Abstract
Complementary and integrative therapies have been used since the beginning of mankind. Their use has increased especially since the mid-20th century. In parallel to the development in diagnosis, treatment, and care, patients also want to be more involved in their treatments and are more inclined to prefer methods that alleviate their complaints. Reasons such as extended life expectancy, increase in degenerative and malign diseases, high costs of modern treatment methods, patients wanting to feel better psychologically, and symptom management have also led people to choose complementary and integrative medicine. In particular, the interest of women in these therapies has significantly increased. Women are more interested in these therapies because they have a wide range of gender-specific health issues, from premenstrual syndrome to dysmenorrhea, from infertility to pregnancy symptoms, and from postpartum depression to postmenopausal vasomotor symptoms. In their quest to find solutions to their problems, women have become more inclined to use complementary and integrative medicine. Nurses are aware of have knowledge and can evaluate complementary and integrative medicine to protect and improve women’s health. This study presents a current literature review to evaluate the use of complementary and integrative medicine in women’s health.
Introduction
With extended life expectancy, the number of malignancies and chronic diseases that are difficult to treat increases every day. Modern treatments’ failure to meet expectations and patients’ wanting to feel better physically and mentally further boosts the interest in complementary and integrative medicine (1). It is a known fact that a holistic approach by nurses toward their patients results in more effective health results (2, 3).
A general description of health for women refers to total physical, mental, emotional, spiritual, cultural and social wellbeing (2). Women go through many life stages including childhood, puberty, sexual maturity, climacterium, and senium (old age) (3). Menstruation, pregnancy, breastfeeding, and menopause are important stages in a woman’s life. Women can experience unpleasant symptoms such as pain, nausea, vomiting, and hot flushes during these stages (4, 5). Women want to live more comfortably, improve their quality of life, and live longer and healthier without experiencing these symptoms. Women use complementary and integrative medicine to prevent and manage symptoms, reinforce their immune systems, develop healthy behavior (6, 7). Complementary and integrative medicine includes non-pharmacological interventions, which are believed to assist in pain relief along with standard drug treatment. While drugs used in pharmacological treatment have an effect on somatic pain, interventions used in non-pharmacological therapies affect emotional, cognitive, behavioral, and sociocultural aspects of pain (3, 7). Non-pharmacological interventions allow women to relax and have a reduced perception of pain without using any drug (7, 8).
In their study that included 170 pregnant women, Yazdi et al. (8) reported that 46.5% of these women used complementary and integrative medicine during pregnancy and women who had complications during their previous pregnancies were more likely to use complementary and integrative medicine than women without any complications. A study that included infertile couples found that approximately half of 162 infertile couples tried complementary and integrative medicine and almost half of these couples tried herbal medicines at least once, and women were more inclined to use these therapies compared with men (9). A study that included 1106 menopausal women reported that 33.5% of the women used complementary and integrative medicine (10).
The Regulation on Traditional and Complementary Medicine of the Turkish Ministry of Health dated October 27, 2014, describes who can practice complementary and integrative medicine. Among the therapies that nurses can independently administer according to this regulation are massage and yoga. Reflexology, aromatherapy, and musical therapy are administered under the supervision of physicians. Acupuncture, phytotherapy, and hypnosis are therapies that are not administered by nurses (11).
The objective of this literature review was to assess complementary and integrative therapies that women use throughout their life stages.
Herbal Therapies
Aromatherapy: The use of plant-based essential oils for therapeutic purposes. Today, aromatherapy is used for three different purposes: Esthetic, clinical, and holistic (12). There are approximately 400 types of plant-based essential oils, and 300 of these essential oils are used by professional aromatherapists for treating diseases (13). Essential oils are most frequently used for massage. They can also be applied through inhalation, steam, and baths. Almost 100 of these essential oils are used in aromatherapy, and 46 of them are used for women’s health (12, 13).
Some of the most frequently used essential oils are listed below:
Bay Laurel (Laurus Nobilis): Analgesic, antimicrobial, antifungal, antispasmodic, anti-neurological, antifebrile, appetite stimulant, diuretic, and cognitive enhancer (13).
Juniper: Has analgesic, antimicrobial, antiarthritis, anticeptic, antispasmodic, and diuretic properties; supports the urinary system, helps with chronic skin problems, helps alleviate menstrual pain, helps remove uric acid, helps relax, helps eliminate negative thoughts, and helps reduce fatigue (14).
Bergamot: It has analgesic, antidepressant, antiseptic, invigorative, and regenerative properties. At the same time, it stimulates the release of hormones, improves the quality of sleep, helps to relax, helps with the treatment of cystitis, and has antibacterial and anti-inflammatory properties (15).
Rosemary: Has analgesic, antiarthritic, antibacterial, antioxidant, antirheumatic, antispasmodic, antineurological, aphrodisiac, antiseptic, anticarcinogenic, antiflatulent, styptic, antifungal, and antidepressant properties; it helps with hair growth, prevents dysmenorrhea, reduces wrinkles, speeds up wound healing, supports mental activity, and reduces stress and anxiety (13).
Spearmint (Mentha piperita): Mint: has analgesic, antibacterial, anticarcinogenic, antifebrile properties; reduces nausea and vomiting, and improves self-confidence (13, 14).
Rose: Has anti-inflammatory, antiseptic, antispasmodic, vasoconstrictive, antiviral, antifebrile, antibacterial, anticonvulsant, antidepressant, and aphrodisiac properties; it makes scar tissues and wrinkles less visible, nourishes the skin, balances female hormones, regulates the menstrual cycle, supports liver functions, helps with constipation, improves the quality of sleep, reduces stress and anxiety, helps with anger control, reinforces the feeling of love, and helps with traumatic memories and feelings of loneliness (13).
Thyme: Has analgesic, antiparasitic, antibacterial, antifungal, antiviral, anti-inflammatory, antiarthritic, anesthetic, antimicrobial, antispasmodic, antiviral, antiflatulent, diuretic, expectorant, antidepressant, and stimulant properties; reduces scar tissue and wrinkles, supports treatments for injuries, sprains etc, reduces hair loss, speeds up wound healing, relieves headache, boosts memory, increases concentration, and reduces fatigue (13, 15).
There are studies in the literature that explore the effects of aromatherapy on nausea-vomiting, fatigue, anxiety, striae gravidarum, itching, and lower back pain during pregnancy (14-17). In their study in 100 pregnant women in Saudi Arabia, Ghani and Ibrahim (16) evaluated the effects of inhalation of a mixture of lavender and mint on nausea-vomiting, fatigue, and energy levels of pregnant women. The study reported that nausea-vomiting and fatigue decreased and energy level increased in pregnant women (16). In a study that included 141 pregnant women in Turkize, pregnant women received 15 min of massage every day with bitter almond oil to prevent formation of striae gravidarum, and a reduction in striae gravidarum formation was observed (17). In another study conducted in Spain, 198 pregnant women received massage with rosehip seed oil to prevent formation of striae gravidarum, and striae gravidarum formation was reduced (18). A study conducted in 40 pregnant women reported that massage with rose oil twice a day for four weeks reduced lower back pain in these women (19).
Behavioral Methods
Alexander technique: Alexander is a method that inhibits movements of the body that has become an unhelpful habit over time to relieve stress from the body. This technique was discovered by Frederick Matthias Alexander (1869-1955), an Australian actor, when he experienced recurring aphonia (loss of voice) on stage and doctors could not find a cure for this problem, which led him to self-exploration and experimentation for a long time. When this technique proved to be successful for other people, it began to gain popularity fast in the world (20).
The Alexander technique can especially be used as an alternative method to alleviate pain in the lower and upper back in the third trimester of pregnancy (21). More studies are needed to understand the effects of the Alexander technique on women’s health.
Dance therapy: A type of psychotherapy that deals with the mind-body connection and uses movements as tools. In this approach, every movement is a correct movement. Dance therapy is a method that is used to help with childbirth and improves the comfort of the mother during delivery. The dance of birth is the Turkish version (adapted by Michal Bardavid) of a program known as “dancing thru pregnancy” which has been used in the USA for 25 years. It is recommended for a healthy and safe pregnancy (21).
A study conducted in 60 primiparas between the ages of 18 and 35 evaluated the effect of dancing on reducing labor pain. The study concluded that dancing reduced the level of pain women experienced during childbirth (22).
More studies are needed to understand the effects of dance therapy on women’s health.
Yoga: Is the oldest system in the world, which focuses on the importance of the balance between the body, mind, and soul for human development. Although it is mostly thought to have benefits for the body, yoga has physiopsychological and psychospiritual aspects and acts as a catalyst for bodily maturation as well as mental, emotional, and spiritual growth (23-26).
Yoga strengthens muscles and improve body’s flexibility. Therefore, it plays an effective role in reducing and treating pain caused by postural problems and increased weight and pressure during pregnancy (23, 26).
It reduces stress caused by pregnancy and helps to experience a happier pregnancy. Yoga helps the mother accept her body and the baby, which results in better maternal-infant bonding (24). According to studies in the literature, yoga-based techniques are used for treating stress, depression in pregnancy, and maternal anxiety (25-29). Studies that focus on the effects of yoga on menopausal symptoms report that yoga reduces menopausal symptoms (25, 26).
Hypnosis: Is an unconscious state in which a person can be influenced to have access to his or her own subconscious mind during an inner journey. Hypnosis is a mental state in which, while still having personal control and cognitive functions, the person responds voluntarily and more willingly to suggestions by the therapist and takes responsibility for his or her own treatment (27).
Hypnosis, as a therapeutic tool, was first used by Fanton Menser in 1748. Later, Sigmund Freud also conducted experiments and used hypnosis to understand the subconscious causes of anxiety in his patients (29). Hypnotherapy is a non-pharmacological treatment used for nausea and vomiting, especially in the first trimester of pregnancy (28, 29). In their study Madrid et al. (29) reported that hypnotherapy reduced nausea and vomiting.
Complaints such as dysmenorrhea and premenstrual syndrome experienced by many women can be eliminated or reduced with hypnotic concentration (27). Hypnotherapy is also used for treating sexual dysfunctions and is especially helpful for treating dyspareunia (30). In addition to psychological treatments, hypnosis has recently shown effective results in the treatment of vaginismus (27, 30).
Hypnobirth is a childbirth method that uses self-hypnosis techniques; in other words, therapists teach women self-hypnosis. Hypnobirth has several advantages: It is effective in reducing labor pain and does not require pharmacological agents and equipment, and does not have any negative effect on the newborn and fetus. Hypnosis has been shown to shorten the first stage of childbirth, provide better analgesia, and make childbirth a pleasant experience, and it has been demonstrated that women who used hypnotherapy reported a more satisfactory childbirth experience and no side effect was seen in the neonatal period (31).
Cognitive-intellectual Therapies
Meditation: Is described as the name for the mind-controlling techniques and experiences that allow the person to achieve inner peace, calmness, and different consciousness levels and find his inner self (32).
A study investigated the stress level perceived by Indian pregnant women who were past the first trimester. The study included 74 pregnant women and reported that meditation improved the parasympathetic functions of these women (33).
More studies are needed to understand the effects of meditation on women’s health.
Music therapy: This is described as the design and use of music by a trained music therapist to improve communication, relationship, learning, organization, and other skills of a person or group of people to meet their physical, emotional, social, and cognitive needs (34). Music can also affect feelings such as happiness, joy, rage, and hate. Music has been used as a therapy for centuries. Plato (400 AD) said that music affects the depths of the soul through rhythm and harmony, increasing tolerance and comfort, and music is accepted as a remedy with healing power (13, 35).
Music played to mothers during childbirth helps them gain courage, trust themselves, reduce anxiety, handle pain and supports mother-baby relationship (35). A study that evaluated non-pharmacological pain control methods used during childbirth reported that out of 46 mothers who listened to music, 30% found it very effective, 55% found it somewhat effective, and 15% found it ineffective (36). A study which evaluated physiological measurements, satisfaction, and anxiety levels of women during c-section delivery reported that the women in the experiment group had lower levels of anxiety and higher levels of satisfaction than the women in the control group (37). A study conducted in Malaysia that included 64 postpartum mothers evaluated the effect of music therapy on the mothers’ stress level, breast milk amount, and cortisol level through house visits in 2., 6., 12. and 14. weeks. The study reported that the stress and anxiety levels of the mothers in the experiment group were low, the breast milk amount was increased by 59% (mean difference: 329 d/dL), and the cortisol levels in the last breast milk were significantly lower (mean: -44.5%) (38).
Tactile Therapies
Acupuncture: Is a scientific therapy that helps the body find balance by stimulating specific points in the body using needles. Acupuncture can be used in obstetrics and gynecology for example, to help with labor. Factors such as localization of pain, stage of labor, maternal fatigue level, tension or anxiety play an important role when trying to reduce labor pain (39).
In the study, the acupuncture group was compared with the placebo group and minimal acupuncture group (at non-acupuncture points and superficial application). The visual analog scale was used simultaneously to assess pain in both groups, and people in the acupuncture group experienced significant reduction in pain at 30, 60, and 120 min after acupuncture. In the real acupuncture group, pain was low at 2 h postpartum. It was also reported that the acupuncture group required significantly less epidural analgesia (40).
The use of acupuncture in fertility treatment has been increasing in recent years. Acupuncture is applied to meridians that agree with the energy flow along the body. Acupuncture points are selected according to traditional Chinese medicine based on diagnosis and patient-specific symptoms (41). A systematic review that included seven randomized controlled studies evaluated the effects of acupuncture on 1366 patients who received embryo transfer. Live birth and pregnancy rates were reported to be 65% higher than those in the control group (42).
A review that included three randomized studies that explored the effectiveness of acupuncture in childbirth reported that pharmacological analgesics were needed more in the control group than in the experimental groups in which acupuncture was used (43).
Reiki touch therapy: This is an energy therapy that focuses on electromagnetic fields outside the body and energy fields in the body. Reiki has an important role in modern medicine because it can provide relief for many treatment-resistant diseases, is easy to practice, safe, and cost-efficient, and has no side effects compared with drugs. Similar to acupressure, reflexology, and massage, Reiki is also used for specific purposes by trained people who touch energy centers (chakras) on the body (44, 45).
In the 1970s, D. Kruger became a pioneer in nursing by teaching Reiki to thousands of nurses. In modern medicine, Reiki touch therapy has become an independent function of nurses and a part of nursing care. Reiki helps for a more comfortable pregnancy. The mother and baby communicate before birth through Reiki. Expectant mothers calm their babies with Reiki. It relieves nausea and relaxes painful muscles. It is also effective in postpartum depression (45, 46).
Reiki touch therapy is reported to reduce the use of pain management and analgesic agents, shorten hospitalization, improve patient satisfaction, promote relaxation, make it easier to sleep, reduce nausea and emotional distress, facilitate communication, and reduce anxiety and high blood pressure (44-48).
In their study that evaluated the effect of reiki touch therapy on the symptoms of menopause Yeşil (49) concluded that reiki is effective in reducing somatic, psychological, and urogenital complaints of women. A study done to evaluate the effect of Reiki on pain, fatigue, and quality of life of adolescents with dysmenorrhea also reported that Reiki had a positive effect on pain and fatigue (47).
Massage: Reduces stress and pain by providing relaxation and stimulating circulation. Massage is “intentional and systematic manipulation of soft tissue to improve healing and health value” (13, 49).
In this study, 80 pregnant women were randomly divided into two groups to understand the effect of massage on reducing edema in legs at the later stages of pregnancy and the experiment group received 20 min of massage every day for 5 days. At the end of the study, edema levels in the experimental group were significantly lower than those in the control group (49).
Leg cramps caused by painful spasms mostly on calves during pregnancy, especially in the last weeks of pregnancy. These complaints mostly occur at night, and their mechanisms are not fully understood. Massaging the legs is reported to be sufficient most of the time to relieve pain during spasms (50, 51).
In their study, Oskay and Şahin (52) reported that 24.7% of young women received massage on their belly and back to reduce dysmenorrhea and obtained positive results. In a randomized controlled study, women were given back, foot, hand, and head massage by their spouses every 20 min for a duration of 5 h. Frequent massage is reported to reduce pain and anxiety in women and improve their emotional state (53). Furthermore, perineal massage applied during labor is also reported to reduce perineal trauma caused by childbirth (54).
Reflexology: Reflexology, which has been used in many cultures for centuries, is a therapy based on the principle that feet have reflex points that correspond to organs and systems in the body, and these points mirror the body’s anatomy (55). Pressure applied on these reflex points using special hand and finger techniques is claimed to reduce stress, which leads to physiological changes in the body. Reflexology is not recommended for the first trimester of pregnancy because it can cause miscarriage and is considered a therapy that should be applied with care (56).
A study that included 31 women who suffered dysmenorrhea reported that reflexology reduced dysmenorrhea in 95% of the women and reduced premenstrual symptoms (edema, nervousness, reduced concentration etc.) in 46% of the women who experienced PMS (57). Studies have reported that reflexology can be recommended as a complementary therapy to reduce the severity of PMS symptoms in young women (58). In another study, 42 menopausal women received reflexology massage and 17 (40.5%) of these women experienced full recovery, 20 (47.6%) experienced significant improvement, and 4 (9.5%) women had effective results in menopausal symptoms (hot flushes, nervousness etc.) (53).
Özdelikara and Arslan (59) reported that reflexology regulates nervous system functions by applying massage on reflex points and reduces nausea-vomiting (60). In a study conducted by Akköz Çevik and Incedal (61), 60 primiparas were assigned to the experimental and control groups. The experimental group received reflexology, whereas the control group received routine care, and 40 min of reflexology was applied during the active phase of labor. The study reported that reflexology reduced labor pain, lowered anxiety levels of pregnant women, shortened the length of the second and third phase of labor and helped women have a better childbirth experience (61).
Therapeutic touch (TT): Is based on the belief that all living creatures are surrounded by an energy area that can be maintained in balance by passing hands over this area. Correcting and balancing this energy area that hovers 3-5 over the body is called therapeutic touch. This is an alternative technique that requires special training (62).
Nurses can use this TT technique or couples can be taught this technique to reduce complaints, including nausea, fatigue, constipation, edema, and back pain during pregnancy. Additionally, it has also been reported that TT helps with several complications associated with pregnancy, such as hypertension, toxemia, and the risk of premature birth (63).
TT is also recommended for pregnant women to have a more comfortable labor, to bond with their babies earlier and to start breastfeeding sooner (47, 62).
TT also contributes to reducing the need for postoperative analgesia and accelerating the abdominal and perineal wound healing process after childbirth (62, 63). A reduction in pain, reduction in cortisol levels, and increase in natural killer cell numbers of patients who had TT post-surgery have also been reported in the literature (63).
A study conducted by Pınar and Demirel (64) reported that TT applied during labor reduced pain and anxiety levels in women and had a positive effect on their attitude toward childbirth. The authors did not observe any increase in the pain level or any change in the anxiety and attitude levels of the women in the control group.
Nurses’ Roles in the Use of Complementary and Integrative Medicine in Women’s Health
The roles and responsibilities of nurses have changed in response to technological developments in healthcare and increasing scientific knowledge. Therefore, nurses are expected to develop nursing practices regarding the use of complementary and integrative medicine, develop effective strategies, and provide guidance to patients/healthy people to use complementary therapies effectively and correctly (65). A study conducted in nurses in Turkey reported that almost half of the nurses included in the study were already using complementary and integrative medicine, and herbal products, vitamins, and massage were the most frequently used therapies. Almost all of the nurses reported that they did not have sufficient information about these therapies, and the majority of the nurses reported that they asked about the use of these therapies only when taking the patient’s medical history (64, 65).
Nurses are aware of have knowledge to evaluate complementary and integrative medicine. It is concluded that developing training programs after the efficiency, effectiveness, benefits, and risks of these therapies are determined based on evidence and including these programs in nursing education will yield positive outcomes for the nursing profession and women’s health.
Conclusion
Roles and responsibilities of nurses have changed in response to technological developments in healthcare. Therefore, nurses need to develop practices and identify effective strategies for the use of complementary and integrative medicine. This will ensure the effective and correct use of these therapies by patients.
Author Contributions: Surgical and Medical Practices – G.M.A.D., N.H.Ş.; Design – G.M.A.D., N.H.Ş.; Concept – G.M.A.D., N.H.Ş.; Data Collection and/or Processing – G.M.A.D., N.H.Ş.; Analysis and/or Interpretation – G.M.A.D., N.H.Ş.; Literature Review – G.M.A.D., N.H.Ş.; Writing – G.M.A.D., N.H.Ş.
Declaration of Interests: No conflict of interest was declared by the authors.
Funding: The authors declared that this study received no financial support.