The role of naturopathic medicine in the management of women with polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome or PCOS was first described in 1935 by Irving F. Stein and Michael L. Leventhal as Stein Leventhal Syndrome; ‘women with ovarian hyperthecosis presenting with persistent anovulation, obesity and hirsutism.’ Today, PCOS is the most common reproductive endocrinopathy of women, the most common cause of ovarian infertility and the cause of significant distress. PCOS is associated with serious health risks in the short and long term including significantly increased risks for diabetes, cancer and cardiovascular disease, independent to body weight. For the health care system, the annual cost of PCOS in Australia was conservatively estimated as AU$400 million. The negative personal impact of PCOS on women’s quality of life and self-esteem is well defined and recognised. Current evidence-based medical management emphasises a multidisciplinary approach with lifestyle intervention recommended as first-line treatment. However, the strength of evidence for lifestyle intervention is limited by high attrition in RCTs and the clinical uptake remains impeded by the lack of evidence for optimal dietary and exercise practices. Additional forms of management are often needed. Pharmaceuticals and surgery may be used to regulate menstruation, reduce androgens and treat infertility and hyperinsulinaemia however these have limited capacity to address the range of PCOS symptoms, are often contra-indicated due to increased risk of co-morbidities or have high adverse effect profiles. In addition, women with PCOS have expressed preferences for alternatives to birth control pills and fertility drugs. Naturopathy is a type of complementary medicine with traditional origins in ancient western civilisations. Naturopaths could be described as complementary ‘general practitioners’ as they provide health care for a wide range of conditions using a variety of treatment modalities to enhance well-being and support the natural healing capabilities of the body. The case for naturopathy for PCOS is presented here based on three rationales; first on the basis of a clinical gap in medical management; second based on the clinical potential for naturopathic herbal medicine and nutritional supplements in women’s reproductive pathology, and third based on the increasingly high use and acceptability of complementary medicines by women throughout the world

Perceptions and experiences of lifestyle interventions in women with polycystic ovary syndrome (PCOS), as a management strategy for symptoms of PCOS

Background: The international clinical practice guidelines for PCOS emphasize diet and exercise as first-line management of clinical signs and symptoms. This study aimed to describe the patterns, perceptions and experiences of lifestyle interventions for women in the community with PCOS. Method: An electronic survey of 493 members of two PCOS consumer support groups, collected by cloud-based Survey Monkey, described women’s types and patterns of diet and exercise, experiences and perceptions of effectiveness. Women were recruited from the Polycystic Ovary Association of Australia (POSAA) and from the Facebook group, PCOS University Research Group. Associations between participants perceptions of effectiveness, and diet types and exercise patterns were assessed using logistic regression. Response bias for the POSAA group was assessed with a continuum of resistance model. Results: 91% of POSAA members and 311 Facebook group members aged 16–50 years responded to the survey. Nearly all women reported adjusting their dietary and exercise practices with the aim to improve their health and/ or PCOS (82% and 73% respectively), however less than 13% reported achievement of health goals (12.2% and 8.1% respectively). Low carbohydrate, high protein diets, and vigorous activity were associated with self-perceived effectiveness (r.0.16, p<0.01; r.0.15 p<0.01 and r.0.2 p<0.01 respectively). Barriers for lifestyle interventions included psychosocial factors. Response bias was not assessed for the Facebook group, however self-reported PCOS aligned with prevalence of clinical phenotypes and suggests results are generalizable to clinical populations of women with PCOS, who are responsible for self-directing and administering lifestyle interventions to manage their PCOS. Conclusions: Perceptions of effectiveness for lifestyle interventions by women with PCOS may be complicated by a lack of rigorous evidence. The strength of recommendations in clinical practice guidelines may be enhanced by clinical trials investigating flexible and feasible lifestyle interventions for women in the community with PCOS

A survey of the use of complementary medicine by a self-selected community group of Australian women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex reproductive endocrinopathy affecting up to 20% of reproductive aged women. Whilst there are effective pharmaceutical treatment options, women with PCOS have expressed a strong desire for alternatives. This study investigates the use and attitudes of women with PCOS towards complementary medicine (CM). Methods: Women as members of PCOS support groups responded to an anonymous on-line survey which examined rates and patterns of use for CM's, areas of health for use, perceptions of effectiveness, safety and demographic features. Data collection targeted women with PCOS using two consumer support groups. The first group self-selected following direct email to members of a land based consumer support group, the Polycystic Ovary Syndrome Association of Australia (POSAA). The second sample was generated through the electronic social network Facebook, using a snowball technique. Two surveys, identical in content, were collected by cloud based Survey Monkey. Data were described and associations between the variables, 'reasons for use' and 'perceptions of effectiveness' were explored. Non-response bias was assessed using a continuum of resistance model. Results: 493 women participated in the study; 91.1% response rate from the POSAA group. Over 70% reported use of complementary medicine, usually nutritional and herbal supplements and 76.6% of CM users reported consultation with a complementary practitioner. Many participants were using CM to treat PCOS however most were using it to concurrently treat a range of health conditions, describing women's desire for more than single symptom management. Disadvantages for CM use were cited by 71% of respondents. Women using complementary medicine with specific treatment goals in mind reported greater self-perceived effectiveness, suggesting that informed use may improve women's satisfaction with CM. Adverse reactions were reported by 12.2% of women and the need for further research into adverse reactions for CM's was identified. Demographic and PCOS characteristics were similar to clinical populations of PCOS and non-response bias was shown as not significant. Conclusion: This study describes the prevalence of use for complementary medicine by women with PCOS as over 70% and adds to our understanding of women's experiences with CM and their motivations for use of CM

A cross-sectional study of traditional Chinese medicine practitioner’s knowledge, treatment strategies and integration of practice of chronic pelvic pain in women

Background: Chronic pelvic pain (CPP) in women is persistent, intermittent cyclical and non-cyclical lower abdominal pain, lasting for more than 6 months. Traditional Chinese Medicine (TCM) is a popular treatment option for women’s health conditions, but little is known about how treatment for CPP is delivered by TCM practitioners. The aim of this survey was to explore practitioners understanding and treatment of women with CPP, and how they integrate their management and care into the health care system. Method: An online cross-sectional survey of registered TCM practitioners in Australia and New Zealand between May and October 2018. Survey domains included treatment characteristics (e.g. frequency), evaluation of treatment efficacy, referral networks, and sources of information that informed clinical decision making. Results: One hundred and twenty-two registered TCM practitioners responded to this survey, 91.7% reported regular treatment of women with CPP. Treatment decisions were most-often guided by a combination of biomedical and TCM diagnosis (77.6%), and once per week was the most common treatment frequency (66.7%) for acupuncture. Meditation (63.7%) and dietary changes (57.8%) were other commonly used approaches to management. The effectiveness of treatment was assessed using multiple approaches, most commonly pain scales, (such as the numeric rating scale) and any change in use of analgesic medications. Limitations to TCM treatment were reported by over three quarters (83.7%) of practitioners, most commonly due to cost (56.5%) and inconvenience (40.2%) rather than safety or lack of efficacy. Sources informing practice were most often Integration within the wider healthcare system was common with over two thirds (67.9%) receiving referrals from health care providers. Conclusion: TCM practitioners seeing women with various CPP symptoms, commonly incorporate both traditional and modern diagnostic methods to inform their treatment plan, monitor treatment progress using commonly accepted approaches and measures and often as a part of multidisciplinary healthcare for women with CPP

Zinc for the prevention or treatment of acute viral respiratory tract infections in adults : a rapid systematic review and meta-analysis of randomised controlled trials

Objective To evaluate the benefits and risks of zinc formulations compared with controls for prevention or treatment of acute viral respiratory tract infections (RTIs) in adults. Method Seventeen English and Chinese databases were searched in April/May 2020 for randomised controlled trials (RCTs), and from April/May 2020 to August 2020 for SARS-CoV-2 RCTs. Cochrane rapid review methods were applied. Quality appraisals used the Risk of Bias 2.0 and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Results Twenty-eight RCTs with 5446 participants were identified. None were specific to SARS-CoV-2. Compared with placebo, oral or intranasal zinc prevented 5 RTIs per 100 person-months (95% CI 1 to 8, numbers needed to treat (NNT)=20, moderate-certainty/quality). Sublingual zinc did not prevent clinical colds following human rhinovirus inoculations (relative risk, RR 0.96, 95% CI 0.77 to 1.21, moderate-certainty/quality). On average, symptoms resolved 2 days earlier with sublingual or intranasal zinc compared with placebo (95% CI 0.61 to 3.50, very low-certainty/quality) and 19 more adults per 100 were likely to remain symptomatic on day 7 without zinc (95% CI 2 to 38, NNT=5, low-certainty/quality). There were clinically significant reductions in day 3 symptom severity scores (mean difference, MD-1.20 points, 95% CI-0.66 to-1.74, low-certainty/quality), but not average daily symptom severity scores (standardised MD-0.15, 95% CI-0.43 to 0.13, low-certainty/quality). Non-serious adverse events (AEs) (eg, nausea, mouth/nasal irritation) were higher (RR 1.41, 95% CI 1.17 to 1.69, NNHarm=7, moderate-certainty/quality). Compared with active controls, there were no differences in illness duration or AEs (low-certainty/quality). No serious AEs were reported in the 25 RCTs that monitored them (low-certainty/quality). Conclusions In adult populations unlikely to be zinc deficient, there was some evidence suggesting zinc might prevent RTIs symptoms and shorten duration. Non-serious AEs may limit tolerability for some. The comparative efficacy/effectiveness of different zinc formulations and doses were unclear. The GRADE-certainty/quality of the evidence was limited by a high risk of bias, small sample sizes and/or heterogeneity. Further research, including SARS-CoV-2 clinical trials is warranted

Strategic integration of traditional and complementary and integrative medicine into clinical practice guidelines

Strengths of recommendations in clinical practice guidelines (CPGs) are informed by the quality of evidence of efficacy and safety, and transformed into decision making by balancing generalizability, availability, affordability, acceptability, direct and indirect costs and the values and preferences of patients, providers and policy makers. There is a paucity of evidence for many Traditional, Complementary and Integrative Medicine (TCIM) interventions and services, however their recognition in CPGs contributes to co-ordinated continuity of care across multiple healthcare settings and enhances evidence-based, person-centered clinical effectiveness and policy decisions. CPG development is a complex process that includes multidisciplinary panels of experts and stakeholder consultation. TCIM experts are required to articulate modifying factors and inform PICO questions, to accurately inform the inclusion of TCIM in CPGs. This scoping and evidence review informed the updated CPG: Deciding palliative and end of life care for people with diabetes. Method: A two phased literature search included 1. a scoping review and 2. a rapid systematic review of evidence. Electronic databases and grey literature were systematically searched to clarify modifying factors and shortlist 20 TCIMs of a rapid systematic review of efficacy. Results: 209 studies clarified seven key modifying factors including patient preferences; routine use; safe TCIMs for co-morbidities; simultaneous acting TCIMs; high quality evidence of effectiveness or ineffectiveness; risks and logistic feasibility. Evidence-based strong recommendations of the CPG included when to start or continue a TCIM intervention, refer to an appropriately qualified TCIM practitioner and when to stop a TCIM intervention or service. Conclusion: Inclusion of TCIM in CPGs requires a systematic approach to the quality of evidence, balanced against patients' values, benefits and harms, available resources, feasibility of the intervention, acceptability by stakeholders and effect on health equity. Inclusion of TCIM in CPGs can provide succinct high-level recommendations that facilitate patient centred evidence-based care and accurately inform evidence-based policy

The influence of hydrastis canadensis on the gastrointestinal microbiota – beneficial or detrimental effects? : a critical review to update naturopathic and western herbal clinical practice

Hydrastis canadensis (H. canadensis) is utilised in naturopathy and herbal medicine as an antimicrobial agent and vulnerary and is considered to have strong actions against pathogenic microorganisms. Traditional Western herbal practice suggests that Hydrastis should only be utilised as a short-term treatment due to the potential for it to have negative impacts on the microbiota of the gastrointestinal tract (GIT). This research piece will critically appraise the recent clinical trial evidence on this topic and evaluate whether H. canadensis is detrimental or beneficial to the gut microbiome. A PubMed and Google Scholar search sought studies on the microbiome effects of H. canadensis and its constituents. Quality was assessed using CASP instruments. Articles related to the research question were purposely sought and included in a narrative, critical synthesis. Research assessing the impact of H. canadensis as a herbal preparation on the human GIT ecosystem is scant; however, evidence for one of its constituents, berberine, is emerging. Clinical benefit from berberine administration have been observed for people with diabetes, diabetes-related cardiovascular risk factors and for people with Graves’ disease when taken from periods between 1 week to 6 months. However, clinical improvements were associated with negative shifts in the gastrointestinal ecosystem that could have detrimental impacts over longer periods, including increasing the risk of chronic diseases, including the increased risk of colon cancer. Few non-serious adverse events were reported for berberine, these were mostly gastrointestinal in nature. The evidence is limited in volume and more clinical investigations are needed, particularly examining the effects of whole preparations of H. canadensis in humans, as no studies evaluated the herbal extract as it is prescribed in naturopathic and Western herbal medicine practice

Improving Fertility Naturally

Australia's falling birth rate has recently drawn attention to fertility, and while the impact of social change - such as advancing maternal age for first pregnancy, financial disincentive and 'commitment-phobic' men - are topics of sociopolitical debate, the rising incidence of clinically diagnosed infertility brings the issue into the medical arena. Current statistics indicate that one in six couples are infertile. The most common treatment options include medically assisted conception procedures, which can be met with apprehension by couples concerned about the lack of choice, invasiveness of treatment and any undiscovered side effects. So are there any alternatives

The role of traditional and complementary medicine to improve fertility and emotional well-being

Traditional and Complementary Medicine (T&CM) is a broad set of healthcare practicesthat sit outside conventional medicine in many countries [1]. They are described by users aspreventative and holistic, aimed to treat illness, promote health and well-being and used dueto personal beliefs, preferences and resonance with traditions and cultural practices [2]. Commontherapies include acupuncture, naturopathy and physical and manual therapies such as yoga,and massage [3]. Complementary medicines sold in pharmacies and health-food shops includingherbs, vitamins, minerals and nutritional supplements are regulated under the TherapeuticGoods Act 1989. Few high-quality studies of the effect of T&CM on fertility have beenundertaken. Of the published studies, most have focused on female fertility. Existing evidenceof the effects of T&CM on subfertility and infertility-related distress is reviewed

Protocol for a rapid evidence review of traditional and complementary medicine for people with diabetes receiving palliative or end-of-life care

Background: Rapid review methods are increasingly used as an alternative to systematic reviews when there is time, resource or other logistical constraints. The Cochrane Rapid Reviews Methods Group recommends further methodological development and publishing protocols to improve the transparency and quality of the review. The authors of this paper were invited to provide timely, expert input for the revision of the 2010 Guidelines for Providing Palliative and End of Life Care for People with Diabetes (Guidelines), Australia, regarding the evidence-based use of traditional and complementary medicine (T&CM). The inclusion and consideration of T&CM in guidelines is often ad-hoc and would benefit from more systematic methods. Evidence of efficacy on clinical outcomes is not the only reason to review an intervention. Other reasons relevant to the T&CM context is: interventions that are commonly used by people with diabetes in the palliative care setting, have potentially high costs or risks, or present a conflict in choices between individual and societal perspectives. Method: The aim this review is to rapidly identify and synthesise the highest quality evidence about the safety and efficacy of a selection of T&CM interventions and provide timely information to update the Guidelines. The review has two stages 1) a rapid scoping review to inform the framing of the review questions and identify important modifying factors and 2) a rapid evidence review of up to 20 T&CM interventions to inform the Guidelines. Project constraints include limiting the number of interventions for appraisal and databases to be searched, and including only papers published in English. Searches and evidence appraisals will be conducted by single reviewers, with one tenth to be checked by another reviewer. No meta-analyses or modelling will be undertaken. Discussion: The proposed rapid review protocol is designed to address the time and resource constraints of the Guidelines developers, and inform rapid review methodology. Notwithstanding the methodological constraints, the proposed protocol and its reporting will be transparent, systematic and reproducible