Perceptions, Benefits, and Use of Complementary and Integrative Therapies to Treat Menopausal Symptoms: A Pilot Study

Background: Menopause symptoms can be debilitating, and the use of menopausal hormone therapy (MHT) has declined significantly since the Women's Health Initiative. Materials and Methods: We surveyed 508 peri- and postmenopausal females to determine (1) the use of complementary and integrative therapies (CIT), MHT; and pharmacotherapies; (2) the perceptions, perceived benefits/risks of CIT, MHT; and pharmacotherapy use; and (3) factors associated with CIT and MHT use for menopause symptom treatment. Results: The majority of respondents used CIT to treat menopause symptoms based on physician recommendation and research studies. Treatments that were perceived as most beneficial included exercise, mind–body therapies, diet, and spiritual practices, with exercise and mind–body therapies chosen to treat the most common symptoms of sleep disturbances, depressive mood, and anxiety. Higher education level was the main predictive variable for choosing exercise (odds ratio [OR] = 1.27, p = 0.02) and mind–body therapies (OR = 1.57, p = 0.02) to treat menopausal symptoms. Perceptions, beliefs, and use of different CIT by primarily white, affluent, and educated peri- and postmenopausal females to treat menopause symptoms, including sleep disturbances, depression, and anxiety, are driven by conversations with physicians and evidence-based research. Conclusion: These findings reinforce the necessity for both additional research in more diverse populations, as well as comprehensive, individualized personalized care from an interdisciplinary team that considers the best options available for all female patients.


Introduction
Menopausal symptoms, such as insomnia, vasomotor symptoms (VMS, hot flashes, night sweats, sweating), 1 mood and sleep disorders, and memory difficulties, 2 can be debilitating and significantly influence quality of life. 3 Over 70% of females will experience at least some of these symptoms. 4 Menopausal hormone therapy (MHT) was a standard and effective treatment for menopausal symptoms until the 2002 Women's Health Initiative reported a greater risk-benefit ratio for breast cancer, stroke, and other disorders. 5 Despite subsequent studies demonstrating MHT safety for perimenopausal females up to 10 years following menopause onset, symptom management using MHT remains low [6][7][8] and 47% of middle aged females still report a preference for not taking MHT. 1 Studies published since 2002 estimate increased complementary and integrative therapies (CIT) use, 9,10 including findings that 89.7% of the 79.3% females discontinuing MHT had used CIT for menopausal symptoms, 11 and others estimating CIT use between 31% and 82%. 12,13 Despite evidence of increased CIT use, prevalence, perceptions, and beliefs regarding CIT effectiveness in menopausal females are poorly understood. The purpose of this study was to determine (1) CIT, MHT, and other pharmacotherapy use for menopausal symptom treatment; (2) CIT, MHT, and other pharmacotherapy perceived risks and benefits for menopausal symptom treatment; and (3) factors associated with increased or decreased CIT and MHT use for menopausal symptoms.

Methods
A convenience sample of peri-and post-menopausal females >35 years old completed a pilot, crosssectional design survey in collaboration with the University of Minnesota Driven to Discover Program at the 2019 Minnesota State Fair. Menopause is defined by 12 consecutive months without menses. Younger females (>35 years old) may experience menopausal symptoms during perimenopause (onset of menopause-related symptoms and menstrual cycle changes) or premature menopause (at or before the age of 40) and were included in this study. 14 The University of Minnesota Institutional Review Board approved the study protocol (IRB No. 00006540), and the study was conducted in accordance with the Declaration of Helsinki.

Instrument
A previous survey assessing CIT perceptions and beliefs in nurses 15,16 was modified (with permission) to determine CIT use in females experiencing menopauserelated symptoms. Therapies utilized (n = 28) followed complementary therapies reported by the National Center for Complementary and Integrative Health. 17 Demographics, health, and social history Demographics included: race, education, employment, marital status, annual income, and religion. Participants reported their primary health care provider and frequency of visits. Female health, menopause, and cancer history, including gynecological and breast cancer, chemotherapy, MHT use, and pregnancy histories, were collected. Menopause history included age, menopause onset age, history, and reason for hysterectomy and/or oophorectomy. Average stress level (Likert scale 1-10, 1 = little to none to 10 = most possible stress); history and frequency of nicotine, caffeine, and alcohol use; history of MHT use/nonuse, rationale, forms of MHT used (pills, creams, sprays), rationale for using/not using MHT; and any nonhormone medications used to treat menopause symptoms were also collected ( Table 1). One-way ANOVA analysis was used to compare interactions between demographic data (age, education, employment, marital status, and annual income) and therapy effectiveness beliefs; exercise choice, income levels, and age and therapy effectiveness beliefs; and MENQOL scores and age. A binary logistic regression analysis was performed to determine if demographic variables were predictors for commonly chosen treatment methods. The resulting odds ratio (OR) and estimated conditional probabilities illustrated which demographic variables influenced CIT use for menopausal treatment. p-values <0.05 were statistically significant.
Participants with VMS were significantly more likely to choose more forms of treatment than their counterparts without VMS, including exercise (OR = 1. Personal use and perceived effectiveness The majority of females (59%) reported using an average of 1.8 -2.8 (range 0-9) different types of CIT. Participants most commonly chose exercise (n = 219), mind-body therapies (n = 135), diet (n = 98), and spiritual practices (n = 91) for treatment. Most considered CIT at least moderately effective (59.9%), very effective (27.9%), or not effective (12.2%). When asked how effective specific CIT were in treating menopause symptoms, 93.3% of participants using energy therapies felt they were moderately to very effective, followed by mind-body therapies (91.9%), exercise (91.3%), spiritual practices (90.1%), and diet (73.5%).
Participants most often chose walking (n = 212), biking (n = 102), strength training (n = 87), and yoga (n = 73) exercises for menopause symptom treatment (Fig. 1). Participants chose to treat sleep problems (33.7%), depressive mood (28.6%), and anxiety (27.2%) the most (Fig. 2), using exercise, mind-body therapies, diet, and spiritual practices. They also treated irritability (26.5%), hot flashes (25.1%), and exhaustion (20%) using exercise, mind-body therapies, diet, and spiritual practices (Fig. 3). The most common exercise, mind-body, diet, MHT, and spiritual practices are illustrated in Figure 4. Education was the strongest predictive variable associated with the treatment individuals chose for menopausal symptoms. Indeed, participants achieving higher education levels were more likely to choose exercise (OR = 1.27, p = 0.02) or mind-body therapies (OR = 1.57, p = 0.02). Females with a college degree were significantly more likely to choose exercise to treat menopause symptoms than their peers (OR = 2.38, p = 0.009), and those with graduate degrees were significantly more likely to choose mind-body therapies to treat menopause symptoms (OR = 2.36, p = 0.01) than individuals without graduate degrees.

Types of evidence required
Participants reported that doctors' recommendations (74.5%, n = 353) and ''successful use myself'' (63.5%, n = 301) were important/somewhat important when choosing menopause symptom treatment. Research studies by physicians or large academic institutions supporting therapy effectiveness (63.3%, n = 300) and research evidence by physicians or large academic institutions suggesting that the therapy may be effective (but has not yet been proven) (49.2%, n = 233) were also important for decision-making. Unimportant/ somewhat unimportant factors when making treatment decisions included news media reports that the treatment works (58.2%, n = 276) and information on a blog, popular journal, or similar website suggesting the Post hoc analysis revealed that individuals with a technical degree or higher believed that exercise, mind-body, mental health therapies, and spiritual practices were more effective in treating menopause symptoms than females with a high school diploma. Income and age did not influence beliefs of therapy effectiveness ( p > 0.05).

Discussion
Most participants used at least one CIT to treat menopause symptoms and relied on physicians' recommendations and research evidence to assist with decisionmaking. Exercise and mind-body therapies were most chosen to treat menopause symptoms, perceived as beneficial, and used most often to treat sleep disturbance, the most common menopause symptom. Furthermore, education most influenced CIT selection for menopause symptom treatment. Exercise and mind-body therapies This cohort found exercise and mind-body therapies useful in treating sleep problems, depression, and anxiety. Exercise benefits have been clearly demonstrated; however, evidence-based effectiveness of mind-body therapies is equivocal. Exercise improves cardiorespiratory capacity, weight preservation/loss (with diet), bone mineral density, and muscle strength in postmenopausal females. 20 Furthermore, walking programs improve cardiovascular markers, lipid and carbohydrate metabolism disorders (thereby decreasing hypertension), 20,21 physical and mental health, and sexual quality of life. 22 Exercise can be a safe, useful intervention strategy to alleviate menopause symptoms. 23 Mindfulness, massage, and yoga may be beneficial for reducing insomnia, VMS, and depression [24][25][26][27] ; however, there is insufficient evidence for long-term VMS relief using mindbody therapies in healthy menopausal females. 28 Furthermore, psychological and behavioral therapies only moderately reduce VMS. 29 Thus, exercise programs can provide significant symptom relief and health benefits but mind-body therapy use should be explored with a well-informed health care professional.

Sleep disturbances and menopause
Sleep difficulty prevalence can range from 34% to 60% in peri-and post-menopausal females (33.7% in this cohort) and increases with age. [30][31][32] Although complex, poor sleep etiology is closely related to menopause symptoms, such as hot flushes. 32,33 Females experiencing sleep difficulties are at greater risk of depression 34 and cardiovascular risk markers than females without sleep difficulties. 35,36 Furthermore, VMS directly correlate with insomnia and depression and are primary predictors of sleep problems in menopausal females, 37 often resulting in sleep deficiencies, irritability, and mood changes. 38 Fortunately, evidence-based treatment for menopauserelated sleep disturbances is well supported. Pharmacological management of postmenopausal insomnia may include MHT, selective serotonin reuptake inhibitors (SSRIs), and dual serotonin and norepinephrine reuptake inhibitors (SNRIs) 39 ; however, cognitive behavioral therapy (CBT) for insomnia (CBT-I) may be the gold standard for insomnia treatment. 40 Moderate-tolow intensity exercise can also improve sleep quality and quality-of-life scores and reduce nighttime hot flushes in postmenopausal females. 41,42 Thus, interre-lated sleep and menopause symptom management may warrant pharmacological, CBT-I, and exercise treatment strategies. 40 Depression, anxiety, and menopause Upwards of 70% of perimenopausal females will experience depressive symptoms compared with premenopausal females, which can be disruptive and decrease quality of life. 43,44 Increased risk of major depressive disorder (MDD) development or recurrence may be related to prior MDD history, prior anxiety diagnosis, being peri-and post-menopausal, hormonal status changes, 45 and history of VMS. 46 Consensus recommendations for perimenopausal depression treatment include SSRIs and SNRIs, which may also improve VMS 47 ; a combination of CBT and antidepressant pharmacotherapy can effectively decrease depression symptoms and improve recovery rates and treatment compliance. 48 Ultimately, encouraging exercise while concurrently addressing depression, sleep disturbances, and VMS in both peri-and postmenopausal females may be the most effective treatment strategy. 47 Limited support for hypericum perforatum (St. John's wort) treatment of mild/ moderate depression exists; however, it is less effective with severe depression and comes with multiple safety concerns. 49 Estradiol treatment may be beneficial depression treatment for menopausal females. 44 The ''window of vulnerability,'' during which females experience increased sensitivity to hormonal changes that could contribute to depressive symptoms and MDD development, 50,51 coincides with the timing hypothesis ''window of opportunity,'' 52 during which MHT lowers coronary heart disease and atherosclerosis incidences, decreases mortality, and improves quality of life in perimenopausal females. Furthermore, MHT antidepressant effects in perimenopausal females can persist despite VMS reemergence 53 and may provide some value for depression and VMS symptom prevention or for patients unwilling or unable to utilize antidepressants; however, MHT is not recommended for late-postmenopausal females 47,54,55 and is not approved to treat depression in the United States or Europe. 49 Despite anxiety symptom reports as high as 52% in 40-55 year old females, 56 many challenges make diagnosis and treatment challenging, 57 anxiety symptoms with age. 64,65 Fortunately, quality evidence exists for anxiety treatment in older females. Pharmacological management of anxiety can include SSRIs, SNRIs, and benzodiazepine anxiolytics. 66,67 Menopausal hormone therapy may be helpful when anxiety coincides with frequent VMS. 67 Psychotherapies, including CBT, discussion groups, and relaxation training, 68 can also be successful in older females, 69 particularly because depressive symptoms and loneliness are strong predictors of generalized anxiety disorder symptom severity. 70 Lavender oil (silexan), 66,71 chamomile oil, 71 and physical activity 72 are additional anxiety treatments for older females.

Influence of education
Education level most influences menopause therapy effectiveness beliefs and symptom treatment choices. Higher education attainment increased the likelihood of choosing exercise or mind-body therapies to treat menopause symptoms, participants with college degrees were more likely to choose exercise, and those with graduate degrees were more likely to choose mind-body therapies. Similar findings indicate higher CIT use in affluent, educated, white, postmenopausal females with nonprivate insurance and excellent or very good self-reported health. 13,73 Perhaps higher-educated females are more aware of menopausal symptoms and treatment strategies, and thus more likely to seek symptom treatment, 74 or have greater access to information and financial resources to use CIT.

Physician recommendations
Participants primarily relied on doctors' recommendations and research to aid in CIT use decision-making, which is well supported in the literature. 13 Unfortunately, poor or biased communication from health care providers can result in patients feeling ill-informed about CIT options, 13 potentially resulting in use of less reliable information sources and failure to disclose CIT use.
Racial, ethnic, and socioeconomic differences may also influence decision-making. [75][76][77] African-, Hispanic-, and Asian American females experience, report, and treat menopause symptoms differently and may choose to rely on information from elders or close friends. In addition, they may choose more holistic treatments over medication management or may avoid seeking care and discussing CIT options with an ill-informed health care provider. 78 It is imperative that health care providers stay current on evidencebased CIT and MHT recommendations, exercise use for symptom management, and engage patients in culturally sensitive conversations and education regarding CIT use for menopause symptom treatment.

Strengths and limitations
There are several strengths of this study. This study included a large sample size. Participants had a wide variety of options for mind-body therapies (n = 19), diet (n = 14), integrative therapies (n = 13), and exercise (n = 11) in a well-validated survey. 15 Clear descriptions allowed the survey to capture more clearly how participants used different CIT. Furthermore, while participants knew that researchers were from the University of Minnesota, minimal information regarding researcher backgrounds was shared during data collection, reducing potential bias toward specific treatments.
There were also several limitations. As with any selfreported survey, information may be incomplete, overreported, or under-reported. There was also a risk that participants were using CIT for symptoms that may be directly related but not attributed to menopause. Furthermore, the large number of CIT assessed limited more specific data collection, and information was not collected on past versus current treatments, use of multiple CIT simultaneously, and if use of particular CIT was linked with specific symptoms.
An additional and important limitation of this study was the lack of sample population diversity. Use of a convenience sample from the Minnesota State Fair resulted in a population that was predominantly white, highly educated and compensated, employed, married, Christian, and primarily from either Minnesota or Wisconsin (85%). The absence of ethnic and racial minorities in this study may have led to over-or under-estimation of CIT use, and any regional differences in CIT use could not be observed. Ethnic, racial, and regional differences in CIT use [79][80][81] have proven to be critically important considerations when treating female patients. Larger, national multicenter studies would improve understanding of CIT use in the United States.

Conclusion
This study supports previous findings that the majority of peri-and post-menopausal females are using at least one type of CIT to treat their menopause-related symptoms. In addition, this study suggests that exercise and mind-body therapies were most utilized to treat sleep disturbances, depression, and anxiety. Furthermore, education levels influenced perception of CIT effectiveness and choices; doctor recommendations and research studies/evidence were valuable in aiding participant decision-making process.
Despite reported reliance on quality resources when choosing CIT for menopause symptom treatment, education regarding evidence-based supported therapies for symptom treatment, such as SSRI for depression and anxiety, or CBT-I for sleep difficulties, is necessary to ensure that females make well-informed decisions. Additional research needs to be conducted with more geographically, financially, ethnically, and racially diverse populations. In the interim, comprehensive, personalized care that considers the best available evidence-based therapies will provide the best care for all female patients.

Author Disclosure Statement
No competing financial interests exist.

Funding Information
Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number K01AG0 64038-01A1, EJL: F32HL160012.