Volume 27 • Issue 4 • 2015

Herbal Medicine

A publication of the NHAA

Australian Journal of Herbal Medicine 2015 27(4)

Optimal Quality Optimal Education Optimal Innovation Introducing NEW Herbs to our range Green Tea (Camellia sinensis)

Tienchi Ginseng (Panax notoginseng)

Green Tea is valued in traditional Chinese and Ayurvedic medicine systems primarily as a stimulant, diuretic, astringent, for heart health, to treat flatulence, regulate body temperature and blood sugar, clear phlegm, neutralise poisons, and to improve digestion, mental function and eyesight. These actions have been verified by modern scientific studies. Most of the research has been conducted on a polyphenol constituent of Green Tea; epigallocatechin-3-gallate (EGCG), however the other constituents remain important to the varied applications of Green Tea. The constituents and whole leaf extract of Green Tea have demonstrated many therapeutic actions including; anti-ageing, antiatherosclerotic, anti-cancer, antidepressant, anti-diabetic, antifungal, anti-inflammatory, selective antimicrobial, antioxidant, antiviral, cardioprotective, central nervous system (CNS) stimulant, hepatoprotective, nephroprotective, neuroprotective, thermogenic, and wound healing.

Hemidesmus (Hemidesmus indicus)

In Traditional Chinese Medicine (TCM), Tienchi Ginseng is renowned for its ability to stop bleeding and transform blood stasis. Therefore, Tienchi Ginseng is traditionally used as a haemostatic medicine to control both internal and external bleeding, reduce swelling and pain, as well as to disperse blood clots, eliminate blood stasis and promote blood circulation. Tienchi Ginseng contains a group of triterpenoid saponins known as ginsenosides, which are thought to be responsible for many therapeutic activities and are found nearly exclusively in Panax species. The therapeutic activities of Tienchi Ginseng supported by research include; adaptogenic, antiarrhythmic, anti-inflammatory, anti-haemorrhagic and haemostatic activity internally and topically, anti-HIV, antiobesity, antioxidant, anti-thrombotic, cardioprotective, hepatoprotective, hypoglycaemic, and neuroprotective activities. Additionally, the herb is often successfully employed to improve the stamina and endurance of athletes.

Pomegranate (Punica granatum)

Hemidesmus is widely used in Indian Traditional Medicine systems such as Ayurvedic and Unani medicine. In the West, Hemidesmus is highly regarded by modern clinicians for its mild depressant action upon the immune system, which can be of great value in the management of autoimmune conditions. Preclinical studies have supported this indication, determining that Hemidesmus is able to suppress both the cell-mediated and humoral aspects of the immune system. Autoimmunity plays a key role in the pathogenesis of many diseases, such as rheumatoid arthritis and multiple sclerosis, and Hemidesmus has demonstrated that it may address the persistent activation of the immune system in these complaints. Hemidesmus’ anti-inflammatory and antioxidant activities may also help dampen the chronic inflammation and reduce the oxidative damage that occurs with this disease progression. Furthermore, the herb has been found to be analgesic, antimicrobial, anti-ulcer, antipyretic, diaphoretic, cardioprotective, hepatoprotective, renoprotective, and cognition enhancing in the scientific literature.

The Pomegranate fruit has been used extensively in the folk medicine of many cultures. For instance, the anthelmintic and vermifuge properties were well known traditionally, and it was used to kill and expel worms and parasites. Furthermore, historically Pomegranate was commonly used to address aphtae, ulcers, diarrhoea, dysentery, acidosis, haemorrhage, microbial infections, and respiratory pathologies. The recent resurrection of interest for this phytomedicine may be attributed to the scientific evidence that suggests significant antiparasitic, selective antimicrobial, antioxidant, anti-inflammatory, antiatherosclerotic, anticarcinogenic and anti-inflammatory effects. These activities give Pomegranate a wide range of therapeutic benefits and applications. According to the scientific literature, all parts of Pomegranate appear to possess therapeutic properties, and in Western Herbal Medicine the rind and seeds are used medicinally in liquid extract form.

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Australian Journal of Herbal Medicine 2015 27(4)

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Australian Journal of Herbal Medicine The Australian Journal of Herbal Medicine is a quarterly publication of the NHAA. The Journal publishes material on all aspects of western herbal medicine and is a peer reviewed journal with an Editorial Board. Members of the Editorial Board are: Jane Frawley PhD MClinSc BHSc GradCertAppSc Katoomba NSW Australia

the first choice for herbalists and naturopaths The NHAA was founded in 1920 and is Australia’s oldest professional association of complementary therapists. The NHAA is a non-profit, member based association run by a voluntary board of directors and assisted by interested members. Representing Western herbalists and naturopaths, the NHAA is the only national professional association specifically concerned with the practice and education of Western herbal medicine (WHM) in Australia. Our mission is to serve and support our membership and promote and protect the profession and practice of Western herbal medicine and naturopathy.

Erica McIntyre BSocSc(Psych)(Hons) BHSc DipBM Blackheath NSW Australia

Andrew Pengelly PhD BA DBM ND Laurel Maryland United States of America

Amie Steel PhD, MPH, GradCertEd, ND Brisbane Queensland Australia

Janelle Wheat PhD MMedRadSc(Nuclear Medicine) MHSc(herbal medicine) BAppSc(radiography) Wagga Wagga NSW Australia

Dawn Whitten BNat Hobart Tasmania Australia

Hans Wohlmuth PhD BSc Ballina NSW Australia

Sue Evans PhD Melbourne Victoria, Australia

Matthew Leach PhD, BN (Hons), ND, Dip Clin Nutr, RN Adelaide South Australia, Australia

Susan Arentz BHSc(Hons), ND Sydney NSW, Australia

Janet Schloss Post Grad Cert Clin Nutr, Adv Dip Health Science (Nat), Dip Nut, Dip HM, BARM Brisbane Queensland, Australia

The Editorial Board advises on content, structure and standards for the Journal, keeping it relevant to the profession of herbal medicine. Peer reviewers will come from the Editorial Board as well as being sourced globally for their expertise in specific areas. Contributions are invited to the journal.

Aim & scope The Australian Journal of Herbal Medicine (AJHM) is Australia’s leading herbal publication. A thoroughly modern, peer reviewed and clinically relevant journal, the AJHM can trace its origins back to publications issued by the Association as long ago as the 1930s. Issued quarterly, the AJHM publishes material on all aspects of herbal medicine including philosophy, phytochemistry, pharmacology and the clinical application of medicinal plants.

Editorial policy • • • •

Subject material must relate to herbal medicine. Accepted articles become the property of the NHAA. Contributions are subject to peer review and editing. Contributions to the Australian Journal of Herbal Medicine must not be submitted elsewhere.

Advertising For advertising enquiries please contact the NHAA office on telephone (02) 9797 2244, fax (02) 8765 0091 email [email protected] or visit www.nhaa.org.au / Publications and Products / AJHM Publisher: NHAA

Editor: Jane Frawley

Postal Address: NHAA PO Box 696 Ashfield NSW 1800

Email: [email protected]

Follow us on facebook: www.facebook.com/pages/ Australian-Journal-of-HerbalMedicine/1416725668550367

Website: www.nhaa.org.au

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The Australian Journal of Herbal Medicine is an independent academic entity and as such does not necessarily reflect the views of the NHAA.

Telephone: +61 (0) 2 9797 2244 Fax: +61 (0) 2 8765 0091 Email: [email protected] Editorial Committee: Erica McIntyre (Blackheath NSW) Jane Frawley (Katoomba NSW) Proofreaders: Greg Whitten (Hobart TAS) Kath Giblett (Perth WA)

© NHAA 2015. All rights reserved. No part of this publication may be reproduced or utilised in any form whatsoever without prior written permission from the NHAA. All advertising is solely intended for the information of members and is not endorsed by the NHAA. The NHAA reserves the right to determine journal content. The views in this publication are those of the authors and may not reflect the view of the NHAA. The NHAA does not have the resources to verify the information in this publication and accepts no responsibility whatsoever for the application in whatever form of information contained in this publication.

ISSN 22003886

ABN 25 000 009 932

PP 23692/00006

CONTENTS Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Jane Frawley

Commentary Screening for cervical cancer in Australia: Future changes to the program and the evidence for screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Jodie Tester

Person-centred care and naturopathy: patient beliefs and values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Despina Lord

Articles Use of complementary and alternative medicine in children: research opportunities and challenges in an ever growing field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Sandra Lucas, Saravana Kumar and Matthew Leach

Being herbal practitioners: The experience of five prominent Australian herbalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Assunta Hunter, Jenny Adams, Sue Evans, Judy Singer and Gill Stannard

Medplant Thuja occidentalis in a rat model of polycystic ovary syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . Topical bitter apple extract in painful diabetic neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cinnamon compared to Ibuprofen in Primary Dysmenorrhoea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Berberis integerrima compared to sildenafil in pulmonary hypertension . . . . . . . . . . . . . . . . . . . . . Effectiveness of ginger for relieving symptoms of primary dysmenorrhea . . . . . . . . . . . . . . . . . . . . Curcumin alleviates symptoms of PMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effect of fenugreek seed extract on sex hormones and sexual function in healthy females . . . . . .

146 146 147 148 149 150 151

Medjourn Gut microbiota as a therapeutic target in diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Traditional dietetic advice compared to low FODMAP diet in irritable bowel syndrome . . . . . . . . . Spicy food consumption and mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The effect of food order on postprandial glucose and insulin levels. . . . . . . . . . . . . . . . . . . . . . . . . Antibiotic use and risk of type 2 diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modifiable risk factors of Alzheimer’s disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CAM use in Australian women with heart disease, hypertension and diabetes . . . . . . . . . . . . . . . .

153 153 154 155 156 157 157

AJHM based CPE questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Editorial

Australian Journal of Herbal Medicine 2015 27(4)

Editorial: The need to characterise paediatric visits to complementary medicine practitioners Jane Frawley Editor, Australian Journal of Herbal Medicine PO Box 696 Ashfield 1800 [email protected]

The article by Lucas, Kumar and Leach1 in this current edition of Australian Journal of Herbal Medicine draws attention to the lack of research in the area of complementary and alternative medicine (CAM) for infants and children. Indeed, there has been very little health services research in Australia that has focused on the prevalence of CAM use for children, the drivers and determinants of this use, and parental attitudes and decision-making regarding health service utilisation, including CAM, for their children. Some commentators have expressed apprehension concerning CAM use in the paediatric population in relation to delayed diagnosis and treatment, issues associated with dietary restriction, changes to prescription medications by CAM practitioners and

Australian Australian Journal Journal Herbal of Herbal Medicine Medicine of

A publication of the NHAA

the lack of evidence related to efficacy and safety.2, 3 Additionally, many parents prescribe CAM medicines themselves for their children, buying them over the counter4 and not disclosing this use to their primary health care practitioner.5-7 Therefore, it appears that there is an explicit need to understand the drivers of CAM use in the paediatric population and explore parental attitudes and information sources they trust to inform these health care decisions. Additionally, and in line with this, there is a need to characterise paediatric consultations with CAM practitioners such as naturopaths. I am frequently asked by colleagues which conditions naturopaths treat in infants and children, and how do they treat these conditions. Do they diagnose and offer support for

The NHAA invites contributions to the Australian Journal of Herbal Medicine • Feature articles, case histories, evidence based practice, growing, reviews and more • Set topics • Style proforma available • Published articles may be paid

Share your clinical experience Be part of your professional publication For details contact the Editor on [email protected] or telephone (02) 9797 2244, fax (02) 8765 0091, www.nhaa.org.au #nhaaic @thenhaa

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Editorial

infant feeding problems, do they advise on alternatives to breastfeeding, do they recommend special diets, do they diagnose and treat common childhood complaints, what role do they play in the diagnosis and treatment of more serious conditions, and if they refer to medical health practitioners, in what circumstances and who do they refer to? In truth, the content of a naturopathic consultation in any patient group is not well known; however, it is especially important to characterise and understand naturopathic, paediatric consultations due to the special health needs of this population. The use of complementary medicine for children with chronic illnesses and/or disabilities is high when compared to healthy children and children without disabilities.9 It is important to understand how CAM practitioners such as naturopaths approach these consultations. Whilst research emphasises that CAM treatment is usually adjunct to conventional care and does not replace medical treatment for children9, it appears that parents are looking for something more than an orthodox model of care.9 It is also important to determine if there is a need for specialty training in paediatrics for CAM practitioners.10 Determining how naturopaths approach the treatment of infants and children may be the first step in developing practice-based clinical guidelines for common paediatric conditions, to ensure safe and coordinated treatment of children. Despite vast heterogeneity in naturopathic training, due to a variety of training and education standards historically, the new bachelor minimum standard for naturopathy8 affords the opportunity for more standardised course content and therefore a greater consistency in practice standards. A chief principle of naturopathy is individualised patient care that takes into consideration the whole person and treats accordingly. Clinical guidelines do not contradict this approach; they complement it and ensure a high level of patient care. Clinical guidelines are very different to treatment protocols; clinical guidelines assist the practitioner and patient to make treatment decisions, optimise patient outcomes and reduce unacceptable variations in practice. Patients desire open communication between complementary medicine practitioners and medical practitioners, which contributes to patient-centred care. A greater understanding of how naturopaths approach the

© NHAA 2015

Australian Journal of Herbal Medicine 2015 27(4)

treatment of infants and children is an important step in opening up lines of communication between naturopaths and other paediatric health professionals and bridging referral pathways. Many CAM practices sit outside of the dominant medical model of health care in Australia; however, there is danger in ignoring them. Many CAM modalities are popular models of care and will continued to be utilised by Australian health consumers for their own care and the care of their children. Research to understand the approach to care of primary CAM modalities, such as naturopathy, will help to facilitate open communication between CAM practitioners, medical providers, and their patients, helping to build referral pathways and ultimately, optimising paediatric, patient care.

References 1.

Lucus S, Kumar S, Leach M. 2015. Use of complementary and alternative medicine in children: research opportunities and challenges in an ever growing field. Australian Journal of Herbal Medicine 27(4):136-141. 2. Hunt K, Ernst E. 2011. The evidence-base for complementary medicine in children: a critical overview of systematic reviews. Arch Dis Child 96:769-776. 3. Lim A, Cranswick N, South M. 2011. Adverse events associated with the use of complementary and alternative medicine in children. Arch Dis Child 96:297-300. 4. Robinson N, Blair M, Lorenc A, Gully N, Fox P, Mitchell K. 2008. Complementary medicine use in multi-ethnic paediatric outpatients. Complement Ther Clin Pract 14:17-24. 5. O’keefe M, Coat S. 2010. Increasing health-care options: the perspectives of parents who use complementary and alternative medicines. J Paediatr Child Health 46:296-300. 6. Pike A, Etchegary H, Godwin M, Mccrate F, Crellin J, Mathews M, Law R, Newhook LA, Kinden J. 2013. Use of natural health products in children: qualitative analysis of parents’ experiences. Can Fam Physician 59:e372-378. 7. Sidora-Arcoleo K, Yoos HL, Kitzman H, Mcmullen A, Anson E. 2008. Don’t ask, don’t tell: parental nondisclosure of complementary and alternative medicine and over-the-counter medication use in children’s asthma management. J Pediatr Health Care 22:221-229. 8. Frawley J. 2014. Bachelor degree now minimum qualification for naturopathy and Western herbal medicine in Australia. Australian Journal of Herbal Medicine 26(3):84. 9. Kemper KJ, Vohra S, Walls R. 2008. The use of complementary and alternative medicine in paediatrics. Pediatrics 122(6):1374-1386. 10. Surette S, Vanderjagt L, Vohra S. 2013. Surveys of complementary and alternative medicine usage: a scoping study of the paediatric literature. Complementary Therapies in Medicine 21(1):S48-S53.

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Commentary

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Screening for cervical cancer in Australia: Future changes to the program and the evidence for screening Jodie Tester Private practice Melbourne, Victoria, Australia Contact: [email protected]

Abstract The environment has changed considerably since the introduction of Australia’s National Cervical Screening Program (NSCP) in 1991 with an increased understanding of the role of human papillomavirus (HPV) and cervical cancer, the introduction of HPV vaccination, and new technologies in screening and diagnostics. Accordingly, the Medical Services Advisory Committee have reviewed the NSCP and made a number of recommendations for changes to the program, which have recently been accepted by the Australian Government. Key changes include replacing cytological testing with HPV testing; increasing the age of commencement to 25 years; screening every 5 years until the age of 70-74; and availability of self-collection tests. The changes to the NSCP will take effect in 2017. This commentary will provide an overview of cervical cancer in Australia and the current screening program, and also discuss the recommendations and supporting evidence for the changes. The role of complementary and allied health providers in understanding these changes is also considered. Keywords: Australia’s National Cervical Screening Program; human papillomavirus; cervical cancer; Pap smear; complementary medicine practitioners, allied health practitioners

The National Cervical Screening Program (NSCP) was introduced in 1991 in an attempt to reduce the incidence of cervical cancer and associated morbidity and mortality. Since its inception, the incidence of cervical cancer diagnoses and deaths have effectively halved.1 Despite its success, the environment in which the NCSP operates has changed significantly with increasing knowledge of cervical cancer, vaccinations and the availability of new technologies for screening. The Australian Government recently accepted recommendations of the Medical Services Advisory Committee to make changes to the National Cervical Screening Program. In light of this, this commentary aims to provide an overview of cervical cancer rates in Australia and the current screening program, and discuss the changes that will come into effect in May 2017. Whilst cervical screening is beyond the scope of practice for complementary and allied health practitioners, a role remains for health promotion and a duty of care to ensure optimal patient care, hence the importance of understanding these changes.

Cervical cancer in Australia The rates of cervical cancer cases and deaths in Australia are low by international standards, accounting for less than 2% of all female cancers.1 Worldwide, cervical cancer is the fourth most common cancer affecting women, and is the seventh most common cancer overall. The majority of cervical cancers, however, occur in less developed regions, accounting for a higher burden of incidence.1 127

The most recent Australian data from the Australian Institute of Health and Welfare (AIHW) reported that in 2011, 801 new cases of cervical cancer were diagnosed with 226 associated deaths recorded in 2012.1 This corresponded to 632 new cases and 143 deaths in women aged 20-69 years, or 9.5 new cases of cervical cancer and 1.8 deaths per 100,000 women aged 20-69 years. The incidence of cervical cancer in Aboriginal and Torres Strait Islander women was found to be more than twice that of non-indigenous women, with 4-times the mortality rate.1 Over recent years, the understanding of cervical cancer has increased with the identification of the causal role of some human papillomavirus (HPV) infections in the development of cervical cancer.2 Infection with HPV can occur from sexual activity and may lead to viral persistence and subsequent progression to precancerous abnormalities, and finally invasive cervical cancer.1 Whilst a number of high-risk types of HPV are recognised, types 16, 18 and 45 are most predominantly associated with cervical cancer globally. In Australia, HPV types 16 and 18 are detected in 70-80% of cervical cancer cases.3 It is important to note that most women with HPV infections will not develop cervical cancer.3 Over 70% of cervical HPV infections will clear spontaneously within 24 months, without causing lesions, and only a small proportion of infections will persist beyond 2 years.4 Cervical cancer is one of the few cancers that has a precancerous stage lasting for a number of years prior to the © NHAA 2015

Commentary

development of invasive disease, hence an opportunity exists for early detection, prevention and treatment of cervical cancer.5 With this knowledge, cervical cancer has been described as a largely preventable disease as cervical cancer does not and will not develop in the absence of the persistent presence of HPV DNA.2 In Australia, the understanding of cervical cancer and HPV has allowed for the implementation of both primary and secondary strategies for the prevention of cervical cancer. Primary prevention of cervical cancer is undertaken by vaccination against HPV infections through the National HPV Vaccination Program, established in 2007 to prevent women being infected with a number of HPV types including high-risk 16 and 18. Secondary prevention of cervical cancer is undertaken through population-based cervical screening.5

Australia’s National Cervical Screening Program The aim of population-based screening programs for a disease is to reduce the burden of the disease in the community, including disease incidence and associated morbidity and mortality. The Australian Government developed a Population Based Screening Framework, adapted from the World Health Organisation (WHO) principles of screening published in 1968, to guide the introduction of organised screening programs based on disease condition, available screening tests, follow up assessments, treatment, economics, benefits versus risks, and ongoing management criteria.6 The NSCP was established in 1991 and is the only population-based screening program that exists for a gynaecological cancer in Australia. The aim of the program is to reduce the incidence of cervical cancer in Australia and associated morbidity and mortality through an organised approach to cervical screening, which aims to detect and provide appropriate treatment and management of high-grade abnormalities before progression to cervical cancer. The target population of the current screening program is women aged 20-69 years.7 This program is government-funded and is based on the conventional Papaniclaou (Pap) smear, during which cells are collected from the transformation zone of the cervix, the site where most cervical abnormalities and cancers are detected, and assessed through conventional cytology.5, 8 Routine screening is recommended every two years for women with no symptoms or history suggestive of cervical cancer for women aged 18 years, or 2 years after the commencement of sexual activity, whichever is later. If results from the screening are not negative, then follow up management occurs in accordance with the 2005 National Health and Medical Research Council (NHMRC) guidelines for management of screen-detected abnormalities.9 © NHAA 2015

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Evaluating the current system Despite the success of the NSCP with significant reductions in both cervical cancer incidence rates and mortality since its inception, continuous review and evaluation of the appropriateness of the program are required to ensure best practice. Recently, methods of screening, frequency of screening period, and costeffectiveness of screening, have been subjected to further evaluation. Screening intervals The 2-yearly screening interval for Australia has been reported to take into account a safety margin, as it differs to the International Agency for Research on Cancer (IARC) working group review on the effect of screening interval, which concluded that 3-yearly screening conferred a substantial level of protection against cervical cancer and that more frequent screening offered little further protection.10 The IARC conclusions are supported by a recent analysis of cervical cancer incidence and mortality rates, in which the findings did not support the more frequent recommendations of 2-yearly cervical screening in Australia.11 Cost effectiveness Cost effectiveness studies have reported shifting to a 3-yearly screening program would result in predicted savings of $10-18 million (AUD) annually, which is equivalent to 6-11% of the total cost of the current program, by reducing the number of women undergoing diagnostic and treatment procedures, without any significant increase in cervical cancer cases or deaths.12 Accuracy of the cytology Differences about the accuracy of cytology methods have been reported, with the sensitivity of a single conventional Pap smear reported to range from 51% to 64.5%.13 The AIHW reports that squamous cytology is generally a good predictor of the subsequent histology finding, with a positive predictive value of high-grade squamous abnormalities cytology results reported as 68.3%.1 Endocervical cytology is also suggested to be a reasonable predictor of the true disease state, with a positive predictive value of high-grade endocervical cytology result reported as 73.0%. It is recognised that the abnormalities preceding adenocarcinoma are less well understood than those preceding squamous cell carcinoma and can be more difficult to interpret.1 Critics of the cytology method argue that as cytology is based on subjective interpretation of the cells, it is therefore associated with interpretation and screening errors. One author highlights that the repetitive nature of screening smears leads to fatigue and, invariably, errors and missed lesions, adding that the most critical shortcoming of the Pap test is the high false negative rate.14 128

Commentary

Effectiveness of the screening program Despite a low sensitivity, conventional cytology for cervical cancer is reported to be one of the most successful cancer screening tests. Conventional cytology has led to a significant reduction in invasive cervical cancer incidence and associated mortality rates observed in countries that have adopted high-quality and broadcoverage screening programs using the Pap test.15 In support of this, since the introduction of the NSCD in 1991, both cervical cancer incidence rates and mortality in Australian have effectively halved.1 Participation in the screening program not only reduces the risk of cervical cancer for individual women, but high participation rates reduce the overall incidence and burden of disease in Australia, and is hence integral to the success of the screening program. In 2012-2013, more than 3.8 million women participated in the NCSP, accounting for 58% of the target population on women aged 20-69. Participation rates differed slightly based on remoteness ranging from 58-60% for all areas except very remote which was 55%.1 The current cervical screening program, however, has been associated with lower participation rates in areas of increasing disadvantage, including lower socioeconomic status, at both state and national levels.1, 16 Studies that have reviewed women diagnosed with cervical cancer have produced mixed results regarding diagnosis and screening history. It has been reported that 80% of Australian women with cervical cancer are lapsed or never-screeners.17 One review, however, reported 47% of women who developed invasive cervical cancer had adequate screening histories within 5 years of detection, and whilst some women had failed to follow up on an abnormal smear, many had a history of negative smear results.18

The introduction of HPV vaccination In addition to the NCSP, a second program aimed at reducing cervical cancer was established by Australian legislation in 2007 and implemented in 2008. The National HPV Vaccination Program targets girls and boys in their first year of high school (aged 12 and 13 years), with catch-up programs previously available for women up to 26 years until 2009. The HPV vaccine program protects against high-risk HPV types 16 and 18, as well as types 6 and 11.16, 19 Of note, it has been reported that women vaccinated against HPV in the community catch up program are being screened for cervical cancer at lower rates than unvaccinated women, with significantly lower cervical screening participation in women aged 20-24, 25-39 and 30-34.19

A changing environment: A time for change The environment in which the current NCSP has provided great benefit has changed significantly since its introduction with greater understanding of the role 129

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of HPV in cervical cancer, the introduction of the HPV vaccination program, and new screening technologies to detect HPV infection.7, 20 As the population and number of women vaccinated against HPV increase, it has been suggested that cervical screening will become less costeffect over because the average risk of cervical cancer will subsequently decline in the Australian context.12 Accordingly, a review of the NCSP has recently been undertaken to ensure the program is based on current best practice and evidence. Following from this, a number of recommendations by the Medical Services Advisory Committee7 have been considered and accepted by the Australian Government for implementation commencing in May 2017. The changes to the NCSP include: • Replacing cytological testing with HPV testing using a molecular diagnostic assay • Increasing the age of commencement to 25 years • Screening every 5 years until the age of 70-74 years • Using partial HPV genotyping and reflex liquid-based cytological tests for triaging those who test positive for HPV • Availability of self-collection in under-screened and never-screened women The proposed changes in combination with the HPV vaccination have been reported to have to the potential to reduce the incidence of cervical cancer by an additional 15 per cent.5

Evidence supporting the changes HPV screening methods In support of HPV-screening methods, a follow up investigation of four randomised controlled trials assessed the relative efficacy of HPV-based screening compared to cytology-based screening for the prevention of invasive cancer in women who undergo regular screening. The authors concluded the HPV-based screening provided 60-70% greater protection against invasive cervical carcinomas compared with cytology.21 This furthers earlier results from research findings that HPV molecular techniques are better than cervical cytology with respect to diagnostic sensitivity and reproducibility, to detect high-grade lesion precursors of invasive cervical cancer.15 Some data, however, has reported that HPV tests have reported reduced specificity and increased sensitivity in younger women compared to older women, defined as 30 years or older.18 Further to this point, whilst a recent meta-analysis concluded screening of cervical cancer by HPV DNA testing in comparison to cytology resulted in a relatively higher detection rate, it was only found in the 30 years and over age groups, with specificity similar between cytology and HPV methods. Across all ages, the specificity actually favoured cytology, with authors ultimately concluding that HPV DNA testing as a screening method is appropriate with maximum detection and adequate specificity for women 30 years and older.4 © NHAA 2015

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Age of Screening Increasing the commencement age for screening of women to 25 years is in line with IARC and WHO guidelines for unvaccinated populations.5 Furthermore, no change in cervical cancer associated mortality has occurred in women under 25 years since the introduction of the NCSP, suggesting that screening in this age group is not effective.22 Interval of screening The previously mentioned follow up investigation of four randomised controlled trials assessing the relative efficacy of HPV to cytology screening for the prevention of cervical cancer found the decrease in invasive cervical cancer incidence was not significant within 2.5 years but became significant over a longer follow-up period.21 Importantly, the observed incidence of invasive cervical cancer was lower 5.5 years after a negative HPV test than 3.5 years after a negative cytology test. These findings support the view that 5-year intervals for HPV screening are safer than 3-year intervals for cytology, which is in line with the recommended changes to Australia’s cervical cancer screening program.5 Self-collection The recommended availability of self-collection for under-screened and never-screened women may improve participation rates of the program providing access to the test regardless of rurality, ethnicity, socio-economic status or disadvantage status.7 High-risk HPV testing from self-collected samples have been reported to be as sensitive, but often less specific for CIN2+ as cytology from clinician obtained cervical samples.23 As these women are at increased risk of cervical cancer17, the HPV self-testing recommendation could lead to improved screening participation rates and improve the overall success of the NCSP.

Economic considerations Cost-effectiveness analyses completed by MSAC concluded that the proposed changes to 5-yearly HPV testing as the screening program are more cost effective than the current 2-yearly Pap smear.7 This is in accordance with other studies that after reviewing cost effectiveness of screening scenarios recommended the effectiveness and cost-effectiveness of HPV testing as primary screening for cervical cancer in European and American populations.24, 25

Laboratory considerations From a laboratory and pathology perspective, the move from a predominantly conventional and liquid-based cytology-screening program to an HPV-screening with liquid-based analysis triage, will result in a reduction of cases that need to be assessed in a laboratory. Pathology interpretation of cellular changes remains of significant importance and the impact of screening program changes © NHAA 2015

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on the laboratories merits consideration.8 Rigorous quality processes and parameters also need to be ensured for HPV testing as a screening tool, and also to colposcopy which will have increased importance in the new program.26

The role of complementary and allied health practitioners Whilst the undertaking of cervical cancer screening is beyond the practice of complementary and allied health practitioners, it remains important to be informed of the changes to the updated screening program that will take effect in May 2017 (summarised in Table 1) to ensure patients are receiving the best care possible. The HPV vaccines do not cover all cancer-associated HPV types and additionally, as a prophylactic vaccination, it will not protect women who had already acquired HPV prior to vaccination. With reported lower rates of cervical cancer screening in younger Australian women following HPV vaccination19, changes to the screening program and delaying the age to start screening needs to be monitored to ensure optimal participation levels across all age groups, with young women appropriately informed and motivated to participate. As health practitioners, we are in the privileged position of being a trusted health care provider and advisor. Ensuring all women in the target population are being adequately screened, with particular consideration to younger women who may have been vaccinated and have demonstrated reduced screening behaviours, and referring to other medical professionals as appropriate for those who have lapsed, is within our duty of care. Table 1: Changes to the National Cervical Screening Program and considerations for practice Changes to the National Cervical Screening Program have been accepted by the Australian Government and will come into effect in May 2017 Key changes: • • • •

Replacing cytological testing with HPV testing Increasing the age of commencement to 25 years Screening every 5 years until the age of 70-74 years Using partial HPV genotyping and reflex liquid-based cytological tests for triaging those who test positive for HPV • Availability of self-collection in under-screened and neverscreened women Considerations: • No changes this year/2016 with women to maintain current recommended screening intervals • Women women who have been vaccinated against HPV are still at risk of cervical cancer and need to be vigilant in undertaking cervical screening • CAM practitioners can have a role in health promotion and a duty of care to ensure adequate screening

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References 1.

Australian Institute of Health and Welfare 2015. Cervical screening in Australia 2012–2013. Cancer series no. 93. Cat. no. CAN 91. Canberra: AIHW 2. Bosch FX, Lorincz A, Muñoz N, Meijer CJ, Shah KV. 2002. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol 55:244–265. 3. Brotherton JM. 2008. How much cervical cancer in Australia is vaccine preventable? A meta-analysis. Vaccine [Internet]. 2008 [cited 2015 May 10]; 26:250—256. 4. Pileggi C, Flotta D, Bianco A, Nobile CG, Pavia M. 2014. Is HPV DNA testing specificity comparable to that of cytological testing in primary cervical cancer screening? Results of a meta-analysis of randomized controlled trials. Int J Cancer 135:166–177. 5. Medical Services Advisory Committee (MSAC) 2013. National Cervical Screening Program Renewal: Evidence Review. Commonwealth of Australia 2013. Available from: http://www. cancerscreening.gov.au/internet/screening/publishing.nsf/Content/ E6A211A6FFC29E2CCA257CED007FB678/$File/Review%20 of%20Evidence%20notated%2013.06.14.pdf (accessed May 2015) 6. Australian Health and Medical Advisory Council. 2008. Population based screening framework. Commonwealth of Australia. Available from: http://www.cancerscreening.gov.au/internet/ screening/publishing.nsf/Content/population-based-screeningframework (accessed May 2015) 7. Medical Services Advisory Committee 2014, Standing Committee on Screening. Application no. 1276 — renewal of the National Cervical Screening Program. Commonwealth of Australia. Available from: http://www.msac.gov.au/internet/msac/publishing. nsf/Content/1276-public (accessed May 2015) 8. Cummings MC, Marquart L, Pelecanos AM, Perkins, G, Papadimos D, O’Rourke P, Ross JA. 2015. Which are more correctly diagnosed: Conventional Papanicolaou smears or ThinPrep samples? A comparative study of 9 years of qualityassurance testing. Cancer (Cancer Cytopathol) 123:108-116. 9. National Health and Medical Research Council (NHMRC) 2005. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen detected abnormalities. Commonwealth of Australia 2005. Available from: https://www.nhmrc.gov.au/guidelines-publications/wh39 10. Canfell K, Sitas F, Beral V. 2006. Cervical cancer in Australia and the United Kingdom: comparison of screening policy and uptake, and cancer incidence and mortality. MJA 185(9):482–486. 11. Simonella L, Canfell K. 2013. The impact of a two- versus threeyearly cervical screening interval recommendation on cervical cancer incidence and mortality: an analysis of trends in Australia, New Zealand, and England. Cancer Causes Control 24:1727–1736. 12. Creighton P, Lew JB, Smith M, Howard K, Dyer S, Lord S, Canfell K. 2010. Cervical cancer screening in Australia: modeled evaluation of the impact of changing the recommended interval from two to three years. BMC Public Health 10:734.

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13. Cuschieri KS, Cubie HA. 2005. The role of human papillomavirus testing in cervical screening. Journal of Clinical Virology 32S:S34– S42 14. Franco EL, Mahmud SM, Tota J, Ferenczy A, Coutlee F. 2009. The Expected Impact of HPV Vaccination on the Accuracy of Cervical Cancer Screening: The Need for a Paradigm Change. Archives of Medical Research 40:478-485 15. Isidean SD, Franco EL. 2014. Embracing a new era in cervical cancer screening. The Lancet 383:493-493. 16. Barbero B, Brotherton JM, Gertig DM. 2012. Human papillomavirus vaccination and cervical cancer screening by socioeconomic status, Victoria. MJA 196(7):444-445. 17. Bessell T. 2014. Renewal of the National Cervical Screening Program. Available from: http://www.cancerscreening.gov.au/ internet/screening/publishing.nsf/Content/renewal-ncsp-pres 18. Kulasingam SL, Hughes JP, Kiviat NB, Mao C, Weiss NS, Kuypers JM, Koutsky LA. 2002. Evaluation of human papillomavirus testing in primary screening for cervical abnormalities: comparion of sensitivity, specificity and frequency of referral. JAMA 288(14):1749-1757. 19. Budd AC, Brotherton JM, Gertig DM, Chau T, Drennan KT, Saville M. 2014. Cervical screening rates for women vaccinated against human papillomavirus. MJA 201(5):279-282. 20. Scalzo K, Mullins R. 2015. The recommended interval for cervical cancer screening: Victorian women’s attitudes to an extended interval. Aust NZ J Public Health 39 (2):153-156. 21. Ronco G, Dillner J, Elfstrom KM, Tunesi S, SNijders PJ, Arbyn M et al. 2014. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet 383:524–532. 22. Australian Institute of Health and Welfare. Cervical screening in Australia 2010-11, supplementary tables. 2013. Cancer series no. 76. Cat. no. CAN 72. Canberra: AIHW 23. Snijders PJ, Verhoef VM, Arbyn M, Ogilvie G, Minozzi S, Banzi R et al. 2013. High-risk HPV testing on self-sampled versus clinician-collected specimens: a review on the clinical accuracy and impact on population attendance in cervical cancer screening. Int J Cancer 132(10):2223-2236. 24. de Kok IM. 2012. Primary screening for human papillomavirus compared with cytology screening for cervical cancer in European settings: cost effectiveness analysis based on a Dutch microsimulation model BMJ 344:e670. 25. Goldhaber-Fiebert JD, Stout NK, Salomon JA, Kuntz KM, Goldie SJ. 2008. Cost-Effectiveness of Cervical Cancer Screening With Human Papillomavirus DNA Testing and HPV-16,18 Vaccination. J Natl Cancer Inst 100:308–320. 26. Farnsworth A. 2014. Changes to cervical screening in Australia: applying lessons learnt. MJA 201(5):245-246.

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Person-centred care and naturopathy: patient beliefs and values Despina Lord Private practice, Sydney, New South Wales, Australia Contact: [email protected]

Abstract This paper explores patient beliefs and values for those consulting with a naturopath in Australia with relevance to personcentred care. Understanding, respecting and honouring the patient as a person with individual beliefs and values are important aspects in ensuring person-centred care, and are an important component of naturopathic practice development. Collaboration, inclusiveness and participation (CIP) principles are important teachings incorporated into practice development to advocate for better person-centred care. This is important in developing a health management plan. Practitioners need to also be mindful of their own values and beliefs in supporting their patients. Further research is needed to understand more on the patient-practitioner values and beliefs, and the effects on person-centred care and patient outcomes. Keywords: person-centred care, naturopathy, patient belief and values

Introduction This paper explores patient beliefs and values for those consulting with a naturopath in Australia with relevance to person-centred care. Understanding, respecting and honouring the patient as a person with individual beliefs and values are important aspects in ensuring person-centred care, and are an important component of naturopathic practice development. Patient-centred care is internationally recognised as a dimension of the broader concept of high-quality health care.1-3 It is recognised that good patient health outcome must be defined by what is meaningful and valuable to that individual patient.1, 2 Practitioner mindfulness of the patient’s beliefs and values, alongside their own, is important in identifying possible areas of conflict that may exert some influence on clinical decision making.2 Being mindful of what the patient considers important, as well as their beliefs and values, is important for maintaining trust and open communication channels. A general practitioner, reflecting on clinical practice, highlighted this.4 The practitioner noted that being open and nonjudgemental to her patients’ beliefs and values allowed for open dialogue which allowed the practitioner to provide differing opinions and evidence in a non-threatening way.4 This collaborative approach provides the patient with empowerment to actively participate in their health plan and health decisions. Ultimately this practitioner found this approach allowed her patients to reach the best possible health outcomes.4 Shared decision making has also been shown to support treatment adherence.5 Identifying the patient’s beliefs and values helps to clarity their treatment expectations, which benefits practitioner and patient. On-going evaluation and readjusting of values, beliefs and expectations is important, especially as some needs, beliefs and values may change © NHAA 2015

as a health condition moves from acute to chronic. This has been demonstrated in patients with HIV/AIDS, as their values and beliefs in using complementary medicine (CM) and consulting with CM practitioners differed as their condition progressed.6 Cultural background and religious beliefs can also influence health beliefs and values. For example, Islam prohibits the use of swine derived products,7 which may influence what medicines are deemed acceptable by the patient. Evidence-based practice encompasses personcentred care. The practitioner must consider the patient’s individual needs, including beliefs and values, and combine this with clinical experience, knowledge, and scientific evidence for clinical decision-making.1 Practice development teachings advocate the use of ‘CIP principles’, Collaboration, Inclusiveness and Participation, which allow for authentic practitioner engagement with key stakeholders, including patients and their significant others, such as family.2 Utilising CIP principles, the practitioner is able to ensure that the beliefs and values of the patient are incorporated to collaboratively create a shared vision of desired health outcomes. The practitioner facilitates this by ‘blend[ing] personal qualities and creative imagination with practice skills and practice wisdom.’2 This approach allows for the formation and fostering of healthy relationships through a respectful approach to patients and their needs, beliefs and values, and demonstrates respect for their individual right to self-determination, empowerment and enablement so that they may be involved in their own individual care plan. Ultimately this ensures a wellgrounded foundation for person-centred care.2 With at least 40% of the general Australian population using some form of CM product,8 CMs forms an important part of patient-centred care. Concerns have been raised in relation to patients with serious but treatable conditions, 132

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that they may substitute non-evidence-based CM in the place of evidence-based treatments;9 hence, research in this area is needed to gain a greater understanding of this topic and ensure informed public health, clinician, and patient decision making. In some conditions, such as cancer, CM use is reported to be < 52%, with 75% of patients that use CM, trying more than one therapy.10 Up to 40% did not disclose their use of CM products and practices to their medical doctor. Naturopathic practice is one such therapy that is classified as a form of CM. Naturopathic practice is defined by the application of naturopathic principles and philosophy which emphasises stimulation of an individual’s healing capacity through natural means, treating the cause not the disease, disease prevention, encouraging individual responsibility for optimal health, and the practitioner as teacher.11, 12 These principles are thought to support person-centred care.11-16 Research indicates that up to 10% of Australians engage naturopathic practitioners for their individual care,17, 18 with naturopaths also providing consumer information in pharmacies and health food stores.19, 20 The use of naturopathic practitioners for primary health care needs differs between population groups, and is influenced by beliefs, values, and specific cultural and health needs. For example, 78% of people living in rural communities, with an average age of 66, indicated they had taken a CM product, with 66% consulting with a CM practitioner and 15% with a naturopath.21 Women are key drivers of this trend with recent research finding that 22% of women consulted a naturopath in the prior 12 months.22 Older research found that a total of 10.9% of mid-aged women consult a naturopath, increasing to 15% if they have cancer.23 In general, research has shown that 17.1% of people with cancer consult a CM practitioner, with herbal medicine and naturopathy being the most common therapies utilised.24 In these cases, CM is used as an adjunct, not a substitute, to conventional medicine24 with up to 94% of patients believing that CM enhances conventional medical treatment.25 This is consistent with HIV/AIDS patients, with 49% stating they used CM to assist with the management of the HIV virus. Only 5% indicated that they used solely CM for their HIV/AIDS treatment. 26 There are a number of themes emerging from research literature in relation to patient beliefs and values in relation to naturopathic practices. These include a desire for integrated medicine, health promotion and disease prevention, personal empowerment, sharing of beliefs and values with the practitioner including cultural and post-modern values, naturopath as service provider of information and tailored natural medicines.

1: Integrative Medicine: the best of both worlds Patients with HIV/AIDS describe using CM to improve their health, rather than as a result of dissatisfaction with 133

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conventional medicine.6, 26, 27 This demonstrates a desire for integrative medicine (IM) care; a desire to continue to use conventional medicine and support this with the use of CM. To fulfil patient need, a number of IM clinics have been established in Australia. These clinics are multi-disciplinary, incorporating conventional medicine practitioners with allied health and complementary medicine practitioners, such as naturopaths, all located in the one premises. The aim of IM clinics is to be patient-centric, holistic and to focus on health.28-31 3.8% of practicing Australian naturopaths, herbalists or acupuncturists surveyed in research work with a GP in an IM clinics.31, 32 There is evidence to support the idea that an IM approach contributes to higher levels of patient satisfaction and improves patient perceptions of health.31 In this sense, the IM approach supports person-centred care principles, although more research is needed to establish if patient beliefs and values related to IM clinical settings are being met. Limited research has established two main IM models operating in IM clinics.31 The ‘equitable partnerships’ model puts patient preference, needs and values ahead of practitioner needs, and is marked by all involved practitioners adopting a shared and collaborative approach to patient care.31 The second model is more hierarchical, where the general practitioner acts as gatekeeper, monitoring which CM practitioner and therapy is most relevant for the patient.31 Either approach may be person-centred depending on the patient’s preference, and the willingness of practitioners to co-operate to ensure best patient outcomes in line with the patient’s vision of health.31 From the perspective of patients and practitioners IM: (1) provides authentically patient-centred care; (2) fills the gaps in treatment effectiveness, particularly for certain patient populations (those with complex, chronic health conditions, those seeking an alternative to pharmaceutical health care, and those seeking health promotion and illness prevention); and (3) enhances the safety of primary health care (due to IM retaining a general medical practitioner as the primary contact practitioner and using strategies to increase disclosure of treatments between practitioners).28

2: Health promotion and prevention of disease Users of CM in the general population cited promotion of general health and prevention of illness as the primary reasons for CM medicine and therapy use.19 Self-care, active coping and valuing self-reliance were identified as primary motivators for using CM and consulting a CM practitioner in older adults living in a rural location in Australia.21

3: Personal empowerment A clear theme of positive empowerment emerges from the research, especially in relation to the use of © NHAA 2015

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CM for chronic conditions such as HIV/AIDS and cancer. Patients describe gaining a sense of control from the active involvement in their health care.6, 27 Aspects of personal empowerment and self-reliance are also apparent in rural, aging communities.21

4: Shared beliefs and values a) Cultural: Research within Australian rural communities indicate patients are more inclined to consult a naturopath who was a local member of the community.21, 33 Practitioners noted that it was only once they were accepted as locals that their services were sort.33 Patients valued autonomy, self reliance and self-care.21, 33 Patients also valued practitioners providing them with additional information and reading, which encouraged shared decision making and empowerment in their personal health management.5, 21, 33 Cultural factors, values and beliefs inherent in immigrant communities may influence the use of naturopaths and herbalists for specific health needs. Ethnographic research found that Latin American immigrants in Melbourne consulted traditional healers for specific conditions, the knowledge of which was kept within the community.34 The research indicates that South American immigrant women living in Australia, who would culturally consult traditional medicine healers, consult naturopaths or herbalists in Australia, mainly for digestive issues.34 The traditional medicine healer, naturopath or herbalist did not replace the need for a medical practitioner, especially in what was considered more serious disease such as sexually transmitted disease.34 The shared beliefs and values, as well as the sharing of common language was found to be the key influencers in the use of traditional medicine healer, naturopath or herbalist.34 Some CM users believe the historical use of traditional medicine validates its use in contemporary health care.19 It is important to note that not all cohorts found the traditional aspect or ideologies of naturopathic practice of significance. For example, patients with HIV/AIDS consulting with a naturopath placed more importance on what they perceived as beneficial for their health and wellbeing6 as opposed to naturopathic philosophy. For these patients it was common to be overwhelmed by the advice and possible impracticalities provided by the CM practitioners, which resulted in the participants deciding to limit their involvement. Therapy that was seen to be too onerous on a daily basis was seen as having a detrimental effect on health, and hence dropped.6 This highlights the importance of establishing and re-assessing patient values and beliefs to ensure patient needs are being addressed, as well as understanding the reasons for poor adherence.5 b) Post-modern values: The rise in post-modern values is thought to play a role in the attraction of individuals to CM and IM.19, 28, 35 A range of beliefs include concepts of holism, the importance of © NHAA 2015

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a medicine being ‘natural’, individual responsibility for health and wellness, and consumerism.19 Research indicates that the rise in post-modern values is evident in patients attending IM clinics: 1) Clients did not bring the expectation of prescriptive treatment regimens, saw the practitioner as one source of information or advice resource, and used the service to monitor their health; 2) Practitioners also valued client knowledge and judgement, and respected the client’s right to choose and direct their healthcare. Clients perceived themselves as the health expert — this presented its own challenges to the practitioners in relation to misinformed self-diagnosis or from heavily marketed products.28, 35 There was no strong correlation between post-modern values and CM therapy use in an older rural, community cohort, although themes of ‘natural’, self-reliance and individual responsibility were evident.21

5: Naturopathic service a) Information provider: Naturopathic practitioners are also seen as trusted sources of information on CM by their patients.19 Naturopaths were referred to as highly reliable sources of information with a number of cohorts valuing their information, and evaluation of CM19, for example, in breastfeeding mothers, where natural substances are preferred over conventional medicine.36 A total of 76% of breastfeeding mothers wanted more information on safety and efficacy of herbs during breastfeeding and referred to naturopaths as their preferred source of information.36 The active information seeking from trusted sources also supported the empowering, post-modern, self-reliant and individual responsibility values discussed. The information provided a means to be actively involved in determining their personal healthcare plan. Interestingly, people who regularly consulted with a naturopath are more active in seeking information, and use their naturopath as the first and primary source of information.19 The need to verify information from other sources seemed to diminish after the consulting with their naturopath.19 b) Individualised treatment: High users of CM indicate the value of naturopathic practitioners and herbalists formulating and providing a tailored medicine for their individual health needs.19 There was also the belief that the practitioner-only supplied product, that is only available from the practitioner, or the individualised herbal mixture especially made up for the patient, was more efficacious than pre-formulated off-the-shelf products.19 c) Natural medicines: perceptions of safety There is a tendency for CM users to perceive CM products as being safe.6, 19, 36 This may affect the way users perceive dosage (over-dosing) and interactions,19 and may explain why up to 40% of people with cancer 134

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do not disclose their CM use to their medical doctor.10 Interestingly, some research indicates that high CM users are more likely to disclose CM use with their doctor (66% disclosing use), compared to 48% of low CM users.19 Conversely, research still indicates that high CM users in a rural setting still only disclose CM use in 40% of cases.21

Conclusion Person-centred care emphasises collaboration, inclusion and participation, the CIP principles of practice development, to help understand patient (and other stakeholders) health goals, beliefs and values. Patients have beliefs and values associated with their decision to use CMs which need to be considered by all practitioners. Naturopathic medicine philosophies of practitioner as teacher and individualised care lend themselves to person-centred care. It is, however, important to consider how the patient views or values the practitioner’s philosophies. Collaboratively involving the patient in discussions of differing views/evidence and sharing decision making helps support person-centred care, better patient adherence and ultimately better patient outcomes. Practitioners need to also be mindful of their own values and beliefs in supporting their patients to ensure they do not negatively impact the patient’s health views and priorities. Further research is needed to understand more on the patient-practitioner values and beliefs, and the effects on person-centred care and patient outcomes.

Disclaimer Despina Lord is a qualified naturopath currently employed by Blackmores Ltd. The views and recommendations expressed in the article are her own and do not necessarily reflect the views or assessments of Blackmores Ltd.

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Article

Australian Journal of Herbal Medicine 2015 27(4)

Use of complementary and alternative medicine in children: research opportunities and challenges in an ever growing field Sandra Lucas1, Saravana Kumar2, Matthew Leach3 University of South Australia, School of Nursing and Midwifery, Adelaide, South Australia LaTrobe University, School of Nursing and Midwifery, Melbourne, Australia Email: [email protected] Phone: +61 3 9479 6730 2 School of Health Sciences, International Centre for Allied Health Evidence, University of South Australia, Adelaide, South Australia 3 School of Nursing & Midwifery, University of South Australia, Adelaide, South Australia 1

Abstract The use of complementary and alternative medicine (CAM) continues to rise across the globe and yet there remains a paucity of research underpinning the field; this is particularly evident in the area of paediatric CAM use. The limited evidence base and many unanswered research questions in the field provide a number of opportunities for conducting research into the use of CAM in children; this includes understanding the characteristics of paediatric CAM users, as well as the determinants of CAM use in children and adolescents. These opportunities need to be considered alongside several unique and important challenges if there is to be progressive understanding in the field. Such challenges include access to children and parents, research funding, research capacity, and ascertaining the determinants of parental decision making. Given the numerous research opportunities and challenges that this ever growing field faces, establishing a clear research agenda for key stakeholders in the field is warranted. This paper proposes such an agenda with a view to improving future health practice, education and policy regarding CAM use in children. Keywords: Parent; children; decision making; complementary and alternative medicine; research agenda

Introduction

Opportunities

There has been a significant rise in complementary and alternative medicine (CAM) use over the last few decades, with increases in both self-prescribed CAM and CAM service use. Captured under the umbrella term of CAM are a large and diverse range of therapies, including chiropractic, massage therapy, naturopathy, vitamin and mineral supplementation, herbal medicine, aromatherapy and homoeopathy. Although there is no universally accepted definition of CAM 1, it could be described as representing holistic models of care, encompassing body, mind and spirit, where the practitioner-client relationship is central to therapy. 2-4 CAM is also referred to as a preparation or practice that is not regarded a part of conventional medicine 2, 5, although this description is somewhat more ambiguous. While CAM continues to grow in popularity, research underpinning CAM is in its infancy. Nowhere is this more evident than in the use of CAM in children, including how and why parents choose to use CAM, or mainstream medicine, for their child. This ever growing field presents numerous opportunities and challenges. The aim of this article is to highlight the growth of CAM in children, and to explore the various opportunities and challenges that this provides to stakeholders of CAM.

Current CAM research CAM has given rise to many research opportunities due to its high prevalence of use and considerable amount of money spent on these therapies. 6, 7 The limited evidence base (with much of CAM research being limited to low quality studies), and the plethora of unanswered research questions, also present abundant research opportunities. Seizing these opportunities may help to address a number of knowledge gaps in CAM, particularly gaps relating to paediatric CAM use, including: the extent of CAM use in this population, the commensurate resources of this population, the characteristics of paediatric CAM users, and the determinants of CAM use in children and adolescents. These aspects are further explored below.

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The growing consumer demand for CAM CAM is utilised extensively worldwide7, 8, with prevalence of use ranging from 1 in 8 adults in the U.S.9 and 1 in 4 adults in the U.K.10, to 1 in 2 adults in Australia. 6 High levels of CAM use are also reported in the general paediatric population, varying from 1 in 10 children in Finland 11 , and almost 1 in 9 children in the U.S.12, to 1 in 3 children in Australia. 6 The high 136

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demand for CAM in Western countries presents a number of research opportunities for CAM, particularly in the Australian paediatric population. Notwithstanding, even though the high demand for CAM in Western countries is well documented, there is still a gap in our understanding of the factors that drive this demand; one such example is why CAM use in both the adult and paediatric population is higher in Australia than in other Western countries. The high prevalence of CAM use in the west also equates with high out-of-pocket costs for many CAM consumers. According to the World Health Organization (WHO), annual out-of-pocket expenditure on CAM ranges from US$2.7 billion in the U.S., to US$2.4 billion in Canada, and US$2.3 billion in the U.K. 7 Similar expenditure on CAM medicines and therapists (i.e. US$1.3 billion) is reported in Australia 6, albeit with a relatively smaller population, which suggests that more money is spent on CAM per capita in Australia than other Western countries. Wardle et al, citing an Australian survey 8, suggest CAM use may represent half of all health consultations and half of all out-of-pocket health care costs in Australia. 13 Apart from what might be the most obvious reason (i.e. the high prevalence of use), the factors contributing to the high expenditure on CAM in Australia have not been adequately explored. There is also a paucity of research to date that has examined the cost to parents in providing CAM treatments to their children. Investing in such research would be valuable for several reasons; it furthers our understanding of what parents are willing to pay, and to what extent parents value these products and services, to maintain or improve the health and wellbeing of their child. While the use of CAM in Australia and most Western countries is burgeoning, this has not been complemented by increasing research in the field. 13, 14, 15 There continue to be considerable gaps in terms of the precise estimates of CAM use in Australia, including the use of CAM in children. In addressing these knowledge gaps, an opportunity exists to further our understanding of health care utilisation in Australia, the expressed demand for certain CAM and conventional health care services, and the needs and behaviours of Australian health consumers. The CAM consumer Evidence suggests that CAM users differ from non-CAM users in several ways. Sociodemographic characteristics appear to be the main point of difference, with studies consistently demonstrating that CAM users are more likely to be highly educated, middle-aged, female, in paid employment, often in poorer health, belonging to certain ethnic groups and residing in metropolitan areas. 6, 8, 9, 12, 16-25 This somewhat challenges common anecdotal perceptions that CAM users belong to a particular social and/or demographic group. 22 Another characteristic of CAM users is that they are generally wanting a greater sense of control over their health. 23, 26 CAM users also may take greater responsibility 137

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for their health, with data from the Australian Census of Population and Housing (n = 21,501,719) and the Australian National Health Survey (n = 20,788) indicating that CAM users adopt healthier diets and lifestyles relative to non-CAM users, with users reporting greater fruit consumption and levels of physical activity, and lower rates of smoking than non-users. 18 Another interesting characteristic of the Australian and US CAM consumer is that they do not typically avoid medical practitioners 10, 27, 28, which challenges the assumption that CAM users are anti-mainstream medicine and/or anti-establishment. While studies to date have provided much-needed insight into the typical adult CAM consumer, there is little known about the paediatric CAM consumer. Parents play an important role in making decisions regarding the use of CAM in children up to 12 years of age. 29 Lending support to this claim are findings from a survey of 3015 South Australians, which found in households with children (n=659), 30.6% of parents had used CAM or CAM therapists for their children, with 7.7% receiving treatment from a CAM therapist. 6 In USA the 2007 National Health Interview Survey found that in adolescents, when parental influence might be considered to be less, the use of CAM actually increases. 12 According to the Australian Bureau of Statistics, in 2004-05 people aged less than 18 years accounted for 9% of all consultations to a CAM therapist, with 66,000 children/adolescents consulting chiropractors, osteopaths, naturopaths, acupuncturists, herbalists or traditional healers. 18 With the increasing prevalence of CAM use, and particularly the self-prescribing of CAM, it is important to gain insight into why and how parents select CAM for their children. To date there has been little research exploring this issue. This research would not only determine the education needs of parents and health professionals, but also inform future policy and practice regarding CAM use in children; the primary purpose being to support child health and wellbeing. Motivations for CAM use Factors that motivate persons to use CAM can be broadly categorised into internal and external influences. The internal influences on the decision making process are complex and varied. In the U.S., adult use of CAM appears to be driven internally more by similarity with personal values and belief in CAM than by dissatisfaction with biomedicine. 10 Ernst24 comments that there are positive and negative internal motivations for people using CAM. Amongst the positive motivations are the need for a natural, holistic approach that is safe and effective, and having a good relationship with the therapist. The internal negative motivations include dissatisfaction with biomedicine due to a lack of effectiveness, the presence of adverse effects, a poor relationship with the therapist, and long waiting lists. 24 Similar factors are reported by Shaw et al, who refer to these positive and negative internal motivations as © NHAA 2015

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push and pull factors, respectively. 30 External factors contributing to CAM use are the costs and benefits as experienced by consumers 10, and the influence of other people, the internet and the media; all of which could be equally regarded as challenges to future research. It is unknown what factors influence parents to choose CAM for their children when compared with conventional medicine. While it could be hypothesised that the factors influencing CAM use in adults may play a similar role in children, currently there is a paucity of research from which such conclusions can be drawn. In recent years some research has given attention to the use of CAM in children, although this research has been conducted across diverse populations (e.g. Finland, USA, Saudi Arabia, United Kingdom, Turkey) 11, 12, 21, 31, 32, and among a discrete array of child illnesses and conditions, such as autism, Down syndrome, cancer and asthma. 30, 33, 34,35 There has been little research looking at CAM use in Australian children, and in particular, the role of the parent in driving this use. 36

Challenges Most of the challenges that confront any investigation regarding the use of CAM in children can be attributed to the issue of access, including access to CAM providers, access to children, access to parents who make decisions about the use of CAM in children, and access to research funding. Developing research capacity is critical also, especially in a fledgling area such as CAM use in children, as research can generate new knowledge that can then be used to develop the CAM profession, inform clinical practice and shape future policy. 15 In Australia the use of CAM in paediatric health care is not an immediate research priority. In fact, between 2003 and 2012 CAM research represented only 0.2% of all research funding provided by the Australian National Health and Medical Research Council (NHMRC — the Australian government’s health and medical research agency). 37 Put another way, only 134 successful research grants exploring CAM were awarded by the NHMRC between 2000-2013, totalling AU$62 million 15 of a possible AU$7.2 billion. 37 It is not clear how much of this funding is targeting children. Interestingly, over half of the chief researchers receiving of these grants were conventional medical professionals and not health professionals with specialist skills in CAM. This is likely to be explained, in part, by the limited research capacity in CAM in Australia. Accessing CAM service providers for collaborative research purposes may be one way to improve research capacity in CAM although there are several barriers to be overcome if this approach is to be feasible. One such issue is the educational preparation of CAM practitioners. In the past there have been no nationally consistent education standards for non-registered CAM service providers in Australia, with the educational © NHAA 2015

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backgrounds of CAM practitioners varying considerably, from no formal qualification through to vocational (i.e. certificate/diploma) and higher education (i.e. degree) qualifications. 38, 39 Whilst it is true that there are no minimum education standards required to practice disciplines such as naturopathy, Western herbal medicine and nutritional medicine in Australia — due in part to the absence of professional registration — recent changes by the Skills Council of Australia mean that a Bachelor Degree will soon be the new minimum standard for providers training these disciplines. 40 Further to this, there are more than 100 different professional CAM associations in Australia, each with their own minimum education requirements for practice. 41 This is in contrast to the registered CAM professions, such as chiropractic and osteopathy, for which the minimum standards for education and practice are stipulated by a single governing authority, the Australian Health Practitioner Regulation Agency (AHPRA). This diversity in CAM education and practice can make it difficult for researchers to interact with CAM practitioners, and for CAM providers to effectively engage with high level health and medical research in Australia. 15 The lack of uniform education standards in CAM can be attributed in part to the limited number of dedicated schools of CAM within Australian universities. There are merely a handful of research departments/centres focusing on CAM in Australia, and almost all of these are housed within non-CAM departments such as public health and nursing. The critical mass of CAM research leaders is also small, which has a direct impact on the extent to which research capacity in CAM can be built. Accessing paediatric populations for the purpose of conducting CAM research (including experimental and non-experimental research) presents a number of challenges that might explain the limited volume of research on this topic. These challenges relate to two different but equally important issues; treating a child with CAM, and conducting CAM research in children. Both issues need to take into account the influential effects of the child’s parents/guardians, significant others and current media trends. To elaborate, because of a child’s vulnerability 42, their limited health literacy and cognitive capacity, a child under 16 years of age usually cannot provide informed consent to participate in health research 43, instead, parental consent is required. 44 Having said that, receiving CAM treatment without the express permission of a parent or guardian is highly unlikely due to the access and financial constraints of this population. Whilst parental involvement in the paediatric consent process is of utmost importance, it also has a downside in that it can potentially act as another barrier to the recruitment and retention of participants in health research. 45 This does not mean that research involving children should not be conducted, it just means that more care to manage risks is required. 42 138

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Accessing the parents of children — the key decision makers for CAM use in children — also poses some unique challenges to CAM research. Parents’ decisions relating to their child’s health take into account not only the health risks to their child but also the risk of appearing to others to be a bad parent. 46 The decision of a parent to use CAM treatment for their child may not be considered best parenting practice by some mainstream health professionals and public groups, who may deem the parent as being a risk to the child’s health and wellbeing. 47This may create barriers to accessing parents as participants, as they may feel marginalised, fearful and guarded when engaging with CAM research. The process underpinning parental decision making therefore could be considered to have many complex components. These are important obstacles to consider when designing and recruiting participants for CAM research involving parents and children. A parent’s decision to use CAM for their child is also likely to be influenced by interactions with significant others, including partners, friends, health professionals and teachers. In health care more generally, health care decisions are often influenced by family, friends, neighbours 48, parents 49, the internet 50, and health care providers 51; this is expected to be no different in CAM where therapies are commonly recommended by family members. 29, 32 These external influences on the decisionmaking process are another unexplored area of research in regards to CAM and the paediatric population. From an ecological point of view, the media too can play an important role in parental decision-making. Online or lay media, in particular, can influence a person’s health behaviour as well as their health decision making; one such example is the decision to vaccinate or not 52, on which the internet has had a profound influence. 50 This is particularly troubling as decisions about CAM can be based on information gained from everyday/lay media, much of which has been reported to be either inaccurate or incomplete. 53, 54 Relying on health professionals who are not trained in CAM but are more readily accessible also may not be an appropriate source of correct or reliable information. Another aspect of parental decision making and paediatric CAM use that is particularly worrying is that over 50% of people consuming CAM do not inform their medical practitioner of their CAM use. 6, 7 Various explanations for the non-disclosure of CAM use to medical practitioners have been reported in the literature, including concerns about a perceived negative response, a perception that medical professionals do not have sufficient knowledge about CAM, and because medical practitioners do not specifically inquire about CAM use. 55 These perceptions are likely to also impact on a parent’s decision whether to disclose CAM usage in their child.

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Conclusion While the use of CAM continues to grow around the world, the research underpinning CAM remains in its infancy. This is due to numerous challenges that confront CAM research, including access to participants, the potential stigma of using CAM in the face of mainstream health care, and the availability of research funding. Despite these challenges, there remains a myriad of opportunities to build the evidence base for CAM. An emergent area where these opportunities present is in the use of CAM in children. Despite consistent evidence of the growing use of CAM in children, there remain critical knowledge gaps in terms of “why” and “how” parents make decisions when using CAM for their child. Research addressing these knowledge gaps may provide useful insights into the decision-making process of the wider (adult) population, thus enabling development of critical new knowledge which can then be used to inform health policy and clinical practice.

Conflict of Interest The authors have no conflict of interest to declare.

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Being herbal practitioners: The experience of five prominent Australian herbalists Assunta Hunter1, Jenny Adams2, Sue Evans3, Judy Singer4, Gill Stannard5 Melbourne School of Population and Global Health, University of Melbourne. Room 358-6, Level 3 / 207 Bouverie St, Parkville The University of Melbourne, Victoria, 3010, Australia. Email: [email protected] Phone: +61 3 9386 3289 2 Victorian Foundation for Survivors of Torture (Foundation House). 3 School of Health and Human Sciences, Southern Cross University. 4 University Centre for Rural Health, University of Sydney. 5 Gill Stannard Heath & Happiness Coach | Naturopath 1

Abstract In this article a group of five naturopaths and herbalists discuss their professional trajectories and outline the pathways they have taken as practitioners over the last 35 years. It emphasises the variety of ways that naturopathic and herbal training can be used, and how it can provide the basis for post-graduate education. There are many career pathways open to practitioners with undergraduate clinical skills. The sustainability of practice may be dependent on specialising in a particular area of practice or diversifying into other forms of practice or other disciplines.

There is more than one way to skin a cat, as Assunta’s Glasgwegian mother used to say. And indeed there is more than one way to be a herbalist. In Australia undergraduate training to be a naturopath or a herbalist in the last 35 years has generally taken the form of studying a three- or four-year course at a private naturopathic college.1, 2 There was a period between 1995 and 2010 when undergraduate degrees in naturopathy were offered at a number of Australian universities, but in recent years this has given way to degree courses being offered only through private colleges, probably due to a combination of economic forces and external pressure from groups like Friends of Science in Medicine to exclude the teaching of complementary medicine from academic institutions.3, 4 Evolving patterns of practice in Australia suggest that the workforce is predominantly female and that most naturopaths and herbalists are in solo practice. Only 7% work in multi-disciplinary clinics.5 In this article a group of five naturopaths and herbalists discuss their professional trajectories and outline the pathways they have taken as practitioners over the last 35 years. The article examines the professional lives of five women practitioners who came together through VicHerbalists, the Melbourne chapter of the NHAA, and who have been active in the development of herbal medicine teaching and the development of local communities of practice in herbal medicine in Australia today. We presented this material at the 2015 NHAA International Conference where we discussed what had been important to us in how we established our © NHAA 2015

professional lives. Rather than address only the financial aspects of being a successful practitioner, we talked about what drew us to naturopathy and herbal medicine and how we carved out rewarding and financially stable professional lives. Our biographies emphasise the variety of ways that naturopathic and herbal training can be used, and how it can provide the basis for post-graduate education in both similar and different areas. Four of us graduated from a four-year diploma course in naturopathy in Australia between the late 1970s and early 1990s and one of us studied to be a herbal medicine practitioner in England in the late 1970s — early 1980s. At the time these courses were seen as leading almost exclusively to a career as a practitioner. Our experiences highlight how we have built on undergraduate training in naturopathy and herbal medicine, and show how practice-based training can open doors to other professional paths. This article can be read as an historical account of how we as individual herbal and naturopathic practitioners have created a variety of new careers from very similar undergraduate training. It can also be read as a way of reflecting on the idea that clinical practice is just one of a variety of career pathways for people with an undergraduate herbal medicine or naturopathy qualification. It illustrates some of the potential places where naturopaths can practice and some of the paths that were open to us at the time we were pursuing careers, building on our disciplinary interests and basic training. It is striking that there were very few 142

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ways of being employed as a naturopath, at least in the period from 1980 to 2000. It was perhaps in part because of this lack of employment opportunity that we each had to look creatively at our own career development. Our cases illustrate how we were able to earn financially stable independent incomes in the Australian context. These are not the only ways of earning a sustainable living in this field but we do note that for naturopaths there are not the same range of options for work in the health system as there are for other graduate health practitioners. The article takes up the stories of these practitioners.

Jenny Adams — Collaborative practice in public and community health I feel fortunate to have been in the ‘right place at the right time’, entering the naturopathic profession in the late 1980s at a time when naturopathy was steadily gaining popular appeal. On graduating I joined one of Melbourne’s first multidisciplinary (now called integrative) medical clinics. Riding the zeitgeist of the time, at its peak our clinic comprised a team of four doctors, two psychologists, a massage therapist and osteopath, while upstairs we ran a program of yoga classes every night. I loved working as part of a multidisciplinary team, as ‘unconventional’ as some of my colleagues were! Unfortunately none of us were particularly business savvy; eventually we incurred considerable debt and made the decision to close. By then I was clear that solo practice was not for me — I thrived on the stimulation, the cross-fertilisation of ideas and the challenges of working in a multidisciplinary environment. Back in my student days I had done a year of clinical observation with Ruth Trickey, gaining invaluable experience from Ruth’s mentorship. I was in awe of Ruth’s professionalism, diverse skills (naturopath, herbalist, midwife, acupuncturist) and encyclopaedic knowledge. When the opportunity arose I jumped at the chance to join Ruth’s clinic, a dynamic team of talented practitioners. For the next six years I became immersed in the world of women’s health and collaborative health care. Periodically, when I felt the need to increase my skill set and expand my horizons, I enrolled in further study. I was midway through a Graduate Diploma in Health Counselling when I attended a Victorian Herbalists’ meeting one night where my friend and colleague Judy Singer spoke about the fascinating cross-cultural work she was doing at Foundation House6, a mental health agency for refugees. Within six months I was doing a clinical placement there, the following year I was employed, and 17 years later I’m still there (part time). It is a rare privilege as a naturopath to work with such a large health care team and diverse client group. I still get a lift from walking through a waiting room full of people from all over the world! Through my work at Foundation House and an international residency in 2002 — a research project conducted with the Tibetan refugee community living 143

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in exile in India — I became more interested in the global picture of naturopathy and traditional medicine.7 These experiences inspired me to undertake my Master’s in Public Health. I continue to pursue a passion for promoting the integration of naturopathy into community settings and the broader public health arena. I see this as the naturopathy of the future.

Sue Evans — Expanding choices through further education As I look back on my herbal life there has been a dance between life and work as my work shaped my life and my life shaped my work. Opportunities in herbal medicine have affected how and where I have lived, and choices about the life I want to live have affected what herbal opportunities I have sought and been able to take up. From my earliest days as a student I loved the feeling that I had ‘room to move’, that I need not be tied to doing one thing all my life. However I have found that my herbal training was not enough to let me make these sideways moves. I needed further qualifications. I started clinical practice in 1982, on my return home to Melbourne after completing my training with the National Institute of Medical Herbalists in the UK. A few years later I was enjoying teaching at Southern School of Natural Therapies, and seeing myself as a teacher as well as a herbalist. This led me to take time out to return to university to complete an education qualification. At the time I had no particular expectation of where this might lead, but some years later it assisted me in being appointed to the position of foundation lecturer in the Bachelor of Naturopathy program at Southern Cross University. The experience of establishing that program — the first naturopathic degree at a publicly funded Australian university — was great fun; a huge challenge and it changed me. I started to ‘think academically’ and was invited to participate in research projects both in Australia and overseas and once again, I enjoyed the process. I also found that there are so many interesting research questions! But, in order to be able to generate my own projects, I needed training. This meant a PhD — with all its associated false starts and hiccoughs. The skills I developed during my PhD process enabled me to begin researching my own questions and continues to give me a sense of having ‘room to move’ within the world of medicinal plants. Clinical practice and undergraduate teaching have now given way to working with groups and institutions on a range of projects, as well as continuing with my own research priorities — including issues around contemporary medicinal plant supply chains, and the role of medicinal plants in Australian colonial history. My training as a herbalist has been a wonderful foundation — but it has been very much a starting point, not an endpoint. © NHAA 2015

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Assunta Hunter — Cross cultural perspectives on the developing profession After graduating from the Southern School of Natural Therapies in 1982 I set up practice first in Canberra and then in Melbourne. My plan such as it was, saw no further than practice but teaching quickly became part of my career. I practiced mostly in a women’s health area and taught naturopathic philosophy and herbal medicine for more than 25 years. A combination of teaching and watching the way herbal and naturopathic professions were changing, encouraged me to consider how ‘others’ saw my profession, and to reflect on the process of change the professions were clearly undertaking in the 1990s. I engaged in the rough and tumble of politics, first on the Executive of the Australian Natural Therapies Association and then on the Board of the National Herbalists Association of Australia. There I was both observer and agent of some of the shifts in education, philosophy and practice which were produced from within the profession and as a response to external factors like the Therapeutic Goods Act (1989) and the increasing public usage and acceptance of herbal medicines and naturopathy. Naturopathy and herbal medicine were gaining legitimacy and seemed to be becoming mainstream. I began to reflect on these processes of professional development and the patterns of change that were emerging not just in Australia but in traditional medicine systems world-wide. As someone who saw a large number of menopause patients I was part of the surge in women’s usage of naturopathy, which saw many women choose herbal medicines in preference to Hormone Replacement Therapy. I completed a Master of Women’s Health as part of my desire to pursue a more academic path and also because it opened the doors to new disciplines that looked at what I did in different ways. Medical history, and medical anthropology offered new ways of thinking about the roles that herbalists had taken in history and in other cultures. By the time I stopped practising in 2008 I had decided that my next path was looking at how traditional medicine systems re-invented themselves in response to modernity and how the processes of professionalization had occurred in other cultures. My doctoral research centred on how the education of traditional medicine practitioners had changed in Thailand in the last 30 years.

Judy Singer — Applying naturopathic perspectives to social science research During my student days at the Southern School of Natural Therapies I was fortunate to be taught by a number of inspiring teachers. My naturopathic training became more of a ‘world-view’ than a career path and I developed a passion to work as a naturopath in contexts where people would not ordinarily have access to naturopathic treatment. © NHAA 2015

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In the early 1990s, a colleague, Tracey Potter and I established a naturopathic clinic within a women’s prison in Melbourne. Funded by a philanthropic trust, we provided individual consultations and ran an ongoing educational program focusing on wellbeing practices. Given the constraints, we were inventive! Concurrently, I started working as a naturopath at Foundation House — a mental health service for refugees. Responding to a request for volunteer naturopathic practitioners from the recently established complementary therapies program at Foundation House, I joined the team. Twelve months later I took on the position of complementary therapies coordinator. A few years later my colleague Jenny Adams also joined the Foundation House team. After ten years working with refugees I felt compelled to document this innovative program that uses complementary therapies alongside psychological therapies to support refugee survivors of torture and trauma.6 In my role as a naturopath my knowledge base had developed but I did not have an opportunity for critical reflection. So I embarked on a PhD exploring the meanings and experiences of naturopathic treatment in a refugee healthcare context.8 Since completing my PhD I have been employed by the University Centre for Rural Health in Lismore (University of Sydney) as a research officer. I no longer work as a naturopathic practitioner, but still have a keen interest in the profession, particularly from a research perspective. Recently I conducted a qualitative study exploring the roles and perspectives of managers of public healthcare services that have included complementary therapies as part of their service delivery. This gave me the opportunity to further my interest in exploring how complementary therapies can be provided in public healthcare settings.9, 10 My current academic work involves research in Aboriginal mental health. Although technically far from ‘naturopathic practice’, my embedded naturopathic knowledge has served me well in this work. Viewing health, and particularly mental health, in terms of ‘social and emotional wellbeing’ is remarkably similar to applying naturopathic principles and a holistic worldview. So, twenty-five years on, and in a very different work context, core naturopathic understandings are still a guiding influence for me.

Gill Stannard — An evolving practice When I graduated from the Southern School of Natural Therapies in 1991, employment opportunities were limited to a few jobs in health food stores. Private practice as a sole operator was basically my only option. The practice model was equally limited; you could set up on your own clinic, operate from home or join an existing clinic. Naturopathy was viewed as a vocation rather than a potentially lucrative business. I followed the path unquestioningly with more ideals than business 144

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sense. My first year was very lean, paying the rent with a part-time administration job in a related industry. But within 18 months of starting practice, the clinic was my primary income. Having worked previously in non-profit and government sectors, I lacked business skills. However, a couple of years into my new career, taking over the lease of the group practice I worked in, provided a steep and un-mentored learning curve. Running City Natural Therapies in Melbourne for more than two decades brought more profit than loss. But it also came with various unexpected stresses. These included relocating the clinic at short notice and annual negotiations with real estate agents. There were also sometimes issues with practitioners who sub-let rooms in the practice, with building management and with other tenants. I am not sure I would have survived those initial years of practice if I had not for been involved in VicHerbalists. The ongoing learning, friendships and mentoring were invaluable. The skills I bought from my life before naturopathy were also useful — especially critical thinking, writing and communication abilities developed through a political science degree and research jobs. But surprisingly, it was my earlier involvement in student radio that landed me a talkback show about natural therapies, which ran for almost 20 years. Community radio helped me grow my practice from the start, also creating television and writing opportunities that helped publicise the profession. While most of my practice over the decades has been old-fashioned naturopathic consulting, professional supervision arose from teaching final-year herbal medicine at Sothern School of Natural Therapies. Eighteen years ago, there was little or no support for new practitioners so I started offering group and individual supervision. This has blossomed to supporting practitioners in all stages of practice from newbie to mid-career and beyond. After closing the clinic in 2014 and moving to Sydney I have adopted a coaching model as a new way of sharing my clinical experience and grass roots naturopathic principles. I continue to work with old and new clients around the world and support fellow practitioners.

Conclusion There are now a greater variety of paths for practitioners who have completed an undergraduate qualification. Some people never practice even after undertaking a three- or four-year course. The majority of practitioners are in part-time practice, which they may combine with other forms of employment. Employment in pharmacies, health food stores and in naturopathic practices doing dispensary and clinic work have emerged as options in the last 15 years. The growth of the herbal medicine industry has provided roles for many practitioners either in research, technical writing or as sales managers. Some practitioners pursue further studies in post-graduate

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courses in related modalities, and in public health. Academic careers for naturopaths researching their own profession are an emerging option. Twenty five to thirty years since we started our careers as naturopaths and herbalists, there are now many career pathways open to practitioners with undergraduate clinical skills. Setting up a solo practice is not the only way to earn a living using the skills and knowledge learnt in a naturopathic degree. The sustainability of practice may be dependent on specialising in a particular area of practice or diversifying into other forms of practice or other disciplines. Working collaboratively and working in public health settings using herbal and naturopathic skills is possible. Using undergraduate skills to move into other areas such as psychology, medicine and teaching are all career paths that have opened up in the last 15-20 years. As practitioners move through their working life they may be swayed by longer-term considerations of sustainability, like accumulating superannuation. Ultimately, their careers, like ours, will be guided by their interests and values and their desire to create meaningful work, building on their original herbal or naturopathic training.

References 1.

Evans S. 2000. The story of naturopathic education in Australia Comp Ther Med 8(4):234-40. 2. Baer HA. 2006. The drive for legitimation in Australian naturopathy: successes and dilemmas Soc Sci Med 63(7):1771-83. 3. Wardle J, Steel A, Adams J. 2012. A review of tensions and risks in naturopathic education and training in Australia: a need for regulation J Altern Comp Med 18(4):263-70. 4. Brosnan C. 2015. ‘Quackery’in the Academy? Professional Knowledge, Autonomy and the Debate over Complementary Medicine Degrees Sociol 2015:0038038514557912. 5. Lin V, McCabe P, Bensoussan A, Myers S, Cohen M, Hill S, et al. 2009. The practice and regulatory requirements of naturopathy and western herbal medicine in Australia Risk Man Heal Pol 2:21. 6. Foundation House 2015. Available from: http://www. foundationhouse.org.au 7. Adams J. 2004. Traditional medicine within the Tibetan healthcare system. Aust J Med Herb 16(4):111-4. 8. Singer J, Adams J. 2011. The Place of Complementary Therapies in an Integrated Model of Refugee Health Care: Counsellors’ and Refugee Clients’ Perspectives. J Refugee Stud 24:351-75. 9. Singer J, Adams J. 2-13. An Exploratory Study of the Health Service Managers’ Role in Providing Effective Integrative Health Care Eur J Integ Med 5(27-35). 10. Singer J, Adams J. 2014. Integrating Complementary and Alternative Medicine into Mainstream Healthcare Services: The perspectives of health service managers BMC CAM 14(167-178).

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Reviews of articles on medicinal herbs Jodie Tester These abstracts are brief summaries of articles which have appeared in recent issues of herbal medicine journals, some of which may be held in the NHAA library.

Thuja occidentalis in a rat model of polycystic ovary syndrome Akkol EK, Ilhan M, Demirel MA, Keles H, Tumen I, Suntar I. 2015. Thuja occidentalis L. and its active compound, α-thujone: Promising effects in the treatment of polycystic ovary syndrome without inducing osteoporosis. J Ethnopharmaol 168: 25-30.

Thuja occidentalis (thuja), of the Cupressaceae family, has traditionally been used for the treatment of various gynaecological complaints in both humans and animals. Previous research has demonstrated antibacterial, antiviral, anti-inflammatory, antispasmodic, antioxidant, and anti-diabetic activities of thuja, whilst phytochemical studies have identified key chemical constituents as terpenoids, steroids, flavonoids, and polysaccharides. In the essential oil of T. occidentalis, thujone has been reported to be the major therapeutically active constituent. The aim of the present study was to investigate the possible activity potential of both T. occidentalis essential oil and α-thujone, in a rat model of polycystic ovary syndrome (PCOS). The study involved 24 female rats with letrozoleinduced PCOS. Letrozole is a non-steroidal aromatase inhibitor that blocks the synthesis of oestrogen from testosterone and induces PCOS in female rats. After PCOS induction, the rats were divided randomly and equally into four groups: control group, reference group {buserelin acetate [a gonadotropin-releasing hormone (GnRH) agonist] 20mg/kg body weight (BW)/day}, treatment group I (T. occidentalis oil 500mg/kg BW/ day), and treatment group II (α-thujone 5mg/kg BW/day) for 45 days of treatment. Rats were sacrificed 24h after the last treatment with blood samples used to analyse circulating levels of serum gonadotropins, steroids, lipids, leptin, glucose and antioxidant activity, and histological examination was undertaken of ovary and bone tissue. After PCOS induction all groups were reported to demonstrate irregular reproductive cycles. After the end of 45 days treatment both active treatment groups and the reference group exhibited regular oestrous cycles, whilst the control group remained irregular. After the 45 days high levels of follicle-stimulating hormone (FSH) and luteinising hormone (LH) were detected in the control group, but these hormones were in the normal range in the treatment and reference groups. Significantly lower levels of testosterone and significantly higher levels of oestradiol and progesterone were observed in the reference and both treatment groups compared to control. © NHAA 2015

Plasma total cholesterol, total glyceride, low density lipoprotein cholesterol (LDL-C), leptin, and glucose levels were significantly decreased after treatment with T. occidentalis, α-thujone, or reference buserelin acetate, when compared to the control group. Active treatments also significantly increased high density lipoprotein cholesterol (HDL-C) levels. Antioxidant activity was variable amongst treatment groups. Serum malondialdehyde (MDA) levels significantly decreased in the T. occidentalis and α-thujone groups, and superoxide dismutase (SOD) levels significantly increased in the α-thujone group when compared to control. There were no other significant effects on antioxidant parameters among groups. Histopathological examination revealed that the corpus luteum, regressed corpus luteum, and follicular cysts were more severe in the control group compared to the T. occidentalis, α-thujone, or reference groups, which authors suggested was representative of good healing activity of the active treatments. Finally, the integrity of the osteogenic tissue was protected in the T. occidentalis and α-thujone groups. Administration of buserelin acetate resulted in increased bone resorption. Previous studies have found similar results, with prolonged administration of GnRH agonists associated with increased bone resorption and induced osteoporosis. The study provides interesting and positive results for a potential role of both T. occidentalis and α-thujone. Whilst authors concluded the results supported the use of T. occidentalis essential oil and its active componenent, α-thujone, for the treatment of PCOS without inducing osteoporosis, more clinical research is required to develop an understanding of the effects and safety in a human population with polycystic ovary syndrome, and to ascertain optimal dosage requirements for treatment.

Topical bitter apple extract in painful diabetic neuropathy Heydari M, Homayouni K, Hashempur MH, Shams M. 2015. Topical Citrullus colocynthis (bitter apple) extract oil in painful diabetic neuropathy: A double-blind randomised placebo-controlled trial. J Diabetes. In press doi: 10.1111/1753-0407.12342.

Diabetic neuropathy is one of the most common complications of diabetes mellitus (DM), affecting over 50% of both type 1 DM and type 2 DM patients. Of those with diabetic neuropathy, it is estimated that between 40-50% will experience painful diabetic polyneuropathy 146

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(PDPN). PDPN can be a significant strain on an individual’s quality of life (QOL), with the burden arising as a result of physical pain, sleep disturbance, limitation of activity, polypharmacy, and depression. Glycemic control is currently the only option for the prevention of diabetic neuropathy, with therapeutic options for PDPN limited to symptomatic treatments, including antidepressants, anticonvulsants, and topical agents for pain management. Bitter apple, Citrullus colocynthis L., is a plant found in Africa and Asia that has been used for a variety of medicinal purposes, including pain relief and as a topical treatment on the feet of diabetic patients. The aim of the present study was to examine the efficacy and safety of a topical formulation of C. colocynthis in patients with PDPN in a randomized, double-blind placebo-controlled clinical trial. Study subjects were recruited from patients attending diabetic clinics associated with an Iranian university. Patients with a clinical diagnosis of PDPN of the lower extremities for a period of three months or more were eligible for inclusion. Subjects were required to have controlled diabetes in the three months prior and be over 18 years age. Exclusion criteria included lower extremity pain caused by other diseases, history of allergic dermatitis, diabetic foot ulcers, and current use of other medications for diabetic neuropathy. Citrullus colocynthis was bought from a local market in Iran, with the fruit ground and decocted in water before being boiled in an oily vehicle (sesame oil) to create the topical formulation. Sesame oil was used as the placebo control. Patients were required to apply 2mL of the bitter apple oil formulation or sesame oil control twice daily for three months to the plantar and dorsal surface of affected feet. Patients were evaluated before and after three months of treatment, with assessment including a neuropathic pain scale, a QOL assessment with scores in physical, psychological, social and environmental domains, and nerve conduction studies of lower extremities. Of the 73 patients assessed for eligibility, 60 were recruited and randomized for treatment on a 1:1 basis. At the completion of the study, results were available for 28 patients in the C. colocynthis group and 27 for the placebo group. Baseline characteristics for the groups were similar except for a significant difference in the prevalence of risk factors for neuropathy, with the C. colocynthis group having more risk factors. After three months of treatment, a significant decrease in subjective neuropathic pain score was observed in both groups, but the mean change in score was significantly greater in the C. colocynthis arm. Mean changes in nerve conduction velocity of the tibial nerve, distal latency of the superficial peroneal nerve and sural nerve, and sensory amplitude of the sural nerve were significantly higher in the C. colocynthis arm than placebo, favouring treatment. No significant differences were observed 147

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in the other nerve conduction studies. In the QOL assessment, a significant improvement in the physical domain was observed for the treatment group, with no significant differences in the other domains. Treatments were generally well tolerated, with one patient from the C. colocynthis experiencing what was considered to be a local allergic reaction. A number of complaints from both study arms were made about the oily formulation. The study presents preliminary support for a potential role in decreasing pain in patients with PDPN, and improvement in some areas of QOL. The study is strengthened by its objective evaluation of nerve function through nerve conduction studies in addition to the subjective pain and QOL scores. Whilst this is the first study evaulating bitter apple as a treatment for PDPN, previous studies have identified analgesic and anesthetic actions of C. colocynthis. The precise mechanism for these effects is unknown. Authors note that the control and vehicle for the C. colocynthis extract was not inert, with sesame having been demonstrated to exhibit anesthetic and anti-oxidant activity. The combination of both ingredients may have contributed to its significant effect and evaluation of bitter apple without an active vehicle may further support a potential role in management of PDPN.

Cinnamon compared to Ibuprofen in Primary Dysmenorrhoea Jaafarpour M, Hatefi M, Khani A, Khajavikhan J. 2015. Comparative effect of cinnamon and Ibuprofen for treatment of primary dysmenorrhea: A randomised double-blind clinical trial. J Clin Diagn Res 9(4): 4-7.

Primary dysmenorrhea is one of the most common gynaecological complaints, affecting more than half of menstruating women at some stage in their lives. It is caused by an increase in synthesis and release of prostaglandins, particularly PGF2 from the uterine endometrium, resulting in contraction of smooth muscles in adjacent tissues leading to colicky pains, spasmodic pain in lower abdomen and lower back pain. Significant impact on quality of life can occur. Primary dysmenorrhea is also a common cause of absenteeism from work, with data from the USA associating dysmenorrhea with an annual economic loss of 600 million work hours and $US2billion. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used to relieve symptoms, but there is concern about side effects, particularly with long-term administration. Cinnamomum zeylanicum (syn. C. Verum), cinnamon, also called Ceylon cinnamon or true cinnamon, has previously demonstrated a number of different therapeutic actions including astringent, antimicrobial, antiinflammatory, antioxidant, analgesic and antispasmodic properties. With a lack of comprehensive research for cinnamon in the management of dysmenorrhoea, the authors of the present study aimed to compare the effect © NHAA 2015

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of cinnamon and Ibuprofen for treatment of primary dysmenorrhoea in a sample of Iranian female college students. The trial was randomised, double-blind and placebocontrolled, with subjects allocated to receive Ibuprofen capsule containing 400mg three times daily (TDS), Cinnamomum zeylanicum capsule containing 420mg cinnamon as dried powder TDS, or a placebo capsule containing starch TDS, for 24 hours. In total, 114 female college students were recruited for the trial, with 38 subjects in each study arm. Inclusion criteria included: being aged 18-30 years; regular menstrual cycles; moderate dysmenorrhea;, lack of chronic diseases; not having symptoms such as burning, itching or abnormal vaginal discharge; lack of pelvic inflammatory disease, tumour, or fibroma; lack of recent stressors; and within defined body mass index range of 19-26 kg/m2. Exclusion factors included: oral contraceptive pill use; medicine or plant allergy; and mild dysmenorrhea. Pain intensity and duration of pain were monitored for subjects in the first 72 hours of cycle. To determine the severity of pain a Visual Analogue Scale (VAS) was employed, and the Cox Menstrual Scale was used to determine the duration of pain. Baseline characteristics between groups were similar, with similar pain scores reported before treatment. After treatment, the mean pain severity score reported for Ibuprofen was significantly less that the placebo group from the first time interval of 1hr post treatment, and at each subsequent interval til 72hrs. For the cinnamon group, no statistically significant difference in pain severity score was observed for the first four hours compared to placebo. After the next time interval of 8hr post intervention, however, a statistically significant reduction in pain severity was observed in the cinnamon group compared to placebo that continued til the end of observation at 72hrs. Duration of pain in the Ibuprofen and cinnamon groups were reported to be significantly less than placebo at reported time intervals after intervention. The effect of cinnamon was lower than that observed with Ibuprofen. The study and the interpretation of its findings are limited by a lack of clarity around the plant and timing of interventions. The authors do not report on the part of plant used nor describe the preparation of plant material. Furthermore, it is unclear from the study when the intervention was initiated, i.e. at onset of menstruation, at onset of pain or another set time point, whether the intervention timing was standardised amongst study subjects, and whether the results were time after the initial or final dose of the intervention. Some discrepancy in tables provided also limit interpretation of the data. The study provides some evidence for the use of Cinnamomum zeylanicum in dysmenorrhoea, demonstrating that compared to placebo, cinnamon intervention significantly reduced the severity and duration © NHAA 2015

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of pain during menstruation, albeit to a lesser extent that Ibuprofen. For women looking for non-pharmaceutical management of dysmenorrhoea, cinnamon may provide some benefit. Whilst the study seems to be a reasonably well-designed trial, it is unfortunate that presentation of data and unclear definitions of the therapy limit the interpretation and ability to apply the findings more broadly. Future studies that address some of these limitations, and with greater numbers of subjects, will further understanding.

Berberis integerrima compared to sildenafil in pulmonary hypertension Mahdavi N, Joukar S, Najafipour H, Asadi-Shekaari M. 2015. The promising effect of barberry (Zereshk) extract against experimental pulmonary microvascular remodelling and hypertension: A comparison with sildenafil. Pharm Biol. In press. DOI: 10.3109/13880209.2015.1050676.

Pulmonary arterial hypertension (PAH) is described as a mean pulmonary artery pressure ≥ 25 mmHg at rest or ≥ 30 mmHg with exercise and a normal pulmonary capillary wedge pressure. PAH may be primary or idiopathic, or associated with other diseases including HIV infection, connective tissue disease, portal hypertension, and congenital heart disease. Untreated, the survival time for idiopathic PAH has been reported to be three years, with the prognosis of secondary PAH influenced by the underlying disease. Three main classes of drugs are currently used for treatment of PAH including prostanoids, enothelin-1 receptor antagonists, and phophodiesterase-type 5 (PDE5) inhibitors. While these medications can attenuate clinical symptoms and slow PAH development, they are not cures for the disease and accordingly interest remains for potential new therapies. The major chemical constituents of the fruits of Berberis integerrima (barberry), of the Berberidaceae family, include coumarin, ascorbic acid, berberine, caffeic acid, β-carotene, flavonoids, malic acid, palmatine, carbohydrates, tannin, and ursolic acid. Whilst related to another barberry species, Berberis vulgaris, comparisons between the two species report differences in chemical make-up such as higher total phenolic and anthocyanin content in the fresh fruits of B. integerrima. Traditionally used for treatment of heart conditions including hypertension and arrhythmia, pharmacological studies on barberry and its key constituent berberine have demonstrated effect on decreasing systemic hypertension. Following from this, authors conducted the present study to examine the effect of a water extract of barberry (B. intergerrima) fruit on a monocrotaline-induced PAH rat model and compare its effect with sildenafil, a PDE5 inhibitor. Seventy-two male Wistar rats were divided into nine groups as follows: the control group, the monocrotaline (M) group, the barberry (B) groups with doses of 50, 100, 148

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and 200 (mg/kg/d), the M plus barberry (MB) groups with doses of 50, 100, and 200 (mg/kg/d) barberry, and the M plus sildenafil group (30mg/kg/d). Two weeks after a single injection of monocrotaline (60 mg/kg) to induce PAH on day one of the study, barberry water extract or sildenafil were gavaged daily for two weeks. At the end of the 4th week, hemodynamic, biochemical, and histopathological parameters were assessed. After two weeks of intervention, both sildenafil and barberry at all doses significantly reduced the right ventricular systolic pressure (RSVP) compared with the M group. The effect on RSVP reduction was comparable between barberry MB100 and MB200 mg/kg and the sildenafil group. Right ventricular hypertrophy was significantly reduced in the sildenafil group and the MB100 and MB200 compared to the monocrotaline group. Histopathological parameters were only evaluated in the MB200 group, which had previously demonstrated the greatest effect in the hemodynamic parameters. Both sildenafil and MB200 intervention attenuated the monocrotaline-induced arteriole remodelling resulting in significant reduction in the medial wall thickness. The effect was significantly greater in the barberry intervention compared to sildenafil. Neither barberry nor sildenafil had any significant effect on the plasma levels of endothelin-1, glutathione peroxidase, and the malondialdehide of lung. This interesting study demonstrated a beneficial effect of a barberry water extract on a monocrotaline-induced rat model of pulmonary hypertension. Furthermore, when compared to sildenafil, a currently used therapy for PAH, barberry demonstrated equivalent or greater effect at a dose of 200mg/kg/d. Authors suggest that the effect of barberry may be attributable to a combination of its phenolic and alkaloid compounds, potentially with some effect on redox balance. The study provides some good preliminary research and evidence for further exploring the potential of barberry or its derivatives in the treatment and management of pulmonary arterial hypertension.

Effectiveness of ginger for relieving symptoms of primary dysmenorrhea Daily JW, Zhang X, Kim DS, Park S. 2015. Efficacy of ginger for alleviating the symptoms of primary dysmenorrhea: A systematic review and meta-analysis of randomised clinical trials. Pain Med. In press. DOI: 10.1111/pme.12853.

Primary dysmenorrhea is one of the most common gynecologic disorders, with a prevalence (of varying severity) of between 30-90% amongst different ethnicities with. Severe dysmenorrhea is estimated to contribute to a loss of 600 million work hours and $2 billion in lost productivity per year. Whist the cause of primary dysmenorrhea is not fully understood, it is known that increased production of prostaglandins derived from inflammatory mediators, including cyclooxygenase (COX)-2, cause excessive contractions of the uterus 149

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with associated pain and cramping. Non-steroidal antiinflammatory drugs (NSAIDs), which inhibit COX-2, are the main treatment for primary dysmenorrhea, butthey are not completely effective and have considerable adverse effects, morbidity and mortality associated with their use. Accordingly, there is interest in interventions that provide efficacy and are well tolerated. The root of Zingiber officinale (ginger) has previously demonstrated anti-inflammatory activity through inhibition of COX-2, NF-κB and 5-lipoxygenase (5-LOX). Additionally, ginger may act as an agonist of transient receptor potential cation channel subfamily V member 1 (TRPV-1), which is associated with transmission of physical and chemical stimuli, and is a target for novel pain relievers in development. With growing evidence that ginger has analgesic and antiinflammatory efficacy in humans, the current study is the first systematic review and meta-analysis of randomised clinical trials (RCTs) assessing the effectiveness of ginger for primary dysmenorrhea. In the undertaking of the systematic review, electronic databases including PubMed, EMBASE, Cochrane Library, Korean databases, Chinese medical databases and Indian medical journals were searched with key terms “ginger”, “Zingiber officinale”, “dysmenorrhea”, and “pain”. Randomised clinical trials that studied the effect of ginger on primary dysmenorrhea as a primary outcome in young women were included. Exclusion criteria included in vitro studies, studies where only an abstract was available, nonclinical trials, studies in which ginger formed part of a complex herbal mixture, and duplicate studies. Of 29 publications initially identified, seven articles were included in the review. All of the RCTs investigated the effect of ginger powder, at varying doses between 750-2000mg/day during the first 3-4 days of menstrual cycle, with each study lasting for two cycles. The age of women enrolled ranged from 13-30 years. Of the RCTs, four compared ginger powder to placebo, one RCT compared ginger powder + exercise to exercise alone, and the remaining two RCTs compared ginger to active analgesic treatments. Outcome measures in the metaanalysis included severity of pain during menstruation, using a pain visual analogue scale (PVAS) and the duration of pain. Of the RCTs in the review, five used PVAS scores, whilst two reported scores as a percentage change from baseline. Of the five using real scores, one did not include standard deviations and one used exercise as its control, leaving only three RCTs, comparing ginger to placebo control, included in the meta-analysis. When pooling the data of the three RCTs, the metaanalysis indicated that ginger is highly effective for the treatment of symptoms of primary dysmenorrhea, with significantly lower pain scores in the ginger group compared to the control across both one and two cycles. The relief from pain was also highly significant in studies © NHAA 2015

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that used analgesic as a positive control, with ginger demonstrating similar improvements to the analgesic drug treatments. Whilst the study reported ginger to be effective for treatment of primary dysmenorrhea, the results are limited by a number of factors. Firstly, the studies included had small sample sizes, ranging from 22-150 subjects. Six of the seven RCTs were reported to exhibit low to moderate risk of bias. Furthermore, authors reported an asymmetrical funnel plot was produced by the metaanalysis, indicative of publication bias. The authors note that the RCTs included did not analyse the constituents of the ginger used, nor reported whether the powders were prepared in a standardized manner, making it difficult to draw conclusions about particular constituents. Authors highlighted that as the efficacy was demonstrated with presumably different ginger preparations, the activity may thus be due to a variety of bioactive components having overlapping or synergistic effects. Accordingly, until more is known about individual constituents, highly purified ginger preparations may risk removing important bioactive compounds. This first systematic review and meta-analysis to report on the subject concluded the evidence is suggestive of effectiveness of 750-2000mg ginger powder during the

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first 3-4 days of the menstrual cycle, for relief of pain and discomfort associated with primary dysmenorrhea. More high quality studies with larger cohorts will further establish the benefit and effect of ginger treatment.

Curcumin alleviates symptoms of PMS Khayat S, Fanaei H, Kheirkhah M, Moghadam ZB, Kasaeian A, Javadimehr M. 2015. Curcumin attenuates severity of premenstrual syndrome symptoms: A randomised, double-blind, placebocontrolled trial. Complement Ther Med 23; 318-324.

Premenstrual syndrome (PMS) is one of the most common health problems affecting women during their reproductive years. Defined as recurrent mood and physical symptoms, usually in the luteal phase of the cycle, PMS has a high prevalence worldwide. Changes of prostaglandin levels and neurotransmitter levels play a major role in the pathophysiology of PMS symptoms, with prostaglandins mostly associated with physical symptoms and neurotransmitters more associated with the incidence of mood and behavioural symptoms. Whilst pharmaceutical medications, including fluoxetine and mefenamic acid, are sometimes used in the management of PMS, they are associated with side effects and often reserved for more severe cases.

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Herbal and complementary medicines are frequently used for management of many female health conditions including PMS, menopausal symptoms, and dysmenorrhoea. Curcumin, one the key curcuminoids of Curcuma longa (turmeric) of the Zingiberaceae family, has demonstrated a number of actions that may support a beneficial role in the management of PMS, particularly its anti-inflammatory and antidepressant effects. Previous studies have demonstrated curcumin reduced prostaglandin synthesis through inhibition of the cyclooxygenase-2 (COX-2) enzyme and antidepressant effects in animal models have been associated with modulation of the neurotransmitters serotonin, dopamine, and norepinephrine. Accordingly, this randomised, double-blind, placebo-controlled study was designed to evaluate the effect of curcumin on the severity of mood, behavioural and physical symptoms of PMS. The study was performed on female students residing in dormitories of a university in Tehran, Iran with data collected over 8 months. Inclusion criteria included healthy premenopausal women with regular menstrual cycles of between 21-35 days, being single, no medications, non-drinkers, non-smokers, no stressful events in the prior three months and no sensitivity to curcumin. Potential subjects completed daily questionnaires based on the PMS symptoms from the DSM-IV, for two cycles before randomisation in order to identify women with at least five symptoms of PMS. In total, 70 women were randomised to treatment of either capsules of curcumin or placebo, with 35 women in each group. Subjects were required to take their allocated intervention every 12 hours from 7 days prior to, and until 3 days after the onset of menstruation. The curcumin dosage was 100mg/12hr. Subjects completed the daily record questionnaire at their first, second and third menstrual cycles and average symptom severity after the three interventions was evaluated and compared to initial severity scores. Treatment with curcumin capsules was associated with significant reduction in the physical, behavioural and mood scores compared to before intervention, with mean scores changing from 41.4 to 18.13, 22.8 to 9.21, and 37.8 to 15.13, respectively. The placebo intervention was associated with a significant reduction in physical scores from 46.7 to 38.50, and non-significant reductions reported for the behavioural and mood scores of 24.4 to 23.14 and 34.8 to 33.85, respectively. Collectively, total PMS score was significantly reduced in the curcumin group only. No side effects were reported for either group. Despite its small size, this is a valuable study demonstrating a beneficial role of curcumin in treatment of PMS symptoms, and is the first study to report on the effect. Whilst the placebo group also achieved significant reduction in physical symptoms, it only just reached statistically significant with p value = 0.0425, compared to that of the curcumin group, p value < 0.0001. Future 151

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studies of greater sample size might provide greater insight into the differences in effects of placebo and curcumin on physical symptoms. Other areas of research that would benefit the understanding of the role of curcumin and turmeric in the treatment of PMS might include: studies of longer duration, with a breakdown of effect at each cycle to understand if benefits are experienced from the initial cycle or if a number of cycles are required for significant effect to take place; differing doses of curcumin to ascertain the optimal dose for management in PMS;, studies evaluating the effect of curcumin on neurotransmitters and inflammatory markers associated with PMS; and finally, a comparison of curcumin with Curcuma longa rhizome to assess if other constituents of turmeric apart from the curcuminoids also have a beneficial effect on symptoms of PMS.

Effect of fenugreek seed extract on sex hormones and sexual function in healthy females Rao A, Steels E, Beccaria G, Inder WJ, Vietta L. 2015. Influence of a specialised Trigonella foenum-graecum seed extract (Libifem), on testosterone, estradiol and sexual function in healthy menstruating women, a randomised placebo controlled study. Phytother Res 29: 1123-1130.

Sexual functioning involves complex and varied interactions between sex hormones such as estradiol (E2) and testosterone, environmental factors, and the autonomic nervous system. Decreased sexual functioning is associated with significant emotional and psychological distress as well as lower sexual and relationship satisfaction. Low sexual desire, or low libido, is a clinical symptom of decreased sexual function and has been reported to affect 39% of pre-menopausal women. Trigonella foenum-graecum (fenugreek) is rich in steroidal saponins that have been demonstrated to exert estrogenic effects and to increase sexual function in men. Accordingly, fenugreek is of interest for improving sexual function in women. The aim of the present study was to evaluate the effect of a T. foenum-graecum seed extract on sex hormones and sexual function in healthy menstruating women who reported low sexual drive in a randomised, double-blind clinical trial conducted at a single site in Brisbane. In total, 80 healthy menstruating women who reported low sexual desire and were in a sexual relationship were recruited for the study, and allocated in a 1:1 ratio to either active treatment (n=40) or placebo (n=40). Subjects had regular menstrual cycles, were aged between 20-49 years, with no diagnosed chronic disease, body mass index