Factors associated with treatment options among
menopausal women in Taiwan
Yah-Wen Chiou
a, Chen-Jei Tai
b,c, Li-Yin Chien
d,∗ aInstitute of Community Health Nursing, National Yang Ming University and Department of Nursing,Taipei Veterans General Hospital, Taiwan
bDepartment of Traditional Chinese Medicine, Taipei Medical University, Taiwan cDepartment of Obstetrics and Gynecology, Taipei Medical University Hospital, Taiwan
dInstitute of Community Health Nursing, National Yang Ming University, 155 Li-Nong St., Sec. 2, Pei-Tou, Taipei 11221, Taiwan Received 30 August 2005; received in revised form 12 October 2005; accepted 14 October 2005
Abstract
Objectives: Taiwan has a two-tiered medical system that includes modern medicine and traditional Chinese medicine (TCM).
The objectives of this study were to compare the characteristics of menopausal women who did not use any treatment, who used hormone replacement therapy (HRT), and who used TCM to treat their climacteric symptoms.
Methods: The study subjects were 182 women aged 46–55 years (non-treatment: 61, HRT: 60, TCM: 61). Variables used
included socio-demographics, climacteric symptoms, other physical symptoms, experiences with the treatment, and attitude toward menopause. Multivariate analyses were performed using multinomial logistic regression.
Results: Compared with women in the non-treatment group, employed women were more likely to have received HRT or TCM.
Women in the TCM group were more likely to have comorbid non-climacteric physical symptoms and were less likely to have family support for the use of HRT. Women in the TCM group were more likely to have an attitude regarding menopause as a natural phenomenon and as having little impact on attractiveness and sexual life. Severity of current climacteric symptoms was lower in the HRT group, while it was higher in the TCM group. These factors accounted for 66.1% of the model variances.
Conclusions: Women in different treatment groups had different characteristics. Health professionals should be aware of the
differences and provide information on treatment options in order to help and support women in making treatment decisions. © 2005 Elsevier Ireland Ltd. All rights reserved.
Keywords: Menopause; Climacteric symptoms; Treatment options; Hormone replacement therapy; Traditional Chinese medicine
∗Corresponding author. Tel.: +886 2 28267142; fax: +886 2 28238614.
E-mail address: [email protected] (L.-Y. Chien).
1. Introduction
Women experience a lot of changes during the menopausal period, including degeneration in phys-ical health, loss of reproductive functions, alter-ations in body images, and changes in interpersonal 0378-5122/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.
relationships[1–4]. It has been reported that more than 80% of menopausal women experienced climacteric symptoms [5,6]. Despite this fact, whether a woman should receive treatment remains a controversy. It has been reported that 10–20% of women experience severe climacteric symptoms, which affect their quality of life significantly and may require medical interven-tions[7,8].
Hormone replacement therapy (HRT) has been used to treat menopausal women for more than a decade in Taiwan. Though there is a lack of data, it is believed that more and more women have been using HRT since the 1990s in Taiwan. However, the increasing trend was counteracted by a large-scale US study, which was widely reported by media in Taiwan. In 2002, a multi-center randomized con-trolled trial including 16,608 postmenopausal women aged 50–79 years recruited from 1993 to 1998 was reported. The experimental subjects who received hor-mone replacement therapy were more likely to develop coronary heart disease, breast cancer, stroke, and pul-monary embolism than the placebo-controlled subjects [9]. This has led to a halt to clinical trials of com-bined hormone replacement therapy for the manage-ment of menopausal symptoms. After the report of this important study, data from the Taiwan Bureau of National Health Insurance showed a decrease of 14.3% in the numbers of HRT prescriptions in Taiwan [10].
Due to the fear of the risks associated with HRT, many women may seek alternative therapies. However, the American College of Obstetricians and Gynecol-ogists noted that there is little research evidence to support the efficacy of the alternative therapies[11]. Several countries in the North America and Europe have licensed acupuncturist, herbalist, and doctors in Chinese Medicine. Natural therapy and/or traditional Chinese medicine (TCM) are increasingly available to the public as treatment options. Taiwan has a two-tiered medical system that includes modern medicine and TCM. The Taiwan Bureau of National Health Insurance generally covers the medical expenses in the two systems [12,13]. There have been few stud-ies on women’s treatment options for their climacteric symptoms since the spread of the important HRT study from US [9]. The objectives of this study were to compare characteristics of menopausal women who did not use any treatment, those who used HRT,
and those who used TCM to treat their climacteric symptoms.
2. Methods
This study applied a descriptive and correlational design. Face-to-face interviews with structured ques-tionnaires were conducted with the study subjects. 2.1. Study subjects
The study subjects were 182 women aged 46–55 years. Women who were pregnant, who had menopause due to hysterectomy or bilateral oophorectomy, or who received cancer treatments were excluded. We divided the treatment options into three categories: non-treatment, HRT and TCM. The non-treatment group included women who had never or had not used HRT or TCM for climacteric symptoms during the year prior to the study period. Those in the HRT group were women who had used HRT for more than 1 month in the year prior to the study period. Those in the TCM group were women who had used TCM for more than 1 month in the year prior to the study period. Women in the TCM and HRT groups were recruited from two walk-in clinics in Taipei, Taiwan. Women in the non-treatment group were recruited from a community screening pro-gram for cervical and breast cancer in Taipei, Taiwan. Data were collected during the period of March to April 2004. The final samples were 61 women in the non-treatment group, 60 in the HRT group, and 61 in the TCM group.
2.2. Measurements
The study variables included socio-demographic characteristics, menopausal status, climacteric symp-toms and non-climacteric physical sympsymp-toms or dis-eases (including hypertension, diabetes mellitus, heart failure, asthma, chronic bronchitis, chronic gastritis, and liver cirrhosis), family support for use of the treat-ment, use of treatment for climacteric symptoms by friends, and attitudes toward menopause. Menopausal status was divided into three stages using the def-inition of the North America Menopausal Society [14]. The three stages were premenopause (men-strual period becomes irregular for no more than
3 months), perimenopause (from menstrual period becomes irregular for more than 3 months to men-struation totally stopped), and postmenopause (from menstruation totally stopped to 1 year after the time).
The severity of the women’s climacteric symptoms and their attitudes toward menopause were measured using scales developed for this study. Five experts (including two gynecologists, a Chinese Medicine doc-tor, a psychological researcher, and a head nurse in gynecological ward) reviewed, evaluated, and mod-ified the contents of the questionnaire. A 33-item scale was developed to measure the severity of the women’s climacteric symptoms. Three groups of cli-macteric symptoms were considered: vasomotor symp-toms, general-somatic sympsymp-toms, and psychological symptoms. A five-point Likert scale was applied. The score assigned to the Likert were none = 0, symptoms present without discomfort = 1, mild discomfort = 2, moderate discomfort = 3, and severe discomfort = 4. The score ranged from 0 to 132, with the higher score indicating higher level of severity of climac-teric symptoms. Attitudes towards menopause were assessed using a seven-item scale with a five-point Likert scale. The score assigned to the Likert were strongly disagree = 0, disagree = 1, neither agree nor disagree = 2, agree = 3, and strongly agree = 4. The scores were reversely coded for four items in the scale, so that a higher score indicated an attitude to regard menopause as a natural phenomenon and as having little impact on attractiveness or sexual life. Internal consistency scores as assessed using the Cronbach’sα were 0.94 and 0.67 for severity of cli-macteric symptoms and attitude toward menopause, respectively.
2.3. Data analysis
The data were analyzed using the Statistical Package for Social Sciences for Windows version 11.0 (SPSS, Chicago, Ill, USA). One-way analysis of variance and chi-squared statistics were used to compare the dif-ferences among the three treatment groups. Symptom improvement between the HRT and TCM group were compared using the student t-test. Multinomial logis-tic regression was used to examine factors associated with treatment options. A P-value of less than 0.05 was considered statistically significant.
3. Results
Characteristics of the study subjects are presented inTable 1. There were no significant differences in ages or menopausal status among the three treatment groups (non-treatment, HRT, and TCM). Women in the TCM group were more likely to be unmarried and currently working, and to have higher education. Women in the TCM group had the highest percentage of using diet and lifestyle changes for their climac-teric symptoms (85.2%), while the HRT group had the lowest percentage (55.0%) in doing so. Women in the HRT and TCM groups had higher percentages of having non-climacteric physical symptoms or dis-eases than women who did not receive any treatment. Women in the TCM group had the highest percent-age of reporting their friends using TCM (52.5%), while women in the HRT group had the highest per-centage of reporting their friends using HRT (76.7%). Family support for the use of HRT was the high-est for the HRT group (70%), followed by the non-treatment group (37.7%), and the lowest for the TCM group (8.2%).
Women in the TCM group had significantly higher overall mean scores in the severity of climacteric symp-toms, as well as in the three subcategories: vaso-motor, general-somatic, and psychological symptoms (Table 2). Women in the HRT group had the low-est mean scores of symptom severity overall and in the three subcategories. The higher mean scores for the TCM group and the lower mean scores for the HRT group were consistent across items. Significant differences were detected in all except for six items (Table 2).
The scale of attitude toward menopause was designed so that a higher score indicated an attitude to regard menopause as a natural phenomenon and as having little impact on attraction and sexual life. Women in the TCM group reported the highest scores in the attitudes toward menopause, followed by the non-treatment group (Table 3). The HRT group had the lowest attitudinal scores.
Multinominal logistic regression results showed that the variables associated with treatment options were work status, presence of non-climacteric symptoms or disease, family support for use of HRT, severity of cli-macteric symptoms, and attitudes toward menopause (Table 4). Variables that were insignificant and thus
Table 1
Characteristics of the study subjects
Treatment option P-value
Non-treatment (n = 61) n (%) HRT (n = 60) n (%) TCM (n = 61) n (%) Age (years) 0.84 46–50 27 (44.3) 27 (45.0) 30 (49.2) 51–55 34 (55.7) 33 (55.0) 31 (50.8) Menopausal status 0.37 Pre-menopause 10 (16.4) 16 (26.7) 11 (18.0) Peri-menopause 28 (45.9) 30 (50.0) 28 (45.9) Post-menopause 23 (37.7) 14 (23.3) 22 (36.1) Currently married 58 (95.1) 58 (96.7) 51 (83.6) 0.02 Educational level <0.01
Elementary school or less 41 (67.2) 40 (66.7) 18 (29.5)
High school or higher 20 (32.8) 20 (33.3) 43 (70.5)
Currently working 20 (32.8) 25 (41.7) 36 (59.0) 0.01
Have religious beliefs 53 (86.9) 55 (91.7) 53 (86.9) 0.64
Have other non-climacteric symptoms or diseases 21 (34.4) 32 (53.3) 35 (57.4) 0.03
Friends’ use of HRT 33 (54.1) 46 (76.7) 38 (62.3) 0.03
Friends’ use of TCM to treat climacteric symptoms 16 (26.2) 22 (36.7) 32 (52.5) 0.01
Family support for use of HRT 23 (37.7) 42 (70.0) 5 (8.2) <0.01
Family support for use of TCM 24 (39.3) 26 (43.3) 35 (57.4) 0.11
Use of diet and lifestyle change for climacteric symptoms 39 (63.9) 33 (55.0) 52 (85.2) <0.01 P-value from chi-squared statistics.
were excluded were marital status, educational level, family support for the use of TCM, use of HRT or TCM by friends, and use of diet and lifestyle change for cli-macteric symptoms. Compared with the non-treatment group, women who received HRT or TCM were more likely to be currently working (OR = 2.98 for HRT, OR = 2.89 for TCM). Women in the TCM group were more likely to have other non-climacteric symptoms or diseases (OR = 3.44), while there were no significant differences in the presence of non-climacteric symp-toms between HRT and non-treatment groups. Women in the TCM group had significantly lower family sup-port for the use of HRT (OR = 0.14), while there were no significant differences in family support between HRT and non-treatment groups. Compared with the non-treatment group, the severity of climacteric symp-toms was significantly lower in the HRT group, while it was significantly higher in the TCM group. Women in the TCM group reported more positive attitudes toward menopause (OR = 1.15). The Nagelkerke R2 showed that the model explained 66.1% of the variances.
To examine whether the differences in the reported severity of climacteric symptoms were due to
dif-ferential treatment efficacy between the HRT and TCM groups, we further compared the mean scores in perceived symptom improvement after treatment. The TCM group reported greater overall improve-ment in severity of climacteric symptoms, and greater improvement in vasomotor and psychological symp-toms (Table 5). There were no significant differences in the perceived symptom improvement in the general somatic symptoms.
4. Discussion
Since the widespread of the study results of the risks associated with HRT use, many women stopped their HRT use and tried to find alternatives. In the Taiwanese context, traditional Chinese medicine is a readily available alternative for people. The traditional Chinese medicine views health as a state of somatic balance of yin and yang, hot and cold. Many people believe that the Chinese medicine is natural, and is milder and safer than the modern medicine[12,15]. The results of our study showed that women in the
Table 2
Mean scores of severity of menopause symptoms by treatment options (N = 182)
Non-treatment mean (S.D.) HRT mean (S.D.) TCM mean (S.D.) P-value
Total scale 16.48 (13.17) 5.23 (2.62) 24.67 (15.67) <0.001
Vasomotor symptoms 5.21 (4.11) 2.00 (1.32) 7.49 (5.48) <0.001
Hot flash 0.79 (0.86) 0.77 (0.89) 1.02 (1.22) 0.32
Night sweating 0.43 (0.78) 0.13 (0.47) 0.59 (0.97) 0.005
Spontaneous sweating 0.57 (0.76) 0.57 (0.79) 0.46 (0.91) 0.689
Cold hands and feet 0.34 (0.54) 0.12 (0.37) 0.69 (0.99) <0.001
Numbness and tingling in the limbs 0.44 (0.62) 0.48 (0.70) 1.03 (1.20) <0.001
Headache 0.49 (0.91) 0.50 (0.89) 1.39 (1.36) <0.001 Palpitation 0.82 (0.85) 0.57 (0.83) 1.13 (1.12) 0.005 Dizziness 0.52 (0.79) 0.28 (0.56) 0.95 (1.09) <0.001 Dry eyes 0.49 (0.74) 0.18 (0.60) 1.46 (1.21) <0.001 Uncontrolled tearing 0.31 (0.56) 0.25 (0.51) 0.51 (0.89) 0.09 General-somatic symptoms 5.66 (4.63) 1.85 (1.44) 9.30 (6.05) <0.001 Dry skin 0.70 (0.78) 0.28 (0.59) 1.07 (1.09) <0.001 Breast tenderness 0.26 (0.66) 0.18 (0.62) 0.75 (0.96) <0.001 Poor appetite 0.05 (0.22) 0.03 (0.18) 0.21 (0.61) <0.001 Constipation or diarrhea 0.21 (0.55) 0.13 (0.50) 0.82 (1.19) <0.001 Ache in neck, back and waist 1.00 (1.08) 0.57 (0.87) 1.90 (1.15) <0.001
Arthralgia 0.75 (0.96) 0.30 (0.67) 1.30 (1.20) <0.001
Heel pain 0.10 (0.35) 0.07 (0.25) 0.48 (0.87) <0.001
Frequent urination 0.79 (0.76) 0.67 (0.77) 0.89 (0.99) 0.36
Incontinence 0.21 (0.45) 0.18 (0.47) 0.89 (1.05) <0.001
Dyspareunia 0.54 (0.70) 1.04 (0.85) 1.22 (1.25) <0.001
Weight gain of more than 2–3 kg 0.39 (0.67) 0.35 (0.69) 0.69 (0.85) 0.02
Blurred vision 0.64 (0.84) 0.32 (0.70) 1.59 (0.92) <0.001
Psychological symptoms 5.61 (5.65) 1.38 (1.34) 7.89 (6.57) <0.001
Tiredness and fatigue 0.80 (0.91) 0.62 (0.78) 1.82 (0.94) <0.001
Irritability 0.67 (0.77) 0.65 (0.76) 0.98 (1.04) 0.06
Depressed mood 0.36 (0.78) 0.08 (0.28) 0.72 (0.97) <0.001
Poor memory 0.69 (0.79) 0.40 (0.69) 1.48 (0.99) <0.001
Difficulty falling to sleep 0.61 (0.86) 0.40 (0.92) 1.26 (1.35) <0.001
Insomnia 0.79 (0.97) 0.75 (1.04) 1.48 (1.27) <0.001
Short of breath 0.16 (0.52) 0.17 (0.49) 0.57 (0.96) 0.001
Worries about changes in the body and health 0.52 (0.79) 0.63 (0.90) 1.08 (0.82) 0.001
Stress and anxiety 0.44 (0.79) 0.38 (0.67) 1.03 (1.08) <0.001
Moodiness 0.38 (0.69) 0.37 (0.66) 0.57 (0.96) 0.26
Unfaithfulness 0.18 (0.47) 0.05 (0.22) 0.51 (0.81) <0.001
Score range: total scale: 0–132; vasomotor: 0–40; general-somatic: 0–48; psychological: 0–44; item: 0–4; higher score indicates higher level of symptom severity; P-value from ANOVA.
TCM group were more likely to have an attitude to regard menopause as a natural phenomenon and as hav-ing little impact on attractiveness and sexual life. On the contrary, women who used HRT had lower mean attitude scores. The differences in attitudes toward menopause may be associated with differences in the basic treatment assumptions for HRT and TCM. In the HRT treatment, hormones are given to women due to the belief that the lack of hormones causes the
uncom-fortable climacteric symptoms. In the TCM treatment, because of the balanced view of health, the focus is on the balanced function of the whole body system, rather than on the lack of hormones. Thus, women in the TCM group may believe that they are taking the TCM to help the body adjusting to the menopausal changes rather than dealing with insufficient hormones. Therefore, women who have more positive attitudes toward menopause chose the TCM to help them adjust
Table 3
Mean scores of attitude toward menopause by treatment option
Non-treatment mean (S.D.) HRT mean (SD) TCM mean (S.D.) P-value
Total scale 12.49 (3.82) 10.47 (2.90) 14.95 (2.96) <0.001
Women can go out freely after menopause 2.74 (0.73) 2.65 (0.82) 3.16 (0.71) <0.001 It is natural for problems and symptoms associated with
menopause to occur
1.97 (0.93) 2.42 (0.79) 2.98 (0.72) <0.001 After menopause, sex is more enjoyable and I do not worry
about pregnancy any more
1.95 (0.90) 1.60 (0.69) 2.56 (0.79) <0.001 The following items were reversely coded
Women are getting older after menopause 1.20 (0.93) 0.57 (0.53) 1.26 (1.00) <0.001 Menopause decreases women’s attractions 1.79 (1.04) 1.27 (0.90) 1.98 (1.01) <0.001 Frequency of sexual intercourse decreases after
menopause
1.67 (1.00) 1.35 (0.71) 1.57 (0.85) 0.11 Menopause causes unpleasant symptoms and makes
women irritable and angry
1.18 (1.06) 0.62 (0.74) 1.43 (1.02) <0.001 The score range: total scale: 0–28; item: 0–4 hihger score indicates an attitude to regard menopause as a natural phenomenon and as having little impact on attraction and sexual life.
Table 4
Multinomial logistic regression model for treatment options (N = 182)
HRT TCM
OR 95% CI P-value OR 95% CI P-value
Currently working 2.98 1.05–8.41 0.04 2.89 1.22–6.83 0.02
Have non-climacteric symptoms or diseases 1.17 0.43–3.17 0.76 3.44 1.44–8.24 0.005 Family support for use of HRT 2.10 0.65–6.76 0.21 0.14 0.04–0.50 0.003 Severity of menopausal symptoms 0.69 0.59–0.81 <0.001 1.03 1.00–1.07 0.03
Attitudes toward menopause 0.89 0.76–1.06 0.21 1.15 1.00–1.31 0.049
The reference group was those women who did not receive any treatment.
Table 5
Mean scores in perceived symptom improvement by treatment method Na Mean S.D. P-value Overall scale 0.002 HRT 262 1.19 0.52 TCM 1035 1.33 0.99 Vasomotor symptoms 0.001 HRT 101 1.28 0.55 TCM 308 1.54 0.97 General-somatic symptoms 0.834 HRT 87 1.22 0.47 TCM 374 1.20 1.01 Psychological symptoms 0.001 HRT 74 1.03 0.50 TCM 353 1.28 0.97
aN here represents the number of reported symptoms, rather than the number of women; individual score range was 0–3: 0 = no improvement; 1 = some improvement; 2 = medium improvement; 3 = significant improvement.
and adapt to menopausal changes, while women who have more negative attitudes toward menopause chose the HRT to prevent the climacteric symptoms from occurring. This speculation is partly evidenced by our findings that women in the TCM group were more likely to also use diet and lifestyle changes for cli-macteric symptoms, while women in the HRT group were less likely to do so. In a study from Thailand, researchers reported that women who intended to use HRT had more negative attitudes toward menopause than women who did not intend to use HRT [16]. Our study did find that women in the HRT group had the lowest mean attitude scores, but the differences in the attitude scores between HRT and non-treatment groups were not apparent after the multi-variable anal-yses.
In our study, we found that women who did not have family support for the use of HRT and who had non-climacteric symptoms or diseases were more likely to be in the TCM group. This may suggest that these
women felt that they had health problems and need medical attention, but because of the low support for the use of HRT, they then sought treatment from TCM practitioners. The findings that employed women were more likely to have received either HRT or TCM treat-ment may be associated with the job demands placed on them. Thus, the employed women chose to treat their climacteric symptoms so that the symptoms would not interfere with their work. It is also possible that the employed women had more resources concerning treatment options and the treatment was more accessi-ble and affordaaccessi-ble to them. Further study is needed to validate this speculation.
In our study, we found that at the time of the study, women in the HRT group reported the lowest severity of menopausal symptoms, while women in the TCM group reported the highest severity of menopausal symptoms. Since the study was a cross-sectional study, the results need to be explained with caution. The observed differences in severity of climacteric toms could be due to the initial differences in symp-tom severity between the HRT and TCM group before the treatment. Equivalently, the results may suggest that HRT is more effective in alleviating climacteric symptoms than TCM. We further tested the perceived improvement in symptom severity after the treatment and found that women in the TCM group reported greater improvement in their climacteric symptoms. Thus, initial differences in symptoms severity before treatment rather than differential treatment effects were supported. Nonetheless, randomized controlled trails are needed to determine and compare the treatment effects.
Our study was limited by the cross-sectional design, thus a causal relationship cannot be established. This study examined the relationship between women’s characteristics and their treatment options. Future study should consider the care provider’s characteristics and their effect on women’s use of HRT or TCM. The study subjects were from a convenience sample. A population-based study is needed to further examine the issue.
5. Conclusion
In this study, we found that menopausal women in different treatment groups had different
character-istics. Women in the TCM group were more likely to have attitudes to regard menopause as a nat-ural phenomenon and as having little impact on attractiveness and sexual life than women in the HRT and non-treatment groups. Women in the HRT group demonstrated the lowest severity of climac-teric symptoms. Family support for the use of treat-ment was significant, thus inclusion of family mem-bers in the treatment decision was implicated. Health professionals should be aware of the differences of women in different treatment groups and pro-vide information on treatment options in order to help and support women in making their treatment decisions.
References
[1] Yang SC, Lu ZY. The politics of the menopausal body among Taiwanese women. J Nurs Res 2000;5:491–502.
[2] Tsao LI. Living with changing health: perimenopause among Chinese women in Taiwan. J Nurs Res 1998;6:448–60. [3] Abernethy K. The menopause and hormone replacement
ther-apy. Nurs Stand 1997;11:49–56.
[4] Lindsay SH. Menopause, naturally: exploring alternatives to traditional hormone replacement therapy. AWHONN Lifelines 1999;3:32–8.
[5] Lee I, Wang HH. Patterns and related factors of self-care behaviors among perimenopausal women. Public Health Q 2001;28:151–60 [in Chinese].
[6] Porter M, Penney GC, Russell D, Russell E, Templeton A. A population based survey of women’s experience of the menopause. Br J Obstet Gynaecol 1996;103:1025–8. [7] Hvas L, Thorsen H, Sondergaard K. Discussing menopause in
general practice. Maturitas 2003;46:139–46.
[8] Jokinen K, Rautava P, Makinen J, Ojanlatva A, Sundell J, Hele-nius H. Experience of climacteric symptoms among 42–46 and 52–56-year-old women. Maturitas 2003;46:199–205. [9] Writing Group for the Women’s Health Initiative Investigators.
Risks and benefits of Estrogen plus Progestin in healthy post-menopausal women. Principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321– 33.
[10] Bureau of National Health Insurance. Drug and special materia medica: analysis of materia medica usage. Avail-able at: http://www.nhi.gov.tw/02hospital/hospital 6 05.html. Accessed October 17, 2003.
[11] American College of Obstetricians and Gynecologists Com-mittee on Practice Bulletins—Gynecology. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Use of botanicals for management of menopausal symptoms. Obstet Gynecol 2001;97(Suppl.):1–11. [12] Chen YC. Chinese values, health and nursing. J Adv Nurs
[13] Liang CC. The development and examination of the Chinese–Western medical beliefs scale. J Nurs Res 1999;7:445–58.
[14] North American Menopause Society corporate authors. Menopause Core Curriculum Study Guide 2002. USA: NAMS.
[15] Seidl MM, Stewart DE. Alternative treatments for menopausal symptoms. Qualitative study of women’s experiences. Can Fam Physician 1998;44:1271–6.
[16] Burusanont M, Hadsall RS. Factors associated with intention to use hormone replacement therapy among Thai middle-aged women. Maturitas 2004;47:219–27.
