Asignificant proportion of Australian women experience

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1 Menopause: The Journal of The North American Menopause Society Vol. 14, No. 3, pp. 397/403 DOI: /01.gme f4 * 2007 by The North American Menopause Society Women s health during mid-life survey: the use of complementary and alternative medicine by symptomatic women transitioning through menopause in Sydney Corinne Patching van der Sluijs, Dip Ed, BSc, BHlth Sc, 1 Alan Bensoussan, PhD, 1 Liwan Liyanage, PhD, 1 and Smita Shah, MBChB, MCH 2 Abstract Objective: To survey the extent of complementary and alternative medicine (CAM) use among women for the alleviation of menopausal symptoms. Design: A total of 1,296 eligible women aged 45 to 65 years were recruited from three Sydney menopause clinics, general practice clinics, and government agencies between July 2003 and July Volunteers were invited to complete a 19-item questionnaire covering basic demographics, general health status, use of CAM therapies and products, use of pharmaceuticals, and sources of CAM advice. Results: Of respondents, 53.8% had visited a CAM practitioner and/or used a CAM product during the past year, with 34% using a product only and 5% consulting a practitioner only. The most commonly visited practitioners were naturopaths (7.2%) and acupuncturists (4.8%), whereas the most popular products were soy (25.4%) and evening primrose oil (18.4%). Massage, chiropractic, and nutrition were rated the most effective therapies, and phytoestrogen tablets, evening primrose oil, and black cohosh were deemed the most effective products. Of the 59.9% of respondents currently using prescription or over-the-counter pharmaceuticals, 62.5% reported using CAM products during the past 12 months. Of CAM users 71% had informed their doctor about CAM use, whereas 26.4% of respondents reported their doctor had inquired about CAM use. Conclusions: CAM use by women to alleviate menopausal symptoms is common, with several therapies perceived to be effective. Although a significant proportion of women may use CAM in conjunction with pharmaceuticals, relevant communication between medical practitioners and patients remains inadequate and may expose the patient to potential drug-herb interactions. Key Words: Menopause Y Hot flushes Y Complementary medicine Y Quality of life Y Australian Y Survey. Asignificant proportion of Australian women experience vasomotor symptoms during the menopausal transition. 1 The treatment frequently prescribed for the alleviation of these symptoms is hormone therapy (HT). Despite the effectiveness of HT, 2 a significant number of women discontinue treatment within 12 months of its initiation 3 because of side effects such as bloating, breast tenderness, and breakthrough bleeding. 4 Low adherence rates may also result from concerns about increased risk of Received May 7, 2006; revised and accepted August 8, From the 1 CompleMED Research Centre, University of Western Sydney, Sydney, Australia; and 2 Primary Health Care Education and Research Unit, Sydney West Area Health Service, Sydney, Australia. Funding/support: This work was supported by a University of Western Sydney student project funding research grant. Financial disclosure: None reported. Address correspondence to: Corinne Patching van der Sluijs, Centre for Complementary Medicine Research, University of Western Sydney, Locked Bag 1797, Penrith South DC, New South Wales 1797, Australia. cpatchin@bigpond.net.au. cancer 5 or other conditions linked to HT use. 6 Moreover, recent unfavorable results reported from large clinical trials on HT 5,7 have led to a further decline in its use. 8 Therefore, it is not surprising that women transitioning through menopause seek other treatments, such as complementary and alternative medicine (CAM), to alleviate symptoms and improve quality of life. 9<11 CAM is a broad term encompassing a range of diverse modalities and diagnostic approaches that generally lie outside the dominant healthcare system. These range from self-care techniques and CAM products to therapies requiring consultations with specialized practitioners. Popular CAM treatments for menopausal symptoms include products such as red clover (Trifolium pratense), black cohosh (Cimicifuga racemosa), and soy; practitioner-centered modalities such as acupuncture, naturopathy, and herbal medicine; and self-help approaches that include relaxation and stress management. 9,11 Although several overseas studies have been conducted to specifically investigate CAM use among menopausal Menopause, Vol. 14, No. 3,

2 PATCHING VAN DER SLUIJS ET AL women, 9<12 only one such study has been undertaken in Australia. 13 No comprehensive Australian study has documented the use of CAM and its perceived effectiveness. Therefore, the specific aims of this study were to determine the nature and extent of CAM use among women aged 45 to 65 years who were symptomatic when transitioning through menopause or asymptomatic but taking menopause-specific treatments (HT and/or CAM). We sought to identify the most commonly used CAM therapies and main determinants for their use, their perceived effectiveness along with concurrent use of pharmaceutical medications, and the extent of communication between patients and medical practitioners about CAM. METHODS Participants and setting Recruitment of participants occurred from July 2003 to July We used convenience sampling by recruiting participants from 3 specialist menopause clinics, 11 general practice clinics, and government agencies (New South Wales public service sector and the University of Western Sydney [UWS]). All women aged 45 to 65 years attending menopause and general practice clinics during the designated survey period who were literate in English were invited by the clinic nurse or receptionist to complete the voluntary and anonymous questionnaire before their appointment. Respondents were excluded if they fell outside the age range, completed less than 80% of the questionnaire, or were asymptomatic and not taking treatments specifically for menopausal symptoms. The completed questionnaire was placed in an envelope provided and then sealed and returned to the nurse or receptionist. Completed questionnaires were collected from the clinics once a fortnight. Women from the government sector were recruited by circulation of an invitation with a link to an electronic version of the questionnaire to the following New South Wales government staff lists: chief executive officers, agencies, spokeswomen and women liaison officers, and Premier s department staff. Invitations were also sent to the following UWS staff lists: UWS colleges, human resources, and information technology and corporate services. Ethics approvals were obtained from UWS, Western Sydney Area Health Service, South Western Sydney Area Health Service, and Northern Sydney Health. Permission was also granted from the Co-ordinator General of the New South Wales government for distribution of the questionnaire. Survey instrument We developed a 19-item self-administered survey instrument that collected data on demographic details, general health status, 14,15 use of HT and other prescription medication, menopausal status, and symptoms experienced during the previous 12 months. 16 The menstrual status of respondents was recorded as their last Bnatural^ menstrual period occurring either more than 12 months ago, during the last 2 to 11 months, or last 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). 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, and CAM products included soy food products, soy or phytoestrogen capsules, Remifemin, Promensil, Menocalm, black cohosh, Meno-eze, dang gui (Angelica sinensis), and evening primrose oil. Space was provided for respondents to include additional therapists and products. Nonusers 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 questionnaire was pilot tested on 24 eligible women from two community groups and a menopause clinic. Feedback was obtained about the comprehension of items and time for completion. The questionnaire was revised and then sent to health professionals for comment on face validity. Reliability was assessed by administering the questionnaire to a separate second cohort of 32 eligible participants and then readministering the instrument 2 weeks later. The Wilcoxon sign test was applied to assess reliability by matching the before and after answers of the test-retest. Sample size and data analysis The sample size calculation was based on previous overseas studies in which CAM use by women specifically for menopausal symptoms was conservatively determined to be at least 15%. 9,10 Therefore, to determine whether a similar rate of CAM use existed among our sample, the minimum sample size (n) was calculated so that the estimated proportion lay within 5% (or T2.5%) of the true percentage value within a 95% confidence interval. To allow for a 95% confidence band to lie within T2.5%, the sample size was determined to be 784. The Statistical Package for Social Sciences (version , SPSS, Chicago, IL) software was used for all data analyses. Descriptive statistics identified CAM use, perceived effectiveness of treatments, pharmaceutical use, sources of information, and demographic details. Ratio data were analyzed using analysis of variance, and chi-square analyses were used to determine differences between groups for discrete variables. Univariate analyses (chi-square) were undertaken to determine the 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. Statistical significance was set at Menopause, Vol. 14, No. 3, 2007 * 2007 The North American Menopause Society

3 WOMEN S HEALTH DURING MID-LIFE SURVEY RESULTS Reliability The Wilcoxon sign test showed that 70 of the 74 variables were highly reliable at the 10% significance level. Demographic and health characteristics A total of 1,356 surveys were collected, of which 1,296 eligible surveys were included in the analyses. Respondents were excluded if they fell outside the age range (37), completed less than 80% of the questionnaire (7), or were asymptomatic and not taking treatments specifically for menopausal symptoms (16). Basic demographics and symptomatology for the total sample and recruitment groups are presented in Table 1. The three groups differed in mean age (P G 0.001), educational background (P G 0.001), occupation (P G 0.001), menstrual status (P G 0.001), and severity of menopausal symptoms. More women attending menopause clinics were symptomatically menopausal (76.6%) compared with those from general practice clinics (70.1%) and government agencies (52.9%). Significantly more women at menopause clinics reported having severe hot flushes (P = 0.002), night sweats (P G 0.001), sleeping difficulties (P = 0.001), and vaginal dryness (P G 0.001). 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. CAM users regarded all symptoms as more severe than nonusers. Most women considered their general health to be good or excellent. However, menopause clinic recruits reported their overall health status to be slightly worse than the other two groups of women. When compared to 1 year ago, most women rated their health status as the same or better with no significant differences between recruitment groups (P = 0.31). CAM use More than one in two women had visited a CAM practitioner and/or used a CAM product during the past year for the alleviation of menopausal symptoms (Table 1). Of this total, 20.3% consulted CAM practitioners and 48.7% used CAM products, whereas 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% and 43.8%, respectively) or government agencies (19.4% and 48.4%, respectively). Overall, the two most commonly visited practitioners were the naturopath (7.2%) and acupuncturist (4.8%), whereas the two most popular products were soy (25.4%) and evening primrose oil (18.4%). Twelve percent of respondents had consulted at least one practitioner, whereas 8.3% had consulted two or more therapists (mean, 0.33; SD, 0.78; range, 0<6 practitioners). Of the women using CAM products, 25.2% had used at least one product, whereas 23.7% had used two or more products (mean, 0.92; SD, 1.30; range, 0<9 products). 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. Effectiveness of treatments 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 (90% moderately to very), and consulting a nutritionist was rated third (86.4% moderately to very). The three most effective CAM products were phytoestrogen tablets (72.6% moderately to very), evening primrose oil (66.3% moderately to very), and black cohosh (63.7% moderately to very). Overall, 59.5% of respondents found at least one practitioner or product to be very effective in improving symptoms. Sources of CAM advice Women sought advice about CAM from a wide variety of sources, 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. Communication with physicians Of respondents who were CAM users, 70.4% reported informing their doctor about their CAM use. However, only 26.4% of women reported that their doctor had specifically inquired about CAM use. Respondents from specialist menopause clinics were significantly more likely to tell their doctor about CAM use than general practice and government agency respondents (P = 0.03). There was no significant difference between recruitment groups in terms of medical practitioner inquiry about CAM use (P = 0.34). Pharmaceutical use 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. The three most commonly taken drug categories were HT (22.6%), antihypertensive agents (17.6%), and nonsteroidal anti-inflammatory agents 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 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 overall use of pharmaceuticals among CAM product Menopause, Vol. 14, No. 3,

4 TABLE 1. Basic demographic characteristics, medicine use, and symptomatology of participants by total sample and recruitment group Characteristic Total sample (n = 1,296) PATCHING VAN DER SLUIJS ET AL Menopause clinics (n = 306) General practice clinics (n = 267) Government agencies (n = 723) P Age, y 52.5 T T T T 4.5 G0.001 a Country of birth, n (%) Australia/New Zealand 939 (73.3) 208 (68.2) 188 (71.8) 543 (76.1) 0.03 Other 342 (26.7) 97 (31.8) 74 (28.2) 171 (23.9) Main language spoken, n (%) English 1,205 (95.4) 288 (95.4) 234 (94.0) 683 (95.9) 0.45 Other 58 (4.6) 14 (4.6) 15 (6.0) 29 (4.1) Marital status, n (%) Partner 899 (70.3) 200 (65.6) 186 (71.3) 513 (72.1) 0.11 No partner 379 (29.7) 105 (34.4) 75 (28.7) 199 (27.9) Education, n (%) Tertiary 603 (47.3) 126 (42.3) 74 (28.2) 403 (56.3) G0.001 Nontertiary 673 (52.7) 172 (57.7) 188 (71.8) 313 (43.7) Occupation, n (%) Professional 648 (50.5) 134 (44.1) 85 (32.6) 429 (59.7) G0.001 Nonprofessional 560 (43.6) 133 (43.8) 148 (56.7) 279 (38.9) Not employed 75 (5.8) 37 (12.2) 28 (10.7) 10 (1.4) Medicine use (past year), n (%) Used HT Yes 421 (32.6) 209 (68.3) 74 (27.7) 138 (19.2) G0.001 No 872 (67.4) 97 (31.7) 193 (72.3) 582 (80.8) Used CAM Yes 697 (53.8) 184 (60.1) 132 (49.4) 381 (52.7) 0.03 No 599 (46.2) 122 (39.9) 135 (50.6) 342 (47.3) Taking pharmaceuticals, n (%) Yes 774 (59.9) 219 (72.3) 194 (72.4) 361 (50.0) G0.001 No 518 (40.1) 84 (27.7) 73 (27.3) 361 (50.0) Last menses, n (%) 912 mo 795 (62.0) 229 (76.6) 185 (70.1) 381 (52.9) G <11 mo 182 (14.2) 47 (15.7) 34 (12.9) 104 (14.0) Last month 306 (23.9) 23 (7.7) 45 (17.0) 238 (33.1) Menopausal symptoms, n (%) Hot flushes None 648 (50.6) 129 (42.3) 134 (51.1) 385 (53.9) Moderate 394 (30.8) 99 (32.5) 87 (33.2) 208 (29.1) 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) G0.001 Moderate 401 (31.5) 106 (35.0) 83 (31.3) 212 (30.1) Severe 205 (16.1) 303 (22.8) 42 (15.8) 94 (13.3) Sleeping difficulties None 443 (34.5) 79 (26.0) 97 (36.6) 267 (37.3) Moderate 506 (39.4) 130 (42.8) 91 (34.3) 285 (39.9) Severe 335 (26.1) 95 (31.3) 77 (29.1) 163 (22.8) Irregular menses None 1,037 (80.8) 242 (80.4) 220 (83.0) 575 (80.1) 0.44 Moderate 158 (12.3) 33 (11.0) 32 (12.1) 93 (13.0) 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) G0.001 Moderate 301 (23.5) 94 (30.9) 57 (21.8) 150 (20.9) Severe 150 (11.7) 54 (17.8) 34 (13.0) 62 (8.7) Health status, n (%) Now Poor 26 (2.0) 9 (3.0) 6 (2.3) 11 (1.5) 0.07 Good 695 (53.8) 177 (58.0) 150 (56.4) 368 (51.0) Excellent 573 (44.2) 119 (39.0) 110 (41.4) 343 (47.5) Compared with 1 y ago Worse 72 (5.6) 20 (6.6) 18 (6.8) 34 (4.7) 0.31 No change 791 (61.3) 192 (63.0) 151 (56.8) 448 (62.2) Better 428 (33.2) 93 (30.5) 97 (36.5) 238 (33.1) Values are mean T SE or number (valid percentage). HT, hormone therapy; CAM, complementary and alternative medicine. a Analysis of variance (ratio data). users (60.8%) and nonusers (58.8%). However, CAM nonusers were significantly (5% significance level) more likely to use two or more pharmaceuticals (34.2%) than CAM users (27.6%). Determinants of CAM use Variables covering basic demographics (age, marital status, occupation, country of birth, and language spoken), current health status, current CAM use for other conditions, 400 Menopause, Vol. 14, No. 3, 2007 * 2007 The North American Menopause Society

5 WOMEN S HEALTH DURING MID-LIFE SURVEY TABLE 2. Maximum likelihood estimates of the logistic regression function for predicting CAM use Coefficient (A) SE Exp(A) (odds ratio) 95% CI Present health status (1.01<1.25) Hot flush severity (1.55<2.60) Using CAM for other (1.64<3.05) health conditions HT use (1.15<1.98) Advice from (1.13<2.21) physician Advice from (2.44<6.64) naturopath Advice from health (1.16<2.57) food store attendant Advice from books (1.32<2.84) Advice from (1.29<2.51) magazines Constant j Hosmer-Lemeshow goodness of fit for the model, W 2 = 8.99; df =8(P = 0.34); Nagelkerke R 2 = CAM, complementary and alternative medicine; HT, hormone therapy. menopausal symptoms, and sources of advice about CAM and HT use were explored to predict CAM use using logistic regression. 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 (Table 2). However, because these nine variables explained only 23% of the variation (R 2 ), we also applied the correct classification rate method (Table 3) to explain the model s goodness of fit. Using the correct classification rate model, 67.8% of CAM users were correctly classified; hence, the logistic regression model is reasonably well supported. DISCUSSION Our study showed that 53.8% of surveyed women aged 45 to 65 years used at least one type of CAM intervention during the past year to alleviate menopausal symptoms. Previous studies have reported a range in prevalence of use from 11% to 82.5%. 9<13 Although several studies reported results comparable with ours, 11,12 higher usage was noted when the CAM definition included lifestyle factors such as healthy eating. 13 The lowest rate of use was reported by an earlier Finnish study, in which only one aspect of CAM was surveyed. 10 The use and self-prescribing of CAM products was far more popular (33.5%) than consulting a practitioner (5.1%), possibly because of ease of purchase and lower financial outlay. All listed menopause-specific products could be purchased at supermarkets, pharmacies, and health food stores in Sydney. The use of soy is very popular among menopausal women and involves a simple lifestyle change. 9 Epidemiological research has suggested that the inclusion of soy products in the diet can reduce the severity of vasomotor symptoms. 17 There is very modest evidence from clinical trials to suggest that phytoestrogens isolated from soy may alleviate menopausal symptoms. 18 Some evidence also suggests that black cohosh may provide symptomatic relief. 19,20 Although evening primrose oil was a popular supplement among respondents, little evidence exists for its benefit in alleviating menopausal flushing. 21 With the exception of evening primrose, it seems that patients are not simply using 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 was using CAM for menopausal and other health complaints and hence may be perceived as repeat rather than one-time users of CAM. Interestingly, massage therapy was rated as the most effective therapy and chiropractic as the second, a finding similar to that of another large US study. 9 However, it was not possible to elicit which therapy was the most effective in reducing a particular symptom because of the way in which the questions about symptomatology and CAM use were structured. Nevertheless, the most common symptoms troubling respondents using massage and chiropractic were tenseness, sleeping difficulties, and pain, symptoms often associated with stress. Menopausal symptoms, such as vasomotor symptoms, may be induced by stress, 22 resulting in increased arousal of the sympathetic nervous system 23 and raised cortisol levels. 24 Massage has been noted to decrease cortisol levels, increase serotonin and dopamine levels, 25 and reduce blood pressure 26 and heart rate. 27 Chiropractic has been found to be effective for relieving pain 28 and stressrelated conditions such as migraine headaches. 29 Although relaxation techniques have been found to be beneficial in reducing menopausal symptoms, 30,31 no research has been conducted on the direct effect of massage and chiropractic on menopausal symptoms. Further work on the effect of these therapies is warranted. The results from our study highlight the fact 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. Therefore, it is imperative that health professionals discuss and record the use of CAM with patients as part of their routine medical assessment. Despite this usage, only a quarter of participants reported that their general practitioner inquired about CAM use. Furthermore, women TABLE 3. Misclassification matrix Predicted CAM nonuser CAM user Correct classification, % Observed CAM nonuser CAM user Overall Estimate of correct classification rate = , estimate of misclassification rate = , estimate of standard error of misclassification rate = CAM, complementary and alternative medicine. Menopause, Vol. 14, No. 3,

6 PATCHING VAN DER SLUIJS ET AL attending menopause clinics indicated that hospital-based clinicians were just as unlikely to ask about their CAM use. The omission of documentation about CAM use while taking a medical history has been reported to occur commonly among hospital-based medical staff. 32 With the high concurrent use of CAM and pharmaceuticals, the potential for drug-herb interactions becomes a possibility. 33 Monitoring pharmaceutical drug and CAM use is an important aspect of ongoing patient care that should be undertaken by all practitioners involved in the shared care of a patient. The most significant factors associated with CAM use were current health status, severity of hot flushing, current use of CAM for other conditions, and sources of CAM advice. For each additional unit increase in hot flush severity, the odds of using CAM increased by 70% (Table 2). As indicated by the odds ratio, a woman who received advice from a naturopath was four times (95% CI, 2.44<6.64) more likely to use CAM than one who did not receive such advice (Table 2). These data may suggest a change in usage patterns for this age group of women, possibly instigated by the recent publications of unfavorable results from several large clinical trials of HT. 5,7 The findings of these studies resulted in a decline in the use of HT therapy among menopausal women. 8 Furthermore, articles and information about use of CAM for menopausal symptoms have appeared regularly in various media, possibly causing a greater awareness of CAM among the public. This study specifically investigated CAM use among symptomatic women transitioning through menopause or those who were asymptomatic but taking menopausespecific treatments. To achieve a wide representation of women with various degrees of menopausal concerns, we drew from three convenient groups: 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). However, because of the large number of clinics involved and the lack of access to information about the numbers of eligible women working at government agencies, we were unable to elicit an accurate response rate from some of the services. Therefore, because of these aforementioned limitations, it is difficult to generalize our findings to all menopausal women aged 45 to 65 years. As with all voluntary surveys, there may have been a bias by participants in choosing to complete the questionnaire. Although all patients attending clinics were invited, those interested in CAM may have been more likely to participate. For these reasons, the study may have generated higher CAM usage estimates than that of the general population. Nevertheless, we believe there are a number of key strengths to our study, including a large and diverse sample size, 12 months of usage data consistent with most general CAM surveys, and the exploration of use and perceived usefulness of both CAM practitioners and products. The varied representation of symptomatic menopausal women may generate a better understanding of trends within the community in addition to an understanding of variations between the three groups considered. CONCLUSIONS This study provides further insight into the continuing popularity of CAM use among women transitioning through menopause. The widespread dissemination of relevant information through the media after publication of several large studies on HT may have made CAM more accessible to those who would not have previously considered using such alternatives. 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