double- 148 Group Health, Healthy peri or post- 160mg herb/day Identical looking Vasomotor symptoms did not blind, placebo controlled (73; 75) Washington menopausal women (standardised to at placebo of lactose differ between Cimicifuga and trial State. Recruited aged 45-55 years with 2 least 2.5% placebo (p>0.05) Duration 1 year from mailing lists or more vasomotor triterpene episodes per day, with at glycosides. least 6 of moderate Amount detected intensity during run-in 3.125%)

162

163

Table 8.3: Comparison of trial methodologies on Cimicifuga racemosa for vasomotor symptoms according to ten benchmark measures

Benchmark measures First author and date Clear Clear inclusion Recruitment Sample size Randomised Randomisation Double Blinding Appropriate Treatments objectives and exclusion described calculated participants procedure blinded checked statistical clearly criteria described analyses described

Warnecke, 1985654

Stoll, 1987210

Lehmann- Willenbrock, 1988655

Jacobson, 2001656

Liske, 2002170

Wuttke, 2003172

Munoz, 2003214

Frei-Kleiner, 200526

Nappi, 2005657

Osmers, 200525

N/A Pockaj, 2006658 Crossover design

Newton, 2006659

Present study

Red- not stated or not clearly stated Yellow- stated and not completed or completed in part Green- clearly stated

163

164

Research groups included subjects of varying menopausal status resulting in heterogeneous treatment groups. As discussed previously, this may be partly due to the lack of a uniform definition for the menopause resulting in some trialists devising their own definitions. The trials included:

655 • Women with hysterectomies

172, 657 • 6 months amenorrhoea

214, 656, 658 • A history of breast cancer

25, 26, 170, 210, 654, 659 • Peri- and postmenopausal women.

The baseline number of vasomotor symptoms also varied greatly between trials and ranged from no number specified25, 214, 654-656 to five or more per day.657 Most trials required 2-3 vasomotor episodes per day. As discussed previously, women with more vasomotor symptoms experience a greater benefit from treatment. The FDA recommends trials evaluating the therapeutic efficacy of HT include subjects with at least seven moderate to severe vasomotor episodes per day at baseline.630 Therefore, trials assessing herbal treatments should strive to include subjects with a comparable number of flushings per day.

The 12 studies included 1,316 women, with an average sample size of 42 (range 15 to 145). Justification of sample size was provided by four research groups.25, 656, 658,

660 Most studies were conducted on the Cimicifuga product Remifemin25, 170, 210, 654,

655, 657 while two assessed the product Menofem/Klimadynon.172, 214 Menofem, an aqueous ethanol extract, contains 32.5mg dry root per tablet. No details on the standardisation or composition of the extract have been reported. The report by

Jacobson and colleagues656 omitted descriptions of the herbal and placebo treatments

165 and dosages administered. Only two studies adequately described placebo and herbal treatments, including standardisation of the Cimicifuga extract used in the trial.658, 659 Most authors assessed the efficacy of treatment on vasomotor symptoms as part of the Kupperman Index26, 170, 210, 655 and/or self reports through the use of hot flush diaries.26, 214, 656, 658, 659

The studies incorporating a positive control group reported a remarkable similarity172, 654, 655, 657 or superiority210 in efficacy of Cimicifuga compared to HT.

These findings raise questions regarding the overall quality and validity of the studies, which are plagued by a number of design flaws as highlighted on Table 8.3.

Stoll210 conducted a double blind positive controlled trial that randomised 80 women with menopausal symptoms including three or more hot flushes per day to receive either 40mg Remifemin, 0.625mg conjugated oestrogens or placebo per day for 12 weeks. Remifemin significantly improved somatic and psychological parameters as measured by the Kupperman Index and Hamilton Anxiety Scale compared to the oestrogen or placebo groups. Women on oestrogen fared no better than those receiving placebo. The positive results may have been due to a significant placebo effect and/or an ineffective dose of oestrogen. A diverse range of women were included in the trial, and as discussed previously, perimenopausal women contribute to a higher placebo response in clinical trials.5 The report by Stoll failed to give details of the randomisation procedure or success of blinding. No sample size calculation was undertaken and appropriate statistical analyses had not been carried out. Stoll mentions that all tablets were made to look identical, but no details of the formulations were given.210 Lehmann-Willenbrock and Riedel655 conducted an open-labelled study randomising 60 women with hysterectomies and one functioning

166 ovary to receive either 40mg of standardised Cimicifuga (Remifemin), lmg oestradiol, 1.25mg conjugated oestrogens or an unspecified dose of an oestrogen- gestagen combination. Improvements were noted in the Kupperman Index with no significant differences between the groups. Since HT has been demonstrated to significantly reduce vasomotor symptoms, it is remarkable that a herbal treatment can have a similar or superior effect to HT in as little as four weeks.

All studies evaluating the efficacy of the proprietary extracts Remifemin25, 210, 654, 655,

657 or Menofem172, 214 reported positive outcomes, whereas the trials conducted by

Pockaj and associates658 and Newton colleagues659 using non proprietary but standardised extracts found no superiority of herb over placebo. Authors assessing

Remifemin did not disclose if company funding for conducting their research was given. Newton and co-workers659 and Wuttke and associates172 were the only research groups providing details of funding sources.

Most studies failed to give details on compliance,26, 170, 172, 210, 214, 654-658 adverse events172, 654, 655, 657 and participants who withdrew.26, 172, 214, 655, 657, 658 Four studies mentioned analyses were conducted on an ITT basis.25, 26, 656, 659 Forty five percent of trials included a baseline period before commencement of the treatment phase26,

170, 172, 658, 659 and 75% of trials presented baseline characteristics of treatment groups.25, 26, 170, 210, 214, 656-659 Baseline periods were either one658 or two weeks26, 170,

172, 660 in length.

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The randomisation procedure was not described in 50% of the reports. Amongst the double blinded studies, not one manuscript mentioned that blinding of participants was checked. Two studies were published by a single author without acknowledging any other form of help.210, 654 Conducting a RCT is time consuming and requires the combined skills of a research team of various experts; therefore it seems unlikely the task could be undertaken by a single author.

Three studies found no effect of Cimicifuga on vasomotor symptoms.656, 658, 659 The

RCT by Jacobson and colleagues,656 which recruited 85 women with a history of breast cancer, found the herb did not significantly reduce the number and intensity of hot flushes compared to placebo over a 60 day period, although the treatment group reported a significant improvement in sweating (p=0.04). The report does not mention the dose of extract or placebo given. The outcomes of this study have limited external validity to menopausal women in general as the recruited women had suffered from breast cancer and 70% were taking Tamoxifen which is known to cause severe hot flushing. Therefore, the results suggest that Cimicifuga does not alleviate vasomotor symptoms amongst women with a history of breast cancer who are using Tamoxifen. Pockaj and co-workers658 undertook a double-blind, randomised cross-over trial with two four week periods and found that a Cimicifuga herbal extract failed to reduce hot flush score (p=0.53) or mean hot flush frequency

(p=0.36) compared to placebo. A four week treatment period is a short time period in which to see an effect of treatment. Most clinical trials assessing a herbal intervention include a treatment period of 12 weeks or longer. For a cross-over trial, four weeks is probably too short a time period to allow the effects of treatment to subside and for the hot flush intensity to return to baseline levels in those women

168 who received the active treatment before a cross-over in treatment to placebo occurred. It is likely carry-over effects of Cimicifuga treatment continued while these women were taking placebo.

The RCT conducted by Newton and colleagues659 is the most rigorous trial conducted to date660 (refer to Table 8.2). Three hundred and fifty one women aged

45 to 55 years with two or more vasomotor symptoms per day were randomised to one of five treatment arms, including Cimicifuga extract and a multibotanical containing Cimicifuga, for one year of treatment. Eighty women were allocated to the Cimicifuga arm. The authors found that the number of vasomotor symptoms per day, symptom intensity and Wiklund Vasomotor Symptom Score did not differ significantly between the herbal intervention and placebo (p>0.05). Therefore it was concluded that Cimicifuga alone and in combination as a multibotanical demonstrated little potential as a therapy for the relief of vasomotor symptoms.

However, as discussed previously in section 7.3.1.2, a baseline rate of at least two vasomotor symptoms per day is too low to see meaningful treatment differences. HT trials require a minimum of seven moderate to severe hot flushes per day.630 Since the efficacy of a herbal intervention is less than HT,139 a requirement of greater than two vasomotor symptoms per day is warranted in order to observe the treatment effect of an agent whose efficacy will be less than the most effective clinical treatment.

An analysis of the trial protocols is summarised on Table 8.3 as a stop-go analysis.

Fifty percent of the studies addressed six or more key benchmark measures listed on the chart. The chart also includes the present study which improves on the

169 methodologies of previous studies in order to rigorously evaluate the effectiveness of

FF-01. Studies finding Cimicifuga to be efficacious in reducing vasomotor symptoms were predominately those comparing the herb with oestrogen, concluding the herb to be equi-potent to HT. However, studies which compared the herb to a placebo found the herb to be no more effective than placebo treatment. These studies were also the most rigorous in design. Therefore in conclusion, Cimicifuga may have some therapeutic benefit in reducing the severity of vasomotor symptoms, however further clinical work using sound trial methodology is needed to assess the therapeutic potential of standardised Cimicifuga extracts.642

8.3.1.2 Mode of action

The exact pharmacological action of Cimicifuga has not been fully elucidated. An observed increase in uterine weight and the induction of oestrus in early animal studies led to the conclusion that Cimicifuga induced an oestrogen-like effect.661 An in vivo study on rats conducted by Jarry and Harnischfeger662 using a non- standardised Cimicifuga extract found the herb caused an initial decrease in LH levels with no effect on FSH and prolactin. Similarly Duker and associates663 found that Cimicifuga significantly reduced LH but not FSH in menopausal women after eight weeks of treatment compared to placebo. However, the authors did not define the menopausal status of the women nor did they report baseline LH and FSH serum concentrations. Subsequent studies did not find any effect of the herb on oestrogen,170 LH, FSH,170, 655, 656 prolactin or sex hormone binding globulin,170 nor was the herb found to effect vaginal cytology170, 664 or uterine tissue.664-666

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Many studies have demonstrated an inhibitory effect of Cimicifuga on the proliferation of oestrogen-receptor positive667-677 and oestrogen-receptor negative675,

677 human breast cancer cell lines. The herb may also enhance the antiproliferative effects of tamoxifen.671 An ethyl acetate fraction of a methanolic extract of the herb was found to inhibit the growth of two human breast cancer cell lines. On further analysis it was found that the triterpene glycosides specifically inhibited the growth of MCF-7 human breast cancer cells and caused cell cycle arrest at G1. The most potent triterpene was determined to be actein.674 The antiproliferative effect may be due to the activation of caspases675 by triterpene glycosides and cinnamic acid esters,678 which induce cell apoptosis.675

Conversely, two research groups found that Cimicifuga had a stimulatory effect on the proliferation of the MCF-7 cell line.650, 679 Liu and colleagues679 reported a significant enhancement of MCF-7 cell growth at a dose of 4.75μg of an undefined

Cimicifuga extract. Kruse and co-workers650 determined that fukinolic acid isolated from Cimicifuga caused an increased proliferation of the MCF-7 cell line (126% at

5x10-8 M). However, results from studies on human cancer cell lines may be meaningless unless these results can be extrapolated to the human in vivo situation.

A number of factors may contribute to the contradictory outcomes of studies investigating the affects of Cimicifuga on cell proliferation. As described earlier, the concentration of active compounds within a plant depends on growing conditions and extraction methods. Research groups may have used non-standardised or undefined Cimicifuga extracts from different plant sources containing varying amounts of active constituents. Plant material may have been misidentified,

171 especially if the appropriate identification tests were not conducted.680 Originally,

Cimicifuga was thought to contain formononetin,681, 682 an oestrogen receptor ligand, however subsequent analyses failed to identify this compound in several populations of the herb.683, 684 Formononetin is an isoflavone found in significant amounts in

Trifolium pratense (red clover).685 This suggests that the oestrogenic and gonadotrophic effects observed in studies conducted prior to 1985 may have been due to plant material contaminated with formononetin.661, 680 To date no known phytoestrogens have been isolated from Cimicifuga.

Wuttke and colleagues172 suggest that Cimicifuga may act as a selective oestrogen receptor modulator (SERM) causing either an agonistic or antagonistic effect depending on the function and location of the target tissue.686 However, this claim has not been supported by several recent studies which imply a lack of oestrogenic activity on hormone levels and target organ tissues.170, 665, 666, 669, 687 Liu and colleagues669 found that a methanolic extract of Cimicifuga did not bind to oestrogen receptor (ER) subtypes α and β, did not induce oestrogen-dependent activity of alkaline phosphatase in Ishikawa (endometrial) cells and did not up-regulate oestrogen inducible genes presenelin-2 and progesterone receptor messenger ribonucleic acid (mRNA). A further study found that the triterpene glycosides cimicifugoside and cimiracemoside F or their enzymatically prepared aglycones did not bind significantly to the ligand binding domain of the ERβ, although the 27- deoxyactein aglycone showed some weak binding affinity.688 Therefore, the cumulative evidence from published studies on Cimicifuga does not support an oestrogen-like mode of action.680

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A number of other theories regarding the mechanism of the therapeutic effect of

Cimicifuga have been proposed. A pharmacological review of in vitro and animal studies investigating the herb’s mode of action concluded that the effects may be due to constituents possessing dopaminergic activity, although the authors note that this hypothesised mechanism is based on indirect evidence and requires further investigation.661 Dopaminergic agonists can cause a significant decrease in the proliferation of MCF-7 breast cancer cell lines.661 However, the stimulatory effect caused by Cimicifuga on MCF-7 cancer cells at low concentrations679 may be due to a loss of dopaminergic activity resulting in cell proliferation caused by fukinolic acid.650 A significant reduction in vasomotor symptoms by dopaminergic agonists689 adds further weight to this hypothesis. Alternatively, it has been suggested that the effects of Cimicifuga may be mediated via the binding of serotonin receptors. An in vitro study determined that an extract of Cimicifuga binds to specific subtypes of serotonin receptors located in the hypothalamus.690

Although the mode of action of Cimicifuga is not fully known, evidence indicates the herb does not contain phytoestrogens nor does it induce an oestrogen-like effect.

Several alterative mechanisms have been postulated including dopaminergic activity or mediation via serotonin receptors. Alternatively, currently unidentified compounds may exert an effect that is still to be determined.

8.3.1.3 Adverse effects

Ethanolic and isopropanolic extracts of Cimicifuga have been used in Europe for more than 40 years in over 1.5 million cases and have demonstrated excellent tolerability and low-risk side effects. Uncontrolled studies, post marketing

173 surveillance and clinical trials of over 2,800 participants indicate Cimicifuga has a low incidence of adverse events.213 Two critical evaluations on the safety of

Cimicifuga concluded that the herb can be safely used continuously for up to six months when used within the recommended dose range.212, 691 Gastrointestinal complaints and skin rash were the most commonly reported minor adverse events.206,

212, 213, 692 Other reported adverse events include hypotension, dizziness, nausea and allergic reactions.212 Higher doses can cause a frontal headache with a dull, full or bursting feeling.692 Overdose may cause vertigo, nausea, and vomiting, impaired vision, nervous and circulatory disturbances.692, 693 1321, 694 The toxic dose may cause death due to respiratory arrest.695 Cimicifuga is not recommended for use during the first trimester of pregnancy due to an emmenagogue effect.696

Recently, a number of case reports have linked the ingestion of Cimicifuga to hepatotoxicity resulting in three cases of acute hepatitis and fulminant liver failure.697-699 Two of the reports provided no detail of the herbal products, including identification, extraction methods or chemical analyses.697, 699 The third report noted that except for ground ivy and oats, the herbs of the formula had been sent to the

Therapeutic Goods Administration (TGA) for analysis.698 Ground ivy is known to contain pulegone, a hepatotoxin, yet the authors ascribed the toxic effects to

Cimicifuga without undertaking chemical analyses on ground ivy to rule out possible toxic levels of pulegone. Thomsen and Schmidt700 contend that these case histories provide insufficient exclusion of other possible causes of hepatotoxicity and note that hepatitis due to unknown causes is not uncommon. The authors conclude there is a large body of evidence and pharmacological research that does not support a hepatotoxic effect of Cimicifuga.700 Studies assessing the influence of Cimicifuga

174 extracts on liver metabolism have not been carried out to date.691 Nevertheless, the

TGA now requires all products containing Cimicifuga to display a statement on the label advising the possible risk of liver damage.

8.3.2 Rehmannia glutinosa (Gaertn.) Liboschitz

Rehmannia clears Heat, nourishes Yin and generates fluids; therefore the herb is indicated for Heat pathogenic disease with high fever, thirst, insomnia, irritability, haemorrhage and constipation. Rehmannia is also indicated to treat Yin deficiency giving rise to signs of Heat and injury to Fluids, which manifests as dry mouth, continuous low grade fever, hot flushes, constipation, dry cracked tongue, dry mouth and night sweating.701, 702

The main active constituents isolated from Rehmannia are β-sitosterol, mannitol, campesterol,701 rehmannans703, 704 and oligosaccharides. Stachyose is the main component extracted from the water extract. Other sugars include: raffinose, glucose, sucrose, fructose, mannotriose, verbascose and galactose.705, 706

8.3.2.1 Research

According to TCM philosophy, the main actions of Rehmannia are to clear Heat, nourish Yin and promote the production of body fluids. Pharmacological research indicates that Rehmannia acts as an anti-inflammatory and immunosuppressant; mechanisms by which the herb may mediate its Heat clearing action, especially in the case of inflammation resulting in heat production. Inflammation is considered to

175 play a major role in the progression of a number of diseases of distinct aetiopathogenic origin.707 An aqueous extract of Rehmannia inhibited the secretion of TNF-α (p<0.05) and interleukin-1. Interleukin-1 generates and potentiates inflammatory immune responses via the induction of inflammatory mediators including TNF-α. TNF-α is implicated in the pathogenesis of conditions such as multiple sclerosis, cancer and Alzheimer’s disease.708 Rehmannia was also found to regulate immediate type allergic reaction in vitro709 and to possess anti-tumour activity.710

According to TCM philosophy, diabetes mellitus is a disease caused by poor lifestyle habits, such as an excessive intake of sweet, rich food which leads to a weakening of the digestive processes resulting in obesity and fatigue. Eventually Yin is consumed and Heat accumulates giving rise to symptoms such as excessive thirst, dry mouth and hunger. Recent research has demonstrated Rehmannia oligosaccharides exert a hypoglycaemic action in a number of type 2 diabetic rat models,711, 712 which may be mediated via an interaction between insulin and glucocorticoids, thereby affecting hepatic glucose metabolism by increasing glycogen content and decreasing glucose-

6-phosphate activity.712

Traditionally, Rehmannia is considered a powerful Kidney tonic. Animal studies have suggested that Rehmannia may have a protective effect on the kidneys. A decoction of the herb was found to inhibit the progression of diabetic nephropathy in a rat model. Renal histopathological lesions were considerably ameliorated in rats administered high glucose syrup with the herbal decoction, but were conspicuous in

176 animals not given Rehmannia.713 An aqueous extract of Rehmannia was demonstrated to have a protective action in the renal derangement occurring in rats with ischemia/reperfusion induced acute renal failure. Renal functional parameters including creatinine clearance, urinary sodium excretion, urinary osmolarity and solute-free reabsorption were also markedly restored.714 According to TCM physiology, hearing is associated with Kidney function. A recently published report suggests that Rehmannia may prevent auditory damage via the scavenging of free radicals.715

Clinical work has mainly investigated the use of Rehmannia for the treatment of a number of inflammatory conditions such as rheumatoid arthritis, eczema, neurodermatitis and hepatitis.716 A search of the literature found no clinical research to substantiate the use of the herb for the treatment of sweating and flushing.

8.3.3 Epimedium sagittatum (Sieb. & Zucc.) Maxim.

Epimedium tonifies the Kidney and Yang and has traditionally been used for patterns of Kidney Yang deficiency with symptoms including lack of libido, infertility, urinary frequency, forgetfulness, soreness and weakness of lower back and knees.702

The herb has also been indicated for joint pain, numbness in the extremities701 and hypertension.717

Eight species of Epimedium each with similar properties and flavonoid glycoside content are used in TCM.718 Over 130 different compounds have been isolated from

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Epimedium species.718 The main active constituents isolated include; the flavonoids icariin,719 epimedin A, B, C,720 kaempferol and quercetin721, 722 and the icariside series glycosides.718, 723

8.3.3.1 Research

The traditional use of Epimedium as a Kidney Yang tonic suggests an effect on the reproductive organs and sexual functioning. Several studies conducted in China found the herb promoted semen production in dogs and increased the weight of the prostrate, seminal vesicles and levator ani in mice. The results of these studies suggest the herb has a gonadotrophic effect.716 Clinical studies assessing the affect of the herb on sexual functioning in humans have not been undertaken.

The traditional use of Epimedium as a Qi and Jing tonic may be due to its regulatory effect on the immune system. Pharmacological studies indicate that the icariside series glycosides increase immune activity and may act synergistically with other immune enhancing agents to stimulate interleukin production.718 Icariin and epimedin C isolated from Epimedium increased phagocytic activity of macrophages.724 Icariin also promoted natural killer cell and lymphokine-activated killer cell activity in patients with solid tumours, while in healthy subjects icariin induced lymphokine-activated killer cell activity and stimulated the production of

725 TNF-α in monocytes.

Epimedium may have a protective effect on the heart. An injection of Epimedium flavonoids were found to have a protective effect against acute myocardial ischemia

178 caused by ligation of the left anterior descending branch of the coronary artery in rats. The treatment also decreased the activity of creatine phosphokinase and lactate dehydrogenase, decreased the amount of malondialdehyde and significantly increased the activity of serum superoxide. The area of myocardial infarct was significantly reduced.726 Administration of a decoction or extract of Epimedium caused a hypotensive effect in a number of animals including rabbits, cats and rats.716, 727 The hypotensive action is believed to be primarily related to a blockade of sympathetic ganglions.716 Epimedium extracts increased coronary blood flow in rabbit and guinea pig heart, as a result of reduced vascular resistance.716

Epimedin A and ikarioside F, isolated from Epimedium, bound to S-adenosyl-L- homocysteine hydrolase and inhibited its action, thus regulating biomethylation and reducing cellular homocysteine levels.728 Elevated homocysteine is a causative factor of a number of diseases such as cardiovascular disease729 and diabetes.730 The inhibitory effect of Epimedium extract was more pronounced in the hepatic cell line, a major site of transmethylation.728

Clinical research on Epimedium predominately consists of observational studies undertaken in China. Epimedium may be beneficial for the treatment of angina pectoris and hypertension.716 Li and colleagues731 clinically observed 120 coronary heart disease patients treated with Epimedium. Half took tablets while the other half received treatment as intra-muscular injections. The treatments improved angina pectoris in both groups with a cure rate of 85.6%, no statistical differences were found between the groups (p<0.05). The herb was also effective in relieving choking sensations in the chest, palpitations, shortness of breath and hypertension. However,

179 no exploratory statistics were reported and a control group was not included for comparisons with treatment.731 A decoction of Epimedium was found to be effective in improving quality of life and stimulating the cellular immunity of patients undergoing dialysis treatment.732 The results of two other studies also found an improvement in immune functioning of dialysis patients after three months treatment with Epimedium.733, 734

8.3.4 Curculigo orchioides Gaertn.

Curculigo is a potent Kidney Yang tonic and is often combined with Epimedium to comprise the main herbs of the formula Er xian tang (Two Immortals Decoction).

Curculigo is primarily indicated to treat urinary incontinence, polyuria, irregular menses, arthritis pain, feelings of weakness in bones and sinews and/or lower back and knee pain.702

Active constituents isolated from Curculigo include a number of triterpenes such as curculigosaponins A-M,735-737 curculigol738 and curculigenin A.735 Phenolic glycosides include curculigoside A,739 B,740 C,741 D,742 curculigine A,701 B, C,740 orchioside A and B.743

8.3.4.1 Research

The pharmacological research conducted on Curculigo indicates the herb has a stimulatory effect on the immune system, an action which supports the traditional use of tonifying the defensive Qi. The administration of a 70% alcohol extract of the herb once daily for seven days increased the phagocytic activity of macrophages in

180 mice.702 Curculigosaponin G isolated from Curculigo was found to increase the weight of mouse thymus.736 Lakshmi and colleagues744 demonstrated that the purified glycoside-rich fraction isolated from Curculigo stimulated both humoral and cell-mediated immune responses by acting on macrophages and lymphocytes.

Curculigo may protect the body from oxidative stress. The antioxidant activity of a methanol extract of Curculigo rhizomes was investigated using the carbon tetrachloride (CCl4) intoxicated rat liver as an experimental model. It has been hypothesised that CCl4 induces liver injury via lipid peroxidation by free radical derivatives of CCl4. Hepatotoxic rats were given an oral daily dose of 70mg/kg body weight of a methanolic extract of Curculigo rhizomes for 90 days. The extract was efficient in combating oxidative stress due to hepatic damage and demonstrated significant antioxidant activity.745 A subsequent study found that the phenolic glycosides possess antioxidant activity.746

A literature search did not locate any pharmacological or clinical studies that substantiate the effects of Curculigo on urinary incontinence or arthritis. Further work is needed to investigate the traditional uses for this herb.

8.3.5 Phellodendron amurense Rupr

Phellodendron is a bitter and cold herb that clears Heat and eliminates Dampness.

Traditionally the herb is used to treat night sweating, afternoon fevers and sweating, diarrhoea, jaundice, oral ulceration, urinary tract infections, painful, red and swollen legs, skin infections with local redness and swelling.701

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Phellodendron contains 1.6-4.0% berberine,716 an isoquinoline alkaloid.747, 748 The actual amount depends on the variety and growing conditions.716 Other alkaloids isolated from Phellodendron include palmatine,748 magnoflorine and phellodendrine.749 Other constituents include triterpenes,750 glycosides751 and phenols.751, 752

8.3.5.1 Research

Phellodendron has traditionally been indicated to treat diarrhoea and dysentery caused by a range of pathogens, conditions that are considered to be Damp and Hot in nature. Pharmacological research has demonstrated that the decoction or ethanol extract of Phellodendron exhibited varying degrees of inhibitory action against a range of micro-organisms.716 The alkaloid berberine, demonstrated in vitro efficacy against Candida,753, 754 Streptococcus pyrogenes,755 Salmonella typhimurium,756 leishmania,757 methicillin-resistant Staphylococcus aureus,758 Trypanosoma brucei and T. congolense,759 Entamoeba histolytica,760 Giardia lamblia, Trichomonas vaginalis761 and Vibrio cholerae.762 Berberine may exert its effects via the inhibition of key enzymes involved in the biosynthesis of structural molecules,754 the blocking of pathogen adherence to host cells755, 763 or the inhibition of RNA and protein synthesis.764 The quaternary ammonium group of berberine may impart its antibacterial action. Derivatives such as tetrahydroberberine which do not contain the quaternary ammonium group demonstrate little antibacterial activity.764

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Phellodendron has been investigated as a potential anti-allergic agent and suppressor of the cellular immune response. An extract of Phellodendron decreased anaphylactic reactions occurring in mice sensitised and challenged with peanut.

Mice treated with Phellodendron had significantly lower histamine (p<0.05) and immunoglobulin E levels (p<0.01).765 The alkaloids magnoflorine and phellodendrine may have some value as immuno-suppressors. These alkaloids were found to suppress the induction but not the effector phase of the cellular immune response.749 The topical application of a Phellodendron extract significantly inhibited oedema induced by 12-O-tretradecanoylphorbol-13-acetate in mice

(p<0.05).766 Berberine was found to possess anti-inflammatory properties both in vitro and in vivo.767 The results of these preliminary studies confirm the traditional use of Phellodendron for skin conditions such as eczema and other skin conditions.

Clinical studies on Phellodendron conducted in China have predominately investigated the herb’s potential for treating infectious diseases. The herb has been successfully used to treat acute dysentery and chronic bacillary dysentery.716 Chang and But716 report that Phellodendron on its own or as part of a formula has demonstrated varying degrees of effectiveness in the treatment of other infectious diseases such as epidemic cerebrospinal meningitis, acute conjunctivitis, chronic maxillary sinusitis, chronic suppurative otitis media, impetigo, acute urinary tract infection, cervical erosion, candidial and trichomonal vaginitis.716

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8.3.6 Anemarrhena asphodeloides Bunge

Anemarrhena is a herb with cooling and moistening properties and is used to clear

Heat, nourish Yin and counteract dryness. Clinically, the herb is most useful when excess Heat damages body fluids and is indicated for high fever with thirst, perspiration and irritability. Other applications include tidal fever, night sweats, sweating palms and feet and for menopausal related conditions. Due to its cooling nature, Anemarrhena may neutralise the effect of warming herbs.702

Anemarrhena rhizome contains about 6% saponins.716 Sarsapogenin is the major aglycone of the saponins and constitutes about 0.5% of the dried root.768 Flavonoids include mangiferin,769 neomangiferin770 and isomangiferin.701

8.3.6.1 Research

Anemarrhena has been investigated for its anti-diabetic actions. Diabetes is traditionally considered a condition whereby excess Heat injures body fluids.

Anemarrhena counteracts dryness due to its action of nourishing Yin. Aqueous and ethanol extracts of Anemarrhena were found to lower blood glucose in animal models of diabetes.771-773 A decoction of the rhizome reduced blood glucose in alloxin-induced diabetic mice. A subsequent hypoglycaemic-activity guided fractionation isolated two glycosides (pseudoprototimosaponin III and prototimosaponin III) which demonstrated hypoglycaemic effects in a dose dependent manner in streptozotocin-induced diabetic mice. Since these compounds had no effect on glucose uptake and insulin release, the authors concluded the mechanism may be due to the inhibition of hepatic gluconeogenesis and/or

184 glycogenolysis.771 The glycans anemarans A, B, C and D extracted from a decoction of the herb also displayed hypoglycaemic effects. These constituents significantly reduced glucose levels in alloxan-induced hyperglycaemic mice (p<0.01).774

Mangiferin was also found to lower blood glucose in an animal model for type 2 diabetes mellitus (KK-Ay mice)772 but the compound had no effect on normal mice.775 The authors of these studies suggest that the antidiabetic mechanism of mangiferin may be due to decreased insulin resistance.772, 775

The decoction of Anemarrhena rhizome inhibited the growth of a range of pathogenic micro-organisms including Staphylococcus aureus, α- and β-haemolytic streptococcus, Salmonella typhi, Escherichia coli, Bacillus subtilis, Vibrio cholerae,

Pseudomonas spp., Mycobacterium spp. and Candida albicans.702, 716 The isolated compound nyasol showed antimicrobial activity against 38 strains of fungi and five strains of bacteria.776 In a subsequent study, Iida and colleagues777 demonstrated an in vitro synergism between nyasol and azole agents against four strains of Candida albicans. The authors suggest nyasol could be used as an adjuvant to azole treatment.777

A literature search did not locate any clinical studies investigating the action of

Anemarrhena as a single herb. There has been no scientific verification of the herb’s beneficial use for the treatment of menopausal complaints.

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8.3.7 Asparagus lucidus Lindley (syn. A. cochinchinensis Lour. Merr.)

Asparagus has traditionally been used to nourish Yin and moisten dryness, especially of the Lung and Intestines. Asparagus is indicated for non-productive dry cough or dry cough with little sputum that is difficult to expectorate. The herb is also used to treat constipation caused by dryness and Heat accumulation.702

The root tuber contains saponins including four furostanol saponins Asp-IV, V, VI,

VII,701, 727 asparacoside,778 asparosides A and B.779 The herb also contains asparagus oligosaccharides,780 aspacochioside A, B and C.781

8.3.7.1 Research

Asparagus is traditionally indicated to treat dry cough. In a recent animal study, the methanol extract of Asparagus tuber exhibited significant anti-tussive activity against sulphur dioxide-induced cough in mice. The inhibitory action was comparable to codeine phosphate.782 These results are promising; however the antitussive action of the herb in humans has not been investigated.

An aqueous extract of Asparagus demonstrated inhibitory activity against a range of bacteria in vitro including: Bacillus anthracis, B. diphtheria, B. subtilis, Diplococcus pneumoniae, Staphylococcus aureus, streptococcus702, 727 and Corynebacterium diphtheriae.702

Very little clinical research has been conducted on the single herb Asparagus. A small uncontrolled clinical study conducted in China on 42 women with lobular

186 hypertrophy of the mammary glands found that the herb administered orally, intramuscularly or via intravenous injection caused a remarkable improvement with an overall 83% rate of effectiveness.702

8.3.8 Zizyphus jujube Mill var. spinosa

Zizyphus is traditionally used to treat insomnia with difficulty falling or staying asleep, shallow sleep with a tendency to wake easily, excessive dreaming, palpitations, fatigue, poor appetite, forgetfulness and sallow complexion. The herb is also indicated to prevent sweating; spontaneous or night sweating due to Qi or Yin deficiency.702

The saponin content of Zizyphus seeds is approximately 0.1%716, 783 and includes

784 785 784 785 jujubosides A1, B, C, acetyljujuboside B, protojujubosides A, B, B1, oleanolic acid, maslinic acid786 and betulinic acid.787 Flavonoids extracted from the seeds include spinosin,788 swertisin789 and puerarin.790 Alkaloids include sanjoinines

A791 and B-F.792 The seeds contain approximately 32% fixed oil.716, 793, 794

8.3.8.1 Research

The hypnotic, sedative and analgesic properties of Zizyphus have been extensively studied and substantiated. Zizyphus induces sedative, hypnotic, analgesic and anticonvulsant effects in a range of animals including mice, rats, cats, rabbits, guinea pigs and dogs. Sedative and hypnotic actions were also observed in humans.702, 716,

727 Zizyphus may have varying effects depending on the dose. The results of two validated tests assessing anxiety in rodents revealed that an ethanolic extract caused

187 an anxiolytic effect at a lower dose and a sedative effect at higher doses in mice.795

At a dose of 1.0g/kg Zizyphus decreased locomotor activity in rats.795 Zizyphus causes a synergistic action between many sedatives and hypnotic agents. The herb prolongs sleeping time induced by barbiturates and reduces hyperactivity caused by caffeine and morphine.702, 716, 727, 796

A number of active compounds isolated from Zizyphus have an inhibitory effect on the central nervous system (CNS). Liao and colleagues797 demonstrated that a decoction of Zizyphus seeds act on CNS receptors 5-hydroxytryptamine (5-HT1A and

5-HT2) and γ-amino-n-butyric acid. A subsequent study found that oleamide potentiates the actions of 5-HT2 receptors and this mechanism partly explains the sleep inducing properties of Zizyphus.798 Jujuboside A inhibited both the in vivo excitability of dentate gyrate cells evoked by the paired-pulse stimulus and the in vitro penicillin sodium-induced hyperactivity of pyramidal cells.799 A high dose of jujuboside A (0.1g/L) was also found to have an inhibitory effect on the glutamate- mediated excitatory signal pathway in the hippocampus by significantly blocking penicillin-induced glutamate release (p<0.05).800 Jujuboside A is a non-competitive inhibitor of calmodulin, a calcium ion binding regulatory protein.801 Zhang and co- workers800 found that jujuboside A significantly inhibited glutamate-induced calcium ion increase. The calmodulin antagonist trifluoroperazine demonstrated a similar effect as jujuboside A, therefore the authors conclude that the inhibitory effects of jujuboside A probably act via an anti-calmodulin-like action.800

A decoction of Zizyphus was found to decrease convulsion and death rates in animals receiving an ED50 of pentylenetetrazole, a CNS and respiratory stimulant which has

188 been used experimentally to study seizure phenomenon. Zizyphus also prolonged the latent period of convulsion induced by strychnine in mice and delayed the death of these animals.716, 727

Zizyphus seeds exert a hypotensive effect in dogs and rats. The intravenous administration of a decoction of Zizyphus to anesthetised dogs caused an immediate and prolonged hypotensive effect. In rats with renal hypertension, 20-30g/kg of the seed given ad libitum also significantly decreased blood pressure.716, 727 The herb has been used clinically to treat arrhythmia caused by aconitine, chloroform and barium chloride.702

Clinical studies have not been conducted using the single herb Zizyphus; however several studies have investigated the use of the herbal formula Suan zao ren tang, of which Zizyphus is the principle herb. The formula is mainly indicated for the alleviation of insomnia.702 Chen and Hsieh802 conducted a cross-over trial on the use of Suan zao ren tang for the treatment of sleeping disorders in 60 patients. After receiving a placebo for one week, patients were given 1g of Suan zao ren tang to take 30 minutes before bedtime for two weeks and were then given placebo again for one week. Suan zao ren tang was found to improve sleep quality and well-being during the treatment period compared to placebo (p<0.001). A similar clinical study was conducted on Suan zao ren tang for the treatment of anxiety as measured by the

Morbid Anxiety Inventory and Hamilton Anxiety Scale. Thirty six patients were given placebo for one week, then 750-1500mg Suan zao ren tang per day for one week followed by another week of placebo. The herbal formula was found to improve mood, decrease anxiety and improve psychomotor performance.803 A third

189 trial conducted by the same authors found that Suan zao ren tang significantly reduced anxiety in cardiac patients within two weeks of administration of the formula (p<0.001).804 A further study demonstrated that Suan zao ren tang had a similar anxiolytic effect to low dose diazepam without affecting psychomotor performance during the day.805

8.4 CHM Pharmacological Research

Pharmacological evidence supporting and substantiating the traditional uses of the

Chinese herbs of FF-01 is limited. This may be due to a number of factors. The traditional actions of Chinese herbs are described in a theoretical language foreign to

Western pharmacology and medicine. TCM mechanisms are depicted in broad terms such as tonifying Qi, clearing Heat or nourishing Yin. The matching of these diffuse functions with precise pharmacological actions poses many difficulties. Agreement is needed on which biochemical actions define the various TCM concepts. For example, herbs that increase the immune response may be described as tonifying Qi while herbs with an anti-inflammatory action clear Heat.

The practice of TCM rarely uses herbs in isolation but as complex formulae containing from two to numerous herbs. Each herb has a variety of pharmacological actions and when used in combination these actions may complement, augment or mitigate undesired effects of a herb. Investigating the actions of these formulae requires a great deal of work. Such research initially involves the characterisation of the individual herb and chemical standardisation of the active constituents, while subsequent work includes subjecting the standardised formulae to biological assays

190 consistent with their presumed in vivo activity and investigating the effect of the formula on appropriate animal models which mimic the condition in question. These studies should be pre-requisites before clinical testing is commenced on human subjects. Pharmacological studies on human subjects should also include the measurement of metabolised active compounds found in both blood and urine.806

A great deal of research on the pharmacological actions of herbal medicine is being conducted in China. However, the language barrier may prevent the dissemination, discussion and peer review of findings with members of the wider scientific community. A lack of peer review may result in the publication of poorer quality studies. This has been noted with the reporting of RCTs.807 Furthermore, since most

RCTs claim the treatment to be effective, a bias toward the publication of positive outcomes has been suggested.644

In the West, a lack of funding greatly restrains the type and amount of research conducted on the therapeutic actions of herbs. The economic viability and financial returns for the support of this research is; at worse limited and at best not realised.

Pharmaceutical companies may commit funds for research if there is some financial return. Therefore, research tends to centre on the search for chemical compounds isolated from herbs that may be cures or treatments for chronic diseases such as cancer or diabetes. When modified and patented, these isolated compounds have the potential for good financial returns.

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8.5 Summary and Conclusions

This chapter examined the available pharmacological and clinical research undertaken on the herbs comprising FF-01. A large amount of work has been conducted on Cimicifuga, mostly in Germany and the US. The overall scientific evidence for the symptomatic relief from vasomotor symptoms with Cimicifuga is moderate. A significant number of clinical studies were conducted using standardised extracts or products such as Remifemin or Menofem. Although earlier research was plagued with similar design flaws as described for CHM, recent clinical studies have been more rigorous. However, further clinical work employing sound

RCT methodology to assess the true therapeutic efficacy of CHM and Cimicifuga for the treatment of vasomotor symptoms is warranted.

FF-01 is loosely based on two classical Chinese herbal formulae and consists of seven Chinese herbs and Cimicifuga. The Chinese herbs were primarily chosen for their Yin nourishing and Heat clearing properties in order to augment the action of

Cimicifuga to alleviate menopausal vasomotor symptoms. Anecdotal evidence obtained from a similar formula that had been on the market for a number of years, suggested an effective treatment with minimal side effects. Therefore, it was hypothesised the new formula would demonstrate similar efficacy for the alleviation of symptoms. Given the problems associated with long-term HT use, an effective low risk herbal treatment to alleviate hot flushing would be highly sought after by symptomatic menopausal women.

There is scant available pharmacological and clinical evidence to substantiate the traditional uses of the Chinese herbs comprising FF-01. Although the evidence

192 supporting the use of Zizyphus for the treatment of sleep disorders is promising, little evidence supports the traditional uses of nourishing Yin and clearing Heat for the treatment of sweating, flushing and thirst as indicated for the other herbs. CHM is mostly administered as complex herbal formulae and this may be one reason why little clinical work has been conducted on individual herbs.

A number of factors contributed to the decision to conduct a clinical trial evaluating a CHM formula for the alleviation of vasomotor symptoms. These were: increasing concerns regarding the safe use of HT created an interest in the search for alternative treatments, anecdotal reports of a similar efficacious formula and finally support of this project by the sponsor Global Therapeutics. Therefore, the following randomised double-blind placebo controlled trial was planned to evaluate the efficacy of FF-01. The trial protocol was planned in accordance with the CONSORT statement recommendations for the reporting of clinical trials.642 Since vasomotor symptoms may impact negatively on quality of life, the formula will also be evaluated for improving quality of life through the use of two validated menopause specific scales. The trial protocol is outlined in Chapter 9.

The following chapter discusses the impact of the menopausal transition on bone turnover and investigates the favourable effects of several herbs comprising FF-01 on bone metabolism. The chapter proposes the need for a pilot investigation on the effect of FF-01 on bone turnover.

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CHAPTER 9 MENOPAUSE AND BONE METABOLISM

9.1 Introduction

Menopause is associated with an increased rate in bone turnover, which may lead to the osteoporotic thinning of bones and a greater rate of fracture. Osteoporotic fractures are a major cause of morbidity and mortality among postmenopausal women. The cost of treating these fractures has been estimated to be $1.9 billion per annum. Due to an increasingly aging population, the financial outlay and social burden of osteoporotic fractures will continue to impose a considerable strain on the healthcare system and society. Although often prescribed to prevent or treat osteoporosis, HT is now not recommended for long-term use because of associated health risks.

The following chapter discusses the impact of the menopausal transition on bone metabolism and the risk of fracture. A number of pharmacological treatment options

194 for reducing the progression of osteoporosis and the incidence of fractures will be discussed. FF-01 includes several herbs which have been reported to favourably affect bone. Evidence for the beneficial effect of these herbs on bone will be discussed in order to justify investigating the formula’s effect on bone turnover as a pilot study. The pilot study assesses changes to biochemical markers of bone turnover in response to treatment. These markers are useful in evaluating therapies for preventing bone loss as they respond more rapidly to the effects of therapy than any detectable changes in BMD.

9.2 Definition of Osteoporosis

Osteoporosis is a chronic skeletal disorder characterised by excessive loss of bone mineral content and micro-architectual deterioration leading to enhanced bone fragility and increased risk of fracture.808, 809 A clinical diagnosis of osteoporosis is confirmed by a history of low trauma skeletal fracture, primarily occurring at the vertebrae and long bones, especially the neck of the femur. The diagnosis of osteoporosis in the absence of fracture is made when bone mineral density (BMD) falls below 2.5 standard deviations of the mean for young healthy women or a t score of -2.5.810, 811 The reference standard for diagnosis is measured by dual-energy x-ray absorptiometry at the femoral neck of the hip.811

Osteoporosis is classified into a number of types. Post-menopausal osteoporosis is related to a decline in ovarian function and oestrogen production resulting in an initial loss of trabecular bone. Senile osteoporosis affects both men and women over

70 years of age, and is due to the age related decline in both cortical and trabecular

195 bone.812 Secondary osteoporosis is mediated via an identifiable agent or disease, while idiopathic osteoporosis refers to bone loss due to unknown causes. This chapter will focus primarily on post-menopausal osteoporosis with some reference to bone loss with aging.

9.3 Risk Factors for Osteoporosis

A number of risk factors for sustaining an osteoporotic fracture have been identified

(refer to Table 9.1).813 Increasing age814, 815 and being female816 are two major non- modifiable risk factors. Women are at greater risk of fracture due to their lower peak bone mass at maturity, an acceleration in bone loss at menopause and a greater likelihood of falling with age.817 Women also live significantly longer than men.

Other strong factors include previous fragility facture,818 low oestrogen levels,819 acquired peak bone mass,820, 821 use of corticosteroids,822 anticoagulant use823 and low body weight.824 Racial825, 826 and genetic827 factors may also play a role in the risk of developing osteoporosis. A number of lifestyle factors affect BMD such as smoking,828, 829 exposure to cigarette smoke,830 chronic alcohol consumption,831 exercise,832 high caffeine consumption833-835 and low intake of fruit, vegetables and seafood.836, 837 Although a significant correlation has been found between bone density and calcium intake,838 many women fail to consume the recommended daily allowance of calcium.839 This deficit is further compounded by the reduced ability to absorb calcium with age.840 Recently, high levels of serum homocysteine have been implicated as a strong and independent risk factor for osteoporotic fractures;841 a high serum level incurs nearly twice the risk of hip fracture.842 Finally, falling increases the risk of fracture and the likelihood of a fall depends on the physical

196 condition of the woman and her home environment. Lack of exercise, muscle weakness, visual impairment, reduced mobility2, 843 and the use of CNS-active medications844, 845 all increase the risk of falling in older women.

Table 9.1: Risk factors for osteoporotic fractures

• Female gender • Age • History of fragility fracture • Attained peak bone mass • Premature menopause • Primary amenorrhoea • Caucasian or Asian ancestry • Genetic factors • Elevated homocysteine • Prolonged immobilisation • Lack of physical exercise • Muscle weakness • Visual impairment • Poor diet • Low calcium intake • Vitamin D deficiency • Alcohol abuse • Smoking • Corticosteroid use • Use of CNS-active medications

9.4 Burden of Osteoporotic Fractures

Osteoporotic fractures most commonly occur at the vertebrae, hip, forearm, wrist and rib.846, 847 Vertebral and hip fractures are associated with a substantial increase in morbidity and mortality.9 A history of previous fracture significantly increases the chance of future fractures,818 particularly vertebral.848 Women with pre-existing vertebral fractures have approximately a four times greater risk of sustaining another

197 fracture compared to women with no history of fracture. This risk increases with the number of prior fractures848 and is highest immediately after the fracture event.849

Fractures significantly impact on quality of life, resulting in physical, psychological and social consequences.847, 850 Following a fracture, most women are restricted in their daily activities and often suffer pain, a loss of confidence, independence and quality of life.850-852 Morbidity may extend to at least a year post-fracture.853 Back pain and functional limitations are common in women with vertebral fracture and disability increases with multiple fracture sites.854 Hip fractures are the most severe of osteoporotic fractures and are often the result of a fall, although they may also occur spontaneously. Hip fractures are usually painful, require hospitalisation and are a significant cause of morbidity.855 Fractures are associated with an increased risk of mortality, particularly within the first year of the event.856 Women who sustain a clinical vertebral or hip fracture have a six to nine fold increased risk of mortality9 compared to women with no fracture. The risk of death increases with advancing age857 and is greater for those with coexisting morbidities and poorer pre- fracture health status.858

Fractures place a huge economic and social burden on society.859-861 Costs to society include medical and institutional care, death, pain, functional limitations, loss of independence, inability to work and reduced quality of life. Of women who sustain a hip fracture, approximately 7% will require help with daily activities while 8% need long-term care in an institution or nursing home.862 Survivors may also require modifications to living accommodation and the use of aids to assist walking.863

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Osteoporotic fractures have been estimated to account for 0.83% of the global burden of non-communicable disease.864 Similarly, the treatment of osteoporotic fractures imposes a considerable financial strain on the Australian health care system. This burden is likely to increase as the Australian population of women over

65 has been forecasted to climb from 14.5% of the total population to 19% by 2021, or approximately 2.4 million women.865 Based on fracture rates and hospitalisation data, Access Economics10 determined that nearly two million Australians suffered osteoporosis related conditions in 2001; 75% were women. This number was projected to increase to three million by 2021, with a fracture occurring every 3.5 minutes. The annual health cost of osteoporosis was estimated to be $1.9 billion per annum, with a heavy burden being placed on hospitals and nursing homes. A further

$5.6 billion in indirect costs was attributed to lost earnings, volunteer carers, equipment and modifications to housing. Osteoporosis was determined to be more expensive to the community than either diabetes or asthma, both of which are considered National Health Priorities.10

9.5 Skeletal Changes Associated with Menopause

The amount of skeletal mass accumulated during adolescence and early adulthood is an important determinant for the future risk of osteoporosis.820, 866 The accrual of peak bone mass is essentially complete by the end of the teenage years.867, 868 A slight and gradual decline in bone mass occurs in regularly menstruating women during the following years up until the menopausal transition, which translates to approximately 0.2% loss at the proximal femur.869 However, bone loss accelerates at

199 menopause,869, 870 especially the first five years post-menopause, resulting in a 10 times greater annual change in spine density and total bone calcium compared to the premenopausal years.871 Prospective studies suggest an annual rate of bone loss of between 2-2.4% during this time period872-874 independent of age at menopause.872

Thereafter, the rate of bone loss decreases exponentially with time until it plateaus to a similar level as the premenopausal years.874, 875 The amount of bone lost following menopause is similar, irrespective of the age at which menopause occurs876 as no correlation has been found between the age of menopause and BMD of late postmenopausal women.872, 877

Bone loss at menopause takes place throughout the skeleton, however the initial loss is more likely to be trabecular than cortical bone.870, 878 Since the vertebral bodies predominately consist of trabecular bone, the accelerated loss of bone at these sites accounts for the vertebral fractures which occur some 10-20 years after menopause.879 Subsequent bone loss due to aging involves both cortical and trabecular bone.812

9.6 Biochemical Markers of Bone Turnover

The adult skeleton is constantly renewed in order to maintain elasticity, mechanical support and calcium homeostasis. This process, termed remodelling, occurs predominately at skeletal sites rich in trabecular bone, such as the vertebrae, proximal femur, calcaneus and ultradistal radius.880 The process of bone remodelling occurs in cycles. Osteoclasts move into a resorption site and adhere to bone. Bone is removed due to the osteoclastic secretion of protons and proteases

200 which dissolve the mineral matrix and breakdown collagen respectively. Soon after osteoclasts leave the site, osteoblasts invade and begin forming new bone by secreting osteoid, a matrix of collagen and other proteins. Eventually this new matrix is mineralised.881 The processes of bone formation and resorption are closely coupled in order to maintain bone mass and integrity.882 Changes in bone remodelling with aging increases bone loss and plays a significant role in the development of osteoporosis.883, 884 As bone remodelling or turnover increases with age,884 bone formation proceeds at a slower rate than resorption885, 886 resulting in decreased bone mass and strength.

Oestrogen deficiency is the most significant factor in the pathogenesis of postmenopausal bone fragility.887, 888 A decline in BMD has been associated with declining oestrogen levels at menopause819, 889 and with a sudden drop in oestrogen following oophorectomy.890 A prospective study conducted over 15 years from the time of menopause, found a significant correlation between postmenopausal serum oestradiol levels and changes in BMD (r=0.34, p<0.001).891 Oestrogen deficiency causes an increase in the rate of bone remodelling, by increasing the lifespan of osteoclasts and shortening that of osteoblasts and osteocytes. These changes result in an overall decrease in the amount of bone formed during each remodelling cycle.881 The decline in BMD due to a decrease in oestrogen can be prevented or reversed by HT.892-894

Bone turnover can be monitored by measuring biochemical markers detected in serum or urine. Osteoblasts synthesise a number of bone-specific proteins such as osteocalcin and bone-specific alkaline phosphatase (BAP) which enter the blood

201 stream from the skeleton. These can be detected using sensitive radio-immuno or enzyme-linked immunosorbent assays, giving an index of bone formation. During bone resorption, osteoclasts release skeletal matrix products which enter the circulation without being metabolised by the kidneys. These products include type 1 collagen cross-links which originally bridge collagen fibrils giving support to the tertiary collagen structure. There are several bone resorption markers found in urine and the type depends on the site of cleavage. These include free pyridinoline and deoxypyridinoline (DPD), N- and C-telopeptides. The biochemical products of bone formation and resorption are collectively termed biochemical markers of bone turnover.895, 896

Although the levels of bone markers indicate the rate of bone remodelling, they do not provide information on the existing status of BMD. Therefore, they cannot provide or confirm a diagnosis of osteoporosis and are not a substitute for BMD testing.895 Nevertheless, evidence suggests that high values of marker levels are associated with an increased risk of fracture, possibly independently of BMD.897 As discussed previously, accelerated bone turnover leads to an imbalance in bone remodelling, causing deterioration to the skeletal micro-architecture and a reduction in bone strength. Garnero and colleagues884 demonstrated that bone turnover markers increase in perimenopausal women with irregular menses and elevated FSH levels and these markers continue to remain high after menopause. The menopausal transition induced an elevation of bone formation and resorption markers of between

37-52% and 79-97% respectively (p<0.0001). These data indicate that a high rate of bone turnover is associated with lower bone mass. A prospective study found that elderly women with increased levels of bone resorption markers had a greater risk of

202 hip fracture independent of hip BMD. The authors conclude that a combination of

BMD with bone resorption markers may be useful in improving predictions of hip fracture risk in elderly women.898 A recent meta-analysis of 18 clinical trials on antiresorptive therapy undertaken by Hochberg and colleagues899 provides further evidence that elevated bone turnover strongly influences fracture risk. The authors estimated that a 70% reduction in resorption markers resulted in a 40% decrease in non-vertebral fractures, while a 50% decrease in formation markers translated into a reduction in fracture risk of 44%. However, despite this promising evidence, bone markers have not been fully established to predict the likelihood of fracture and therefore should not be used in the place of BMD in establishing a prediction of risk.900

Bone turnover markers are useful in monitoring the skeletal response to therapy as these indices decrease more rapidly than any detectable therapeutic change in BMD.

Since BMD represents a net balance between bone resorption and formation, BMD measurements do not detect small changes in bone metabolism. BMD changes in response to therapy are generally less than 2% per year or reach a maximum of less than 1% over 3-6 months.900 However, changes in BMD of less than 1% are difficult to measure due to limitations in the precision of measuring devices.901 Bone markers generally reach a nadir within 3-6 months after the initiation of treatment. Although a reduction in markers to a pre-menopausal level with therapy is suggested, there is some controversy as to their exact premenopausal range,895 as markers may vary considerably between individuals. Depending on the marker, a decrease of 20-50% from baseline measures has been suggested as a good indication of therapeutic efficacy.902

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A number of shortcomings have been identified with the use of bone markers, and these should be carefully considered when evaluating treatments. The levels of urinary bone markers may vary considerably within an individual903, 904 and between collection times on a given day.903 Urinary markers measurements can differ by up to 30% over the course of a day, while serum markers vary by less than 10% within an individual.903 Variability between marker measurements can be reduced by collecting specimens at approximately the same time each day and by taking duplicate samples and measurements.895 Since, most bone markers may be influenced by non-skeletal diseases such as malignancy, chronic renal and hepatic failure,905 clinical research should include healthy subjects and the assay of bone markers most specific to skeletal metabolism, such as BAP and DPD (as a ratio to creatinine excretion).896 This may reduce the inter-individual variability in marker measurements.

9.7 Pharmacological Treatments for Osteoporosis

Presently there is no cure for osteoporosis, nor can the loss of bone with aging be prevented. However, the onset of osteoporosis may be delayed and the severity reduced with careful management of risk factors and pharmacological treatment.

Treatment involves maximising bone mass and reducing postmenopausal bone loss in order to minimise the risk of fracture.906 The treatment of osteoporotic bone loss is warranted due to the significant morbidity and mortality associated with fractures and the increased risk of fracture with aging. Initial measures should include

204 minimising the risk of falling and undertaking lifestyle modifications that ensure adequate nutrition, appropriate exercise, reduction in excess alcohol consumption and the cessation of smoking. A range of pharmacological therapies are now available for the management and treatment of osteoporosis. Therapies include hormonal medications which prevent bone loss and maintain bone quality, antiresorptive therapies such as bisphosphonates and over-the-counter treatments such as calcium. Preliminary evidence also suggests that a number of herbs may have a beneficial effect on bone metabolism. The following section reviews a number of treatments for preventing osteoporotic bone loss.

9.7.1 Hormonal and oestrogen-like medications

9.7.1.1 Hormone therapy

Numerous observational and clinical studies document the positive effect of HT on

BMD892-894, 907 and on reduction in fracture risk.908-910 An evaluation of 11 epidemiological studies investigating the use of oestrogen and hip fracture found a reduction of approximately 25% in hip fracture risk whenever users of oestrogen were compared with non-users.543 A subsequent meta-analysis of randomised trials on HT for the prevention of nonvertebral fractures noted a significant reduction in fractures particularly for women younger than 60 years (RR 0.45; 95% CI, 0.26-

0.79; p=0.005). However, the beneficial effect of HT on fracture seems to be reduced in women who initiate therapy after 60 years of age.911 The WHI confirms that HT also reduces the incidence of hip fractures in relatively healthy low risk postmenopausal women. The study recruited 16,608 women aged 50-79 years with an intact uterus who were followed for an average of 5.6 years. During this time

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8.6% in the active group and 11.1% taking placebo experienced a fracture (hazard ratio 0.76; 95% CI, 0.69-0.83). After three years of treatment the total hip BMD increased by 3.7% compared to placebo of 0.14% (p<0.001).892

For a therapeutic benefit to bone, oestrogen should be taken continuously over a long period of time.908 However, as discussed previously (refer to section 6.6.1.1) the long term use of HT increases the risk of breast cancer, thromboembolism, stroke and cardiovascular disease and these risks may outweigh any skeletal benefits16, 892 even in women considered to be at high risk of fracture.892 Furthermore, side effects such as breakthrough bleeding, breast tenderness and weight gain contribute to low compliance with HT.140, 535 A study conducted by McCombs and colleagues912 found that one year compliance rates for osteoporosis therapies, including HT, was below 25%. The mean adjusted duration of continuous therapy with oestrogen only was 262 days and 292 days for oestrogen plus progestin.912

There is some controversy as to the best time to begin HT for the prevention of fracture. A number of studies suggest that early initiation of treatment confers the greatest benefit. A prospective cohort study on osteoporotic fractures in older women found that starting oestrogen therapy within five years of menopause was associated with a 50% reduction in the risk of non-spinal fractures amongst long- term users, while no effect was noted if oestrogen was initiated after five years.908

Women who began therapy within 3-4 years of oophorectomy regained BMD while those who started therapy after six years did not.894 Similarly, Nachtigall and colleagues913 note that women who were therapeutically administered oestrogen within three years of menopause had the greatest increase in metacarpal bone

206 density. Conversely, the Rancho Bernado study found that oestrogen therapy began after age 60 and continued for at least nine years offered nearly equal bone- conserving effects when compared to women who initiated treatment before this age.914

A number of observational studies908, 915, 916 and clinical trials917-921 indicate that the discontinuation of oestrogen therapy results in a loss of BMD. Withdrawal of therapy leads to a decrease in much of the BMD that was gained with hormone treatment921, 922 resulting in an increased rate of fractures.908, 916 Evidence from the

National Osteoporosis Risk Assessment study suggests that postmenopausal women who discontinued oestrogen therapy for five years or more have a risk for hip fracture that is as high as, or higher than, women who never used oestrogen.921

Therefore, the dilemma for women at high risk of osteoporosis is; HT taken for the reduction in fracture risk must be continuous and long term, yet long term treatment with HT is associated with increased health risks to the extent that the risks may outweigh the benefits.

9.7.1.2 Selective oestrogen-receptor modulators

Selective oestrogen-receptor modulators (SERMs) are pharmaceutical agents that have oestrogen-like effects in some tissues (e.g. bone) and oestrogen antagonistic activity in other tissue such as breast and the endometrium.18 The only SERM agent available on the PBS for the treatment of osteoporosis is raloxifene.906 This pharmaceutical causes a modest increase in bone density,923 less than that reported by oestrogen or bisphosphonates (refer to section 9.7.2.1). In postmenopausal

207 women with prevalent vertebral fractures, 36 months of raloxifene therapy reduced fracture risk by 30%; while women without fractures experienced a 50% reduction in the risk of vertebral fracture. An effect on non-vertebral fractures was not reported.924 In a subsequent post-hoc analysis of this study (the MORE cohort), raloxifene was found to significantly decrease the risk of subsequent non-vertebral fractures in a small subgroup of women with severe baseline vertebral fractures at three years [RR 0.53(95% CI 0.29, 0.99); p=0.046].925 Due to its SERM-like action, raloxifene decreases the risk of invasive breast cancer by 76-84% over a 2-4 year period.926, 927 Nevertheless, the drug is associated with an increased risk of thromboembolic disease with a relative risk similar to HT926, 927 and a worsening of vasomotor symptoms.926 Compliance with raloxifene tends to be low.912

9.7.1.3 Calcitonin

Calcitonin, a polypeptide hormone produced by the thyroid, inhibits osteoclastic bone resorption.928 Calcitonin is usually administered as an intranasal spray but may also be given intramuscularly. Clinical studies have suggested that calcitonin significantly increases spinal bone mass929 and reduces the risk of new vertebral fractures in postmenopausal women with osteoporosis.930 A meta-analysis of calcitonin for the treatment of postmenopausal osteoporosis suggests that the hormone increases bone density predominately at the lumbar spine and forearm and reduces the risk of vertebral fracture. The effect on non-vertebral fractures is unknown. However, the authors note that the true effect of calcitonin on BMD and fracture risk is not certain as methodologically weaker studies demonstrated greater effects on bone density and the results regarding lumbar spine density suggest

208 publication bias.931 Calcitonin is generally considered safe, although the injectable form causes flushing and local irritation at the injection site. Milder rates of flushing and irritation were reported by those using the intranasal spray.932

9.7.1.4 Vitamin D

Vitamin D is a pro-hormone essential for the absorption of calcium. The hormone is produced in the skin with exposure to sunlight. Serum vitamin D concentrations decline with age due to decreased synthesis by the skin933 and kidneys,934 reduced consumption of vitamin D rich foods935 and a reduction in intestinal responsiveness to the hormone.936, 937 Consequently, intestinal absorption of calcium is reduced,938 which leads to increased parathyroid hormone secretion939, 940 causing dissolution of bone in order to make calcium available during periods of deficiency.941, 942

Supplementation with vitamin D decreases serum parathyroid hormone levels and to some extent depresses bone turnover.943

The results from a number of studies investigating the affect of supplementation with vitamin D on bone and fracture risk are mixed. Heikinheimo and colleagues944 found that intramuscular injections of 150,00-300,000IU (international units) of vitamin D annually over 4.5 years to 341 elderly subjects reduced the incidence of upper limb and rib fractures by 25%, compared to 458 subjects who received no injections. Similarly, a study conducted by Trivedi and others945 concluded that vitamin D supplementation reduced the rate of first fracture at any site by 22% and caused a 33% lower rate for fracture at the hip, vertebrae, wrist or forearm over a 5 year period. Vitamin D supplementation significantly reduced winter-time bone loss

209 and improved net spinal bone density in postmenopausal women residing at a latitude of 42 degrees.946 However, a RCT administering 400IU vitamin D or placebo for 3.5 years to 2,578 community based men and women concluded that supplementation with the hormone did not reduce the incidence of fracture.947 A recently published meta-analysis on the effect of vitamin D supplementation alone on the risk of fall and fracture found a trend towards a reduced fall risk amongst treated patients. However, there was no clear evidence for a reduction in the risk of non-vertebral or vertebral fractures.948

9.7.2 Non-hormonal medications

9.7.2.1 Bisphosphonates

Bisphosphonates are stable analogues of pyrophosphate which inhibit bone resorption by suppressing osteoclastic activity949 and increasing cell apoptosis.950

New bone formed with bisphosphonate treatment is histologically normal.951, 952

Bisphosphonates approved in Australia for the treatment of established postmenopausal osteoporosis are alendronate and risendronate.953

Oral treatment with bisphosphonates suppresses bone turnover, particularly bone resorption, by about 50-60% below baseline values after 3-6 months of treatment.954,

955 These agents increase BMD by reducing activation of bone modelling units and bone remodelling activity, thereby prolonging the secondary mineralisation of bony tissue.956 With therapy, bone turnover decreases to values within the premenopausal range.957

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Bisphosphonates increase BMD both at the vertebrae and hip. Women treated orally with risendronate for three or more years had increases in BMD of approximately

6% at the lumbar spine and 2-5% at the hip.951, 955, 958 Increases in BMD with alendronate were slightly higher.954, 959

Alendronate and risendronate therapy reduces the risk of vertebral fractures in women with pre-existing baseline fractures and in women diagnosed with osteoporosis but with no history of vertebral fracture.951, 958, 960 Fracture protection begins several months after the initiation of treatment951, 961 and continues for several years.962 Clinical data also suggests a reduction in the risk of non-vertebral fractures.

An analysis of four phase III clinical trials conducted on risendronate concluded that the incidence of non-vertebral fractures was reduced by 59% in women with pre- existing fractures; with a significant protection against fracture after six months of treatment. No fractures were reported during three years of treatment amongst patients diagnosed with osteoporosis who had no history of prior vertebral fractures.963

The bisphosphonates, ibandronate and zoledronic acid have a similar action to alendronate and risendronate. Ibandronate administered daily or monthly is highly effective in reducing bone turnover,964 increasing lumbar spine and hip BMD964, 965 and in reducing fractures.964 Intravenous zoledronic acid has also demonstrated similar effects on bone turnover and bone density.966 However, no studies have been conducted assessing fracture risk reduction amongst postmenopausal osteoporotic women with zoledronic acid.

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The use of bisphosphonates has been associated with a number of adverse events and toxicity may vary considerably from one compound to another. High doses may impair skeletal mineralisation and increase the rate of fractures; however at doses used to treat osteoporosis, no signs of adverse mineralisation were apparent.

Gastrointestinal absorption of bisphosphonates is low and therefore the drug must be taken on an empty stomach. Oral amino derivatives may induce gastrointestinal lesions with erosive oesophagitis.967 However, an assessment of gastrointestinal safety found that treatment with bisphosphonates did not increase the incidence of upper gastro-intestinal adverse events when compared to placebo. Nevertheless, because dyspepsia and abdominal pain were frequently reported by women taking part in placebo controlled trials of bisphosphonates,968, 969 it has been suggested that these medications be used with caution in patients with a history of reflux or hiatus hernia.906 Weekly administration of bisphosphonates may further reduce the risk of gastrointestinal symptoms.969 Other reported adverse events with bisphosphonate treatment included inflammation of ocular structures, abnormal liver function970 and bone necrosis of the jaw.971 Intravenous or high dose oral therapy has been associated with flu-like symptoms970 and renal failure.972, 973

These agents are deposited and gradually accumulate within the skeleton. Due to their long half-life they may remain in the body for decades. The long-term negative effects of bisphosphonate accumulation are unknown as the longest follow-up has only been 10 years. These agents may have adverse physiological effects on bone metabolism that are yet to be determined.974 Over-suppression of bone turnover by alendronate has been recently reported in the literature. Suppression of bone

212 turnover caused spontaneous non-spinal fractures and delayed or prevented the healing of fractures during therapy.975

Overall compliance with bisphosphonate therapy is low.912, 976 Approximately 70% of women who initiate drug therapy are non-adherent to treatment within 12 months, and almost 50% discontinued therapy by this time.976 The average duration of treatment was 245 days. Bisphosphonates do not seem to offer any compliance advantages over HT.912

9.7.2.2 Calcium

Calcium is important for bone strength. An adequate intake during childhood is necessary for the acquisition of good peak bone mass which may confer a reduced risk of osteoporosis in later life.838, 977 However, many women do not consume the recommended daily allowance of calcium.839 Furthermore, a high dietary intake of sodium increases urinary excretion of calcium ions978, 979 further reducing calcium reserves. The ability to absorb calcium840, 980 and synthesise vitamin D981 decreases with age, causing an increased secretion of parathyroid hormone resulting in an increased release of calcium from bone.940 Calcium supplementation by older women with low intakes of dietary calcium may partially reverse raised parathyroid hormone levels, decrease bone turnover and bone loss.982

Calcium supplementation alone has a modest effect on bone density. An analysis of

20 trials investigating the postmenopausal supplementation of calcium found a mean rate of bone loss to be 1% per annum amongst control subjects and 0.014% per

213 annum for subjects taking calcium (p<0.001).983 A recently conducted clinical trial demonstrated a beneficial effect of calcium supplementation on bone in older healthy postmenopausal women. An analysis of the per-protocol population, women who had a compliance rate of greater than 60%, demonstrated a 64% reduction in bone loss at the hip and a 59% reduction in total body bone loss amongst women taking calcium for five years. However, the effect of calcium on fracture could not be determined due to poor long-term compliance.984 Although calcium does not prevent early postmenopausal bone loss,985 supplementation may be most beneficial to women who are six years or more postmenopause.986

The effects of calcium supplementation may be augmented when taken with vitamin

D or other anti-resorptive agents. The supplementation of vitamin D with calcium reduces bone loss at the hip, spine and total body987 and decreases the risk of hip and other non-vertebral fractures.988, 989 These studies suggest that vitamin D and calcium are both necessary to reduce bone loss and fracture risk, and their supplementation may be a safe and inexpensive preventative measure. An analysis of published trials evaluating the efficacy of calcium in conjunction with oestrogens and intranasal calcitonin on change in bone mass found that calcium potentiates the positive effect of oestrogen at the lumbar spine, hip and forearm and possibly increased the effect of calcitonin at the lumbar spine.990

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9.7.2.3 Phytoestrogens

Epidemiological studies suggest that the regular consumption of phytoestrogens may have beneficial effects on bone; as the incidence of osteoporotic fractures is lower in countries that typically consume large amounts of soy.188-190 Phytoestrogens are non-steroidal plant compounds that are structurally similar to oestrogen and possess weak oestrogenic and anti-oestrogenic effects via their interaction with oestrogen receptors.991 Isoflavones are the most potent phytoestrogens and are found in high concentrations in soybeans.176, 992 Increased dietary consumption of soy isoflavones may be associated with a lower rate of bone resorption,189, 190 higher BMD189, 190, 993-

995 and a reduced risk of fracture.996

The main soy isoflavones, genistein, daidzein and glycitein, are present in the inactive glycosidic forms, genistin, daidzin and glycitin.175 The inactive glycosides are converted into active aglycones by glucosidases produced by intestinal bacteria.997, 998 However, individuals vary greatly in their ability to metabolise isoflavones due to differences in microbial flora and diet.999, 1000 Women harbouring the appropriate gut bacteria which metabolise soy isoflavones were found to have significantly greater total BMD than women who were non-metabolisers.1001

However, increased dietary fat intake was found to decrease the capacity of gut microflora to metabolise isoflavones.1002 Fermentation of soy increases the bioavailability of isoflavones,1003 as fermented soy foods have a higher aglycone content due to the partial hydrolysis of isoflavone glycosides.1003

Phytoestrogens, such as isoflavones and coumestans, have a similar chemical structure to oestradiol and are therefore able to occupy oestrogen receptors, although

215 the time of bonding is significantly shorter than that of oestradiol.1004 Oestrogen receptors exist as two main subtypes, oestrogen receptor α and β. Phytoestrogens

1005, 1006 tend to have a higher binding affinity for oestrogen receptor β, which are more abundant in tissue such as bone, brain and vascular endothelia. Genistein is able to stimulate transcriptional activity of both oestrogen receptor subtypes at a concentration of 1x10-10nM.1006

A large body of work using animal models to investigate the phytoestrogenic effects on bone suggest that isoflavones modestly improve or maintain bone mass.1007 A dose of 0.5-0.7mg/day of genistein was found to be effective in preventing ovariectomy-induced bone loss without uterine stimulation in animal models.1008, 1009

Isoflavones enhance bone formation while simultaneously suppressing bone resorption.1010 Genistein, in particular, has been noted to stimulate protein synthesis in osteoblast cell lines.1008

The results of double blind RCTs using isoflavone enriched soy protein suggest a modest effect on vertebral bone mineral content and BMD,1011-1013 with little effect on bone at the hip.1012, 1014 However, not all studies produced positive outcomes. A

RCT conducted by Kreijkamp-Kaspers and colleagues1015 found no significant change in BMD after 12 months supplementation, while Dalais and co-workers1016 noted no change to indices of bone resorption.

A number of studies evaluated the effect of the synthetic isoflavone, ipriflavone, on

BMD. Ipriflavone increased vertebral BMD by approximately 1.2-1.4%,1017, 1018 maintained radial BMD1019 and prevented the rapid loss of bone following

216 ovariectomy.1020 Ipriflavone was found to inhibit bone resorption and enhance bone formation.1017-1021 However, Alexandersen and colleagues1022 found ipriflavone did not prevent bone loss, did not affect biochemical markers of bone metabolism nor did the isoflavone prevent vertebral fractures.

Studies conducted on red clover-derived isoflavones demonstrate less consistent outcomes. One double-blind, randomised, placebo-controlled trial found red clover isoflavones significantly reduced the loss of vertebral bone mineral content and

BMD (p=0.04 and p=0.03 respectively),1014 while another study concluded that two red clover supplements had no effect on bone turnover markers in menopausal women.1023

To conclude, isoflavones cause a modest effect on BMD at the spine with little effect at the hip. Since, the bioavailability of soy isoflavones depends on gut microflora and diet, the supplementation of soy may not be beneficial to all women. The long term affect of isoflavones on the reduction of fracture has not been clinically assessed.

9.7.2.4 Chinese medicinal herbs

According to TCM physiology, the Kidney is the Organ which governs the bones.

Jing, the vital essence, is stored in the Kidneys and is important for the formation of marrow and nourishment of bones. An age related decline in Jing can lead to thinning of the bones, deterioration of the teeth and weakness of the legs. TCM considers osteoporosis to be related to a decline in Kidney Qi, particularly Jing.

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Research conducted in China has indicated that BMD is decreased in individuals with Kidney-deficiency compared to those without this diagnosis.1024 Chen and colleagues1025 investigated the association between osteoporosis and a diagnosis of

Kidney deficiency. Patients diagnosed with Kidney-Qi-Yin deficiency had the greatest probability in developing osteoporosis compared to those with Kidney-Qi or

Kidney-Yin deficiency. Nevertheless, patients with Kidney-Qi or Kidney-Yin deficiency were more likely to develop osteoporosis than those without these diagnoses. No significant differences in the rates of osteoporosis were found between patients presenting with Kidney-Yang deficiency or other non-Kidney Yang deficiencies. Therefore, Kidney-Qi deficiency, in particular Yin, may be a good predictor for developing osteoporosis. A formula that contains Kidney Qi and Yin tonics would be recommended for strengthening the bones.

TCM has a long history in the use of herbs for the treatment of bone disorders.

Animal33, 1026-1031 and human studies1032-1035 suggest that various herbal formulae have a beneficial effect on bone.

9.8 The Effect of Herbs on Bone Metabolism

Preliminary evidence suggests that a number of herbs included in FF-01 have a favourable effect on bone metabolism. These include: Epimedium,1032, 1036, 1037

Rehmannia1038 and Cimicifuga.172, 1039 Berberine, a constituent isolated from

Phellodendron, may also have a beneficial effect on bone.1040, 1041 Although

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Epimedium and Rehmannia are strong Kidney tonics, Rehmannia in particular tonifies Kidney Yin. Ross646 suggests Cimicifuga also acts as a Kidney Yin tonic.

9.8.1 Rehmannia glutinosa

A series of studies conducted by Oh and colleagues1038 found that an extract of

Rehmannia enhanced bone metabolism in vitro and in vivo. Treatment with

Rehmannia also increased the expression of bone-related genes, enhanced osteoblast cell proliferation by 15%, promoted osteoprotegerin secretion and significantly increased alkaline phosphatase activity of osteoblasts (p<0.01). Rehmannia also inhibited osteoclast generation and decreased osteoclastic bone resorption. In vivo investigations using ovariectomy-induced osteoporotic rats demonstrated that

Rehmannia prevented a decrease in trabecular BMD, and increased the thickness of cortical bone and the trabeculation of bone marrow spaces. These results demonstrate that Rehmannia has a beneficial effect on bone and may attenuate bone loss in ovariectomy-induced osteoporotic rats.1038 To date, no studies have been conducted investigating the effect of Rehmannia on bone metabolism and BMD in osteoporotic women.

9.8.2 Epimedium sagittatum

Epimedium is a major Kidney tonifying herb which has been traditionally used for disorders of the joints, lower back and knees. Pharmacological research indicates the herb has potential in modulating bone metabolism. The main active constituents are the flavonoids, with icariin being the most potent.1042 Icariin stimulated the proliferation and differentiation of osteoblastic precursor cells from rat bone marrow.

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In a dose dependent manner, icariin caused an increase in alkaline phosphatase activity, osteocalcin* secretion and calcium deposition of precursor cells during osteogenic induction. These results suggest that icariin is effective in encouraging the strengthening of bone by stimulating proliferation and osteogenic differentiation of osteoblastic precursor cells.1043 A subsequent study by Qian and colleagues1044 demonstrated that Epimedium flavonoids increased the expression of Core Binding

Factor (CBF) α1 mRNA in the bone of ovariectomised rats in a dose-dependent manner. CBF α1 is a member of the runt family of transcription factors which play a pivotal role in regulating differentiation of osteoblastic precursors and activity of mature osteoblasts.1044 Icariin also increased proliferation and differentiation of human osteoblasts1045, 1046 possibly by increasing the production of bone morphogenetic protein 2,1046 a bone cell-differentiating factor and bone formation stimulator.1047, 1048 Epimedin B and C are other flavonoids which have a stimulatory action on osteoblasts.1042, 1045

Studies conducted in China have demonstrated the bone sparing effects of several

Epimedium species in various animal models. In the ovariectomised rat model of osteoporosis, Epimedium flavonoids inhibited bone resorption and stimulated bone formation1036, 1049-1051 without any hyperplasic effect on the uterus.1051 Epimedium also prevented prednisone induced bone loss in rats.1052 The growth of embryo chicken bones were stimulated in the presence of the herb. After six days of treatment, the length and weight of the bone increased by 116% and 112%

* A non-collagenous protein secreted by osteoblasts and is involved in mineralisation and calcium ion homeostasis.

220 respectively (p<0.01) and strength increased by 122% (p<0.01).1053 The results from a recently conducted randomised double-blind placebo-controlled clinical trial found

E. brevicornum was beneficial in preventing bone loss in late postmenopausal women over a 24 month period. The herb did not cause a hyperplasic effect on the endometrium.1054

In conclusion, results from pharmacological and clinical studies investigating the bone modulating effects of Epimedium are promising. Further work is needed to substantiate the clinical effect of the herb on BMD and fracture risk reduction.

9.8.3 Phellodendron amurense

Animal studies indicate that berberine, an active compound isolated from

Phellodendron, ameliorates bone loss associated with menopause and aging. Oral administration of berberine to ovariectomised rats prevented a decrease in BMD at the lumbar vertebra without affecting the weight of the uterus.1040 In an animal model for senile osteoporosis, the administration of berberine for 22 weeks caused an overall increase in BMD (p<0.05). A reduction in the concentration of deoxypyridinoline was only observed in female rats.1041 Although these preliminary results are promising, clinical trials are needed to substantiate a beneficial effect of

Phellodendron and berberine on BMD and fracture risk reduction in human subjects.

However, the safety of berberine in humans at effective doses to affect bone needs to be substantiated before further clinical studies can be conducted.

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9.8.4 Anemarrhena asphodeloides

Recent studies suggest that Anemarrhena may have an affect on bone metabolism.

Steroidal saponins isolated from Anemarrhena increased alkaline phosphatase activity and decreased the concentration of osteocalcin. In ovariectomised rats, saponins prevented bone loss due to the promotion of bone formation. Bone resorption was not inhibited.1055

9.8.5 Cimicifuga racemosa

Preliminary research indicated Cimicifuga has a beneficial effect on bone. A

Japanese research team led by Li1056 first reported on the potent inhibitory activity of triterpenoids extracted from Cimicifuga heracleifolia and C. foetida on bone resorption stimulated by parathyroid hormone in bone tissue culture. A subsequent paper noted that extracts of the two Cimicifuga species significantly increased lumbar BMD in the ovariectomised rat model of postmenopausal osteoporosis.1057

Due to these promising results, Nisslein and Freudenstein1039 investigated the effect of an isopropanolic extract of C. racemosa (Remifemin) on urinary crosslinks and bone quality using the same rat model. Remifemin caused a decrease in urinary excretion of cross-links. The positive effect of Remifemin on trabecular BMD and bone quality was weaker than raloxifene but greater than changes noted in ovariectomised control animals.1039 Two further studies using a different C. racemosa extract demonstrated weak bone sparing effects on the tibia in ovariectomised rats, with no effect on uterine weight. The extract had varying effects on bone turnover markers.1058, 1059

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A small amount of preliminary work has been undertaken investigating possible bone preserving effects of C. racemosa in humans. Viereck and colleagues1060 found that C. racemosa stimulated osteoblastic osteoprotegerin secretion in a human bone cell culture by 3-5 times within 12 hours. Osteoprotegerin inhibits the differentiation of macrophages into osteoclasts and regulates the resorption of osteoclasts in vitro and in vivo. A double-blind RCT assessed the effect of a C. racemosa extract on bone turnover markers in postmenopausal women. Concentrations of serum BAP after 12 weeks of treatment with oestrogen or placebo did not increase significantly, however women given C. racemosa extract exhibited a significant rise in BAP with no increase in serum C-telopeptides. Oestrogen caused a significant decrease in C- telopeptides. The authors conclude that both oestrogens and the C. racemosa extract are beneficial to bone and the herbal extract has an anabolic effect on bone.172, 1061

Preliminary research using animal models of osteoporosis and a human bone cell culture indicates C. racemosa may have a beneficial effect on bone. Further clinical work is needed to investigate the effect of the herb on bone turnover, BMD and fracture risk in postmenopausal women.

9.9 Summary and Conclusions

Osteoporotic fractures place a huge social and economic burden on society. This burden is likely to continue as the number of Australian women aged 65 years and over is forecasted to increase over the next 20 years. The treatment of osteoporotic bone loss is warranted due to an increased fracture risk with aging and the significant morbidity and mortality associated with fractures. There is no cure for osteoporosis

223 nor can the loss of bone with aging be prevented, therefore treatment aims to maximise bone mass and/or reduce the rate of postmenopausal bone loss in order to minimise the risk of fracture.

Medications to prevent bone loss have various side effects and low compliance rates.

HT is no longer recommended for the long-term prevention of osteoporosis, as the risks of therapy outweigh the benefits. Although bisphosphonates are the most promising agents currently available, safety with their long term use has not been assessed, and compliance tends to be low. Other treatments for reducing bone loss generally confer minimal increases in BMD or do not significantly reduce the risk of fracture.

Preliminary evidence suggests that a number of herbs comprising the trial formula

FF-01 may modulate bone metabolism. Therefore, in the context of these promising reports and the need for safe and effective alternative treatments to modulate postmenopausal bone turnover, a pilot study investigating the effect of FF-01 on bone metabolism was proposed. This pilot study evaluates the effect of the formula on bone turnover markers. Bone markers are useful in monitoring skeletal responses to treatment as they change more rapidly than any detectable changes in BMD. Bone markers generally reach a nadir within 3-6 months after initiating treatment.

However, it must be reiterated that although bone turnover markers are useful for the preliminary assessment of a novel treatment, they do not provide information on the status of BMD and therefore should not be used to give or confirm a diagnosis of osteoporosis.

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The preceding literature review covered by Chapters 7 and 8 suggests that herbal medicine may afford a measure of relief from vasomotor symptoms and modulate bone metabolism. Therefore, due to this promising supporting evidence, the following clinical trial was undertaken. The present study aims to assess:

• The effectiveness of FF-01 in reducing the number and severity of vasomotor

symptoms (calculated as a composite hot flush score) and improving

menopause related quality of life

• A pilot study to determine the effect of FF-01 on bone turnover markers,

BAP and deoxypyridinoline (corrected for creatinine).

The clinical trial protocol is detailed in Chapter 10. The trial was planned according to the CONSORT Group recommendations for the reporting of clinical trials.

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CHAPTER 10 TRIAL: RESEARCH DESIGN*

10.1 Introduction

From September 2004 until October 2005 a randomised double-blind placebo controlled multicentre trial was conducted to evaluate the effectiveness of FF-01 for the alleviation of vasomotor symptoms and improve quality of life. In addition, a pilot study investigating the affect of the herbal formula on bone metabolic markers,

BAP and deoxypyridinoline, was undertaken. The trial was designed in accordance with the recommendations of the CONSORT group for the reporting of clinical trials. The following chapter describes the research design of the trial.

* A report on the clinical trial will be submitted to a relevant journal for publication

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10.2 Study Aims and Outcomes

The first null hypothesis states that FF-01 is no more effective than placebo in reducing the hot flush score which incorporates vasomotor symptom number and their severity, while the second states that the formula is no more effective than placebo in improving quality of life in menopausal women experiencing vasomotor symptoms.

The main objectives of the study were to assess:

• the effectiveness of FF-01 in reducing the number and severity of

menopausal vasomotor symptoms as calculated by the hot flush score

• the effectiveness of FF-01 in improving the quality of life of women

experiencing vasomotor symptoms

The primary outcome was the reduction from baseline of the hot flush score, calculated as a product of the number and severity of vasomotor symptoms as recorded on the Daily Flush Diary. The secondary outcome addressed change in quality of life. Quality of life was assessed by the Greene Climacteric Scale,253 a validated menopause specific quality of life instrument, and the Hot Flash Related

Daily Interference Scale (HFRDI Scale),1062 which measures the impact of hot flushes on quality of life.

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10.3 Legal Requirements

Ethics approvals were granted from UWS, Northern Sydney Health (governing

Royal North Shore Hospital) and the South Western Sydney Area Health Service

(for Liverpool Health Service). Approval covered the trial protocol and associated documentation including the subject information sheet, consent form and advertising material.

A Clinical Trial Notification listing the trial sites was lodged with the TGA,

Australian Government Department of Health and Aging. Trial clinics were conducted at the following locations:

• University of Western Sydney, Parramatta Campus

• Royal North Shore Hospital Menopause Clinic

• Chinese Medicine Clinical Research Centre, Liverpool Health Service

• Pine Mountain Ginseng Company, Sydney

• So Chinese Medicine Centre, Chatswood

All herbs used in the herbal formula were listed with the TGA as suitable for human consumption and are non-toxic. Listed medicines are assessed by the TGA for quality and safety, but not efficacy. These medicines are considered of lower risk and usually have a long history of use.1063 All herbs included in FF-01 have a long documented period of use in both the Chinese and Western traditions of herbal medicine. The herbs are currently available over the counter to the public

228 throughout Australia and are classified as food or herbal products. No herb is a controlled or pharmaceutical substance, animal product or an endangered species.

Herbs were administered within standard dosage ranges.

FF-01 and placebo were commissioned by Global Therapeutics to be manufactured by Tabco. Tabco is approved by the TGA for Good Manufacturing Process (GMP) to ensure quality control of the products. Global Therapeutics was also the sponsor of the trial.

10.4 Subject Recruitment

10.4.1 Sample size

The sample size calculation was based on the primary objective. Approximately 31 participants were required per group in order to detect with 90% power (alpha2 =

0.05) a treatment difference of three hot flushes per 24 hours, assuming a standard deviation of 3.8 hot flushes per day. Allowing for up to 30% drop outs, a total of 45 women for each group were recruited.

10.4.2 Recruitment

Recruitment of trial subjects occurred through two hospital specialist clinics, UWS and two private TCM clinics. Advertisements approved by the appropriate ethics committee were displayed at the participating hospitals. Media releases advertising the launch of the trial and the search for appropriate participants were sent to Sydney metropolitan and local newspapers by the UWS’s Office of Media and

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Communication. Television interviews publicising the trial were conducted with the chief investigator (CP) by two Australian stations. CP was also interviewed by two local radio stations.

10.4.3 Participant selection criteria

Women were recruited if they were aged 45-65 years, experienced amenorrhoea of at least 12 months duration and suffered at least six episodes of vasomotor symptoms per 24 hours (approximately 42 episodes per week) of any severity during the last two weeks of the baseline period before randomisation. Since the US FDA requires women enrolled into HT clinical trials to experience at least seven moderate to severe hot flushes per day or 50 to 60 per week,1064 six vasomotor symptoms per 24 hours was deemed severe enough to detect a treatment difference caused by a herbal agent. Women with very severe hot flushing were unlikely to participate in a clinical trial evaluating an unproven herbal treatment and who had one in two chance of receiving placebo. Table 10.1 details the trial inclusion and exclusion criteria in detail.

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Table 10.1: Clinical trial inclusion and exclusion criteria

Inclusion Criteria Exclusion Criteria

• Women with at least 12 months amenorrhoea • Undiagnosed vaginal bleeding. aged 45 – 65 years.

• On average 6 episodes vasomotor symptoms per • History of breast cancer, cancer or oestrogen day (approximately 42 per week) of any severity. dependent tumours.

• Follicle Stimulating Hormone > or = 40mIU/ml • Use of corticosteroids or anticoagulants.

• Oestradiol < or = 80 pg/ml. • Uncontrolled and/or diagnosed medical conditions likely to interfere with or influence • Normal full blood count and liver and renal study treatment, e.g. diabetes mellitus requiring function tests within the past 6 months. medical treatment, hepatic or renal dysfunction.

2 • Body Mass Index of 30kg/m or less. • Uncontrolled or untreated hypertension (defined as systolic> 160mmHg and/or diastolic > 100mmHg).

• Uncontrolled diagnosed psychiatric disorders.

• Have not used HT or CAM for menopausal • Any other condition judged by the investigator symptoms during previous 2 months before that makes the patient unsuitable for or unable baseline. to complete the study.

10.5 Treatment Schedules

The trial consisted of two intervention groups: women taking either FF-01 or an identical looking placebo. The herbs comprising the formula and the extraction details are listed on Table 10.2 (refer to Table 8.1 for details of herbal amounts). No information was provided for Epimedium. The formula was dispensed in the form of

water and ethanol granulated extracts compressed into tablets. Tablets also

contained added materials: 31.4% anhydrous calcium hydrogen phosphate, 13.9%

cellulose microcrystalline, 4% croscarmellose sodium, 2% colloidal anhydrous silica

and 2% magnesium stearate. Cimicifuga was standardised to contain not less than

2.5% triterpene glycosides calculated as 27-deoxyactein (Appendix XII).

Certification was provided confirming the authenticity of the herbal plant material

and microbiological purity of extracts under GMP provisions (Appendix XII). The

control group received placebo tablets manufactured to look and taste similar to the

231 herbal active treatment. The placebo was made of anhydrous calcium hydrogen phosphate, cellulose, croscarmellose sodium, silica, magnesium stearate, talc, carnauba wax, aromatic bitter, liquorice powder and colour.

Table 10.2: Extraction details for FF-01

Extraction Ratio herb Lot Herb Plant part solvent to extract number (% alcohol) Cimicifuga racemosa Root/rhizome 4.9:1 50 26239

Rehmannia glutinosa Root 6:1 75 26278 (uncured) Epimedium sagittatum Herb 5:1 Unknown 26625 26890 Curculigo orchioides Root 7:1 45 26928

Phellodendron amurense Bark 5:1 45 26996

Anemarrhena Root 5:1 40 27030 asphodeloides Asparagus lucidus Root 6:1 60 26626

Zizyphus spinosa Seed 6:1 25 27116

The active and placebo treatments were pre-packaged in amber round glass, tamper proof capped bottles, each containing 112 tablets. Each bottle contained trial medication for a 4-week period with extra tablets for an additional week of dosing in case a follow-up appointment was delayed.

Two 955mg tablets were taken orally twice per day, preferably half an hour before meals with water or fruit juice. Women with sensitive stomachs were advised to take the tablets with meals. The medication was taken for a total of 16 weeks.

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10.6 Trial Protocol

10.6.1 Initial screening and subject consent

Subjects were initially screened for eligibility by telephone. Eligible women were scheduled for an appointment at the nearest clinic and sent an information sheet outlining the trial and requirements, medical health clearance checklist and consent form by post or e-mail. All women were required to undergo a health clearance check with a medical practitioner either at one of the hospital clinics or with a general practitioner. At the initial appointment, the herbal practitioner explained the study in detail by going through the information sheet (Appendix III). Participants were advised that they were free to withdraw at any time during the trial. Informed consent was then obtained (Appendix IV). Signed copies of the information sheet and consent form were given to the participant and another set kept on file with the chief investigator. Refer to appendices V and VI for the registration and initial consultation forms.

Confidentiality and privacy of participant medical information was maintained at all times. Participants were allocated an identification number that appeared on all documentation, questionnaires and data. Participants were able to request access to their own data, and preview the results of the study. Personal data was not made available to others not directly involved in the study. Information concerning all participants was maintained by the Chief Investigator under secure conditions at

UWS to be held for a period of seven years. In compliance to the Therapeutic

Goods Act 1989, research records will be made available to the TGA as required.

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10.6.2 Randomisation

Randomisation ensures that every participant has an equal chance of being allocated to a treatment group. This process generates groups that are more representative of each other so that any differences noted between the groups are due to the treatment and not to other factors.256

Randomisation of participants occurred at the end of the four week baseline period

(Appendix X). An independent data manager used a computerised random number generator using the seed 7215 to draw up a random allocation sequence to randomise

100 subjects into one block. A list containing 20 allocations was given to each clinic.

TCM practitioners assigned an eligible participant the next available randomised number on the list, thereby designating the participant to either placebo or treatment group. Medication was dispensed by matching the randomisation number on the list to the corresponding number on the medication bottle. Codes were held by the hospital pharmacies and by the CompleMed centre manager.

10.6.3 Blinding

Participants, practitioners and data analysts were blinded to the allocation of treatment. Blinding reduces the effects of expectation on measuring outcomes.256

The treatment code was revealed once a participant had completed all study requirements at the end of the follow-up consultation.

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The success of blinding was assessed at each monthly consultation (refer to

Appendix XI for the scale). Each participant was asked which treatment they believed they had received. If blinding was successful, the ability of participants to accurately guess their treatment allocation should be no better than chance.642

10.6.4 Consultation timetable

All consultations were conducted by practitioners who had undertaken an accredited

TCM university degree, had at least five years clinical experience and were members of a professional TCM organisation. The trial consisted of a four week baseline period and 16 week treatment phase.

A four week baseline phase before randomisation was necessary to eliminate placebo responders. Clinical trials assessing interventions for the alleviation of vasomotor symptoms have reported a substantial placebo effect in the reduction of both vasomotor symptom frequency and score.5, 1065 During the baseline phase, participants were required to submit a blood sample to Douglass Hanly Moir (DHM)

Pathology for assessment of the following base-line characteristics:

• Oestradiol

• FSH

• Full blood count

• Liver function test

• Urea, creatinine

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During the initial consultation demographic details, lifestyle factors, medical history and data from the two quality of life scales253, 1062 were obtained. Height, weight and blood pressure measurements were also taken. Measurement of weight (kg) and height (cm) to the nearest 0.1 units were taken with the participant wearing light clothing and no shoes. BMI as kg/m2 was calculated. Blood pressure was taken after the participant was seated and rested for five minutes. Three readings were taken, the first discarded and the average of the other two recorded. Participants were issued a Daily Flush Diary for the next four weeks with an extra week included in case a follow-up appointment was delayed (Appendix VII). The number and severity of hot flushes and night sweats were recorded at approximately the same time every day for the previous 24 hours. Instructions on how to fill out the diary was given. The diary also included space for adverse event reporting.

At the end of the four week baseline screening phase, participants submitted their

completed flush diaries. Those who failed to fill out 80% of the flush diaries and

those who no longer met the inclusion criteria were excluded from the trial.

Baseline hot flushes were calculated as the average hot flush count over the last 14

days of the four week baseline phase. Participants who were still eligible were

randomised to receive either treatment or placebo. Participants were required to

attend a consultation every four weeks over the 16 week treatment phase in order to

dispense medication, evaluate compliance, collect and replenish diaries and

complete quality of life scales. Table 10.3 outlines the schedule of trial activities

over the 28 weeks

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Table 10.3: Data collection schedule for the monthly consultations

Follow- Baseline Treatment Phase up Week Week Week Week Week Week Week Activity -4 0 4 8 12 16 24 Review questionnaire X X X X X X Weight and blood pressure X X X X X X X

Height X X FSH, oestradiol, full blood count X X

Liver and kidney function test X X

Quality of life questionnaires X X X X X X X

Flush diary collected X X X X X X X (2 weeks) Compliance evaluation X X X X

A follow-up assessment was scheduled eight weeks after completion of the treatment phase to determine if the treatment had any lasting effects on vasomotor symptoms.

Daily Flush Diary recording resumed two weeks prior to this appointment and the quality of life scales were completed during the consultation. At the end of this consultation the treatment codes were broken. Those who were on placebo treatment were given 16 weeks supply of the herbal formula.

10.7 Participant Evaluation

10.7.1 Primary outcome

The hot flush score, a composite score of vasomotor symptom number multiplied by their corresponding severity was the primary outcome for assessing the efficacy of herbal treatment. Number and severity was recorded on the Daily Flush Diary.

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10.7.1.1 The measurement instrument: the Daily Flush Diary

The number and severity of vasomotor symptoms were recorded every 24 hours on the Daily Flush Diary (Appendix VII). The use of self-report diaries to record the symptoms and perceptions of participants is an established and valid methodology in recording subjective data1065-1067 and has been frequently used in menopausal vasomotor clinical trials.168, 264, 1068-1070 Furthermore, preliminary evidence suggests that the results obtained from diaries correlate with those obtained by electronic devices such as hot flush measurement instruments based on skin conductance.1071

The Daily Flush Diary has been determined to be a valid and reliable measurement instrument. The recording of vasomotor symptoms on the Daily Flush Diary was found to correlate significantly with hot flush related symptoms reported at baseline, such as abnormal sweating, sleep disturbances and sleepiness. Likewise, correlation coefficient analysis demonstrated a positive relationship between the percentage of patients who reported a decrease in hot flush related symptoms and those who experienced a reduction in hot flush activity. A further measure of validity was provided by an association between improvements in quality of life with a decrease in hot flush activity.1065 Finally, Sloan and colleagues1065 determined that the Daily

Flush Diary recorded identical outcomes in two independently conducted clinical trials on clonidine for the alleviation of vasomotor symptoms in breast cancer survivors. Such an observation suggests a measure of construct validity in the use of daily flush diaries.

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10.7.1.2 Number of vasomotor symptoms

The mean daily number of vasomotor symptoms was calculated by adding the total number experienced during the two weeks prior to each scheduled visit and dividing by 14.264 Missing values were imputed by the last observation carried forward. The effectiveness of treatment was evaluated by comparing the change in mean number of vasomotor symptoms at the end of the treatment phase with the end of baseline measure.

10.7.1.3 Severity of vasomotor episodes

The severity of each vasomotor episode was recorded using a four point scale. This scale detailing the severity of vasomotor episodes has been utilised in previous studies.1069, 1072 To measure the severity of vasomotor symptoms quantitatively, the descriptions outlined below were used to help categorise and record each flushing episode felt by a participant as being either mild (1), moderate (2), severe (3) or very severe (4).1065

Absent = 0

Mild = 1

Physical symptoms: felt warm, felt slightly uncomfortable, red face.

Emotional symptoms: not expected.

Action needed: usually no action taken.

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Moderate = 2

Physical symptoms: head neck ears or whole body felt warm; muscles felt tense, tight; clammy (wet) skin; a change in heart rate or rhythm (heart speeds up or changes beat); some sweating; dry mouth.

Emotional symptoms: felt irritated, restless, tired, annoyed and embarrassed when having a hot flush in front of others.

Action needed: able to continue with daily activity, needed to use a fan, sometimes awakened at night, needed to remove sheet/blanket, needed to remove some clothing, drank water, changed into lighter clothing.

Severe = 3

Physical symptoms: heat, sometimes described as a raging fire or like burning up; a change in heart rate or rhythm (heart speeds up or changes beat); felt faint; headache; severe sweating; chest heaviness.

Emotional symptoms: embarrassment, anxiety, feelings of having a panic attack.

Action needed: needed to stop what was being done at the time; usually awakened at night and removed bed covers or sheets; needed to remove clothing; take a cold shower; opened windows; move to cooler temperature; frequently used fans.

Very Severe = 4

Physical symptoms: Boiling heat, rolling sweat, difficulty breathing, felt faint, felt dizzy, a change in heart rate or rhythm (heart speeds up or changes beat), felt slightly sick to the stomach.

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Emotional symptoms: had difficulty doing daily activities; felt distressed; felt an urge to escape.

Action needed: awakened often at night; needed to change sheets and pyjamas, needed to take a cold shower, needed to hold ice onto skin.

10.7.1.4 The hot flush score

The hot flush score was calculated by assigning a number on a scale from 1 to 4 for hot flush severity and multiplying this number by the daily number of hot flushes experienced of that severity.1065, 1069, 1072

Sloan and co-workers1065 analysed the data from several trials comparing the efficacy results of hot flush frequency and hot flush score and found both end points to be almost superimposable. Further analysis determined that hot flush frequency and hot flush score are closely related, being within half a standard deviation of each other. The authors concluded that hot flush score is sufficient as a primary end point as it includes measures of both frequency and severity in a single unit.1065

10.7.2 Secondary outcomes

Quality of life may be severely compromised by women experiencing menopausal symptoms 1073 therefore; any statistically significant improvement in quality of life ratings would indicate an effective treatment. One reliable and validated quality of life instrument specific to menopause is the Greene Climacteric Scale (Appendix

VIII). .253 The Greene Scale has been used to assess the effectiveness of treatments in a number of overseas169, 203, 263, 627, 1074 and Australian studies.202, 1075 Normative

241 data for the Greene scale has been obtained from a representative sample of urban

Australian women during the menopausal transition.385 The Greene Climacteric

Scale was constructed on the basis of factor analysis. The results of this analysis resulted in three subscales each measuring a different aspect of symptomatology.

These scales were labelled psychological, somatic and vasomotor.1076 The psychological subscale is further subdivided to measure anxiety and depressed mood.389 Greene253 notes that the scale lists symptom clusters that may occur at any time during the menopausal transition and these symptoms may also be due to differing aetiologies. A respondent rates each symptom according to its severity using a four point scale; not at all (0), a little (1), quite a bit (2) and extremely (3).

The sum of the scores for items 1-11 assess psychological symptoms, which incorporates a separate score for both anxiety (items 1-6) and depression (items 7-

11). Somatic symptoms are addressed by adding the scores of items 12-18, while vasomotor symptoms are assessed by the sum of items 19-20. Item 21 asks about sexual dysfunction. These scales and subscales are referred to as “domains” within this thesis. The total Greene Climacteric Scale score is the sum of all 21 item scores.

The HFRDI Scale is a reliable and validated 10 item instrument that assesses the impact of flushing on quality of life.1062 The Scale determines the impact of hot flushing on nine daily activities, while the tenth item measures the degree of interference with overall quality of life (Appendix IX). Although, the HFRDI Scale is sensitive to negative changes in flushing over time, initial findings suggest the scale may not acutely detect positive changes in hot flushing over time. However, further clinical use of the scale is needed to determine its effectiveness in assessing the impact of an improvement in vasomotor symptoms on quality of life.1062

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10.8 Subject Restrictions

10.8.1 Safety

A number of precautions were taken to ensure the safety of all trial participants. All herbs prescribed during this trial were listed with the TGA and have been acknowledged as suitable for human consumption. The herbs were classified as either food or herbal products and were not controlled substances, pharmaceutical in nature, nor were they derived from animals or endangered species. All herbs used in the formula were assayed for heavy metal and other contaminants and certificates of analysis were issued (Appendix XII). The manufacturer of the trial medications has a certificate of GMP. Safety evaluations undertaken during the trial included: full blood count, liver function testing, urea and creatinine, blood pressure monitoring and adverse event reporting.

10.8.2 Withdrawal criteria

Participants were able to withdraw or be withdrawn due to the following reasons:

1. Serious adverse event

2. Abnormal clinical or laboratory result deemed necessary for the withdrawal

of the subject

3. Non-compliance with therapy

4. Deviation from protocol, including the use of HT, CAM, corticosteroids or

anticoagulants during the trial period

5. Withdrawal of consent

6. Lost to follow-up

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Participants who wished to withdraw during the initial course of treatment due to perceived lack of benefit were encouraged to complete the study, as the full effect of the treatment may not be evident for several weeks. Participants who withdrew from the study were not replaced.

An adverse drug reaction is an unintended, unexpected or undesirable result of an intervention that may occur at any dose.642 The term is used regardless as to whether or not the effect is attributable to the intervention under evaluation. The protocol for this trial monitored adverse events that occurred during the treatment phase.

Menopausal vasomotor symptoms were not considered adverse events unless they increased in severity or intensity.

Adverse event reporting began on the first day of treatment administration until and including the final treatment phase visit. All adverse events, whether related to the trial or not, were recorded on the subject Daily Flush Diary. An assessment of the relationship between an adverse event with treatment and with any concomitant medication was made. An adverse event was followed up until it resolved or for up to a month after the study was concluded.

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10.9 Compliance

Compliance in trial participation not only included taking the prescribed dose at the appointed time but also extended to completing the Daily Flush Diary and keeping scheduled appointments. Compliance can have a major bearing on the final results of a trial; therefore it was imperative that participants were encouraged to stay motivated to continue taking the treatment.

The following measures were adopted in an attempt to increase participant compliance:

• The herbal formula was dispensed as tablets taken orally to mask any

unpleasant taste that may influence a decision to withdraw.30

• Bottles were returned and remaining tablets were counted during

consultations.

• Regular contact was kept to encourage participants and to discuss any issues

as they arose.

• Compliance issues were discussed at the monthly appointments

• Participants were called a day or two before a scheduled appointment.

• During consultations, participants were asked about their compliance and the

success of blinding measures.

Finally, the base-line period gave some indication of how compliant to the trial protocol a participant was likely to be. A participant was withdrawn from the trial if she completed less than 80% of the Daily Flush Diary during the base-line period.

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10.10 Pilot Study: FF-01 on Bone Turnover Markers

The pilot study investigated the effect of FF-01 on bone turnover markers. The objective of this study was to assess the effectiveness of FF-01 in modulating bone metabolism as indicated by the bone metabolic markers, BAP (serum) and DPD

(urine, corrected for creatinine). The null hypothesis states that FF-01 has no effect on bone turnover markers BAP and DPD, compared to placebo.

The first sixty participants admitted into the trial for whom six years or less had elapsed since the final menstrual period and who had not taken the medications listed below (Table 10.4) within the stated time frames were selected for the bone pilot study. The medications listed on Table 10.4 are known to affect bone metabolism, therefore the washout times were necessary to allow bone metabolism to return to its previous rate. The extra requirements for this study were listed on the information sheet and explained in detail at the initial consultation. Consent to this pilot study was obtained at the initial consultation.

Table 10.4: Minimum washout times for medications affecting bone metabolism

Medication Wash-out period Calcitonin 2 months Anabolic steroids and anti-convulsants 4 months Hormone Replacement Therapy 6 months Anti-osteoporotic drugs 12 months e.g. SERMs, bisphosphonates

The two bone markers tested were serum BAP (formation marker) and deoxypyridinoline (corrected for creatinine, breakdown marker) from urine. BAP and deoxypyridinoline were chosen because of their relatively high bone specificity and lower variability than other bone turnover markers.896 Biochemical markers of

246 bone formation and resorption are useful in evaluating therapies for preventing bone loss. Blood and urine samples were collected at weeks -4, 0, 8, 16 and 24.1077 Bone markers are subject to variability due to individual metabolic differences and lifestyle habits. By measuring the bone markers at baseline twice (i.e. at weeks -4 and 0), the variability of these results can be reduced by around 30%. This is important to the validity of the measurements when small sample size numbers are involved. All trial subjects were required to give blood at weeks -4, 8 and 16. The extra inconvenience to participants in this study included giving extra blood samples at weeks 0 and 24 and the vigilant collection of urine samples.

The collection of urine specimens required participants to follow a specific protocol.

A midstream sample of urine was collected at the second morning void after an overnight fast into the specimen jar supplied. The jar was immediately sealed, wrapped in aluminium foil (also supplied) and stored in the fridge until the participant was able to drop the sample off to a DHM collection centre, at which time a blood sample was also taken. No special fasting requirements were necessary before the taking of blood samples. Blood and urine samples were then shipped on dry ice to DHM central. Blood was centrifuged and the collected serum and urine were stored immediately at -70o C until shipment to the ANZAC Research Institute,

Concord. At ANZAC samples were stored at -70o C until analysis. The Immulite

1000 Pyrilinks D kit was used to quantitatively measure deoxypyridinoline in urine and the Metra BAP Eia kit assayed for serum bone specific alkaline phosphatase.

All assays were conducted by the ANZAC Research Institute.

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10.11 Statistical Analyses

Baseline characteristics were reported as means (standard deviations, SD) and percentages. Between-group (placebo vs. treatment) comparisons of demographical variables were performed using unpaired t tests for continuous variables or χ2 tests for categorical variables. To compare the change in each primary and secondary outcome measures from baseline to post treatment and from baseline to follow-up

ANCOVA was performed with the baseline measure as a covariate. Where appropriate, data were assessed for normality and homogeneity. Analyses were carried on the basis of intention to treat and per-protocol. Records of hot flush frequency and severity over 14 days prior to a consultation were used to calculate mean hot flush scores. The last observation carried forward was used to impute missing data. Statistical significance was assessed at p<0.05 and all analyses were conducted using Statistical Package for Social Sciences (SPSS version 12.0.1,

Chicago, Ill, USA) software.

10.12 Summary

The protocol for the clinical trial was planned in accordance with the recommendations of the CONSORT group for the reporting of clinical trials.642 The literature review highlighted oversights and flaws of trials evaluating the effectiveness of CHM and Cimicifuga for the alleviation of vasomotor symptoms.

The protocol for this trial attempted to rectify these shortcomings where practicable.

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The protocol incorporated a randomised, double-blinded, placebo controlled parallel design clinical trial. The trial consisted of a four week baseline phase, 12 weeks of treatment and a follow-up consultation eight weeks after completing the treatment phase. The baseline phase ensured placebo responders were identified and that treatment groups were similar in nature in regards to baseline characteristics.

Women were only included if they experienced six or more vasomotor episodes per

24 hours, a level of severity higher than most clinical trials on herbal medicine published in the literature.

All aspects of the clinical trial are discussed comprehensively in this protocol. The randomisation procedure was described and blinding of participants and practitioners outlined. The success of blinding was tested during and at the end of the study. The compliance of participants was addressed at each monthly consultation.

Confounding factors are controlled for during the trial. Medications and dietary practices were evaluated for compliance with the inclusion and inclusion criteria at the initial consultation and these practices were regularly monitored throughout the trial period. Vasomotor symptoms were recorded on a Daily Flush Diary, a tried and tested form of symptom reporting. Quality of life was measured by two validated and reliable scales. The protocol included an extended follow-up eight weeks after completion of the treatment phase to investigate any long term effects of treatment.

Finally, the trial included a pilot study investigating the effects of FF-01 on bone turnover markers, BAP and deoxypyridinoline. The treatment phase was considered sufficiently long to measure changes in bone metabolism due to the effects of the herbal formula. Women who took part in this study had experienced their final

249 menstrual period within the previous six years and were screened against the use of medications affecting bone metabolism. The following chapter presents the results of the trial.

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CHAPTER 11 TRIAL: RESULTS

11.1 Introduction

From September 2004 until October 2005, a total of 93 women were randomised to receive either FF-01 or placebo for a total of 16 weeks. Eight weeks after completion of the treatment period, women were required to attend a follow-up consultation to assess any long term affect of treatment. Forty-nine women took part in the bone metabolic marker pilot-study to investigate the effect of the formula on bone turnover markers.

This chapter presents the results of the clinical trial and bone metabolism pilot-study.

The trial primary outcome measure was the mean change in hot flush score; the secondary outcome measure addressed the change in quality of life as measured by the Greene Climacteric and the HFRDI Scales. The bone turnover markers assayed were BAP and DPD. Compliance with adherence to trial requirements and adverse events experienced during the treatment phase are also documented in this chapter.

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11.2 Recruitment

From September 2004 until October 2005, 122 women were screened for entry into the clinical trial. A total of 93 women were randomised; 46 to placebo and 47 to herbal treatment (refer to Figure 11.1). Seven participants withdrew during the 16 week treatment period, and a further nine women did not comply sufficiently with the treatment protocol. Therefore, 76 participants were included in the per-protocol analyses; 40 participants to placebo allocation and 36 to herbal treatment. Ninety- two participants were included in the ITT analysis (46 each to placebo and herbal allocation), as one participant withdrew only three days after commencing treatment and no efficacy measurements were recorded. Ninety-one participants were included in the hot flush analyses as one woman completed her flush diaries incorrectly and these could not be used. Seventy-two participants completed the eight week post- treatment follow up consultation.

The majority of participants were recruited via news segments aired on television announcing the commencement of a clinical trial assessing the effectiveness of a herbal treatment for the alleviation of vasomotor symptoms. Over 2,000 telephone calls of interest were made in response to these televised announcements. Other modes of recruitment included radio interviews and articles published in newspapers and magazines. The initial trial telephone interview assessed the eligibility of 413 women (refer to Figure 11.1). On further discussion a significant number of women indicated they were no longer interested in taking part or were found to be taking contra-indicated medications. The baseline consultation screened out a further 26 ineligible participants.

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Figure 11.1: Flow of participants through the trial stages

11.3 Baseline Characteristics

The baseline demographics and health characteristics of randomised participants did not differ significantly between the two intervention groups. Primary and secondary outcome scores at baseline for the two groups were also similar (refer to Table 11.1).

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Table 11.1: Baseline characteristics of trial participant population

Herbal formula Placebo Characteristics p-value* n Mean(SD) n Mean(SD)

Demographics

Age (range), yrs 46 55.68 (4.78) 45 55.66 (3.59) 0.92 Marital status, n (%) Partner 34 (73.9%) 32 (69.6%) 0.64 No partner 12 (26.1%) 14 (30.4%) Weight (kg) 45 67.89 (10.95) 45 68.91 (12.17) 0.67 Height (m) 45 164.07 (7.75) 46 162.54 (6.14) 0.30 Body mass index (kg/m2) 45 25.23 (3.64) 45 26.07 (4.20) 0.32 Number of pregnancies 45 2.80 (1.25) 46 2.74 (1.74) 0.85 Previously taken HT, n (%) 46 26 (56.5%) 46 24 (52.2%) 0.52 Months since stopped HT† 26 20.27 (22.78) 24 34.63 (43.44) 0.14 Previously taken CAM, n (%) 46 28 (60.9%) 46 26 (56.5%) 0.52 Months since stopped CAM†† 28 14.89 (22.78) 25 11.88 (20.46) 0.62 Duration of flushing (months) 44 55.30 (45.10) 45 58.98 (45.13) 0.70 Length amenorrhoea (months) 43 69.21 (78.58) 45 69.20 (59.60) 1.00 Hysterectomy, n (%) 45 10 (22.2%) 46 7 (15.2%) 0.39

Outcome measures at baseline

Mean daily hot flush score 46 17.91 (8.69) 46 17.10 (11.91) 0.71 Mean daily hot flush frequency 46 9.15 (3.50) 46 9.38 (4.51) 0.77 Quality of Life scales Greene Scale score 45 19.93 (10.08) 46 18.52 (7.97) 0.46 Greene Scale domains Psychological 45 9.98 (5.84) 46 8.80 (5.11) 0.31 Anxiety 46 5.60 (3.07) 46 4.93 (2.69) 0.27 Depression 46 4.39 (3.31) 46 3.87 (2.88) 0.42 Somatic 46 4.65 (3.91) 46 3.93 (2.86) 0.32 Vasomotor 46 4.00 (1.23) 46 4.30 (1.33) 0.26 Sex 46 1.45 (1.02) 46 1.48 (1.13) 0.92 HFRDI Scale score 46 38.43 (19.91) 46 37.85 (17.19) 0.46

Additional characteristics

Vaginal dryness 46 1.38 (1.09) 46 1.22 (1.11) 0.57 Dry skin 46 1.36 (1.05) 46 1.11 (0.85) 0.27 *Independent t test for continuous data and Pearson χ2 test for categorical data; †Only of those who had previously taken HT; ††Only of those who had previously taken CAM; Higher scores indicate less

The average age of trial participants was 55.6 years, with 62.36% born in Australia.

Approximately 71% of women were married or had a partner and 31.2% had undertaken tertiary education. Participants experienced on average nine vasomotor symptoms per 24 hours (SD 4.01; range 3.93-30) and reported an average hot flush score of 17.50 (SD 10.37; range 5.79-69.79). The mean total Greene Scale score for the trial population was 19.22 (SD 9.05; range 5-47) while that recorded for the

HFRDI scale was 38.14 (SD 18.50; range 3-78).

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11.4 Reliability and Validity of Outcome Measures

11.4.1 Hot Flush Score

10.7.1.2.1069, 1072 The frequency of hot flushes and their severity were reported every

24 hours on the Daily Flush Diary. Self-report diaries are an established and a valid method for the recording of subjective symptoms such as vasomotor symptoms1065 and have been used extensively in clinical research.168, 264, 1068-1070

Reliability refers to dependability or consistency of a measurement instrument while validity suggests how well a construct used to understand a phenomenon actually fits. Stability reliability pertains to reliability across time and is measured by using the test-retest method.255 The reliability of the hot flush score as a consistent measure of symptom severity was assessed by calculating and comparing the mean hot flush score over the last 14 days at the end of the base-line period with the mean of the last 14 days before the third consultation of the placebo group only. This calculation was based on the assumption that no significant improvement would occur amongst the placebo group after four weeks of supposedly inert treatment.

The Pearson Correlation coefficient was found to be significant at 0.871 (two tailed, p<0.05 n=46) suggesting a reliable measure.

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The correlation between hot flush score and vasomotor symptom number was found to be significantly high at 0.93 (two tailed, p<0.05 n=92). This result also suggests that the hot flush score provides sufficient information regarding the overall symptom severity.

Concurrent validity attempts to verify an indicator according to a pre-existing and accepted measure. Therefore, in order to validate the hot flush score, the score was correlated with the items “vasomotor symptoms” and “sweating at night” as recorded on the Greene Climacteric Scale at baseline. The Pearson Correlation between hot flushes recorded on the Greene scale with the hot flush score was 0.334 while the correlation between sweating at night as recorded on the Greene scale with the hot flush score was 0.358 (two tailed, p<0.05 n=92). These results suggest a moderate level of correlation.

11.4.2 Quality of life scales

Two menopause related quality of life scales were used to address the efficacy of the herbal formula in improving quality of life. The Greene Scale is a self rating questionnaire that measures 21 physical and psychological symptoms associated with the menopausal transition. A six symptom domain scale was constructed using factor analysis on menopausal symptoms. Normative data for this scale has been published for samples of Australian385 and Dutch women.384 The Greene Scale has been used extensively in clinical research assessing the effectiveness of CAM treatments in alleviating menopausal complaints.169, 202, 203, 263, 627, 1074, 1075 The second measure, the HFRDI Scale, assesses the impact of hot flushing on daily

256 activities and overall quality of life. The scale has been validated and was determined to be internally consistent.1062

The reliabilities of the Greene and HFRDI scales were determined by administering and then re-administering the scales during the base-line phase (at weeks -4 and 0).

Correlations between the total Greene Scale and its domain scores completed at the initial interview and four weeks later was high for the total score (r=0.71, p<0.05, two tailed) and for individual domain scores (r=0.66 to 0.72, p<0.05, two tailed)

(refer to Table 11.2). Content validity of the Greene Scale was ensured by using the same symptoms that had been determined by factor analytic studies which produced clusters (domains) with statistically significant factor loadings.253 The HFRDI Scale was determined to have both high internal validity and face validity by its author.1062

Likewise we found the HFRDI Scale to be a reliable scale with a significantly high correlation between the scores of the two administration times (r=0.76, p<0.05, two tailed).

Table 11.2: Test-retest correlation for secondary outcome measures

Test-retest Secondary outcome Number (n) correlation (r) Greene Scale score 77 0.71 Greene Scale domains Psychological 84 0.72 Anxiety 88 0.68 Depression 88 0.69 Somatic 88 0.66 Vasomotor 92 0.67 Sex 89 0.67 HFRDI Scale score 85 0.76

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11.5 Results

The results of the primary and secondary outcome measures were analysed both on an ITT and a per-protocol basis. The ITT analyses included all women randomised to receive treatment and had at least one efficacy measurement (n=92), while the per- protocol analyses included all randomised women who completed the treatment phase with no serious protocol violations (n=76). The last observation carried forward was used to replace missing values.

The 16 participants who were not included in the per-protocol analyses did not differ from those who completed the study with respect to age, demographics and baseline total number of hot flushes, severity score, total Greene Scale and HFRDI Scale scores. However, compared with participants who completed the study, withdrawn participants had statistically higher depression subscale scores (5.85 vs. 4.75 respectively; p = 0.02).

11.5.1 Primary outcome: Hot flush score

Table 11.3 presents the mean change in daily mean hot flush score and frequency from baseline to the end of treatment phase for both ITT and per-protocol populations respectively. Both analyses demonstrate that changes in outcome measures did not differ significantly between placebo and herbal interventions by the end of treatment phase. By the completion of treatment, the herbal intervention recorded a smaller mean change in hot flush score and number when compared to placebo.

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Table 11.3: Changes from baseline to end of treatment in daily mean hot flush number and score for ITT and per protocol populations

Herbal Placebo Difference in mean p- Measure mean (SE) mean (SE) change vs. placebo value n=45 n=46 (95% CI) Intention to treat analysis Hot flush number -2.29 (0.66) -2.81 (0.53) 0.52 (-1.15, 2.20) 0.54 Hot flush score -4.31(1.66) -5.15 (1.19) 0.84 (-3.21, 4.89) 0.68 Per protocol analysis Hot flush number -2.09 (0.74) -3.04 (0.59) 0.94 (-0.92, 2.81) 0.31 Hot flush score -4.05 (1.86) -5.68 (1.34) 1.63 (-2.88, 6.13) 0.47

Figure 11.2 below presents the mean weekly hot flush scores for the treatment and placebo groups of the ITT population. Both groups recorded overall decreases in hot flush scores throughout the treatment phase, although the herbal treatment group mean score was slightly greater by the end of week 16.

Figure 11.2: Mean weekly hot flush scores for the ITT population

16 Placebo 15 Herbal 14

12 Mean hot flush score per day 11

10 Baseline Wk 4 Wk 8 Wk 12 Wk 16 Weeks

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11.5.2 Secondary outcome: Quality of life

Tables 11.4 and 11.5 present the mean changes in quality of life scores for the

Greene and the HFRDI Scales from baseline until the end of the treatment phase for both ITT and per-protocol populations respectively. According to both analyses, by the end of the treatment period, the herbal intervention group had slightly worse total

Greene Scale and HFRDI Scale scores compared to placebo. There were no statistically significant differences between placebo and herbal treatment groups on any of the Greene Scale domains.

Table 11.4: Changes from baseline to end of treatment in quality of life scale scores for ITT population

Herbal Placebo Difference in mean p- Measure mean (SE) mean (SE) changes vs. placebo value n=46 N=46 (95% CI) Quality of Life scales Green Scale domains Psychological* -0.74 (0.67) -1.98 (0.73) 1.24 (-0.73, 3.21) 0.21 Anxiety* -0.48 (0.39) -1.17 (0.36) 0.70 (-0.36, 1.75) 0.19 Depression -0.30 (0.35) -0.80 (0.43) 0.51 (-0.59, 1.61) 0.36 Somatic -0.87 (0.35) -0.46 (0.41) -0.41 (-1.48, 0.66) 0.45 Vasomotor -0.77 (0.24) -0.87 (0.22) 0.10 (-0.54, 0.75) 0.75 Sex -0.19 (0.10) -0.15 (0.16) -0.04 (-0.41, 0.34) 0.83 Greene Scale score -2.40 (1.03) -3.46 (1.17) 1.06 (-2.05, 4.16) 0.50 HFRDI Scale score -10.09 (3.09) -11.67 (2.67) 1.59 (-6.52, 9.70) 0.70 Additional characteristics Vaginal dryness -0.19 (0.20) -0.15 (0.10) -0.04 (-0.32, 0.24) 0.78 Dry skin -0.11 (0.10) 0.02 (0.10) -0.13 (-0.41, 0.15) 0.13 *One participant did not complete psychological and anxiety subscales, total Greene Scale score was not calculated (herbal n = 45)

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Table 11.5: Changes from baseline to end of treatment in quality of life scale scores for the per-protocol population

Difference in Measure Herbal Placebo mean changes p- vs. placebo value n Mean (SE) n Mean (SE) (95% CI) Quality of Life scales Green Scale domains Psychological 35 -1.06 (0.83) 40 -1.72 (0.75) 0.67 (-1.56, 2.90) 0.55 Anxiety 35 -0.60 (0.50) 40 -1.10 (0.39) 0.50 (-0.74, 1.74) 0.42 Depression 36 -0.50 (0.42) 40 -0.62 (0.44) 0.12 (-1.10, 1.35) 0.84 Somatic 36 -0.97 (0.38) 40 -0.35 (0.46) -0.62 (-1.82, 0.57) 0.30 Vasomotor 36 -0.86 (0.29) 40 -0.87 (0.24) 0.01 (-0.74, 0.76) 0.97 Sex 36 -0.11 (0.11) 39 -0.15 (0.19) 0.04 (-0.40, 0.47) 0.86 Greene Scale score 35 -2.77 (1.20) 40 -3.10 (1.24) 0.33 (-3.12, 3.78) 0.85 HFRDI Scale score 36 -10.86 (3.44) 40 -11.82 (2.91) 0.96 (-7.97, 9.90) 0.83 Additional characteristics Vaginal dryness 36 -0.14 (0.12) 40 -0.17 (0.11) 0.04 (-0.29, 0.36) 0.83 Dry skin 36 -0.08 (0.12) 40 0.02 (0.12) -0.11 (-0.44, 0.22) 0.51

11.5.3 Factors affecting primary outcome

A number of variables known to affect the severity of flushing including BMI, cigarette smoking, alcohol intake and baseline hot flush frequency were assessed for any relationship with the severity of flushing. If a significant relationship was found, an analysis of covariance (ANCOVA) was conducted to test the effect of the intervention when controlling for confounding effects of baseline scores on outcome.

ANCOVA, adjusted for the above effects, indicated a non-significant difference between groups for any of the variables for both ITT and per-protocol populations.

11.5.4 Follow-up assessment

The follow-up consultation assessed any long-term affect of treatment on hot flush score and quality of life measurements. This consultation was scheduled eight weeks after completion of the intervention period. Thirty four women in the herbal treatment group and 38 women taking placebo completed the follow-up consultation.

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Changes in mean scores from end of treatment phase to the follow-up consultation demonstrated a decrease in the number of hot flushes, hot flush score and an improvement in quality of life amongst those who received herbal treatment compared to the placebo group (Table 11.6). By the follow-up consultation, the herbal intervention group experienced slightly less than one vasomotor episode per day (p=0.13) and a 1.5 decrease in the hot flush score (p=0.26) when compared to placebo. The intervention group scored a mean change of two points for the total

Greene Scale score (p=0.18) and slightly greater than six points for the HFRDI Scale score (p=0.10). However, these improvements did not reach statistical significance.

Table 11.6: Changes from end of treatment to follow-up in primary and secondary outcomes by intervention group

Herbal Placebo Difference in mean p- Measure mean (SE) mean (SE) change vs. placebo value n=34 n=38 (95% CI) Primary outcome measures Hot flush frequency -0.27 (0.49) 0.67 (0.39) -0.94 (-2.19, 0.30) 0.13 Hot flush score -1.03 (1.10) 0.47 (0.78) -1.50 (-4.14, 1.14) 0.26 Secondary outcome measures Green Scale domains Psychological -0.36 (0.82) 0.53 (0.62) -0.89 (-2.92, 1.14) 0.38 Anxiety -0.36 (0.50) 0.42 (0.32) -0.78 (-1.94, 0.37) 0.18 Depression 0.03 (0.39) 0.11 (0.39) -0.08(-1.18, 1.03) 0.89 Somatic 0.03 (0.34) 0.47 (0.29) -0.44 (-1.34, 0.45) 0.32 Vasomotor -0.21 (0.27) 0.37 (0.25) -0.57 (-1.31, 0.16) 0.12 Sex -0.12 (0.12) 0.03 (0.13) -0.14 (-0.49, 0.21) 0.41 Greene Scale score -0.61 (1.09) 1.39 (1.01) -2.00 (-4.97, 0.97) 0.18 HFRDI Scale score -2.53 (2.39) 3.74 (2.79) -6.27 (-13.68, 1.15) 0.10 Additional characteristics Vaginal dryness -0.18 (0.13) -0.03 (0.10) -0.15 (-0.48, 0.18) 0.36 Dry skin -0.03 (0.14) 0.05 (0.12) -0.08 (-0.45, 0.29) 0.66

11.6 Compliance

Compliance not only involves taking trial medication as prescribed, but also the completion of Daily Flush Diaries, correct procedures for the collection of blood and urine samples, attending monthly consultations and the completion of two quality of

262 life scales. Lack of compliance in any of these activities could have a detrimental effect on the final outcomes of the trial. Therefore, it was imperative to keep participants motivated and interested in taking their medication and completing all trial requirements. Compliance was encouraged by a number of means:

• Dispensing trial medications as tablets to mask any unpleasant taste

• Returning bottles and unused tablets for counting

• Recording the taking of medication on the Daily Flush Diary

• Regular contact by telephone confirming scheduled appointments and

enquiring about progress

• Regular consultations with an accredited herbalist

• Dealing with issues as promptly as possible

• Following up participants and thanking them for their continued

support by the chief investigator

At the initial consultation, the trial requirements were carefully explained to all participants. Submitting blood and urine samples, recording vasomotor symptoms and attending monthly consultations were considerable asks from trial participants.

In exchange for these requests, the cost of all trial related pathology testing and medications were borne by the trial sponsor and participants were consulted by trained and accredited TCM herbalists. On completion of trial requirements, placebo group participants were given 16 weeks of herbal treatment.

The overall burden on trial participants was not particularly onerous. Potential participants who could not meet these demands were screened out during the baseline period (n=12). Many participants carried their Daily Flush Diaries with

263 them in their bags or pockets to record flushes throughout the day. Consultations were conducted at a number of herbal clinics at various locations in Sydney. DHM collection centres were conveniently situated throughout the Sydney metropolitan area. The two initial consultations were about 45 minutes each, while subsequent consultations took on average 15 minutes in length.

Overall compliance with taking trial medications for the 92 participants was good

(89.07% for placebo group and 84.73% for herbal group). Non-study medication including complementary medicines taken by either group did not change significantly during the 28 week intervention and follow-up period.

11.7 Adverse Events

Of participants reporting an adverse event, approximately 48% were taking placebo while 57% were on herbal treatment. During the trial, a total of 30 adverse events were reported by participants receiving placebo, while those receiving herbal treatment recorded 48 events. There were no statistically significant differences between herbal treatment and placebo groups in the proportions of women reporting adverse events (refer to Table 11.7). The two most frequently reported adverse events by women taking herbal formula were headaches, which almost reached statistical significance (p=0.07), and gastrointestinal complaints, including bloating, diarrhoea/loose stools, pain and nausea. All reported events were mild to moderate in severity and did not require medical assistance. Liver and kidney function tests carried out eight weeks after commencement of trial intervention revealed no abnormal values.

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Table 11.7: Frequency of adverse events reported by intervention group

Adverse event Herbal (n=47) Placebo (n=46) p-value* Number (%) Number (%) Gastrointestinal 23 (47.9) 17 (56.7) 0.29 Abdominal bloating 5 (10.42) 2 (6.7) 0.43 Constipation 2 (4.2) 5 (16.7) 0.43 Diarrhoea/loose stools 4 (8.3) 2 (6.7) 0.68 Abdominal pain 6 (12.5) 5 (16.7) 1 Nausea 5 (10.4) 1 (3.3) 0.20 Vomiting 1 (2.1) 1 (3.3) 1 Indigestion 0 (0) 1 (3.3) 1 Headache 14 (29.2) 6 (20) 0.07 Increased urination 2 (4.2) 1 (3.3) 1 Vaginal discharge 2 (4.2) 2 (6.7) 1 Palpitations 3 (6.25) 1 (3.3) 0.62 Dry mouth/throat 4 (8.3) 3 (10) 1 * p values calculated using Fisher exact test comparing herbal treatment with placebo

Three participants withdrew due to adverse events associated with trial medications.

Two participants taking the placebo reported headaches, abdominal bloating, constipation and dehydration. These participants were asked to stop taking the tablets for several days. Symptoms resolved on cessation of trial medication but resumed when therapy was recommenced. The third participant taking the herbal formula cited headaches, nausea, excessive perspiration and intermittent ache in arms and legs. She withdrew without a rechallenge of the medication.

11.8 Success of Blinding

Treatment allocation was only revealed to participants on completion of the follow- up consultation. Success of blinding was evaluated by asking participants which treatment they thought they had been administered at the beginning of the treatment phase, at each monthly consultation and at follow-up. Blinding of participants was evaluated at the end of treatment and at follow-up. At completion of the treatment

265 phase, 70.5% of participants were unsure which treatment they received; 45.5%

(40/88) of participants indicated they did not know what they had received, while

25% incorrectly guessed their treatment allocation. Only 29.5% (26/88) of participants correctly guessed their treatment. At the follow-up consultation, corresponding figures were 41.7% (30/72) stating they did not know their allocation and 30.6% (22/72) correctly guessing.

11.9 FF-01 and Bone Turnover

Forty-nine women were recruited to the bone marker pilot study, with 49 eligible results obtained for the analysis of serum BAP and 47 for urinary DPD (corrected for creatinine). Table 11.8 presents the results for both BAP and DPD. Sixteen weeks of herbal treatment did not cause a significant change to the levels of these markers compared to the placebo group.

Table 11.8: Changes in BAP and DPD between herbal and placebo groups from baseline to end of treatment and end of treatment to follow-up

Difference in mean p- Measure Herbal Placebo changes vs. value n Mean (SE) n Mean (SE) placebo (95% CI) Change from baseline to end of treatment Serum BAP (μg/L) 26 -1.32 (1.00) 23 -0.63 (1.05) -0.69 (-3.61,2.23) 0.64 Urine DPD (nmol/L) 25 -0.35 (0.60) 22 0.08 (0.40) -0.43 (-1.93, 1.06) 0.56 Change from end of treatment to follow-up Serum BAP (μg/L) 20 0.95 (0.96) 18 0.32 (0.88) 0.63 (-2.03, 3.30) 0.63 Urine DPD (nmol/L) 21 -0.63 (0.33) 17 0.16 (0.53) -0.79 (-2.01, 0.43) 0.20

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11.10 Discussion

This trial found that the herbal formula FF-01 was no more effective than placebo in alleviating vasomotor symptoms, improving quality of life and modulating bone turnover markers. There were no statistically significant differences between intervention groups throughout the duration of the trial treatment period for any of these measures. Although the herbal intervention group continued to experience a decrease in symptoms and improvement in quality of life eight weeks after cessation of treatment, these changes did not reach statistical significance.

Effort was made to ensure that this trial was designed according to good clinical trial protocol. Recommendations made by the CONSORT group in improving the quality of reporting of parallel-group randomised trials were considered during the design phase.642 The trial incorporated randomisation of participants, a placebo-control group and blinding of participants, practitioners and the statistician. Randomisation achieved similar treatment groups in respect to demographics, health characteristics and outcome measures. These baseline values did not differ significantly between intervention groups. Results from enquiries about treatment allocation suggested that blinding was successful. Although the large placebo effect inherent in trials on vasomotor symptoms was addressed by incorporating a baseline phase, a significant placebo effect was still noted amongst participants in both treatment groups.

An analysis of the reporting of adverse events suggested that the herbal formula was reasonably well tolerated. There were no significant differences between placebo and herbal treatment groups in the numbers of women reporting adverse events.

Events reported by women were mild to moderate in severity and did not require

267 medical assistance and most resolved spontaneously. During the trial, three women withdrew due to adverse events; one receiving herbal treatment and two taking placebo.

Compliance not only involved taking the recommended daily dose of trial medication but also included attending monthly consultations and undergoing pathology testing. Compliance with taking trial medications was good. A number of methods were employed to enhance and maintain the motivation of trial participants.

Herbal clinics and DHM collection centres were located throughout the Sydney metropolitan area to increase accessibility for women to attend consultations.

Nevertheless, women were generally enthusiastic in taking part in the study and completed trial requirements without difficulty.

In conclusion, FF-01 which consists of Cimicifuga and seven traditional Chinese herbs is not an effective treatment for the alleviation of vasomotor symptoms, improvement in quality of life and the modulation of bone turnover markers. The following chapter discusses the trial results and their implications in detail. The strengths of the study and possible limitations are identified and discussed.

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CHAPTER 12 TRIAL: DISCUSSION AND CONCLUSIONS

12.1 Introduction

The following chapter discusses the results of the clinical trial and their implications for clinical practice. The chapter also presents the potential action and tolerability of the formula. The strengths of the trial methodology will be evaluated and potential limitations which may have impacted on the findings are identified.

12.2 Clinical Effect of FF-01

12.2.1 Vasomotor symptoms and quality of life

This randomised placebo controlled double-blind clinical trial assessed the efficacy of a herbal formula containing seven traditional Chinese herbs and Cimicifuga for the alleviation of vasomotor symptoms and the improvement in quality of life. No significant differences were noted between the herbal formula and placebo groups in

269 reducing hot flush score and improving quality of life measurements. Similarly, there was no significant effect of treatment on daily mean hot flush score during the treatment phase and at follow-up. By the end of the 16 week treatment period, both intervention groups experienced a similar reduction in hot flush score and changes in quality of life. Nevertheless, eight weeks after completing the treatment phase, participants who received the herbal intervention experienced a continued decrease in the number of hot flushes, hot flush score and an improvement in quality of life while the placebo group reported a worsening of symptoms. However, these improvements did not reach statistical significance. Therefore, it must be concluded that the first null hypothesis which states; “FF-01 is no more effective than placebo in reducing the hot flush score” is supported. Likewise the second null hypothesis is also up-held; “the herbal formula is no more effective than placebo in improving quality of life in menopausal women experiencing vasomotor symptoms”.

12.2.2 Bone metabolism

The pilot study on bone metabolic markers included a sub-set of eligible women who participated in the clinical trial assessing the effectiveness of FF-01 in alleviating vasomotor symptoms. The null hypothesis of this study was accepted as FF-01 did not cause any changes to the bone metabolic markers BAP and DPD (corrected for creatinine).

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12.3 Trial Outcomes in Comparison to Other Studies

The results of this study contrast published studies conducted in China which demonstrated a reduction in severity of vasomotor symptoms with the administration of a variety of Chinese herbal formulae. However, many of these studies were not

RCTs and lacked adequate blinding,28, 29, 623, 626 failed to randomise participants,28, 29,

625 included small sample sizes32 or did not involve a placebo control group.28

Furthermore, due to a failure in adopting a standardised definition for the menopause, research groups often included participants of varying menstrual status who reported a wide variety in the number of vasomotor episodes. A systematic review of these studies was reported in detail (refer to section 7.3). The review concluded that the evidence regarding the effectiveness of CHM for the relief of vasomotor symptoms is poor.

The results of the present study are similar to the findings of a well executed clinical trial that randomised 55 postmenopausal women to receive either a Chinese herbal formula or placebo for 12 weeks.30 The researchers concluded that the Chinese herbal formula was no more effective than placebo in reducing the frequency of vasomotor events or in improving the four symptom domains of the Menopause

Specific Quality of Life Questionnaire. However, a follow-up assessment was not conducted to determine if the treatment had any long term effect.

Clinical studies on the effectiveness of Cimicifuga for the treatment of vasomotor symptoms have yielded mixed results. Although earlier research generally reported positive outcomes, many were plagued by poor methodology. Even recently conducted clinical trials have yielded conflicting results depending on trial

271 methodology.26, 658 The most detailed and extensive RCT conducted to date was undertaken by Newton and colleagues,659 who assessed the treatment of vasomotor symptoms with either Cimicifuga, multibotanicals, soy, HT or placebo. The authors found that Cimicifuga used in isolation or as part of a multibotanical regimen did not significantly reduce vasomotor symptoms, symptom intensity or the Wiklund

Vasomotor Symptom Subscale score compared to placebo over a 12 month treatment period. A detailed systematic review of the clinical research on Cimicifuga was reported in section 8.3.1.1 and concluded the overall quality of the research was moderate.

12.4 Action of FF-01

The trial formula was based on two Chinese medical formulae, Er Xian Tang and

Zhi Bai Di Huang Wan, traditionally used to strengthen the Kidneys and to clear

Heat associated with menopausal vasomotor symptoms and sweating. According to

TCM theory, menopause is associated with a gradual decline in Qi of the Organs, in particular the Kidneys. The Kidneys are said to govern the constitution of an individual. Kidney tonifying herbs included Rehmannia, Epimedium and Curculigo, while those that predominately addressed the resolution of Heat were Rehmannia,

Phellodendron, Anemarrhena and Asparagus. Zizyphus has a sedative and hypnotic effect803 and was included to reduce insomnia and irritability.702

The principal herb to alleviate vasomotor symptoms was Cimicifuga. This herb was selected as there was some evidence to suggest that Cimicifuga has a moderate effect in reducing hot flushing. The other seven herbs were chosen to augment the effect of

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Cimicifuga according to their Chinese medical properties. There was some limitation with the selection of the herbs as the sponsor wished the formula to be similar to one that was already on the market.

Although the present study did not find a significant difference between placebo and herbal treatment, it was interesting to note the continued improvement in symptoms amongst women in the active group eight weeks after treatment was discontinued.

According to Chinese medical theory, chronic conditions need to be addressed by treating the root cause of the disease and symptoms will only improve once this root cause has been effectively addressed. This may explain the continued improvement amongst women who took the herbal formula once the treatment phase ended.

Whether this improvement continued beyond eight weeks and reached statistical significance is not known.

The exact mechanism for the actions of Cimicifuga have not been fully elucidated; however as discussed previously, several hypotheses have been postulated. Wuttke and co-workers172 suggested that Cimicifuga may act as a SERM causing either an agonistic or antagonistic effect depending on the function and location of the target tissue. However, this claim has not been supported by several recent studies which imply a lack of oestrogenic activity on serum hormonal levels and target organ tissues.170, 665, 666, 669, 687 Liu and colleagues found that a methanolic extract of

Cimicifuga did not bind to oestrogen receptor subtypes α and β, did not induce oestrogen-dependent activity of alkaline phosphatase in Ishikawa (endometrial) cells and did not up-regulate the oestrogen inducible genes presenelin-2 and the progesterone receptor.669 A pharmacologic review of animal and in vitro studies

273 analysing the mechanism of action concluded that the effects of the herb may be due to constituents with dopaminergic rather than hormonal activity.661 This hypothesised mechanism of action requires further investigation. Alternatively, it has been suggested that the effects of Cimicifuga may be mediated via the binding of serotonin receptors. An in vitro study found that an extract of Cimicifuga bound to specific subtypes of serotonin receptors located in the hypothalamus.690

FF-01 contains many known and unknown active constituents that act either independently or synergistically to promote any therapeutic effect. Therefore, it is not known if the medicinal effect of Cimicifuga was mitigated by unknown constituents contained within the seven additional herbs of the formula. Newton and colleagues659 suggest that the effects of Cimicifuga may be sensitive to dose, extraction methods and the presence of other herbs in a formula. Cimicifuga was the only herb standardised for a known active constituent, containing not less than 2.5% triterpene glycosides calculated as 27-deoxyactein by High Performance Liquid

Chromatography. The dose of triterpenes per tablet was approximately 2.2mg, with the daily dose approximately 8.75mg per day. Cimicifuga was extracted using a

50% ethanol solvent. Remifemin, a moderately effective herbal remedy, is a 40% by volume isopropanyl alcohol extract of Cimicifuga rhizomes and delivers a daily dose of 2 to 4mg triterpenes. Therefore, it may be possible that a lower dose of

Cimicifuga is more efficacious than a large dose or the herb is more effective on its own. These factors may account for an enhanced potency of Remifemin and a decreased efficacy of FF-01. In future, researchers may need to carefully consider the affect of variables such as dose, extraction methods and co-administered herbs on the effectiveness of Cimicifuga and the impact on the herb’s therapeutic potential.

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Preliminary studies on bone cell lines and animal models of osteoporosis suggest that a number of herbs included in FF-01 have a favourable effect on bone metabolism.

These herbs were Epimedium, Rehmannia, Anemarrhena, Cimicifuga and the active constituent berberine isolated from Phellodendron. However, very little clinical work has been conducted investigating the effect of these herbs on bone turnover in humans. It is not known if the beneficial effects of these herbs were mitigated with the addition of the other herbal agents.

12.5 Strengths of the Study

This randomised, double-blind, placebo-controlled clinical trial was conducted according to the recommendations published by the CONSORT group.642 Issues regarding poor methodology identified in the systematic reviews on CHM and

Cimicifuga were addressed to ensure a sound and robust protocol that scientifically evaluated the effectiveness of the formula.

12.5.1 Randomisation and blinding

The random allocation of participants to treatment groups attempts to produce groups with similar baseline characteristics. If groups are similar at the start of the trial then any impact of treatment will be easier to quantify as the potential effects of other factors are minimised. Therefore, randomisation reduces the risk of factors that could have a significant impact on the clinical outcomes of a trial. In the present study, randomisation resulted in groups with similar baseline characteristics (refer to

Table 11.1). Comparisons of both treatment groups after randomisation confirmed similar baseline characteristics and symptom severity.

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The study included blinding of participants, practitioners and statistician to treatment allocation in order to reduce bias. The use of an identical placebo ensured blinding of participants and practitioners to treatment allocation during the trial. The monthly blinding check confirmed that participants were unaware to which group they had been randomised. Blinding is important in order to mitigate any bias that could be introduced with knowledge of treatment allocation. For example, a practitioner’s enthusiasm or scepticism of a treatment may influence the response of a patient to treatment.

12.5.2 Symptom severity

The FDA industry guidelines for assessing the effectiveness of pharmaceuticals for alleviating vasomotor symptoms require women to experience at least seven hot flushes per day for entry into a clinical trial.630 A meta-analysis of 17 randomised clinical trials which determined the effectiveness of isoflavones in reducing vasomotor symptoms found a statistically significant although clinically modest effect amongst women experiencing ten or more hot flushes per day. These women noted a 20% decrease in symptoms after isoflavone supplementation.265 This finding agrees with an earlier analysis on studies assessing the effectiveness of soy products.

These authors found that the efficacy of soy foods and soybean isoflavone supplements was positively related to the initial hot flush frequency.629 Furthermore, a number of recently conducted trials which found no significant improvement in vasomotor symptoms with herbal treatment recruited women with three or more symptoms per 24 hours.26, 658, 659

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Therefore, when assessing the inclusion criteria for this trial, it was believed that women with severe vasomotor symptom number would not want to participate in a clinical trial assessing a treatment with no clinical evidence of effectiveness and with a 50% chance of being randomised to a placebo group. Furthermore, these women would be hesitant in trying a herbal treatment that was likely to be less efficacious than HT. Therefore, it was decided that women experiencing six or more vasomotor symptoms of any severity were likely to participate in a clinical trial and symptoms were sufficiently severe to detect a clinically meaningful treatment effect.

12.5.3 Placebo response

Several methods were employed in an attempt to reduce the large placebo response noted in women experiencing vasomotor symptoms. A larger placebo effect in the reduction of vasomotor symptoms has been noted amongst perimenopausal women,5 due to widely fluctuating hormonal levels.356, 372 Such women experience menstrual irregularity along with an associated variability in symptoms as oestrogen levels cycle erratically. For this study, “menopause” was defined as amenorrhoea of 12 months or longer and therefore we recruited postmenopausal women. In order to further reduce a placebo response due to enrolment into the trial, a four week baseline period was included in the protocol. Baseline measurements were obtained at the end of the four week baseline period. Reliability and validity testing were based on comparisons between scores obtained at trial admission with those at the end of the baseline period.

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A placebo control group attempts to separate the therapeutic effects of taking a medication from any psychological benefits of the therapeutic encounter and the receiving of treatment. With-holding treatment from the placebo group also allows the effects of time on the disease process to become apparent. The placebo group received inert tablets made to look and taste similar to the herbal treatment in order to maintain blinding of participants and practitioners to treatment allocation.

12.5.4 Lifestyle factors

The trial protocol attempted to control variables that may have influenced the reporting of vasomotor symptoms. Participants were counselled not to change their current lifestyle. Each monthly consultation included a range of lifestyle questions to help alert practitioners to any participant who may have made drastic changes.

Monitoring included the intake of phytoestrogens, the use of conventional and complementary medicines, amount of exercise, coffee and alcohol consumption and smoking habits. Assuming questionnaires were answered truthfully, participants did not make significant changes to their lifestyles during the trial.

12.5.5 Bone pilot study

Bone turnover markers were chosen for their specificity to bone, ease of assessment and reduced variation due to external and internal factors. Serum BAP is a specific and sensitive indicator of menopausal changes in bone turnover.1078 BAP is synthesised by osteoblasts and eventually enters the blood stream. The half-life of

BAP in the blood is relatively long.1079 BAP is not affected by renal clearance and is relatively unaffected by diurnal variation when compared to most other markers.1079-

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1082 BAP serum concentrations can be determined using a simple and convenient enzyme specific immunoassay which provides a reliable indication of bone turnover.

For these reasons, BAP was chosen as the bone formation marker. Likewise, DPD was selected for its high specificity to bone; ease of use and for being one of the least variable bone breakdown markers. Although urinary markers of resorption have greater specificity than serum markers, they demonstrate greater variation due to the assay itself, the timing and accuracy of collection and with seasonal and diurnal variations.896

12.6 Limitations of the Study

A number of limitations may have impacted on the results of this study. It may be argued that the negative results of this trial were not due to a true lack of a clinically significant effect but due to a lack in statistical power. Power is the probability that the test will find a statistically significant difference, the probability that the test will reject a false null hypothesis. With a lack of statistical power a type II error may be made (a failure to observe a difference when there is actually one). This occurs when the sample size is too small. However, sample size calculations striving for

90% power were carried out prior to commencing the study. Furthermore, the power was strengthened by using reliable measures. The hot flush score and quality of life scales were found to be valid and reliable measures for assessing the efficacy of treatment. Power may also be increased by increasing the significance level. The significance level of statistical testing was set at 0.05. Increasing this level was not considered appropriate, as this enhances the risk of obtaining a statistically significant result when the null hypothesis is in fact false.

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The only herb to be standardised against a known constituent was Cimicifuga. The remaining herbs comprising the herbal formula were not characterised nor were they standardised to any known active constituent. Certificates of analysis were issued for all herbs confirming the herbal materials and providing evidence of microbial screening. Standardisation against a known constituent ensures consistency between batches of herbal products and the correct identification of plant species. Even though certificates of analyses were provided for the herbs, except Epimedium, one still cannot be sure of the correct identification or chemical composition of the original plant material.

Finally, this randomised controlled clinical trial assessed the effectiveness of a single formula containing Chinese herbs. As mentioned in the introductory chapter, this study did not examine the application of TCM treatment principles for the treatment of vasomotor symptoms since all women in the treatment group were given the same formula. TCM theory recognises that individuals given the same disease diagnosis may exhibit different signs and symptoms and therefore a herbal formula may be individually tailored to address these differences. As time progresses and symptoms change further modifications may be made to the formula. However, very little research has been conducted investigating the purported additional benefit of individualised over standardised treatment. A clinical trial conducted by Bensoussan and colleagues1083 found that herbal treatment individualised according to TCM principles for the alleviation of IBS was no more effective than a standardised herbal formula at completion of the treatment phase. However, 14 weeks after cessation of treatment, the individualised treatment group continued to improve and demonstrated an improvement in symptoms approaching significance compared to standard

280 treatment (p=0.097). Therefore, individualised treatment may not offer immediate benefit over standardised treatment but confer some longer lasting therapeutic effect.

12.6.1 Limitations of the bone study

The biological variability in the measurement of bone turnover markers is a major limitation in their use. In general, serum markers of bone formation have less long- term biological variability than urinary markers.957 Variation may occur due to non- uniform rates in bone turnover, the time at which samples are collected and the season of the year (bone resorption is greater during winter). The assay itself may also cause variations in measurement.

Variability of bone turnover measurements were minimised in several ways. Urine collections were standardised; a mid-stream sample collected at the second morning void after an overnight fast (time of peak excretion). All serum and urine specimens were measured together using their respective assay kits. To further reduce variability, a mean baseline value for BAP and DPD was calculated from the two initial measurements. However, this was not done with subsequent measures.

Although, more reliable results may have been obtained by calculating the mean of several samples obtained at the end of treatment and follow-up, this may have posed a considerable burden and inconvenience to participants who were already submitting to the collection of a number of specimens and the requirements of another study. Variability may have been further reduced by testing the serum and urine samples in duplicate. This was conducted on all serum samples; unfortunately the cost of the DPD assay was too prohibitive to allow for replicated measurements.

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Bone markers generally reach a nadir within 3-6 months after the initiation of treatment.895 Therefore, it may be argued that 16 weeks of herbal treatment may not be long enough to register a therapeutic response. However, no meaningful trend or change in either marker compared to placebo was noted with therapy during this time.

12.6.2 Other factors impacting on the results

Clinical trials assessing treatments for the alleviation of vasomotor symptoms have reported a substantial placebo effect in the reduction of both vasomotor symptom number and score.5, 1065 Sloan and co-workers1065 reported that hot flushes reduce on average by 20-30% after four weeks of placebo treatment. Approximately 25% of patients report a 50% reduction in vasomotor symptoms with placebo, while 15% of patients experienced greater than a 75% reduction in symptoms. The high placebo response may in part be due to fluctuating hormonal levels which correspond to variable rates of symptom reporting over a monthly period. The results of this study also suggest a substantial placebo effect with a reduction in vasomotor symptom score and number of approximately 30%. Therefore, any effect of treatment had to be significantly greater than this large placebo effect.

The passage of time may have a significant effect on the outcome measures of the trial, as several epidemiological studies confirm vasomotor symptom number and severity subside over time.4, 386, 1084 Most women experience these symptoms for between 1-10 years, with a significant proportion reporting symptoms for less than

282 two years.137 A further 15% of women may suffer symptoms for more than 15 years.4 A clinical trial evaluating the effect of soy on vasomotor symptoms found time significantly outweighed any effects of treatment.1085 Women enrolled into the present trial were post-menopausal and had reported symptoms for an average of six years. Therefore, there may have been a significant number of women experiencing a natural decline in symptoms due to the progression of time.

A phenomenon that may have had some bearing on the results is the tendency for a regression towards the mean. This occurs when extreme scores on any measure at one point in time tend to be less extreme the next time they are measured.

Regression towards the mean is unrelated to time and occurs when a sample has been asymmetrically selected and is therefore a more extreme sample group than the general population. A moderate to high intensity of vasomotor symptoms were required for this trial. Because this is a group phenomenon, the group’s symptom score average will move towards that of the general population, although individual scores are likely to move in either direction with repeat testing. The solution to this problem is to include a control group and compare the results of the treatment group with those receiving the placebo.

12.7 Formula Tolerability

In general, the herbal formula was well tolerated. There were no significant differences in overall rates of adverse event reporting by women taking the herbal treatment compared to placebo. Only one participant receiving the herbal formula withdrew due to adverse events. Adverse events reported by trial participants were

283 mild to moderate in severity and resolved once the study medication was reduced or terminated. Since there were no significant differences between treatment groups in the reporting of vaginal discharge, this symptom was likely due to a rise in endogenous oestrogens independent of study medication. Liver function tests were included as a precautionary measure as the use of Chinese herbs had been linked to abnormal liver dysfunction,122 and hepatotoxicity had been suggested with the use of

Cimicifuga,697-699 although causality of this association has not been ascertained.212

Two critical evaluations on the safety of Cimicifuga conclude that the herb is safe when used within the recommended dose range for a period up to 6 months.212, 213

No abnormal liver or kidney function results were reported eight weeks after commencement of the trial treatment phase. Since further tests were not conducted after this time, long term safety of the herbal formula was not determined.

A number of the formula herbs, including Rehmannia, Epimedium and Cimicifuga, have been reported to cause a mild level of gastro-intestinal discomfort and headaches. Adverse events reported with these herbs were mild and resolved spontaneously after several days.206, 692, 716, 727 High doses of Cimicifuga have been noted to cause a frontal headache with a dull, full or bursting feeling.692 It was noted that the number of women in the herbal group reporting headaches almost reached statistical significance when compared to women of the placebo group (p=0.075).

However, we cannot speculate if these headaches were due to Cimicifuga as women were not asked about the location and nature of their headaches. Nevertheless, the overall statistical analyses demonstrated no significant differences between the rates of adverse events reported by women receiving herbal treatment compared with placebo. Therefore, it may be concluded that the FF-01 has good tolerability.

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12.8 Summary and Conclusions

In conclusion, this rigorously conducted RCT did not find FF-01 to be more effective than placebo in reducing vasomotor symptoms or improving quality of life. Some continued improvement in symptoms were noted by the herbal treatment group eight weeks after cessation of treatment, however this difference did not reach statistical significance. This outcome may warrant further investigation to determine if this improvement continued with time and was maintained. The pilot study found the formula did not affect bone turnover markers over the 16 week treatment period.

The results of this study are only generalisible to relatively healthy postmenopausal women experiencing on average six vasomotor symptoms a day.

The trial was designed in accordance with good RCT protocol. The trial design included;

• baseline, treatment and follow-up phases

• randomisation of participants to treatment allocation

• a placebo control group

• blinding of participants, practitioners and statistician.

These measures attempted to control for any placebo effects due to admission into the trial and administration of trial interventions. Randomisation ensured equal representation of participants within treatment groups so that valid comparisons between the groups were made. The baseline phase was a time to monitor flushing and to eliminate placebo responders, while the follow-up period assessed any long term residual benefit of treatment.

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A number of limitations were identified in this chapter. An under-powering of the study was suggested however, this was unlikely as a sample size calculation was conducted, reliable measures were used and an appropriate significance level was adopted. Apart from Cimicifuga, a lack of characterisation and standardisation of the herbs against known marker compounds raises concerns about the content and concentration of the various active chemical constituents. The variability of these constituents may result in differences in in vitro pharmacological activity and bioavailability in humans. The reporting of these assays has been strongly recommended in order to improve the quality of herbal medicine research.634

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CHAPTER 13 GENERAL CONCLUSIONS

13.1 Overview

Menopause is a natural transition in life where reproduction is no longer feasible or possible. Although most women find this change relatively free of symptoms, a significant minority are troubled by vasomotor symptoms which may impact negatively on quality of life. HT is often prescribed to alleviate these symptoms.

However, the results from several large observational and clinical studies suggest a number of health risks associated with the taking of HT. The publication of these results caused many women to cease taking HT and consequently prescriptions for these pharmaceuticals plummeted.582 In addition, a number of medical boards recommended that HT be prescribed for the short-term alleviation of acute symptoms only.

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Epidemiological studies indicate that a significant proportion of middle-aged women have tried a number of alternative therapies for alleviation of vasomotor symptoms and improvement in quality of life. Although CAM use amongst middle-aged women is popular,20, 23 many of these treatments have not been evaluated for their therapeutic efficacy. Unfortunately, the standard of clinical work on herbal therapies has not been consistently robust. Two systematic reviews evaluating the rigor of

CHM and Cimicifuga clinical trials for the alleviation of vasomotor symptoms found the overall quality of the evidence to be lacking, particularly for CHM. A number of methodological flaws were identified in the research protocols of published studies.

For these reasons, we believed it was necessary to investigate the prevalence of

CAM use amongst local Australian women and to evaluate the effectiveness of a herbal product formulated specifically for the alleviation of vasomotor symptoms.

The Women’s Health during Mid-life Survey was conducted to determine the nature and extent of CAM use amongst women aged 45-65 years who were symptomatic or asymptomatic but taking menopause specific treatments. This study also evaluated the perceived effectiveness of various CAM modalities and investigated the level of communication between doctors and their patients. The research protocol for the

RCT addressed flaws identified in earlier clinical work in order to rigorously evaluate FF-01 for the alleviation of menopausal vasomotor symptoms and improvement in symptom related quality of life.

The menopausal transition and the years following the final menstrual period are associated with an increased loss of bone. Bone loss is associated with an accelerated rate of bone turnover, with the balance of remodelling shifting towards

288 excess resorption. The uncoupling of bone metabolism leads to decreased bone mass and strength. Preliminary evidence presented in the literature review, suggested that four herbs of the formula caused a favourable effect on bone metabolism. Therefore, a pilot study investigating the effect of the formula on bone turnover was included.

13.2 Major Findings and Their Implications

13.2.1 Women’s Health during Mid-life Survey

• The results confirm the continued popularity of CAM use by middle-aged

women transitioning through menopause for improving quality of life.

The survey found approximately one in two Sydney women had consulted a

CAM practitioner and/or used a product during the preceding 12 months.

These results confirm the findings of previous epidemiological research on

CAM use. Health care practitioners need to be aware of the high utilisation

of CAM modalities and products. Many herbal, vitamin and mineral

products are available at various retail outlets without prescription.

Therefore, it is likely that many women are self-prescribing any number of

these products with or without professional advice. Health care workers need

to be informed about popular CAM treatments available in order to better

guide their patients and to refer patients on to reputable CAM practitioners if

requested. If patients wish to take an integrated approach to health, medical

and CAM practitioners need to be prepared to work together so that

conventional care is complemented with CAM approaches to meet specific

health care needs.

289

• Although this survey could not determine the concurrent use of

pharmaceuticals with oral CAM treatments, it is likely this practice is

common due to the high reported use of prescription and/or non-prescription

pharmaceutical medicines.

Combining the use of pharmaceuticals and oral CAM therapies increases the

likelihood of drug-herb interactions. Health care practitioners need to be

aware of this practice and carefully and precisely question their patients

regarding the use of all oral medications. Drug prescriptions may need to be

modified to accommodate patient wishes.

• Many medical practitioners are not specifically asking their patients about

the use of alternative treatments.

Doctors must appreciate the continued popularity of CAM use and the

autonomy patients wish to have over their health care. Such a question may

need to be asked regularly as patients may initiate alternative treatment at any

time, especially in response to a change in health status. Practitioners should

record all medications taken by patients in order to lessen the possibility of

interactions between drug and herb. Obtaining a full understanding of all

treatment modalities will help plan the best course of treatment tailored to

suit the individual.

• Body work therapies such as massage and chiropractic were rated by

respondents as the most effective treatments.

Menopausal vasomotor symptoms may be induced by stress. Reducing the

stress response and encouraging a state of relaxation and well-being may be

290

mechanisms by which these therapies work. These therapies may be the best

treatments to try initially before more intensive approaches are suggested.

Exploring and adopting other ways to reduce stress and improve health

should also be encouraged.

• Women seem to be choosing CAM products that are supported by some

scientific evidence and are therefore, not using CAM in a random fashion.

Soy and Cimicifuga have a modest amount of evidence for their effectiveness

in alleviating vasomotor symptoms. Although one clinical trial evaluating

the effectiveness of EPO found the oil ineffective in reducing vasomotor

symptoms, the authors note the treatment significantly reduced the maximum

number of night time flushes (p<0.05).225 Further research confirming the

efficacy of EPO needs to be conducted before this product can be

recommended for menopausal complaints.

• Respondents primarily sought advice about CAM from potentially non-

credible sources.

It is imperative that information about any medical or therapeutic practice be

accurate and reliable. Due to the high use of CAM amongst middle-aged

women, medical practitioners should be informed about the most popular

CAM modalities so they can accurately inform their patients. If health care

practitioners are unable to answer queries they should direct patients to

reliable sources and/or refer patients on to reputable CAM practitioners.

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13.2.2 Clinical trial

The randomised, placebo controlled, double-blind, parallel group clinical trial found

FF-01 to be no more effective than placebo in alleviating vasomotor symptom number or severity as calculated by the hot flush score. Likewise, the clinical trial found the formula no more effective than placebo in improving quality of life as measured by the Greene Climacteric and HFRDI Scales. A continued improvement in symptoms was noted amongst women who had taken the formula, eight weeks after cessation of treatment. However, this change did not reach statistical significance. Any long term improvement past eight weeks would need to be further investigated.

A number of herbal formulae and supplements for the alleviation of vasomotor symptoms are currently on the market. However, these products need to be clinically evaluated before claims regarding therapeutic efficacy can be made.

Clinical trial protocols will need to account for the large placebo response that occurs with vasomotor symptoms and an improvement in symptomatology with the passage of time.

FF-01 was found to be no more effective than placebo in modulating bone turnover markers. Serum and urine concentrations of BAP and DPD respectively did not decrease with herbal treatment over a 16 week period. This preliminary evidence suggests the formula has no effect on bone metabolism and therefore long term effects on bone turnover are unlikely. Conclusions regarding changes in BMD

292 cannot be made, however it is unlikely the formula has an effect on BMD, given the lack of a metabolic effect on bone. A further long term study would need to be conducted to determine any effect of the formula on BMD.

13.3 Limitations of the Research

Extrapolation of the survey findings to the whole community of menopausal women aged 45-65 may be limited due to a number of factors.

• The use of convenience sampling. The use of three recruitment strata is

essentially convenience sampling. Since we were investigating CAM use

amongst symptomatic women, our aim was to have a wide representation of

women with varying degrees of access to medical care at the time of survey

completion; specialist care, general care or no medical care. We believe this

presented a broader representation of women and the results gave a better

overall picture of trends in the community than any strata considered in

isolation. The results of this survey confirm those of overseas and Australian

studies that found CAM use by women transitioning through menopause to

be very popular.

• The voluntary nature of the survey may have led to a selection bias of

participants who were more interested in CAM, resulting in a higher estimate

of CAM use. As with all voluntary surveys, there is some degree of self-

selection that may influence the results.

293

• The exclusion of non-English speakers may have resulted in an under

estimation of CAM use. For example TCM use is popular in Asian

communities while Ayurvedic medicine is common within the Indian

community.

Inaccuracies may have occurred with the recalling of information when answering questions for both the survey and clinical trial. Women, wishing to make a pleasing impression, may have perceived that questions should be answered in a particular way. Concerns about privacy may have been a concern for survey respondents, even though the questionnaire was anonymous. A large number of women failed to give their post-code of residence, which may have reflected concerns about privacy. An enthusiasm for alternative medicine may have resulted in an overstated clinical improvement for both intervention groups of the clinical trial.

The following limitations apply specifically to the clinical trial and pilot study.

• The results of the trial and pilot study are only generalisible to relatively

healthy menopausal women experiencing vasomotor symptoms of moderate

intensity.

• The lack of characterisation and standardisation of FF-01 may have resulted

in the inadvertent use of a product with variable consistency or potency.

Commercial products need to be uniform in consistency and in the

composition of identified marker chemical constituents.

• The inherent problem of variation with the measurement of bone turnover

markers, particularly urinary, is a significant limitation in their use.

294

Variation may occur due to differing rates in bone turnover, excretion of

markers, seasonal variation in excretion and the time of marker collection.

13.4 Conclusions

13.4.1 Survey

• The survey confirms the continued popularity of CAM use during the

menopausal transition for the alleviation of symptoms and improvement in

quality of life.

• Communication between medical practitioners and their patients about the

use of CAM needs to be improved in order to reduce the potential for drug-

herb interactions and improve patient care.

• Women rated a number of therapies as very effective for the alleviation of

menopausal complaints, particularly massage and chiropractic. These require

further investigation.

13.4.2 Trial

• FF-01 is not effective for the alleviation of vasomotor symptoms or for

improving quality of life.

• FF-01 does not affect bone turnover markers over a 16 week treatment period

and is therefore unlikely to have a modulatory effect on bone metabolism.

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13.5 Future Research Directions

The continued popularity of CAM use for menopausal complaints should spur the search for safe and effective treatments. Future research projects could focus on evaluating treatments that were regarded as most effective by survey respondents.

Such research initiatives could include:

• The associations between massage, stress and vasomotor symptom relief.

• Chiropractic for the relief of vasomotor symptoms.

• Investigating an integrated CAM approach for the alleviation of vasomotor

symptoms, for example TCM, Ayurveda or naturopathy.

A number of products on the market have been specifically formulated to relieve menopausal vasomotor symptoms. However, most of these products have no clinical evidence attesting to their therapeutic efficacy in alleviating vasomotor symptoms or improving quality of life. These formulations need to be evaluated so that women can be confident they are taking safe and effective treatments. The characterisation and standardisation of herbal ingredients should also be conducted to ensure consistency in quality and composition.

Menopausal vasomotor symptoms and the menopause associated increased rate of bone loss are major health concerns for a significant number of middle-aged women.

Risks identified and associated with the use of HT has left many women without a safe and effective treatment to alleviate vasomotor symptoms, improve associated

296 quality of life and reduce the rate of bone loss. Therefore, the rigorous scientific evaluation of potential therapies is necessary so that women can confidently make informed decisions regarding treatments for symptom relief of symptoms.

297

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1039. Nisslein T, Freudenstein J. Effects of an isopropanolic extract of Cimicifuga racemosa on urinary crosslinks and other parameters of bone quality in an ovariectomized rat model of osteoporosis. Journal of Bone and Mineral Metabolism. 2003;21(6):370-376. 1040. Li H, Miyahara T, Tezuka Y, et al. The effect of Kampo formulae on bone resorption in vitro and in vivo. II. Detailed study on berberine. Biological and Pharmaceutical Bulletin. 1999;22(4):391-396. 1041. Li H, Miyahara T, Tezuka Y, Tran QL, Seto H, Kadota S. Effect of berberine on bone mineral density in SAMP6 as a senile osteoporosis model. Biological and Pharmaceutical Bulletin. 2003;26(1):110-111. 1042. Meng FH, Li YB, Xiong ZL, Jiang ZM, Li FM. Osteoblastic proliferative activity of Epimedium brevicornum Maxim. Phytomedicine. 2005;12:189-193. 1043. Chen KM, Ge BF, Ma HP, Liu XY, Bai MH, Wang Y. Icariin, a flavonoid from the herb Epimedium enhances the osteogenic differentiation of rat primary bone marrow stromal cells. Pharmazie. 2005;60:939-942. 1044. Qian G, Zhang X, Lu LJW, Wu X, Li S, Meng J. Regulation of Cbfa1 expression by total flavonoids of Herba Epimedii. Endocrine Journal. 2006;53(1):87-94. 1045. Yin XX, Chen ZQ, Dang GT, Ma QJ, Liu ZJ. Effects of Epimedium pubescens icariine on proliferation and differentiation of human osteoblasts. China Journal of Chinese Materia Medica. 2005;30(4):289-291. 1046. Yin XX, Chen ZQ, Liu ZJ, Ma QJ, Dang GT. Icariine stimulates proliferation and differentiation of human osteoblasts by increasing production of bone morphogenetic protein 2. Chinese Medical Journal. 2007;120(3):204-210. 1047. Wang EA, Rosen V, Cordes P, et al. Purification and characterization of other distinct bone-inducing factors. Proceedings of the National Academy of Sciences. 1988;85(24):9484-9488. 1048. Wozney JM, Rosen V, Celeste AJ, et al. Novel regulators of bone formation: molecular clones and activities. Science. 1988;242(4885):1528-1534. 1049. Jiang YN, Mo JY, Chen JM. Effects of Epimedium total flavonoids phytosomes on preventing and treating bone-loss of ovariectomized rats. China Journal of Chinese Materia Medica. 2002;27(3):221-224. 1050. Xie F, Wu CF, Lai WP, et al. The osteoprotective effect of Herba epimedii (HEP) extract in vivo and in vitro. Evidence Based Complementary and Alternative Medicine. 2005;2(3):353-361. 1051. Zhang G, Qin L, Hung WY, et al. Flavonoids derived from herbal Epimedium Brevicornum Maxim prevent OVX-induced osteoporosis in rats independent of its enhancement in intestinal calcium absorption. Bone. 2006;38(6):818-825. 1052. Li QN, Liao JM, Wu T. Epimedium sagittatum Maxim preventing hormone-induced osteoporosis in rats. Chinese Pharmaceutical Journal. 1996;31(8):467-470. 1053. Gao ZF, Yang ZZ, Ma KC, Liu YG, Liu XR. The promising effect of Epimedium brevicornum on the growth of thigh bone in chicken embryos. Zhong Xi Yi Jiehe Zazhi. 1985;5(3):172-173. 1054. Zhang G, Qin L, Shi Y. Epimedium-derived phytoestrogen flavonoids exert beneficial effect on preventing bone loss in late postmenopausal women: a 24-month randomized, double-blind and placebo-controlled trial. Journal of Bone and Mineral Research. 2007. 1055. Nian H, Qin LP, Chen WS, Zhang QY, Zheng HC, Wang Y. Protective effect of steroidal saponins from rhizome of Anemarrhena asphodeloides on ovariectomy- induced bone loss in rats. Acta Pharmacologica Sinica. 2006;27(6):728-734. 1056. Li JX, Kadota S, Li HY, Miyahara T, Namba T. The effect of traditional medicines on bone resorption induced by parathyroid hormone (PTH) in tissue culture: a detailed study on Cimicifugae Rhizoma. Journal of Traditional Medicines. 1996;13:50-58.

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1057. Li JX, Kadota S, Li HY, et al. Effects of Cimicifuga rhizoma on serum calcium and phosphate levels in low calcium dietary rats and on bone mineral density in ovariectomized rats. Phytomedicine. 1996;3(4):379-385. 1058. Seidlova-Wuttke D, Hesse O, Jarry H, et al. Evidence for selective estrogen receptor modulator activity in a black cohosh (Cimicifuga racemosa) extract: comparison with estradiol-17β. European Journal of Endocrinology. 2003;149:351-362. 1059. Seidlova-Wuttke D, Jarry H, Becker T, Christoffel V, Wuttke W. Pharmacology of Cimicifuga racemosa extract BNO 1055 in rats: bone, fat and uterus. Maturitas. 2003;44(Suppl 1):S39-S50. 1060. Viereck V, Grundker C, Friess SC, et al. Isopropanolic extract of Black Cohosh stimulates osteoprotegerin production by human osteoblasts. Journal of Bone and Mineral Research. 2005;20(11):2036-2043. 1061. Wuttke W, Gorkow C, Seidlova-Wuttke D. Effects of black cohosh (Cimicifuga racemosa) on bone turnover, vaginal mucosa, and various blood parameters in postmenopausal women: a double-blind, placebo-controlled, and conjugated estrogens-controlled study. Menopause. 2006;13(2):185-196. 1062. Carpenter JS. The Hot Flash Related Daily Interference Scale: a tool for assessing the impact of hot flashes on Quality of Life following breast cancer. Journal of Pain and Symptom Management. 2001;22(6):979-989. 1063. Therapeutic Goods Administration (TGA). DRAFT- Australian Regulatory Guidelines for Complementary Medicines (ARGCM) Part III - Evaluation of Complementary Substances 2003. 1064. Food and Drug administration, Centre for Drug Evaluation and Research. Guidance for Industry - Bioavailability and Bioequivalence Studies for Orally Administered Drug Products- General Considerations. Rockville: U.S. Department of Health and Human Services; 2002. 1065. Sloan JA, Loprinzi CL, Novotny PJ, Barton DL, LaVasseur BI, Windschitl H. Methodologic lessons learned from hot flash studies. Journal of Clinical Oncology. 2001;19(23):4280-4290. 1066. Richardson A. The health diary: an examination of its use as a data collection method. Journal of Advanced Nursing. 1994;19(4):782-791. 1067. Ross MM, Rideout EM, Carson MM. The use of the diary as a data collection technique. Western Journal of Nursing Research. 1994;16:414-425. 1068. Van Patten CL, Olivotto IA, Chambers K, et al. Effect of soy phytoestrogens on hot flashes in postmenopausal women with breast cancer: A randomized, controlled clinical trial. Journal of Clinical Oncology. 2002;20(6):1449-1455. 1069. Quella SK, Loprinzi CL, Barton DL, et al. Evaluation of soy phytoestrogens for the treatment of hot flashes in breast cancer survivors: A North Central Cancer Treatment Group Trial. Journal of Clinical Oncology. 2000;18(5):1068-1074. 1070. Prior JC, Alojado N, McKay DW, Vigna YM. No adverse effects of medroxyprogesterone treatment without estrogen in postmenopausal women: double-blind, placebo-controlled, crossover trial. Obstetrics and Gynecology. 1994;83:24-28. 1071. Carpenter JS, Andrykowski MA, Freedman RR, Munn R. Feasibility and psychometrics of an ambulatory hot flash monitoring device. Menopause. 1999;6(3):209-215. 1072. Loprinzi C. Chapter 2B: Development of a Clinical Trial for Hot Flash Protocol. Available at: http://symptomresearch.com/chapter_2/HotFlashes/index2b.htm. 1073. Daly E, Gray A, Barlow D, McPherson K, Roche M, Vessey M. Measuring the impact of menopausal symptoms on quality of life. British Medical Journal. 1993;307:836-840. 1074. Sun J. Morning/evening menopausal formula relieves menopausal symptoms: a pilot study. Journal of Alternative and Complementary Medicine. 2003;9(3):403-409.

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APPENDICES

Appendix I Women’s Health during Mid-life Survey Covering Letter

Appendix II Women’s Health during Mid-life Questionnaire

Appendix III Trial Information Sheet

Appendix IV Trial Consent Form

Appendix V Trial Registration and Eligibility Form

Appendix VI Trial Case Report Form: Initial Consultation

Appendix VII Daily Flush Diary

Appendix VIII Greene Climacteric Scale

Appendix IX Hot Flush Related Daily Interference Scale

Appendix X Trial Randomisation Form

Appendix XI Trial Week 12 Case Report Form

Appendix XII Certificates of Analysis for FF-01

Appendix XIII Journal publication: Women’s Health during Midlife Survey

Appendix I 354

School of Exercise and Health Sciences Building 3, Bankstown Campus Ph: 02 9772-6412 Fax: 02 9772-6810

Women’s Health during Mid-Life Survey

Dear Participant

If you are a women aged 45 to 65 and you are going through menopause, this questionnaire is for you! This study aims to find out the types of treatments women find effective in controlling symptoms during menopause and how popular these remedies are. The results of this study will help guide research into looking for new and effective treatments to use during menopause. We hope that you will be able to spare 10 to 15 minutes of your time to complete this questionnaire.

Completing the questionnaire is voluntary and anonymous, so please do not write your name on any part of the questionnaire. Results from all the questionnaires will be added together so any answers you give will not be identifiable. Your consent or permission to be part of this study is given when you fill out the questionnaire, place it in the envelope and return it to the group leader or receptionist. The results of this study will be published and made available to you at the end of the year.

CompleMED at the University of Western Sydney (UWS) supports this study. This survey is part of a post-graduate research project being carried out by Ms Corinne Patching supervised by Associate Professor Alan Bensoussan. If you have any questions, please do not hesitate to call Ms Patching on 9772 6753. If you have any complaints about this study you may contact the Ethics Committee through the Research Ethics Officer, Ms Kay Buckley telephone (02) 4570 1136.

Thank you very much for completing the questionnaire. Your time is greatly appreciated.

Regards

Corinne Patching ------Please Tear Off Here------

A clinical trial using Chinese herbs to treat hot flushing will begin after this survey. If you wish to know more about this study and possibly take part, please contact Corinne on 9772 6753 or email [email protected] with your details. Alternatively fill out the tear off slip below, place it in the second envelope and hand it back along with your questionnaire.

Please tick. I am interested in knowing more about the clinical trial on the treatment of hot flushing with Chinese herbal medicine.

My name is ______

My contact details are: Telephone number: ______Or Email address: ______

Page 1 of 1 June 2003 Appendix II 355

This Survey is supported by:

Women’s Health During Mid-life Survey

If you are a women aged 45 to 65 this questionnaire is for you! This study aims to find out the types of treatments women find effective in controlling symptoms during menopause and how popular these remedies are. The results of this study will help guide research into looking for new and effective treatments to use during menopause. We hope that you will be able to spare 10 to 15 minutes of your time to complete this questionnaire.

The study is being sponsored by the University of Western Sydney and the CompleMED Research Centre.

This questionnaire is divided into 3 sections: ” Your health ” Your use of treatments during menopause ” Your background.

Completing this questionnaire is voluntary and annonymous, so do not write your name on any part of the questionnaire.

Thank you

1. In general, how would you rate your health right now? (Tick one box only)

Poor Excellent

1 2 3 4 5 6 7

2. Compared to a year ago, how would you rate your health now? (Tick one box only)

Worse Better

1 2 3 4 5 6 7

3. Are you taking any medicine prescribed to you by your doctor? (Tick one box only)

Yes If yes, please write down the medication you are taking now.

______

No ______

4. Over the past 12 months, have you used Hormone Replacement Therapy (HRT) to reduce your symptoms of menopause? (Tick one box only)

Yes

I take HRT for other reasons

5. When was your last natural menstrual period? A natural menstrual period is one that is not caused by taking HRT or other treatments. (Tick one box only)

12 months or longer ago

2-11 months ago

last month

6. Over the past 12 months, how much did the following symptoms bother you? Use the scale below to rate your symptoms.

Please complete for each symptom.

Not Extremely bothered bothered at all (Tick one box for each symptom) 0 1 2 3 4 5 6

Hot flushes

Sweating at night

Heart beating quickly or strongly

Feeling tense or nervous

Difficulty in sleeping

Attacks of panic

Mood changes

Feeling dizzy or faint

Headaches

Muscle and joint pain

Crawling under the skin

Breathing difficulties

Irregular periods

Bladder infections

Dry vagina

Other ______

358 Section 2: Your use of treatments during menopause Complementary medicine (also called alternative medicine) includes treatments such as herbal medicine, naturopathy, homeopathy, acupuncture, nutrition, chiropractic, osteopathy, massage and meditation.

7. During the past 12 months, have you visited any of the people below who practice complementary medicine to treat your symptoms during menopause? Do not be concerned if you are not familiar with some of them.

If you have not seen a person please tick “No”.

If you ticked Yes, how effective was the treatment for you? ` Not Excellent effective effect at all (For each person below 0 1 2 3 4 5 6 tick Yes or No)

Yes Herbalist No

Yes Nutritionist or dietition No

Yes Naturopath No

Yes Acupuncturist No

Yes Chinese herbal practitioner No

Yes Homeopath No

Other person visited Yes (please write below)

______

Other person visited Yes (please write below)

______

If you have not used a product please tick “No”.

If you ticked Yes, how effective was the product for you?

Not Excellent effective effect at all

0 1 2 3 4 5 6 (For each product below tick Yes or No) Increased soy Yes products in your diet (eg soy milk or tofu) No

Soy or phytoestrogen Yes capsules (eg Phytolife) No

Yes Remifemin No

Yes Promensil No

Yes Menocalm No

Yes Black cohosh No

Yes Meno-eze No

Yes Dong quai, tong kuei, dang gui No

Yes Evening primrose oil No

Other product used (Please write below) Yes ______

© Copyright UWS/C.Patching Page 5 June 2003 360 9. Are you using complementary medicine now to treat any other health problems? (Complementary medicine includes those mentioned in questions 7 and 8). (Tick one box only)

Yes

10. Does your medical doctor usually ask you if you use complementary medicine? (Tick one box only)

Yes

11. Do you usually tell your medical doctor when you use complementary medicine? (Tick one box only)

Yes

I have never used complementary medicine

12. Where did you get advice about using complementary medicine? (You may tick more than one box)

I have never used complementary medicine1 Complementary or alternative medicine books2 Newspapers3 Magazines4 Television5 Internet websites6 Chiropractor, osteopath7 Chinese medicine practitioner (Acupuncture and/or Chinese herbs)8 Herbalist9 Naturopath10 Health food shop assistant11 Friend or neighbour12 Spouse or relative13 Medical doctor14 Chemist15 Other______(please write this here)

Section 3: About your background

13. What is your date of birth?

Day Month Year

14. What is your highest level of education? (Tick one box only)

Primary school1 High school to Year 10 or equivalent2 High school to Year 12 or equivalent3 Apprenticeship or Technical and Further Education College (TAFE)4 University or College of Advanced Education5

15. Which of the following groups best describes your job at present? (Tick one box only)

Non professional1 For example cleaner, postal worker, kitchenhand, shelf stacker

Sales or personel services2 For example till operator, sales assistant, sales representative

Tradesperson or skilled services3 For example sewing machinist, printer, baker

Clerical or secretarial4 For example secretary, postal clerk, government clerical officer, computer operator, bank clerk

Professional or technical5 For example teacher, lecturer, accountant, social worker, nurse, computer programmer

Manager or senior administrator6 For example general manager, director of nursing, sales manager

Homemaker7

Looking for work or unemployed8

Not in the labour force (eg student, retired)9

16. What is the post code of the suburb you mainly live in?

17. What is your current marital status? (Tick one box only)

Now married1 Living together (not married)2 Separated3 Divorced4 Widowed5 Never married6

18. In what country were you born? (Tick one box only)

Australia1 New Zealand2 Great Britain/United Kingdom3 Italy4 Greece5 China6 Vietnam7 India8 Other country ______(please write here)

19. What language do you mainly speak at home?

______

Please check that you have answered all questions.

Place the completed questionnaire in the envelope, seal it and return the envelope to the receptionist or group leader.

Thank you very much for completing this survey.

If you have any comments you would like to make about this questionnaire, please write them in the space below.

______

Appendix III 363

Randomised Controlled Trial of Herbal Medicine for the Alleviation of Menopausal Vasomotor Symptoms

Participant Information Statement

The following research consists of two studies that will occur at the same time: an analysis of the Chinese medical diagnosis for menopausal hot flushing and night sweats (vasomotor symptoms) and a clinical trial to investigate if a herbal formula is helpful in reducing vasomotor symptoms. Both studies will happen at the same time so participation in both will not involve any extra inconvenience to you. You are invited to take part if you are in general good health, do not have a history of oestrogen dependent cancer, aged between 45-65 years, have not had a menstrual period for at least 12 months and experience six or more vasomotor symptoms every 24 hours.

We will also be seeing if the herbal formula has an effect on bones by encouraging bone build-up. You may be asked to take part in this smaller study. This will involve the assessment of two chemicals produced by your body, one from urine the other from blood on five occasions.

Outline of the procedures: To enter this study, you will need to undertake a brief medical screening, which will include blood tests. An accredited Chinese herbal practitioner will then assess you using a specially prepared record form. Some of the questions may seem unusual, but these are necessary to make an accurate Traditional Chinese Medical (TCM) diagnosis. These answers will be used to make a TCM diagnosis. The results of this study will be completely anonymous, as the answers to all the interviews will be added together so that any answers you give cannot be identified.

You will then be randomly assigned (as in the toss of a coin) to receive herbal treatment or a placebo (an inactive substance). Two 955mg tablets will be taken by mouth twice a day. You or anyone else involved in the trial will not know if you are getting herbs or a placebo.

Before you begin taking the tablets, you will be asked to fill out a daily Flush Diary for four weeks to record the number and severity of your vasomotor symptoms. Once you start taking your tablets, you will continue to fill out your daily Flush Diary until the end of treatment (for a total of 20 weeks) and for 2 weeks prior to your follow-up consultation at week 28. During this time you will visit the trial centre five times to check on your progress. At other times you will be telephoned by the chief investigator to see how you are going. The trial will last for a total of 20 weeks; the first 4 weeks you will not be taking any tablets. At the end of the study you will find out if you were taking the herbs or the placebo. At week 28 there will be a final follow-up consultation to see if the treatment has given you any long term benefit.

Benefits: A potential benefit from taking part in this study is that the herbal treatment may help relieve hot flushing and help the bones. However, we cannot guarantee that you will receive benefits from this study. All treatments and medical tests that relate to this study will be provided to you for free. You will not receive any payment for participation in this study. If the herbal treatment is effective, participants in the placebo group will receive 4 months of herbs at no cost at the end of trial commitments.

Risks and discomfort: The government regulatory body, the Therapeutic Goods Administration, has listed all herbs used in the trial as safe and suitable for use. Therefore, it is unlikely that the Chinese and western herbs used in the trial will cause risk or discomfort. However, there is a possibility some people may have an allergic reaction to the herbs in the formula such as a skin rash. Other side effects may occur such as headache, bloating or gastro-intestinal discomfort. A medical doctor and the chief investigator will closely monitor you throughout the trial. If you do have an adverse reaction, we advise that you temporarily stop taking the tablets and immediately call Corinne Patching. Page 1 of 2

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On three occasions a small sample of blood will be taken. If you are part of the bone study 2 more samples will be taken (total of 5). The blood samples are necessary to check your hormone levels, kidney and liver function. Whenever a blood sample is taken, there is a small risk of pain, bruising, infection or feeling faint. If you are taking part in the bone sub-study, you will also be asked to give a urine sample on five occasions. The effect of the formula on bones will be seen by the concentration of two chemicals, one in your blood and the other in urine.

Study participation: Taking part in this research is voluntary. You may refuse to enter the study or may stop participation at any time. Your decision whether or not to participate will not affect your present or future treatment or your relationship with the University of Western Sydney or any other institution cooperating in this study or any person treating you.

The investigators may stop your involvement in the trial at any time if it is in your best interest, if you do not follow the study requirements or if the study is stopped for any other reason. You will be told of any changes to the study or to the procedures.

You will be informed of any significant new information obtained from this study that relates to your treatment. At the end of the study, you will be invited to a discussion session where the results of the studies will be summarised and presented. You will also have the opportunity to discuss your experiences during the trial.

This trial is being funded by an industry group. The funding will be used to pay for medical consultations, blood and urine tests.

Further questions: This study is part of a Higher Degree research project carried out by Ms Corinne Patching and supervised by Associate Professor Alan Bensoussan. If you have any questions about the research, please contact Corinne on 9555 6608 or Alan on 9772 6363.

Confidentiality: You will be given an identification number at the beginning of the study that will be used to maintain your anonymity. Any information that is obtained during this study that identifies you will remain strictly confidential and will be disclosed only with your permission or except as required by law. Although the study results may be published, information will be provided in such a way that you cannot be identified.

You are making a decision whether or not to participate. Your signature on the consent form indicates that, having read the information provided above, you have decided to participate in both the Chinese medical diagnosis and clinical trial studies of this research project. You will be given a copy of this form to keep.

Note: The University of Western Sydney Human Research Ethics Committee has approved this project. If you have any complaints or reservations about the ethical conduct of this research, you may contact the Ethics Committee through the Research Ethics Officer, Ms Kay Buckley telephone (02) 4570 1136. Any issues you raise will be treated in confidence and investigated fully, and you will be informed of the outcome.

Name of participant:

Name of chief investigator:

Signature:

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RCT of Herbal Medicine for the Alleviation of Menopausal Vasomotor Symptoms

Consent Form

I agree to participate in the above study described in the subject information statement attached to this form.

• I have read the subject information statement, which explains why I have been selected, the aims of the study, risks and how it will be carried out. My signature indicates that I have decided to participate having read the information provided on the information statement.

• I have had the opportunity of asking any questions relating to the study and I have received satisfactory answers.

• I understand that I can withdraw any time from the study without prejudice to my relationship with the University of Western Sydney.

• I agree that research data gathered from the results of the study may be published, provided that I cannot be identified.

• I understand that if I have any questions relating to my participation in this research, I may contact Ms Corinne Patching on telephone 9555 6608, who will be happy to answer them.

• I have received a copy of this Consent Form and the Subject Information Statement.

If you have any complaints or reservations about the ethical conduct of this research, you may contact the University of Western Sydney Ethics Committee through the Research Ethics Officer, Ms Kay Buckley telephone (02) 4570 1136. Any issues you raise will be treated in confidence and investigated fully, and you will be informed of the outcome.

Signature of subject Signature of witness

Please PRINT name Please PRINT name

Date Nature of Witness

Date

UWSF0.1 Page 1 of 1

Appendix V 366

RCT of Herbal Medicine for the Alleviation of Menopausal Vasomotor Symptoms

Registration and Eligibility

Participant Name: ______Address: ______Telephone: ______Date of visit: ____ / ___ / ____ Trial Centre: ______General Practitioner: ______Address: ______Telephone: ______

GENERAL ELIGIBILITY CHECKLIST BASELINE CHECK Tick if criterion met. All criteria must be met for registration. Complete appropriately

Age 45 to 65 years Appointment made for FSH & oestradiol (E27, E28) Six or more hot flushes/night sweats per day/on Appointments needed/made for: average 42 per week 12 months amenorrhoea N Y Full Blood Count (H01) No HRT use for menopausal symptoms during N Y Liver function (S00) previous 2 months N Y Kidney function (S00) No CAM use for menopausal symptoms during previous 2 months Appointment with TCM practitioner in 2 Body mass index less than 30 kg/m 4 weeks Available for long term follow-up (reliable, no drug/alcohol abuse) Eligibility checklist received from GP All criteria met Bone sub-study Written informed consent Appointment made ASAP for bone marker measurements (Z99, Z99) BONE SUB-STUDY ELIGIBILITY CHECKLIST Repeat appointment for bone marker All criteria must be met for inclusion measurements in 4 weeks (before Eligibility checklist received from GP All criteria met next consult) (Z99, Z99) Within first 5 years of post-menopause

INITIAL PATIENT DATA Date of birth Country of birth Language mainly spoken at home

day month year Marital status (see categories) Level of education (see categories) Occupation (See categories)

Participant meets trial criteria (Please tick): No Yes

Participant recommended for bone sub-study (Please tick): No Yes NB: First 60 participants who meet general and bone sub-study eligibility to be nominated for bone sub-study

Investigator’s name: Signature:

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ADDENDUM

Abbreviations HRT: Hormone Replacement Therapy CAM: Complementary and Alternative Medicine FSH: Follicle Stimulating Hormone

Categories for Initial Patient Data Please enter the appropriate number in the box

Categories for martial status 1. Now married 2. Living together (not married) 3. Separated 4. Divorced 5. Widowed 6. Never Married

Categories for level of education 1. Primary school 2. High school to Year 10 or equivalent 3. High school to Year 12 or equivalent 4. Apprenticeship or Technical and Further Education College (TAFE) 5. University or College of Advanced Education

Categories for current occupation 1. Non professional Eg cleaner, postal worker, kitchen hand, shelf stacker 2. Sales or personnel services Eg till operator, sales assistant, sales representative 3. Tradesperson or skilled services Eg sewing machinist, printer, baker 4. Clerical or secretarial Eg secretary, postal clerk, government clerical officer, computer operator, bank clerk 5. Professional or technical Eg teacher, lecturer, accountant, social worker, nurse, computer programmer 6. Manager or senior administrator Eg general manager, director of nursing, sales manager 7. Homemaker 8. Looking for work or unemployed 9. Not in the labour force Eg student, retired

UWSF2 Page 2 of 2

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RCT of Herbal Medicine for the Alleviation of Menopausal Vasomotor Symptoms

Case Report Form: Initial Consultation

Name: ______Date of visit: ____ / ___ / ____ ID Number

Initial Checklist

Consent Form Attached Registration Form Attached

Medical history Please list the medications, vitamins, minerals and herbs that you are currently taking:

Have you had any surgery, injuries, trauma or broken bones?

Do you have any allergies?

Vital statistics Blood pressure Systolic Diastolic

Weight (kg) Height (cm) (Without shoes) (Without shoes)

Gynaecologic History At what age did your periods start? Were your periods regular? No Yes

How many pregnancies did you have? How many full term pregnancies?

Your age at first full term pregnancy

Have you had a hysterectomy? No Yes

How many ovaries were removed? None One Both Don’t know

Have you ever taken birth control pills? No Yes

Have you ever taken HRT? No Yes If yes, when did you stop? Months/years (Delete one) Have you ever taken CAM for menopausal symptoms? No Yes If yes, when did you stop? Months/years (Delete one)

How long have you had hot flushing? Months/years (Delete one)

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369

Life style history

What is the main type of exercise you did this month? In the past week, estimate the total time you spent taking part in this type of exercise. Mins/hrs (Delete one) In the past week, estimate the total time you spent doing vigorous exercise or physical activity (that is, activity that made you breathe harder, puff or pant). Mins/hrs (Delete one)

How often did you eat the following foods in the past 7 days? (Please also include if part of a meal eg stir fries, soups) (Tick one for each)

Never Once 2 or 3 4 or 5 Nearly every day times times or more Soya milk

Tofu

Miso

Soy products eg burgers, breakfast cereal Tempeh

Bean sprouts

Linseed (flaxseed)

Are you a coffee drinker? No Yes If yes, you usually drink: regular (caffeinated) decaffeinated coffee How many cups of coffee do you usually drink each day? Cups

Do you smoke? No Ex-smoker Currently smoke about cigarettes per day/week (Delete one)

Do you drink alcohol? No Yes If yes estimate how many units per day/week/month (Delete one) (1 unit = l glass of wine, 1 bottle of beer or 30ml liquor)

Practitioner checklist Greene Climacteric Scale Completed Appointment for hormone checks Made (E27, E28)

HFRDI Completed Appointment for liver & kidney Made function, FBC (if needed) (S00, H01) Flush Diary Instruction Instructed Appointments for bone markers

Week 0 (Z99, Z99) Made 4 week flush diary given Given Week 4 (Z99, Z99) Made

Verified by practitioner:

UWSF3.0 Initial Case Report Form Page 2 of 2

Appendix Vll

RCT of Herbal Medicine for the Alleviation of Menopausal Vasomotor Symptoms

Treatment Period Daily Flush Diary

ID Number: Week Number: Date week started: ____/____/____ (dd/mm/yy)

Date ____/______/______/______/______/______/______/____

Day of week Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Severity and number of today’s ___ mild ___ mild ___ mild ___ mild ___ mild ___ mild ___ mild hot flushes/night sweats that were ___ moderate ___ moderate ___ moderate ___ moderate ___ moderate ___ moderate ___ moderate mild, moderate or severe. ___ severe ___ severe ___ severe ___ severe ___ severe ___ severe ___ severe

___ very severe ___ very severe ___ very severe ___ very severe ___ very severe ___ very severe ___ very severe

Tablets taken ( X / X )

* One day should be considered to be a 24 hour period (ie 7.00 a.m. to 7.00 a.m. or midnight to midnight)

How many tablets do you think you missed this week? ______Have you noticed any unusual symptoms? How severe were these symptoms? Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe

UWSF4.2 Page 1 of 2 370

Hot Flush Definitions

Please look at these examples of hot flushes. One or more of these descriptions may help to categorise your hot flush as mild, moderate, severe or very severe.

Mild Physical symptoms: felt warm, felt slightly uncomfortable, red face. Emotional symptoms: not expected. Action needed: usually no action taken.

Moderate Physical symptoms: head neck ears or whole body felt warm; muscles felt tense, tight; clammy (wet) skin; a change in heart rate or rhythm (heart speeds up or changes beat); some sweating; dry mouth. Emotional symptoms: felt irritated, felt restless, felt tired, felt annoyed and felt embarrassed when having a hot flush in front of others. Action needed: able to continue with daily activity, needed to use a fan, sometimes awakened at night, needed to remove sheet/blanket, needed to remove some clothing, drank water, changed into lighter clothing.

Severe Physical symptoms: heat, sometimes described as a raging fire or like burning up; a change in heart rate or rhythm (heart speeds up or changes beat); felt faint; headache; severe sweating; chest heaviness. Emotional symptoms: embarrassment, anxiety, feelings of having a panic attack. Action needed: needed to stop what was being done at the time; usually awakened at night and removed bed covers or sheets; needed to remove clothing; take a cold shower; opened windows; move to cooler temperature; frequently used fans.

Very Severe Physical symptoms: Boiling heat, rolling sweat, difficulty breathing, felt faint, felt dizzy, a change in heart rate or rhythm (heart speeds up or changes beat), felt slightly sick to the stomach. Emotional symptoms: had difficulty doing daily activities; felt distressed; felt an urge to escape. Action needed: awakened often at night; needed to change sheets and pajamas, needed to take a cold shower, needed to hold ice onto skin.

Sloan, J.A. et al (2001). Journal of Clinical Oncology. 19(23): 4280-4290

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RCT of Herbal Medicine on the Alleviation of Menopausal Vasomotor Symptoms

The Greene Climacteric Scale

ID Number: Date:

Please indicate the extent to which you are bothered at the moment by any of these symptoms by placing a tick in the appropriate box.

Symptoms Not at all A little Quite a bit Extremely Score 0-3

1. Heart beating quickly or strongly

2. Feeling tense or nervous

3. Difficulty in sleeping

4. Excitable

5. Attacks of panic

6. Difficulty in concentrating

7. Feeling tired or lacking in energy

8. Loss of interest in most things

9. Feeling unhappy or depressed

10. Crying spells

11. Irritability

12. Feeling dizzy or faint

13. Pressure or tightness in head or body

14. Parts of body feel numb or tingling

15. Headaches

16. Muscle and joint pains

17. Loss of feeling in hands or feet

18. Breathing difficulties

19. Hot flushes

20. Sweating at night

21. Loss of interest in sex

22. Vaginal dryness

23. Dry skin

P (1-11) = _____ S (12-18) = _____ V (19-20) = _____ A (1-6) = _____ D (7-11) = _____ S (21) = ____

Green, J.G. (1998). Maturitas. 29: 25-31

Page 1 of 1

Appendix IX

RCT of Herbal Medicine for the Alleviation of Menopausal Vasomotor Symptoms

Hot Flush Related Daily Interference Scale (HFRDIS)

ID Number: Week Number: Date: ____/____/____ (dd/mm/yy)

Please circle one number to the right of each phrase to describe how much DURING THE PAST WEEK hot flushes have INTERFERED with each aspect of your life. Higher numbers indicate more interference with your life. If you are not experiencing hot flushes or if hot flushes do not interfere with these aspects of your life, please mark zero to the right of each question.

Do not Completely interfere interfere 1. Work (work outside the home 0 1 2 3 4 5 6 7 8 9 10 and housework) 2. Social activities (time spent with 0 1 2 3 4 5 6 7 8 9 10 family, friends etc) 3. Leisure activities (time spent 0 1 2 3 4 5 6 7 8 9 10 relaxing, doing hobbies etc) 4. Sleep 0 1 2 3 4 5 6 7 8 9 10 5. Mood 0 1 2 3 4 5 6 7 8 9 10 6. Concentration 0 1 2 3 4 5 6 7 8 9 10 7. Relaxing with others 0 1 2 3 4 5 6 7 8 9 10 8. Sexuality 0 1 2 3 4 5 6 7 8 9 10 9. Enjoyment of life 0 1 2 3 4 5 6 7 8 9 10 10. Overall quality of life 0 1 2 3 4 5 6 7 8 9 10

Carpenter, J.S. (2001). Journal of Pain and Symptom Management. 22(6): 979-989

Page 1 of 1 373

Appendix X 374

ID Number

RCT of Herbal Medicine for the Alleviation of Menopausal Vasomotor Symptoms

Randomisation Form

Participant Name: ______Date of visit: ____ / ___ / ____ Trial Centre: ______

REPEAT ELIGIBILITY CHECK BASELINE LABORATORY RESULTS (Y=Yes, N=No) (enter actual values) Six or more hot flushes/night sweats per day/on average 42 per week

. FSH (mIU/ml) Body mass index less than 30 kg/m2 . Oestradiol (pg/ml)

Has not begun taking trial contra- Bone Sub-study indicated medications (if applicable enter actual values) Serum bone specific alkaline phosphatase (ug/L) . Week 0

. Week 4

Urine deoxypyridinoline/creatinine (nmol/mol) Week 0 .

. Week 4

COMPLIANCE CHECK LABORATORY RESULTS CHECK (Y=Yes, N=No) (Y=Yes, N=No)

Completed 80% or more flush diary Liver Function Tests within normal range entries during the base-line period

Suitable for follow-up (ie good clinic Urea and Creatinine within normal range attendance, no drug/alcohol abuse)

Consent still given to take part Full Blood Count within normal range

FSH >or=40mIU/ml

Oestradiol

To be eligible for randomisation all questions should be answered YES.

Treatment Number (Please write clearly)

Medication dispensed or prescription form issued (Please tick)

Investigator’s name:

Signature:

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Case Report Form: Week 12

Date of visit: ____ / ___ / ____ ID Number

Vital statistics Blood pressure Systolic Diastolic

Weight (kg) (Without shoes)

Life style history What is the main type of exercise you did this month? In the past week, estimate the total time you spent doing this type of exercise. Hrs/mins (Delete one) In the past week, estimate how long you spent doing vigorous exercise or physical activity (that is, activity that made you breathe harder, puff or pant). Hrs/mins (Delete one)

How often did you eat the following foods in the past 7 days? (Please also include if part of a meal eg stir fries, soups) (Tick one for each)

Never Once 2 or 3 4 or 5 Nearly every day times times or more Soya milk

Tofu

Miso

Soy products eg burgers, breakfast cereal Tempeh

Bean sprouts

Linseed (flaxseed)

How many cups of coffee do you usually drink each day? Cups Type of coffee: regular (caffeinated) decaffeinated coffee

Do you smoke? No Ex-smoker Currently smoke about cigarettes per day/week (Delete one)

Do you drink alcohol? No Yes If yes how many units per day/week/month (Delete one). (1 unit = l glass of wine, 1 bottle of beer or 30ml liquor)

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376

Treatment and Compliance (Tick one for each)

Over the past month have your symptoms improved? Symptoms are worse Symptoms are the same Symptoms improved

How logical/appropriate does the treatment seem to you? Not at all Very logical logical 1 2 3 4 5 0

How confident would you be that this treatment would be successful in reducing hot flushing? Not at all Absolutely confident 1 2 3 4 confident 0 5

How confident would you be in recommending this treatment to a friend with hot flushing? Not at all Absolutely confident 1 2 3 4 confident 0 5

If you were offered this treatment for hot flushing would you be willing to take it? Not at all Very willing willing 1 2 3 4 5 0

What treatment do you believe you received? Herbal Placebo Don’t know Count number of tablets remaining. Number =

Practitioner checklist

Greene Climacteric Scale Completed Medication Dispensed

HFRDI Completed Appointment for biochemistry Made panel and FBC (S00, H01)

Flush Diary checked Completed Appointment for bone markers Made New 4 week Flush Diary Given Z99, Z99

Verified by practitioner:

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