Integrative Medicine in OB/GYN, highlights

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1 Disclosures Integrative Medicine in OB/GYN, highlights I have nothing to disclose UCSF Obstetrics and Gynecology Update October 26 th, 2016 By Sanjay Reddy, MD Director Inpatient Integrative Medicine, UCSF Goals of Session Brief overview of Integrative Medicine/CAM Review resources for herb/supplement reference Sampling of evidence for different modalities What is CAM? CAM (Complementary and Alternative Medicine) is a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. 1

2 Integrative Medicine Big Overview Biologically based therapies (fish oil, kava) Whole systems (TCM, homeopathy) Mind-body medicine (MBSR, biofeedback) Manual Medicine (osetopathy, massage) Energy Medicine (reiki, healing touch) 2012 NHIS Highlights 33.2% of U.S. adults used complementary health approaches. Most common approach was natural products (dietary supplements other than vitamins and minerals). Useful organization, but many cross overs 2

3 Botanical Medicine Old as people (probably) In the United States, the use of botanicals has increased significantly over the past two decades. In the USA annual total cost of more than $4 billion! Herbal Usage Dietary Supplement and Health Education Act National Health Institute Survey: 23.6% of American adults have used herbs/dietary supplements A lot of our patients use them, less talk about it 1 Recent study of oncologists showed less than half discuss herbs with their patients Classifies vitamins, minerals, botanicals, and amino acids as nutritional or dietary supplements Supplements can be marketed without proof of safety or efficacy No claims allowed to treat or cure Lee RT et al. National survey of US oncologists' knowledge, attitudes, and practice patterns regarding herb and supplement use by patients with cancer. J Clin Oncol 2014; 32: [PMID: DOI: /JCO ] 3

4 Act 94 continued Manufacturers can make "structure and function" claims Ex. Black cohosh can be marketed to support women s health but not to treat hot flashes. FDA must first prove that a botanical preparation unsafe! Opposite of medications Safety Concerns Adulterated like crazy Heavy Metals Pesticides Poisons Prescription drugs Things I don t even know about How to Advise Patients There s a lot of adulterated products Discuss with their providers what they are taking Review tested products/quality In general, few botanicals have been studied for safety in pregnancy Resources for Clinicians Resources for busy clinicians at UCSF: Natural Medicines Comprehensive Database ( and Natural Standard ( Third-party testing: 2-3$/mo, consumer products University of Maryland and Sloan: 4

5 Purported Ginseng Uses Good evidence in humans Cancer Related Fatigue Glucose lowering Cognitive function (early data) Decreasing URI/colds (some evidence) Not so good Prevent Cancer Athletic Performance Immune Stimulation (animal studies +) Strength and stamina American Ginseng Panax Quinquefolius Asian Ginseng is Panax Ginseng, less human evidence Like Asian ginseng has ginsenosides Exact mechanism of action unknown More calming than Asian ginseng Nourishes Yin Ginseng and Cancer Fatigue 364 patients from 40 institutions >4 on Cancer Related Fatigue (CRF) (0 being none and 10 as bad as it can be ) for at least 1mo prior to study Excluded steroids, opiates, current ginseng or other fatigue agents Showed American Ginseng 2000mg daily led to a significant difference in 8 weeks for CRF scores. Barton et al. Wisconsin Ginseng (Panax quinquefolius) to Improve Cancer-Related Fatigue: A Randomized, Double-Blind Trial, N07C2. J Natl Cancer Inst Aug 21; 105(16):

6 Ginseng Interactions Can induce CYP3A4 Can antagonize Warfarin s effects and reduce effectiveness Ma Huang- Ephedra sinica TCM: typically very low dose with multiple other herbs to treat asthma and very safe Sold for weight loss in massive doses, often with caffeine Contains ephedrine and pseudoephedrine 2004: banned in USA due to severe and fatal reactions: including hypertension, myocardial infarction, and stroke. 6

7 Mindfulness Based Stress Reduction Structured 8wk program, 28h total Secular, based on Buddhist traditions Deliberate, sustained, nonjudgmental attention enhance self-awareness change maladaptive thinking increase the capacity for skillful response reduce suffering MBSR Studies Over 350 and counting, particularly effective for: Anxiety Depression Stress Cancer-related symptoms mood disturbance anxiety stress quality of life Mindfulness-Based Childbirth Gotink RA. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta -analyses of RCTs. PLoS One Apr 16;10(4) and Parenting (MBCP) 3h/wk for 9 wks, plus 7h silent retreat day and a reunion class Pilot study of 27 women, third trimester Statistically significant pre to post-test: + mindfulness and positive affect -pregnancy anxiety, depression, and negative affect Qualitative with majority reporting benefits of mindfulness perinatally and early parenting Duncan LG, Bardacke N. Mindfulness-Based Childbirth and Parenting Education: Promoting Family Mindfulness During the Perinatal Period. J Child Fam Stud Apr;19(2):

8 Yes, I definitely am aware of trying to be in the moment and that each moment, good or bad, will pass. When I got really worried about the birth, I would just breathe to stop my mind from going all sorts of bad places. And in postpartum, I have tried to use the practice to deal with stressful situations whether it be a crying baby or just accepting my new role as a mother who doesn t have much time for herself. Being mindful is always at the back of my mind, no matter what I am doing, even if it isn t a formal practice. Variable Perceived stress (PSS) Pregnancy anxiety Depression (CES-D) Pre-MBCP level: M(SD) Post-MBCP level: M(SD) Mean change (SD) t-value p-value Effect size, Cohen sd (6.73) (4.99) 2.30 (6.13) (.58) 2.09 (.41) 0.39 (.32) 6.36 < (.45) 1.48 (.34) 0.15 (.30) Mindfulness 3.14 (.44) 3.44 (.38) 0.30 (.27) 5.66 < Attention/Aw areness 3.10 (.44) 3.25 (.35) 0.16 (.42) Nonjudging 3.50 (.57) 3.78 (.60) 0.28 (.36) Nonreactivity 2.85 (.59) 3.31 (.51) 0.46 (.45) 5.35 < Positive affect (PANAS) Negative affect (PANAS) Positive affect (DES) Negative affect (DES) 3.30 (.70) 3.58 (.69) 0.28 (.60) (.58) 1.83 (.47) 0.20 (.31) (.67) 3.91 (.69) 0.27 (.56) (.50) 1.83 (.50) 0.14 (.36) Yoga in Pregnancy What are the effects of an integrated yoga practice and guided yogic relaxation in pregnancy on perceived stress and measure autonomic response? 122 women recruited between 18-20wk in Bangalore, randomized to yoga and deep relaxation or standard prenatal exercises for 1h/d. 45/group completed. Yoga intervention decreased perceived stress compared to control with consistent changes in heart rate variability. Satyapriya et al. Effect of integrated yoga on stress and heart rate variability in pregnant women. Int J Gynaecol Obstet Mar;104(3): Yoga and Pregnancy, Results 8

9 Acupuncture Part of larger system of Chinese Medicine Use of needles to access energetic meridians throughout the body Alterations in energy flow cause disharmony Disharmony Disease Western Proposed Mechanisms Acupuncture points unique, Connective Tissue communication 1,2 : Denser innervation, tightly packed connective tissue, different receptor distribution Central opiate receptors (varying types) mediate analgesic effect 3 Spinal and supraspinal neurotransmitter release; Narcan can block effects Local inflammatory mediators 4 1. Langevin et al. Biomechanical response to acupuncture needling in humans J Appl Physiol, 91 (2001), pp Abraham et al. TRPV1 expression in acupuncture points: Response to electroacupuncture stimulation (2011) Journal of Chemical Neuroanatomy, 41 (3), pp Han, JS. Acupuncture Analgesia: Areas of consensus and controversy. Pain Mar;152(3 Suppl):S41-8. doi: /j.pain Leung, L. Neurophysiologic Basis of Acupuncture Induced Analgesia- Un Updated Review. J Acupunct Meridian Stud Dec;5(6): doi: /j.jams Epub 2012 Aug 22. Langevin HM et al. Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture. FASEB J Oct;15(12): NIH 97 Report of Efficacy Myofascial Pain Headache Dental Pain Fibromyalgia Tennis Elbow Osteoarthritis Menstrual Cramps Nausea Asthma Stroke Rehab Addictions Carpal Tunnel Lower Back Pain 9

10 Safety- Many studies Sample study of German physicians: 140 hours of formal acupuncture training Only 19%>350 hours of training >95k people with >700k treatments: 6 Major Complications: Exacerbation of Depression Acute HTN Crisis Vasovagal reaction LOC Asthma attack HTN and Angina Pneumothorax x2 Melchart et al. Prospective investigation of adverse effects of acupuncture in patients. Arch Intern Med.2004 Jan 12;164(1): From: Prospective Investigation of Adverse Effects of Acupuncture in Patients Arch Intern Med. 2004;164(1): doi: /archinte Figure Legend: Nonserious Adverse Events of Acupuncture Reported in Patients Date of download: 5/14/2013 Copyright 2012 American Medical Association. All rights reserved. Post-Op Acupuncture- Nausea Pericardium 6 Cochrane review of 59 studies from 2015 P6 acupoint stimulation vs antiemetics for PONV. Conclusion: To prevent PONV, the effect of PC6 acupoint stimulation is comparable to antiemetics. Lee A et al. Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 11 (2015 Nov 2) CD

11 Primary Dysmenorrhea 3 Arms, avg 36yo 9.5y of symptoms, all received acupuncture: Acupuncture Now, 101 pts Start in 3 Mo, 100 pts Not Randomized 448 pts Improved pain and cost effective Witt CM et al. Acupuncture in patients with dysmenorrhea: A randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol 2008 Pain changes over Time Acupressure for Dysmenorrhea 36 women with dysmenorrhea from 4 dormitories Dorms divided into randomized acupressure and no acupressure, both could use ibuprofen as needed -20min of acupressure to SP-6 intervention 5min x2 alternating each leg: 6s on, 2s off, with thumb Change in pain and ibuprofen use recorded Charandabi S et al. The effect of acupressure at the Sanyinjiao point (SP6) on primary dysmenorrhea in students resident in dormitories of Tabriz. Iran J Nurs Midwifery Res Autumn; 16(4): American Journal of Obstetrics & Gynecology , 166.e1-166.e8DOI: ( /j.ajog ) Copyright 2008 Mosby, Inc. Terms and Conditions 11

12 Spleen 6 Location Comparing the average number of ibuprofen consumption after the treatment in intervention and control groups Pregnancy Depression 150 DSM IV MDD+ patients: 52 needles, 49 control needles*, 49 massage 12 sessions over 8 weeks Excluded: other sig psych or psych tx, active SI, thyroid dz, drug use, uncontrolled dz or med depression, bed rest, no prenatal care Manber R et al. Acupuncture for depression during pregnancy: a randomized controlled trial. Obstet Gynecol Mar;115(3):

13 Electric-Stim in Labor 180 Nulliparous from a Chinese Hospital: 37-42wks gestational age plan vaginal delivery with singleton pregnancy No known complications and fetal vertex dilatation >3cm with regular contractions Randomized to 3 groups: SP-6 EX-B2 T10-L3 Control Dong C et al. Effects of electro-acupuncture on labor pain management. Arch Gynecol Obstet Mar;291(3): Labor and electro-stim, cont. VAS recorded in last contraction before intervention, then 30, 60 and 120 after Change of >3 considered effective Significant differences in pain and duration of active phase of labor EX-B2 more effective than SP6 Dong C et al. Effects of electro-acupuncture on labor pain management. Arch Gynecol Obstet Mar;291(3): VAS Labor and Neonate Outcomes 13

14 Safety, Pregnancy 105 mixed studies Looked at adverse events (AE) and causality No major reported attributable to acupuncture Park J et al. The safety of acupuncture during pregnancy: a systematic review. Acupunct Med Jun;32(3): Thank you! 17 studies with reported AE Acupuncture and Control similar Clarkson CE et al. Adverse event reporting in studies of penetrating acupuncture during pregnancy: a systematic review. Acta Obstet Gynecol Scand May;94(5):