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Complementary and Alternative Medicine (CAM) Therapies in OB/GYN

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Complementary and Alternative Medicine (CAM) Therapies in OB/GYN Special Acknowledgement to Dr. Michael Evers Jenna Beckham * * * * * * * * * * * * National Health ... – PowerPoint PPT presentation

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Title: Complementary and Alternative Medicine (CAM) Therapies in OB/GYN


1
Complementary and Alternative Medicine (CAM)
Therapies in OB/GYN
  • Special Acknowledgement to
  • Dr. Michael Evers
  • Jenna Beckham

2
Goals of this Lecture
  • Describe some common non-traditional medical
    therapies used for obstetrical and gynecological
    conditions
  • Discuss what current evidence says about these
    therapies
  • Identify potential benefits and harms associated
    with commonly used herbal supplements
  • To encourage you to include questions about
    non-traditional therapies when taking a history
    from a new patient

3
Why should you care?
  • The 2007 National Health Interview Survey (NHIS),
    showed that approximately 38 of adults use CAM
  • Women tend to use CAM more than men
  • The use of herbal medicines has increased from
    12.1 to 18.6 (1997 to 2002)
  • According to a 2007 government survey, Americans
    spent 33.9 billion out-of-pocket on CAM during
    the previous year
  • Potential benefits and potential interactions
    with traditional medicines

Altern Ther Helath Med,11(1), Jan/Feb 2005,
42-49 JAMA, 280(18), Nov 11, 1998,
1569-1575 Nahin, RL, Barnes PM, Stussman BJ, and
Bloom B. Costs of Complementary and Alternative
Medicine (CAM) and Frequency of Visits to CAM
Practitioners United States, 2007. National
health statistics reports no 18. Hyattsville,
MD National Center for Health Statistics.
2009. The National Center for Complementary and
Alternative Medicine http//nccam.nih.gov/
4
What Does ACOG have to say?
  • Committee Opinion 227 (November 1997)
    acknowledges seven categories of Complementary
    and Alternative Medicine (CAM)
  • 1. Mind-body interventions--yoga, meditation,
    tai chi, support groups and biofeedback
  • 2. Alternative systems of medical
    practice--Traditional Chinese Medicine (TCM),
    homeopathy, chiropractic, acupuncture and
    Native-American medicine
  • 3. Pharmacologic and biologic treatments--folk
    medicine, medicinal plants
  • 4. Herbal medicine--the use of botanicals with
    pharmacologic activity
  • 5. Diet and Nutrition--the use of nutritional
    supplements or vitamins as well as the use of
    specific diets to obtain health
  • 6. Manual healing methods--massage, chiropractic
    manipulation and biofield therapeutics
  • 7. Bioelectromagnetic applications--magnets,
    nerve stimulation

5
Definitions
  • Diet supplement--product (other than tobacco)
    that is intended to supplement the diet
    containing one or more of the dietary ingredients
    listed here vitamin, mineral, an herb or other
    botanical, an amino acid, a dietary supplement
    used by humans to supplement the diet by
    increasing the total dietary intake, or a
    concentrate, metabolite, constituent, extract or
    combination of any ingredient described above
  • DSHEA--Dietary Supplement Health and Education
    Act, passed in October, 1994 allowed for
    labeling and selling of dietary supplements with
    little to no oversight by the FDA

Clin Obstet Gynecol, 44(4), Dec. 2001, 780-788
6
Definitions
  • Allopathy--A therapeutic system in which disease
    is treated by producing a second condition that
    is incompatible with or antagonistic to the
    first. Conventional medicine in the United
    States.

7
Definitions
  • Homeopathy--System of therapy developed by Samuel
    Hahnemann based on the law of similia, from the
    aphorism, simila similibus curantur (likes are
    cured by likes), which holds that a medicinal
    substance that can evoke certain symptoms in
    healthy individuals may be effective in the
    treatment of illnesses having symptoms closely
    resembling those produced by the substance
  • Therapy mediated through the potentiation of
    substances which are prepared with serial
    dilutions, often to the point in which no
    molecules of the active substance is detectable
  • Flourished during the 1800s when patients often
    did better than those treated with blood letting,
    emetics and other treatments.

8
Definitions
  • Acupuncture
  • 2,000 acupuncture points on the body
  • Connected via 12 main and 8 secondary pathways
    (Meridians)
  • Meridians connect energy, qi (chee), between
    the surface of the body and the internal organs
  • Qi regulates spiritual, emotional, mental and
    physical balance
  • Qi is influenced by the opposing forces of yin
    and yang
  • When yin and yang are balanced, they work with
    the natural flow of qi to keep the body healthy
  • The placement of needles in the acupuncture
    points helps to keep the flow of qi unblocked.

9
Who uses CAM?
  • Why Patients Use Alternative Medicine Results
    of a National Study, JAMA, 1998 279 1548-1553
  • 1500 random surveys were sent out, 69 response
    rate (1035)
  • Three Theories
  • 1. Dissatisfaction with conventional treatment
  • 2. Need for personal control over treatment
    options and decisions over health care decisions
  • 3. Philosophical congruence with patients
    worldview, spiritual/religious philosophy or
    beliefs regarding health and illness

10
Who uses CAM?
  • More educated (50 with graduate degrees as
    opposed to 31 of those with high school diploma
    or less)
  • Those with holistic philosophy of health (The
    health of my body, mind, and spirit are related,
    and whoever cares for my health should take that
    into account)
  • Had a transforming experience (Ive had a
    transformational experience that causes me to
    view the world differently than before)
  • Being dissatisfied with conventional medicine not
    predictive

11
Who uses CAM?
  • Defined their health status as poorer than
    non-users of CAM
  • Specific conditions such as anxiety, back
    problems, chronic pain or urinary tract problems
    were predictive of using CAM
  • Only 4 of people relied solely on CAM for
    therapy
  • Highest rates of use in groups aged 35-49 (42)
    and 50-64 (44)

12
Acupuncture
  • A part of Traditional Chinese Medicine (TCM)
  • 36 States have state licensure for acupuncture
  • 9-12 million visits to acupuncturists take place
    in the United States
  • Acupuncture needles are regulated by the FDA as
    medical devices

Clin Obstet Gynecol, 44(4), Dec. 2001, 801-813
Anat Record, 262, 2002, 257-265
13
Acupuncture
  • Each of 12 primary meridians associated with and
    named for a specific organ
  • Organs represent more than just the anatomic
    structures
  • Approximately 360 acupuncture points lie along
    meridians
  • Endorphins and cortisol are released with point
    stimulation

Clin Obstet Gynecol, 44(4), Dec. 2001, 801-813
Anat Record, 262, 2002, 257-265
www.scienceandsociety.co.uk
14
Acupunctures uses for OB/GYNs
Nausea and Vomiting Revolves around acupuncture
or acupressure at site P6 (Neiguan
point) Sea-Band (Sea Band International,
Greensboro, N.C.)
15
Acupunctures uses for OB/GYNs
Nausea and Vomiting
  • Multiple smaller studies have shown decreased
    levels of nausea and vomiting in the first
    trimester pregnancy, chemotherapy, motion and in
    the postoperative period
  • The most methodologically sound of these studies
    involved 161 women in three groups (treatment,
    control, placebo) for 8 days
  • All three groups reported significant decrease in
    nausea and vomiting, but there was no difference
    among treatment vs. placebo

Am J Obstet Gynecol, 174(2), Feb. 1996, 708-715
Obstetrics Gynecology, 200197184-188
16
Acupunctures uses for OB/GYNs
Nausea and Vomiting
  • 187 women over 21 days with nerve stimulation at
    P6 with ReliefBand (Woodside Biomedical,
    Carlsbad, CA.) or sham device
  • Self-reporting scores for N/V decreased
    significantly
  • Study group gained more weight (2.9 lbs vs. 1.2,
    P0.003)
  • No significant change in medication use between
    groups

Obstetrics Gynecology, 2003102129-135
17
Acupunctures uses for OB/GYNs
Induction of Labor Study from Vienna took 45
women at 40 weeks and administered treatment
every other day for up to 10 days. Study group
had statistical significant cervical shortening
and interval to delivery (5.0 vs. 7.9 days) Two
studies in Norway had mixed conclusions on use of
a single acupuncture treatment after confirmation
of SROM At UNC we took 56 nulliparous women at
394 weeks or beyond and half received 3 daily
treatments. Study group was more likely to labor
spontaneously and less likely to need a C/S
Rabl M, et. al., Wien Klin Wochenshr, 113, 2001,
942-946 J. Mat-Fetal Neonatal Med Aug. 2006
19(8), 465-70 Acta Obstetricia et Gynecologica,
85, 2006, 1348-1353, Acta Obstetricia et
Gynecologica, 86, 2007, 1447-1452
18
Acupuncture is not without potential risks
Infections One-hundred twenty-six cases of
Hepatitis B have been linked to
acupuncture Evidence for Hepatitis C infection
in Japan A few reported cases of HIV infection
as well Subacute bacterial endocarditis Trauma
Thirty two cases of Pneumothorax have been
reported Cardiac tamponade
Pain, 71(1997), 123-126
19
Herbs, Dietary Supplements and your Patients
20
  • Use of dietary supplements is common among the
    U.S. adult population.
  • gt40 used supplements in 19881994
  • gt50 in 20032006
  • Patients do not stop their herbal supplements
    during pregnancy
  • Among the 53 of adults gt50 yrs using CAM, 58
    reported that they have ever discussed CAM with a
    healthcare provider
  • 61 said it wasnt important for my doctor to
    know, 60 said the doctor never asked.

AARP, NCCAM. Complementary and Alternative
Medicine What People Aged 50 and Older Discuss
With Their Health Care Providers. Consumer Survey
Report April 13, 2010 Gache, J et al. Dietary
Supplement Use Among U.S. Adults Has Increased
Since NHANES III (19881994) . NCHS Data Brief.
April 201161. JAMA 200228737-344, Am J Obs
GYN 2003188(4)1039-1045, Ann Intern Med
2001135344
21
What are Herbal Medicines?
Herbal forms of medications are often dietary
supplements They are in the form of tablets or
capsules, bulk herbs, oils, teas or tinctures
(alcohol extracted concentrates added to
liquid) Soup, potato chips or beverages that
contain herbal ingredients are not dietary
supplements, they are foods and regulated by the
FDA There is no standardization as to
concentration of herbal medicines, or whether
it is a raw botanical component or a
distillation. Herbs themselves often have
multiple ingredients which may have biologic
effect, so it is difficult to tell which
ingredient is producing an effect, if any
Clin Obstet Gynecol 44(4), Dec. 2001 780-788,
ACOG Practice Bulletin, No. 28, June 2001
22
Herbal Medicines
About 30-40 of our drugs are grown in plant-form
or are photochemicals made in a laboratory Well
known drugs today were first discovered in
plants AtropineBelladona CodeinePoppy Digoxin
From foxglove EphedrineEphedra Salicylic
acidWillow bark ScolpolamineJimson
weed QuinineFrom Cinchona bark TaxolPacific
yew VincristineMadagascar periwinkle
BMJ 319, Oct. 16, 1999, 1050-1053 Clin Obstet
Gynecol, 44(4), Dec. 2001, 853-863,
www.uptodate.com
23
If it is Natural it must be safe, right?
24
(No Transcript)
25
Areas of Concern with Herbal Medicines
Toxic effects Dangerous interactions with other
medications Discontinuing known and effective
conventional therapies
26
What are Herbal Supplements used for?
  • Generalized Health
  • Menopausal symptoms
  • Mood Disorders
  • Weight Loss

27
Most Common Herbal Products Being Used
  • Echinacea (40.3)
  • Ginseng (24.1)
  • Ginkgo Biloba (21.1)
  • Garlic (19.9)
  • St. Johns wort (12.0)
  • Peppermint (11.8)
  • Ginger (11.7)
  • Soy (9.4)

Barnes, Complementary and alternative medicine
use among adults, Advance Data from Vital
Statistics, US Dept of Health and Human Services,
Rockville, MD 2004
28
Black Cohosh(Actaea Cimicifuga racemosa, black
snakeroot)
Traditionally used by Native Americans for
gynecologic conditions Used today primarily for
treatment of menopausal symptoms We really do
not know the mechanism of action in black
cohosh We do know that Black Cohosh is not
estrogenic as it has no impact on the vaginal
cell status, LH, FSH, estradiol, prolactin or
endometrial thickness in comparison to baseline
Ann Intern Med 137(10), Nov. 19, 2002 805-813,
Menopause 10(4) 2003299-313 Menopause 15(1)
2008, 51-58
29
Black Cohosh
There are small studies that imply that it
decreases the intensity of vasomotor symptoms for
menopausal women Most studies performed with
black cohosh for menopausal symptoms did not last
longer than 6 months Most studies have been done
in Germany where black cohosh is approved for
treatment of symptoms of the climacteric Almost
all studies done on black cohosh is the
formulation Remifemin, distributed by
GlaxoSmithKline in the US
Clin Obstet Gynecol 44(4), Dec. 2001, 853-863,
Ann Intern Med 137(10), Nov 19, 2002, 805-813,
Menopause 10(4)2003 299-313, Obstetrics
Gynecology 2006107247-255.
30
Black Cohosh
  • Herbal Alternatives for Menopause Trial (HALT)
  • --One-year RCT with 351 women
  • --Five arms
  • Black Cohosh (80)
  • Multibotanical that contains Black Cohosh (76)
  • Multibotanical that contains Black Cohosh plus
    dietary soy counseling (79)
  • Hormone therapy Estrogen /- progesterone (32)
  • Placebo (84)

Ann Int Med, 145(12), Dec. 19, 2006, 869-879
31
Black Cohosh
Herbal Alternatives for Menopause Trial (HALT)
Black cohosh used in isolation, or as part of a
multibotanical regimen, shows little potential as
an important therapy for relief of vasomotor
symptoms.
Ann Int Med, 145(12), Dec. 19, 2006, 869-879
32
Black Cohosh
  • Biggest side-effect is gastric discomfort.
  • There have been multiple (about 50) reported
    cases of hepatoxicitythough no known mechanism
    to explain it
  • Regulatory agencies in Australia, Canada and the
    European Union warn about hepatoxicity
  • US Pharmacopeia states black cohosh should have
    cautionary statement on label

Menopause, 15(4), 2008, 628-638
33
Black Cohosh is NOT Blue Cohosh
  • Blue Cohosh (Caulophyllum thalictroides) has a
    very different therapeutic profile
  • Both are sometimes referred to as Squaw root
  • Blue Cohosh is a vasoconstrictor with mild
    uterine effects. Sometimes used to induce labor
  • Case reports of abruption and neonate seizures
    linked to Blue Cohosh

34
St. Johns Wort(Hypericum perforatum)
Named after St. John the Baptists birthday
(6/24) when it typically blooms Multiple RCTs
show that it is better than placebo for MILD to
MODERATE depression Other RCTs show that it is as
effective as prescription antidepressants with
fewer side effects NO better than placebo for
MAJOR depression Side effects include mild HA,
gastric upset, dizziness, fatigue and
photosensitivity MAJOR concern for herb-drug
interaction
Ann Intern Med 200213642-35, Linda K et al
Cochrane Database Systematic Review 2005CD000448
35
St. Johns Wort
  • Induces the CYP3A4 isozyme of the P-450 system
  • CYP3A4 isozyme is responsible for metabolizing
    more than 50 of all prescription drugs
  • Induces the p-glycoprotein transport system in
    cell membranes

MEDSURG Nursing, 17(1), Feb. 2008, 52-54
36
St. Johns Wort Drug Interactions
  • Increases
  • Potency of
  • SSRIs
  • Triptans
  • Barbituates
  • Alcohol
  • Narcotics
  • Fenfluramine
  • Decreases
  • Potency of
  • HIV medications
  • TCAs
  • Cyclosporine
  • Estrogen
  • Digoxin
  • Theophylline
  • Warfarin

37
Red Clover
  • Source of isoflavones and marketed as a soy
    alternative for dealing with menopausal symptoms
  • Three RCT show equivocal results at best, often
    with groups in the placebo and treatment arm both
    having a large drop in symptoms
  • No serious real side effects

Menopause 11(1)200411-33, Ann Intern Med
137(10), Nov 19, 2002, 805-813
38
Evening Primrose Oil
  • Touted for premenstrual syndrome and
    postmenopausal symptoms
  • A potent source of gamma linolenic acid (GLA), a
    type of omega-3 essential fatty acid
  • One well done placebo controlled trial exists
    looking at 56 women with at least 3 hot flashes a
    day
  • Evening Primrose Oil did not perform better than
    placebo
  • The Evening Primrose plant also produces
    substances that have anticoagulant effects

Menopause 11(1)200411-33, Ann Intern Med
137(10), Nov 19, 2002, 805-813, ACOG Practice
Bulletin No. 28, June 2001
39
Dong Quai
  • Traditionally used in TCM for all gynecologic
    conditions
  • Often prepared as a tonic and used in conjunction
    with other herbs
  • Increases uterine volume and weight in
    ovariectomized rats
  • Only one RCT has been done. It shows no benefit
    with hot flashes over placebo
  • Has coumarin-like properties and its root
    contains Safrole, an oil that is a known
    carcinogen

Menopause 11(1)200411-33, Ann Intern Med
137(10), Nov 19, 2002, 805-813, ACOG Practice
Bulletin No. 28, June 2001
40
Ginseng
  • Marketed as an immunity booster and to help lower
    weight
  • Many different types of Ginseng (Chinese,
    American, Siberian) with different effects and
    VERY different concentrations between brands
  • Minimal if any effect on menopausal symptoms and
    no effect on FSH, estradiol levels, endometrial
    thickness and vaginal pH
  • Side effects include insomnia, diarrhea, nausea,
    vomiting and headaches
  • Interacts with warfarin and will lower INR

Menopause 11(1)200411-33, Arch Intern Med
158(20), Nov 9, 1998, 2192-2199, 2200-2211, Ann
Intern Med 200213642-53
41
Herbs you should know
  • GingkoUsed for memory and dementia treatment.
    Inhibits platelet-activating factor, should not
    be used with patients on NSAIDs, warfarin or
    heparin
  • GingerUsed for nausea and vomiting in pregnancy.
    As good as Vitamin B6. Inhibitor of thromboxane
    synthetase which prolongs bleeding time, should
    use with caution while on warfarin
  • May be important to discontinue these prior to
    procedures and surgeries.

Ann Intern Med 200213642-35, Obstetrics
Gynecology 2004103(4)639-645
42
Herbs you should know
  • Bitter Orange(Citrus aurantium, green orange).
    Marketed for weight loss. Works just like
    ephedera, can theoretically cause hypertension,
    stroke and other cardiac problems. Only 1 RCT
    which showed no benefit.
  • GarlicMarketed for lowering cholesterol and to
    help with hypertension. Nausa/vomitting,
    diarrhea, contact dermatitis, inhibition of
    iodine uptake, decreases platelet aggregation and
    increases INR in patients on warfarin. Wide
    range of concentrations. May be important to
    discontinue use prior to procedures and surgeries

Amer J Cardiol 2004941359, Arch Intern Med
158(20), Nov 9, 1998, 2192-2199, 2200-2211,
www.consumerlabs.com
43
Herbs you should know
  • EchinaceaOften used to treat the common cold.
    Herbal products usually draw from closely related
    species, E. pururea, E. pallida or E.
    angustifolia. Two NIH studies have shown no
    benefit for shortening cold or flu symptoms. May
    be helpful in URIs. GI side effects are most
    common, but can cause mild to severe reactions in
    those allergic. People with allergies to other
    plants in the daisy family are more susceptible
    (ragweed, daisy, marigolds).

http//nccam.nih.gov/health/echinacea/
44
In Review
  • There are all types of CAM out there
  • As insurance begins to pay for CAM, you may be
    asked for a referral
  • Some evidence that Black Cohosh, St. Johns
    Wort and acupuncture work for certain conditions
  • Remember the concept of do no harm
  • Ask your patients what other therapies they are
    using, especially before an upcoming surgery

45
Resources
  • The National Library of Medicine
    http//www.ncbi.nlm.nih.gov/PubMed/
  • The National Center for Complementary and
    Alternative Medicine http//nccam.nih.gov/
  • The NIH Office of Dietary Supplements
    http//ods.od.nih.gov/
  • Quackwatch http//www.quackwatch.com
  • To report an adverse event with a supplement
    http//www.fda.gov/medwatch
  • Natural Standard database www.naturalstandard.com
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