CLIMACTERIC 2014;17:635–644

A critical review of traditional Chinese medicine use amongst women with menopausal symptoms W. Peng, D. W. Sibbritt, L. Hickman, X. Kong*, L. Yang and J. Adams Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia; *Department of Treatise on Febrile Diseases, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China Key words: TRADITIONAL CHINESE MEDICINE, MENOPAUSE, WOMEN, SYNDROME DIFFERENTIATION, REVIEW

ABSTRACT Objectives To provide the first critical review of traditional Chinese medicine (TCM) use amongst symptomatic menopausal women, drawing upon work examining the perspectives of both TCM users and TCM practitioners. Methods A search was conducted in three English-language databases (MEDLINE, CINAHL and AMED) and three Chinese-language databases (CNKI, VIP and CBM Disc) for 2002–2013 international peer-reviewed articles reporting empirical findings of TCM use in menopause. Results A total of 25 journal articles reporting 22 studies were identified as meeting the review inclusion criteria. Chinese herbal medicine appears to be the most common therapy amongst symptomatic menopausal women, and vasomotor symptoms and emotional changes are the most frequent symptoms for which TCM is sought. However, evidence regarding the prevalence of TCM use and users’ profile in menopause is limited. Existing studies are of varied methodological quality, often reporting low response rate, extensive recall bias and a lack of syndrome differentiation. Conclusions This review provides insights for practitioners and health policy-makers regarding TCM care to symptomatic menopausal women. More nationally representative studies are required to rigorously examine TCM use for the management of menopausal symptoms. Syndrome differentiation of menopausal women is an area which also warrants further attention.

INTRODUCTION Menopause is a natural process of women that generally begins between the ages of 40 and 55 years resulting from ovarian failure1,2 and is described in three stages: premenopause, perimenopause and postmenopause3. There are an estimated 25 million women passing through menopause every year4 with approximately one-third of these women suffering from menopausal symptoms for up to 5 years or longer5. In the past decade, hormone replacement therapy (HRT), considered as the most effective conventional treatment for women with menopausal symptoms5,6, has experienced a continuing decline in use due to concerns around long-term safety and potential side-effects7,8. Correspondingly, a substantial

number of health-care providers and menopausal women have shown growing interest in traditional, complementary and alternative medicine (TCAM) for the management of menopausal symptoms9,10. Traditional Chinese medicine (TCM), with the experience of more than 2000 years of clinical practice, is a core modality of TCAM used in most Asian and Western countries11, including Chinese herbal medicine (CHM), acupuncture, cupping, mind–body therapy, and dietary therapy12. Women are more likely to use TCM than men, and women aged 45–54 years have the highest rate of TCM utilization13. TCM presents a clear understanding in the field of menopause and relevant treatment. In particular, TCM practitioners in both China and the West deem kidney yin deficiency to be the primary

Correspondence: Professor J. Adams, Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney, Level 7, Building 10, 235-253 Jones St, Broadway, NSW 2007, Australia; Email address: [email protected] REVIEW © 2014 International Menopause Society DOI: 10.3109/13697137.2014.904850

Received 28-01-2014 Revised 07-03-2014 Accepted 12-03-2014

Traditional Chinese medicine use for menopause cause of menopausal symptoms14. However, there remain doubts about the efficacy of TCM in managing menopausal symptoms, although promising results in clinical practice have emerged15. Randomized, clinical trials (RCTs) have found positive findings concerning the effectiveness of CHM for symptomatic menopausal women with mild side-effects16–18, but these studies appear methodologically weak19 and the urgent necessity to conduct more large-sampled RCTs in this area has been identified20,21. Research has revealed both positive and negative findings with regard to the efficacy of acupuncture for hot flushes (an area attracting the most attention amongst the majority of clinical studies on acupuncture for symptomatic menopausal women)22–25. Such diverse findings of acupuncture use may be due to the challenges of achieving adequate blinding in acupuncture trials or the proficiency of the acupuncturists on which the therapeutic effect of acupuncture in practice depends26. As a complement to the emerging efficacy evidence base for TCM use in menopause, there is a need to overview and critically appraise the public health and health services research around this topic27. In addition, a recent critical review found a substantial level of the prevalence of complementary and alternative medicine use among women with menopause28. However, the use of TCM is effectively unknown. Therefore, a critical review of recent international literature regarding TCM use is warranted, examining the perspectives of both women with menopausal symptoms and TCM practitioners and reporting on such issues as the prevalence of TCM use, motivations and perceptions of TCM users, and the syndrome patterning amongst menopausal women. In direct response, this review presents the first synopsis and evaluation of findings from studies on TCM use amongst symptomatic menopausal women reported in international empirical literature (both in English and Chinese literature) with a view to providing significant insights for health-care providers and policy-makers in their efforts to ensure effective and safe health care for menopausal women. More specifically, the aims of this review are to: (1) identify the relevant studies focused on TCM use amongst symptomatic menopausal women, drawing upon data collected from either TCM users or TCM practitioners; (2) evaluate the quality of these relevant studies; (3) demonstrate the key findings from the literature via theme-based analysis; and (4) highlight areas for future research on this topic.

METHOD

Peng et al. CBM Disc (Chinese Biomedical Disc). The English-language databases were MEDLINE (Medical Literature Analysis and Retrieval System Online), CINAHL (Cumulative Index for Nursing and Allied Health Literature) and AMED (Allied and Complementary Medicine Database). English-language and Chinese-language databases were retrieved with a similar search strategy using the following key words: (‘menopause’ OR ‘menopausal symptom’ OR ‘climacteric’ OR ‘hot flash’ OR ‘hot flush’ OR ‘night sweat’ OR ‘vasomotor symptom’ OR ‘pre-menopause’ OR ‘peri-menopause’ OR ‘post-menopause’) AND (‘Chinese medicine’ OR ’TCM’ OR ‘acupuncture’ OR ‘massage’ OR ‘Tuina’ OR ’Qi Gong’ OR ‘Tai Chi’ OR ‘herb’ OR ‘herbal medicine’); (‘更年期’ 或 ‘⚜亅乷期交合征’ 或 ‘潮䂕’ 或 ‘盗汗’ 或 ‘亅乷前期’ 或 ‘亅乷后期’) AND (‘中医’ 或 ‘中北’ 或 ‘搰刺’ 或 ‘搰灸’ 或 ‘俛搰’ 或 ‘䓝搰’ 或 ‘推拿’ 或 ‘按摩’ 或 ‘太㜩’ 或 ‘气功’ 或 ‘北物’). An additional search for relevant studies was undertaken using Google Scholar with the same key words, and finally, bibliographies of publications already identified were also searched for relevant publications.

Selection criteria Articles retrieved from databases were imported into EndNote X5 with duplicated results removed. This search was limited to the peer-viewed literature with an abstract in order to identify articles reporting original empirical study findings. The authors assessed relevant articles as meeting inclusion criteria if the manuscript reported aspects of TCM use from the perspective of either menopausal women or TCM practitioners, or provided general information of menopausal women where TCM use was clearly reported. It is worth noting that publications on different preparation forms of CHM for treating menopausal symptoms were all included, such as powder, tablet, capsule and liquid. Papers without systematic design or data collection/ procedure (editorials, commentaries, and case reports) as well as those identified as TCM clinical trials were all excluded from this review, alongside articles focusing on botanical products or non-Chinese herbs and those reporting on combined interventions of CHM with non-TCM treatments, such as vitamins, minerals, and herbal supplements. If the initial reading of the abstract did not provide sufficient information to make an informed decision, the authors consulted the full text to identify further details to inform their inclusion/ exclusion decision-making.

Search strategies Quality appraisal Six electronic databases (three Chinese-language databases and three English-language databases) were searched for articles on TCM use amongst symptomatic menopausal women published from 2002 to 2013. The Chinese-language databases were CNKI (China National Knowledge infrastructure), VIP (China Science and Technology Journal database) and

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There is no agreed criterion for assessing the quality of TCM-related studies. Therefore, the authors modified a quality scoring system (Table 1) previously used for assessing the studies on prevalence of TCAM use29,30, to systematically evaluate the quality appraisal of the publications

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Traditional Chinese medicine use for menopause

Peng et al.

Table 1 Description of quality scoring system for the traditional Chinese medicine (TCM) surveys reviewed (Sources: Adapted from Fejer et al.31 and Adams et al.32) Points awarded*

Dimensions of quality assessment Methodology A. Representative sampling strategy B. Sample size ⬎ 500 C. Response rate ⬎ 75% D. Low recall bias (prospective data collection or retrospective data collection within past 12 months) Reporting of participants’ characteristics E. Status of menopause F. Age G. Ethnicity H. Indicator of socioeconomic status (e.g. income, education) Reporting of TCM use I. Definition of TCM or modalities provided to participants J. Participants can name TCM modalities used or TCM practitioners inquire about the TCM modalities used K. Use of TCM syndromes/modalities assessed

identified from the review. Two authors assigned scores to the publications separately. Table 2 shows the detailed quality score of each eligible article.

Search outcomes The initial search identified 2066 articles in Chinese and 781 articles in English regarding TCM use for women with menopausal symptoms. A total of 25 journal articles representing 22 empirical studies (three studies were reported by more than one article) met the inclusion criteria, including 14 English articles31,36,38–40,42,45,47–50,52,54,55 and 11 Chinese articles32–35,37,41,43,44,46,51,53. The remaining articles not included in our review mainly reported the results of TCM clinical trials. Note that all Chinese-language literature included in this review is focused upon TCM use in menopause in China. A total of 18 articles (11 published in English and seven published in Chinese) were assessed via the scoring system for quality appraisal. The remaining seven articles reported findings from studies focusing upon more general health-care utilization for menopause rather than exclusively upon TCM use for women with menopausal symptoms and, as such, were excluded from the quality evaluation. General information from each article was re-processed and organized into a pre-established review table (Table 3).

1 1 1 1

1 1 1 1

1 1

1

*, Maximum score ⫽ 11 points

Table 2 Quality score of studies on traditional Chinese medicine use amongst symptomatic menopausal women Dimensions of quality assessment

First author/year

Methodology

Chang, 2004 Chiou, 2006 Liu, 2006 Gold, 2007 Rampp, 2008 Alraek, 2009 Zheng, 2009 Yang, 2009 Guo, 2009 Xin, 2009 Chen, 2010 Du, 2010 Scheid, 2010 Cardini, 2010 Chen, 2011 Liu, 2012 van der Sluijs, 2013 Buhling, 2013

1 2 2 3 0 1 2 2 2 3 2 2 1 2 2 2 3 2

(A) (A, D) (A, D) (A, B, D) (C) (B, D) (A, B) (A, D) (A, B, D) (A, B) (A, C) (D) (A, B) (A, B) (A, D) (A, B, D) (B, D)

Reporting of participants’ characteristics 1 3 4 4 2 1 1 2 1 2 1 2 4 3 2 4 3 2

(F) (E, F, H) (E, F, G, H) (E, F, G, H) (F, G) (F) (F) (F, G) (F) (E, F) (F) (F, H) (E, F, G, H) (E, F, H) (E, F) (E, F, G, H) (E, F, H) (F, H)

Reporting of TCM use 1 0 1 2 1 1 1 2 2 1 2 2 1 2 2 1 2 1

(K) (K) (I, K) (K) (I) (K) (I, K) (J, K) (K) (I, K) (J, K) (K) (I, K) (I, K) (K) (I, K) (K)

Total score 3 5 7 9 3 3 4 6 5 6 5 6 6 7 6 7 8 5

*, Tsao et al., 2002; Shen et al., 2004; Tian et al., 2004; Xia et al., 2005; Wu et al., 2011; Yang et al., 2012; and Lim et al., 2012 do not focus solely upon TCM use for women with menopausal symptoms and, as such, the criterion ‘reporting of TCM use’ does not apply to these seven articles and they were not accessed via the quality scoring system above

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637

638 Rampp T39 Alraek T40

Chinese

Chinese

Chinese

English

Chinese

English

English

English

Chinese

English

Chinese

Chinese

2004/China

2004/China

2005/China

2006/Taiwan

2006/China

2007/USA

2008/China & Germany 2009/Norway

2009/China

2009/Taiwan

2009/China

2009/China

Syndrome differentiation and symptoms of TCM use TCM syndrome differentiation and the disease locations

Guo Y43 Xin Y44

Yang Y42

Syndrome differentiation and symptoms of TCM use Prevalence and symptoms of TCM use

Zheng J41

Acupuncture treatment for postmenopausal hot flushes study

Syndrome differentiation and symptoms of TCM use Symptoms of TCM use

Symptoms of TCM use and demographics of TCM users

Gold EB38 SWAN

TCM syndrome differentiation

Liu Y37

Xia J35 Chiou Y36

Syndrome differentiation and symptoms of TCM use Prevalence and perceptions of TCM use Prevalence and perceptions of TCM use Demographics of, TCM uses

Tian F34

Shen C33

Syndrome differentiation and symptoms of TCM use

Study on the applied basic of syndrome Study on the applied basic of syndrome

Chang H32

Chinese

2004/China

Research focus Perceptions of TCM use

Name of project

Tsao L31

English

2002/Taiwan

First authorreference

Language of article

General information of the studies included

Year/country

Table 3

TCM syndrome differentiation Finished herbal products, acupuncture and manipulative therapies TCM syndrome differentiation TCM syndrome differentiation

TCM syndrome differentiation Acupuncture

TCM syndrome differentiation acupuncture

TCM practitioners and Chinese herbs TCM practitioners and Chinese herbs TCM

TCM syndrome differentiation

TCM formulae and herbs TCM syndrome differentiation

TCM modality

QS/peri- and postmenopause

QS

NHIS

QS

Written statement/ postmenopause

Cross-sectional survey/ pre- and early perimenopause QS

Face-to-face interviews with structured questionnaires QS

QS

QS

QS

Face-to-face audio-taped interviews/perimenopause QS

Method/type of menopause

1582

270

19 379

634

127

70

2118

250

182

4489

4489

400

400

30

3

2, 3

1, 2

2, 3

2

2, 3

1, 2

3

1

1, 2

1, 2

2, 3

2, 3

2

Theme*

(Continued)

Sample size

Traditional Chinese medicine use for menopause Peng et al.

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English

English

van der Sluijs C54 Buhling KJ55

Liu H53

Chinese

TCM syndrome differentiation TCM herbalists and acupuncturists TCM formulae and herbs; and acupuncture

TCM syndrome differentiation TCM syndrome differentiation and formulae TCM practitioners, formulae and herbs TCM formulae and herbs TCM TCM formulae and herbs TCM

TCM therapies, formulae and herbs

TCM modality

QS

Audio-taped interviews/ peri- and postmenopause QS/peri- and postmenopause QS

NHIS/pre- and perimenopause NHIS QS

QS

Postal questionnaire/periand postmenopause

Records from medical charts and a computerized database QS

Method/type of menopause

*, Themes: 1 ⫽ The prevalence of TCM use and user profile; 2 ⫽ motivation for and perception of TCM use; 3 ⫽ TCM syndrome differentiation SWAN, Study of Women’s Health Across the Nation; QS, questionnaire survey; NHIS, National Health insurance survey

2013/Australia & Italy 2013/Germany

Perceptions and symptoms of TCM use TCM syndrome differentiation and the disease locations Consultation with TCM practitioners Prevalence of TCM use

Lim HS52

2012/ Singapore 2012/China

English

English Chinese

2011/Taiwan 2012/China Prevalence of TCM use Prevalence of TCM use

English

2011/Taiwan Wu C50 Yang L51

English

2010/Italy

Scheid V47

Symptoms of TCM use

English

2010/England

TCM syndrome differentiation and the disease locations Syndrome differentiation of TCM use

Du C46

Chen H49

Chinese

2010/China

TCM use

Research focus

Chen L45

Name of project

Prevalence of TCM use

English

2010/Taiwan

First authorreference

Cardini F48

Language of article

(Continued)

Year/country

Table 3

1893

2402

279

14

99 763 500

54 456

1203

319

98

3432

Sample size

1

1, 2

3

2

1 1

1, 2

1, 2

1, 3

3

1

Theme*

Traditional Chinese medicine use for menopause Peng et al.

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Traditional Chinese medicine use for menopause

RESULTS An integrative review method was employed to extract and summarize the findings of the final 25 journal articles included in the review30,56. To fully understand the issues regarding the use of TCM, relevant data were further categorized by target group researched (either TCM users or TCM practitioners) and then grouped into three key themes – the prevalence of TCM use and user profile, motivation for and perception of TCM use, and TCM syndrome differentiation.

Patient/user-focused data: the prevalence of TCM use and user profile There were 12 studies (13 articles) which met the review inclusion criteria focused upon this theme in the quality appraisal, including nine studies with large sample sizes (n ⬎ 500) and three studies with small sample sizes (n ⬍ 500). Only two articles of studies with large sample sizes are written in Chinese. The large-study samples range from 500 to 99 763 menopausal women. In contrast, the small-sampled studies have an average sample size of 210 menopausal women. There are seven articles from six studies which report the prevalence of TCM use amongst women with menopausal symptoms34,35,42,48,50,51,55, including three articles in Chinese and four in English. All of these six studies had large sample sizes (n ⬎ 500), and reported prevalence rates ranging from 4% to 64.9% (mean 33.4%; median 37%). A large national representative survey in Taiwan with a sample of approximate 100 000 menopausal women showed an obvious increasing tendency of the use of TCM over the period 2000 to 200450. Despite limitations in the number of relevant research articles, as well as the challenges in comparing across studies with variations in measurement of TCM and menopausal status, TCM is chosen by no less than 37% of women for the management of menopausal symptoms in four out of seven articles. The therapies commonly used by symptomatic menopausal women in the studies focusing on TCM use include: Chinese herbal formulae or single Chinese herbs34,35,42,45,47–49,55; acupuncture38,40,42,48,55; massage42; and Tai Chi38. Chinese herbal medicine is overwhelmingly the most popular TCM modality used for the management of menopausal symptoms. Findings from one acupuncture study in Norway40 and one survey in Italy48 identified TCM as one of the most effective treatments for relieving menopausal symptoms as self-reported by the women studied. Further, a study in Taiwan revealed that acupuncture and massage were both popular alternatives to using CHM amongst symptomatic menopausal women42. Consistent with the findings of users’ choice of TCM formulae and herbs more generally, Jia-wei-xiao-yao-san42,45 was reported as the most commonly prescribed Chinese herbal formula for women with menopausal symptoms, followed by Qi-ju-di-huang-wan42 and Dan-zhi-xiao-yao-san49. Frequently used Chinese herbs, Dan Shen, Suan Zaoren, and Yi Mucao42,45,49, were associated with the function of blood-activating and qi-moving. These findings are in line

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Peng et al. with the TCM theory that menopausal symptoms are primarily caused by the imbalance of yin and yang and disharmony of qi and blood57. Most of the articles identified in this review were from studies carried out in China and Taiwan (11 in China and six in Taiwan), while the remaining studies were undertaken in the United States, Germany, Norway, England, Italy and Singapore. The typical characteristics of symptomatic menopausal women using TCM practices are only reported in two articles, these being: having somatic symptoms36,38 and little family support for the use of HRT36.

Patient/user-focused data: motivation for and perception of TCM use There are 13 studies (15 articles) focusing upon motivations for and perception of TCM use which met the inclusion criteria of this review. Six studies with large sample sizes (n ⬎ 500), including four English-language articles and three Chinese-language articles, have an average size of 12 567 menopausal women, while the small sample sizes (n ⬍ 500) of seven studies, including four English-language articles and four Chinese-language articles, range from 14 to 400 menopausal women. Findings from the studies identify women who chose TCM to treat menopausal symptoms as commonly experiencing vasomotor symptoms (hot flushes and night sweats)32,33,39,40,42,43,49,52, and emotional changes (depression, anxiety and irritability)32,33,40,43,52. These two sets of symptoms are thus regarded as the most relevant complaints, followed by dryness of mouth/eyes32,33,39,43, sleeplessness32,33,40,43, and headache32,33,38,40. TCM was regarded as a ‘supplementary method’ for some Chinese Singaporean menopausal women when managing abnormal menstrual bleeding52. It is noteworthy that dryness of mouth/eyes is only documented as a common menopausal symptom amongst Chinese women who use TCM services. There are several motivations for and perceptions of TCM use amongst symptomatic menopausal women. An indepth qualitative study conducted in Taiwan showed that many symptomatic menopausal women considered TCM safer than biomedicine with no associated harm over long-term use due to its natural property31. The main reasons identified for menopausal women’s preference for TCM use are: to relieve discomforts, including musculoskeletal diseases or non-specific symptoms31,42,52, and to strength the immune system52. Also, the majority of menopausal women who use TCM appear more likely to explain menopause as a ‘natural phenomenon’ when compared to non-TCM users46,52. The most frequently self-reported reason provided by women who reject TCM use during menopausal transition is experiencing mild menopausal symptoms which are not perceived to require treatment34,35. A lack of evidence about TCM effectiveness is another reason given by menopausal women for not using or for relinquishing TCM treatment52. Research evidence reveals that the low prevalence of consultation with TCM practitioners by menopausal women is

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Traditional Chinese medicine use for menopause inconsistent with these women’s perception of effectiveness of TCM therapies, and their high demand for self-prescribed or doctor-led TCM use. For example, although TCM herbalists and acupuncturists were perceived as the most effective practitioners amongst Italian menopausal women, the rates of visits to these two TCM professions by these women were less than 15%48,54. In addition, one study in China showed that up to 79% of women with menopausal symptoms identified a need to obtain knowledge about menopausal care from either conventional or TCM practitioners41. A Taiwan study reported that only 0.5% of women experiencing menopause visited TCM practitioners, even though more than 64% of women with menopause utilized TCM services42. It is interesting to note that symptomatic menopausal women in China were more likely to seek help from TCM practitioners compared to gynecologists, and the majority of women in China participating in the different studies included in this review preferred to use Chinese medicines rather than HRT for management of menopausal symptoms34,35.

Practitioner-focused data: TCM syndrome differentiation Of the nine studies (ten articles) focusing on syndrome differentiation of TCM use and included in the quality appraisal, two studies draw upon large sample sizes (n ⬎ 500) and seven studies draw upon small sample sizes (n ⬍ 500). Both of the two large-sampled studies are conducted in China with samples of 634 and 1582 menopausal women, respectively. Meanwhile, two studies have a sample size of less than 100 and the remaining three studies present findings from studies with samples between 250 and 400 menopausal women. TCM practice depends on the comprehensive diagnosis of clinical information known as syndrome differentiation, which is beneficial to accurate stratification for effective TCM use36. Syndrome differentiation is a diagnostic tool undertaken by the TCM practitioner58. There are eight articles in Chinese and two articles in English relevant to the types of TCM syndromes in the diagnosis of menopause. The most frequently mentioned TCM pattern of menopausal women is liver-kidney yin deficiency syndrome (a definition from WHO international standard terminologies on traditional medicine in the Western Pacific region59: a pattern attributed to insufficiency of yin fluid of the liver and the kidney with harassment of endogenous heat)32,33,43,44,46,53, followed by kidney yin deficiency syndrome (a pattern attributed to deficiency of yin to nourish the kidney and leading to deficiency-fire or deficiency-heat)41,43,44,46,53, liver qi depression syndrome (a pattern attributed to stagnation of qi in the liver resulting from impairment of free coursing)37,43,44,46,53, kidney yang deficiency syndrome (a pattern arising when declined kidney yang fails to warm the body)32,33,46, and syndrome of dual deficiency of kidney yin and yang (a pattern attributed to deficiency of both kidney yin and kidney yang)43,44,53. Consistent with these syndromes, the visceral locations of menopause are mostly related to the kidney, liver, spleen and heart44,46,53.

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Peng et al. The literature under review appears to show that menopausal syndromes differ amongst women with different ethnic backgrounds. One study carried out in Germany and China simultaneously reported that more than half of the symptomatic German menopausal women suffered from kidney yang deficiency syndrome, whereas the most frequent pattern of Chinese women with menopausal symptoms was kidney yin deficiency syndrome39. Another study demonstrated the inconsistency of TCM syndromes diagnosed for symptomatic postmenopausal women in London with the patterns documented in Chinese TCM textbooks47. In short, these two studies indicate that the syndrome of kidney yin deficiency, which is generally regarded as the most common syndrome of menopausal women in TCM14, is not the main pattern observed in German and British menopausal women. Additionally, two studies carried out in China pointed out that the syndrome of liver qi depression was more commonly diagnosed during the perimenopausal period, while the syndrome of kidney yin deficiency was more frequently diagnosed during the postmenopausal period44,53.

Appraisal outcomes As the quality scores indicate, the studies focusing on TCM use for menopausal symptoms are of variable methodological quality (Table 2). A total of ten out of 18 articles reviewed obtained more than half of the maximum possible score in the quality appraisal system employed, and four of these high-scoring papers were written in Chinese. Six out of seven studies retrieved from Chinese databases utilized a representative sample, only one small-sampled study reported a strategy to maximize response rate. Only three studies focused on the menopausal status of the TCM users examined. Also, only two studies identified the ethnic groups of participants. In comparison, non-Chinese studies were generally of better quality. However, three out of the 11 studies published in English reported no or only one core design feature, including sampling strategy, sample size, response rate or recall bias. It is worth noting that most of the non-Chinese studies lacked consideration of TCM pattern diagnosis, and no study allowed participants to specifically name the TCM modalities used.

DISCUSSION Unlike the focus on efficacy of TCM for menopause from previous literature reviews24,25,60–62, this paper provides the first critical review of the evidence base regarding TCM use amongst women with menopausal symptoms from the perspectives of both TCM users and TCM practitioners reporting the prevalence, motivation, perceptions and TCM syndrome differentiation. Our review shows that the majority of empirical studies on this topic over recent years have been published since 2008 (17 out of 25 articles identified). There is little information on the prevalence of TCM use and profile of TCM users amongst symptomatic menopausal

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Traditional Chinese medicine use for menopause women. Vasomotor symptoms and emotional changes are the most frequent menopausal symptom groups for which TCM is utilized, and climacteric women were more likely to use CHM for the management of associated symptoms. Moreover, the common TCM syndromes of symptomatic menopausal women are liver–kidney yin deficiency syndrome, followed by kidney yin deficiency syndrome and liver qi depression syndrome in clinical diagnosis. The syndromes diagnosed are different when comparing results from studies of menopause women in China to the findings from similar studies in other countries. The existing studies investigating TCM use amongst symptomatic menopausal women provide substantial information. However, it remains difficult to make generalizations from the studies reviewed due to variations in the research methodology employed. There is a lack of utilization of TCM syndrome differentiation in English-language articles, and insufficient data on the prevalence of TCM use as well as users’ characteristics in both Chinese- and English-language articles. The findings identified in this review suggest some directions for further research of TCM use amongst women with menopausal symptoms. First, opportunities remain for large, nationally representative studies to identify the prevalence rate of TCM use, users’ profile and associated factors because of the poorly documented research on this topic. Given the co-existence of limited evidence regarding the prevalence rate of TCM use by symptomatic menopausal women and the low visiting rates to TCM practitioners for the management of menopausal symptoms, together with women’s reported strong desire to obtain knowledge on menopause from their health-care providers and high demand for TCM service use, it is essential that health-care providers are fully aware and communicate effectively regarding potential TCM use. Unexpected side-effects caused by the unknown ingredients of TCM herbal products or interactions with conventional medication can be prevented if health-care providers enquire about TCM use with patients in routine medicine history-taking11,14,63. Indeed, practitioner–patient communication is conducive to ensuring safe, effective treatment (both TCM and conventional medicine) for menopausal symptom management64. Second, kidney deficiency is generally regarded from within TCM practitioner ranks as the root of menopausal symptoms for women, including the decline in kidney yin or yang, or the combination of both65. Nevertheless, the findings from our review are inconsistent with this perception, as liver–kidney yin deficiency syndrome is found to be the most common syndrome of menopausal women during pattern diagnosis.

Peng et al. This finding is not surprising given that one of the most common self-reported symptoms of menopausal women appears to be emotional changes, which are often interpreted in relation to liver qi stagnation amongst TCM practitioners59. Also, Jia-wei-xiao-yao-san, the most frequently used TCM formula for women to alleviate menopausal symptoms, has been used for the treatment of mental disorders for centuries in China with the mechanism of soothing the liver qi66. More research is required to confirm the typical TCM syndrome amongst symptomatic menopausal women between kidney deficiency syndrome and liver–kidney yin deficiency syndrome. Each woman will experience menopause in her own unique way2. In TCM, syndrome differentiation is characterized by personalized diagnosis, and treatment is primarily based on the syndromes67. TCM syndromes could be considered as the generalization of women’s conditions at a certain status in menopause68. To date, limited, empirically based information is available regarding syndrome differentiation for the use of TCM amongst symptomatic menopausal women. As such, the evaluation of TCM use focusing upon the syndromes diagnosed for each menopausal status of women with diverse ethnicities may provide better understanding of the common TCM patterns of symptomatic menopausal women mentioned in this review. Furthermore, identifying TCM syndrome differentiation at each menopausal status is beneficial for optimizing clinical trial designs58.

CONCLUSION Traditional Chinese medicine constitutes a popular treatment option for women with menopausal symptoms. This review provides important insights into TCM use and a broad view of TCM consumption important for practice and policy development in this area. There is a paucity of well-designed, largesampled studies of TCM approaches to menopause. Further research employing both quantitative and qualitative methods is required to examine the details of TCM use including decision-making, information-seeking and challenges to (non) disclosure amongst women at each stage of menopause. Conflict of interest The authors report no confl icts of interest. The authors alone are responsible for the content and writing of this paper. Source of funding

Nil.

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