Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
Has anyone in your family had these problems?	Not that I can think of.
Recreational drug use
How much alcohol would you consume a week?	Maybe 6 to 8 glasses a week, mostly on the weekend.
Functional disease
Do you strain to pass at least 1 in 4 bowel motions and are then left feeling like the evacuation is incomplete or that there’s an obstruction? (functional constipation)	Yes. I seem to have to strain often to pass a bowel motion. But it does feel complete when I pass a bowel motion.
Infection and inflammation
Have you used any vaginal sprays, douches or had several bubble baths recently? (chemical vaginitis, vulvovaginitis)	No, I have not indulged enough in that kind of thing!
Supplements and side effects of medication
Are you taking any supplements or medications?	Just a multivitamin. I thought I should take something since my diet is not good at the moment.
Endocrine/reproductiveTell me about your menstrual cycle.	Gia explains that her periods have become irregular and she is never really sure when it is going to come, when Gia develops a backache or stomachache she realises her period is probably going to come in a couple of days.
Stress and neurological disease
How are you managing your stress at the moment?	Mostly with chocolate! My boyfriend is really great, he’s a great de-stressor.
Eating habits and energy
Tell me about your diet and energy levels.	Gia describes a diet that is high in refined carbohydrates, sugar and caffeine. She does have some whole foods and vegetables but not as much as she knows she should have. She says she finds her energy levels fluctuate, but she finds coffee or cola drinks help with that.

TABLE 5.3 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Daily activities
Describe your daily routine.	When I get up I have a coffee and cereal and then I either go to uni or I study at home. I try to go out for a jog or swim, but haven’t really done much recently. My boyfriend comes over in the evenings 3–4 times a week and I spend all weekend with him if I don’t have to work on an assignment.
Family and friends
What about family and friends?	I haven’t seen much of anyone in the last few months. I try and catch up with my family every 3 or 4 weeks, and talk to mum and dad on the phone a couple of times a week. My friends are understanding and I try to catch up with them on the weekends if I can.
Action needed to heal
How do you hope I can help you?	I thought you might be able to tell me how to improve my diet and lifestyle. Maybe you have some tablets that could help too.
Long-term goals
What are your long-term goals?	Finish uni and have a holiday! Then get a job teaching. Maybe in four or five years if things go well we might try for a baby. I’d like to get my hormones sorted out before we try for one.

TABLE 5.4 GIA’S SIGNS AND SYMPTOMS [2, 6]

Results of medical investigations

No medical tests have been carried out.

TABLE 5.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 7–10]

Conditions and causes	Why unlikely
FAMILY HEALTH
Familial or idiopathic hirsutism	Excess hair growth would not be typically androgenic, appearing on hormonally influenced areas of the body where hair will grow, such as the face, armpits, abdomen, chest and thighs; no known family history of excess hair growth
OBSTRUCTION AND FOREIGN BODY
Polycystic renal disease: lower abdominal and back discomfort	Urinalysis is clear, no high blood pressure
INFECTION AND INFLAMMATION
Chronic salpingo-oophoritis: irregular cycle; can be minimal or excessive menstrual bleed	Usually congestive dysmenorrhoea is the predominant symptom; associated with purulent discharge, fever, period pain and abdominal pain
Cystitis	Urinalysis NAD
ENDOCRINE/REPRODUCTIVE
Diabetes: anovulatory cycles	Urinalysis NAD
Primary dysmenorrhoea: lower abdominal pain, can get worse with menstrual cycle	Period pain usually starts when menses first begins and is often associated with no pelvic abnormality, nausea, vomiting, headache or dizziness
Secondary dysmenorrhoea: acquired due to pathology; period pain begins several years after menarche and due to a pelvic abnormality	Menstrual bleed is presenting as painless
Twisted uterine fibroids and polyps: twisted fibroids can cause symptoms of severe dysmenorrhoea, heavy bleeding, back pain and sometimes vaginal discharge	Usually maintains normal cycle unless submucosal or nearly extruded; causes uterine enlargement; usually causes menorrhagia (blood loss of 80 mL per day and lasting more than 7 days); fibroids form due to excess oestrogen
Premenstrual syndrome: pain in the abdomen before menses	Experiences premenstrual mood changes, feels teary, bloated and swollen 1–12 days before period; experiences a dull pelvic ache, abdominal bloating
Ovulatory bleed: have bleed mid-cycle as well as regular menses and ovulation has occurred	Feels emotional, premenstrual symptoms such as ovulation pain (mittelschmerz) and mood changes; usually spotting or light bleed at time of ovulation, regular cycle; check basal body temperature because it will be biphasic and fluctuate, indicating ovulation has occurred

Case analysis

TABLE 5.6 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [2, 7–11, 59, 60]
CONDITION AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
CANCER AND HEART DISEASE
Ovarian, pituitary or adrenal tumour	Will affect androgen levels, produce symptoms of irregular cycles, lower abdominal pain, acne, increased facial hair, depression, weight gain	No changes in smell or taste; no headaches mentioned indicating a brain tumour
Uterine cancer	Vaginal discharge	Usually brown discharge
Cervical cancer	Vaginal discharge, sexually active	Need to ask if the pain/blood is experienced on intercourse and the date of the last pap smear; vaginal discharge can contain blood
Adult-onset and congenital adrenal hyperplasia/adrenal tumour: can cause primary and secondary amenorrhoea; anovulatory cycles	Usually presents with severe acne and hirsutism; can present with anovulatory irregular menstrual bleeding	Check if rapid development of symptoms and how severe virilisation symptoms are; accompanied by severe virilisation such as frontal balding and enlarged clitoris
TRAUMA AND PRE-EXISTING ILLNESS
Congenital disorders (spina bifida, scoliosis, spondylolisthesis)	Lower back pain	Back pain only mentioned prior to menstrual period
Trauma (strains, sprains, tear, herniated disc, fracture, disc prolapse)	Lower back pain
OBSTRUCTION AND FOREIGN BODY
Intestinal obstruction (bowel cancer, adhesions, hernias, faecal impaction with overflow)	Abdominal distension and pain constipation	No vomiting, abdominal pain associated with menstrual cycle
FUNCTIONAL DISEASE
Functional constipation	Has 3 or fewer evacuations a week; not drinking enough water, high caffeine intake, not enough fruit, vegetables in diet, lack of exercise, stress	Need to check if more than 1 in 4 bowel motions is lumpy and hard, and causes strain, a feeling of incomplete evacuation or blockage; need to check if manual help is needed to facilitate a bowel motion passing
Faulty posture	Possible if sitting for long periods of time studying
INFECTION AND INFLAMMATION
Appendicitis/Meckel’s diverticulum	Intermittent lower abdominal pain, constipation; common age group	If pain becomes acute it could be a possible diagnosis
Pelvic inflammatory disorder: abdominal pain, could be from a sexually transmitted disease	Purulent vaginal discharge, sexually active, abdominal pain; irregular periods, lower backache	Unsure whether vaginal discharge is offensive, and unclear at this stage if there is pelvic pain; no fever; need to clarify if there is any pain on sexual intercourse; physical exam will indicate whether pain on motion during physical examination
Acute and chronic cervicitis: Chlamydia trachomatis, Neisseria gonorrhoea, herpes simplex virus	Vaginal discharge can be produced by cervicitis without vaginal infection; can be profuse discharge with lumbosacral backache	Need to define if the pain is experienced on intercourse associated with purulent discharge; physical exam will indicate whether pain on motion during physical examination
Chlamydia: can be asymptomatic and cause pelvic inflammatory disorder	Sexually active with new boyfriend; vaginal itching not a common symptom	Need to establish if mucopurulent cervicitis is occurring; increased frequency of urination not reported; a physical exam will indicate whether pain motion during physical examination; vaginal discharge usually yellow in colour
Gonorrhoea	Vaginal discharge and abdominal discomfort vaginal discharge can be produced by gonorrhoea without vaginal infection; sexually active with new boyfriend; vaginal itching not a common symptom	Need to define if has had any recent rectal infections, pain on walking or climbing stairs; physical exam will indicate whether pain on motion during physical examination; vaginal discharge usually yellow in colour
Candidiasis (vaginal discharge, sexually active, would be detected when doing a pap smear)	Vaginal discharge, sweet cravings; constipation; Candida is common cause of vaginal discharge in adult women	Need to establish if Gia experiences external pain on urination and whether vaginal discharge has strong odour; vaginal discharge can be curdy (most common in yeast infections), recurrent and chronic episodes; symptom of vulvovaginal itching (most common in Candida infection); physical exam may indicate vulval inflammation
Inflammatory bowel disease	Abdominal and back pain prior to passing a bowel motion	No blood or mucus or episodes of diarrhoea reported; need to clarify if the abdominal pain is relieved when passing a bowel motion
Inflammatory lower back pain (fibromyositis, osteomyelitis, spinal, tubo-ovarian or rectal abscess, myelitis, endometriosis, cystitis, ankylosing spondylitis)	Lower back pain	Still need to be investigated
Trichomoniasis: a flagellated protozoon that causes vaginitis and urethritis, predominantly sexually transmitted; trichomonal vaginitis often associated with gonococcal or bacteroides cervicitis	Common cause of vaginal discharge in adult women; sexually active; common in women of child-bearing age	Usually severe local irritation and itching in vagina; vaginal discharge is usually frothy, profuse, white-greyish green, smelly discharge; increased frequency of urination not reported; can produce vaginitis with coexisting urethritis that causes pain on urination
Bacterial vaginosis: increase in aerobic bacteria (Gardnerella vaginalis) and decrease in lactobacilli	Vaginal discharge; common cause of vaginal discharge in adult women; common during reproductive years; itching not a prominent symptom; usually no symptoms of vaginal inflammation	Need to establish if vaginal discharge is offensive watery grey-white discharge, changes normal flora of the vagina; discharge is homogeneous; no increased frequency of urination reported
ENDOCRINE/REPRODUCTIVE
Ectopic pregnancy	Irregular periods; can present with no pain (rare) and can leak over several days slowly; may be missed; common cause of secondary amenorrhoea, purulent vaginal discharge	Usually associated with severe and acute abdominal pain, abdominal fullness, increased desire to urinate; may have signs of fever and dull headaches
Pregnancy [65]	Irregular periods; missed periods; most common cause of secondary amenorrhoea; can present with vaginal discharge and pelvic/abdominal pain	Can present with fever; may have signs of breast tenderness and may have morning sickness
Ovarian disease: premature menopause often due to autoimmune disease	Menses beginning to change; can present with symptoms of menopause and irregular periods	No hot flushes
Polycystic ovarian syndrome (PCOS): extremely common cause of secondary amenorrhoea; anovulatory cycles [59, 60]	Irregular menstrual cycles, lower abdominal pain, hormonal acne, increased facial and body hair (hirsutism), sugar cravings, weight gain	Check if symptom development has been slow and steady; may have thinning of hair on the head (like men do) called androgenic alopecia
Hypothyroidism: cause of secondary amenorrhoea due to hyperprolactinaemia and endocrine disorder; anovulatory cycles	Weight gain, irregular periods, constipation, increased facial and body hair (hirsutism), weight gain, constipation	No skin and hair changes mentioned; no significant fatigue, temperature intolerance or visible goitre noted; no significant depression mentioned
Cushing’s syndrome: causes amenorrhoea, irregular menstrual cycles	Irregular menstrual cycles, increased facial hair, weight gain	Check if symptom development has been rapid; no moon-shaped face, frontal balding or hypertension and oedema; no significant depression mentioned; urinalysis NAD and no indication of glucose intolerance or diabetes which can be associated with Cushing’s syndrome
Adenomyosis: benign invasion of endometrium (inner layer of uterus) into myometrium (thick muscle layer of uterus); can be associated with endometriosis, pregnancy, abortions, caesarean sections, tubal surgery	Heavy bleeding common	Common complaint that often does not cause symptoms; more often occurs between the ages of 30 and 50; can cause painful periods due to excess oestrogen
Endometriosis	Irregular periods; lower back and abdominal pain prior to menstrual bleed; can have symptoms of vaginal discharge	No significant pelvic pain or pain on menstrual bleed reported; no bleeding from the bowel; usually brown discharge with associated abdominal and pelvic pain
Dysfunctional uterine bleeding (DUB): endometrial hyperplasia, PCOS, from taking exogenous oestrogen; endocrine dysfunction not associated with inflammation, tumour or pregnancy; anovulatory hormone related bleeding is most common	Usually causes unpredictable frequency and amount of bleeding; menorrhagia (heavy bleed with regular cycle) common but interval between periods is usually shorter	No use of exogenous oestrogen reported
Anovulatory bleeding: irregular bleeding that appears to be menstrual although no ovulation has occurred; can be associated with both short and long cycles [63]	Irregular cycle; no significant premenstrual symptoms reported to show evidence of regular association with menses cycle; bleed is painless; blood volume can be excessive but irregular; physical findings will often include hirsutism, acne, and indicate PCOS	Check if bleed is unexpected; check basal body temperature, if anovulatory it will not fluctuate (monophasic)
Oestrogen-withdrawal bleeding: causes intermenstrual bleeding; occurs when the endometrium proliferates and becomes unstable when oestrogen drops below threshold; can happen outside of the secretory phase or in the absence of progesterone	Common cause of irregular periods in reproductive years, especially if ovulation has not occurred; menstrual bleeding is prolonged and profuse when does occur	Need to investigate if Gia experiences pain when bleeding as this is not usually present with oestrogen withdrawal [64]
Progesterone-withdrawal bleeding: only occurs when there is an oestrogen-primed endometrium; can occur when oestrogen therapy continued and progesterone stopped; also when progesterone is administered to test endogenous oestrogen	Irregular menstrual bleed often present in conditions such as PCOS
Oestrogen-breakthrough bleeding – 1st type: when oestrogen levels are low but constant causing sections of endometrium to degenerate	Intermenstrual bleed; common when have PCOS	Need to investigate if she experiences any spotting of blood [64]
Oestrogen-breakthrough bleeding – 2nd type: oestrogen levels are well above threshold causing endometrium to become hyperplastic and outgrow blood-borne hormone supply	Causes degeneration of endometrium with prolonged and irregular bleeding	More common in oestrogen-based tumours
Ovarian cyst	Lower abdominal pain, irregular periods	Ovarian cysts almost never cause heavy menstrual bleeding
Physiologic leukorrhoea: must be in absence of yeast infection, Trichomonas	Vaginal discharge; discharge usually thick, greyish white, no odour but profuse; usually no itching associated	More common in girls beginning their menarche
AUTOIMMUNE DISEASE
Rheumatoid spondylitis	Lower back pain; can be early signs of rheumatoid arthritis	Need further investigation
STRESS AND NEUROLOGICAL DISEASE
Causal factor: Stress	Constipation, dietary changes, increased sugar cravings, lack of exercise
New sexual relationship	Vaginal discharge, pregnancy, irregular periods	Check if using contraception
EATING HABITS AND ENERGY
Causal factor: Diet: Eating more chocolate, carbohydrates, lack of water, excess caffeine	Insulin resistance connection with symptoms of PCOS, constipation, increase stress	Need to clarify dietary changes and duration of changes
Causal factor: Lack of exercise	Affect insulin resistance, PCOS, weight gain, stress, lower back ache

TABLE 5.7 DECISION TABLE FOR REFERRAL [2, 7–10, 13]

Complaint	Context	Core
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Hirsutism associated with menstrual change and other virilising symptoms such as acne

• A menstruating woman of any age can bleed from pregnancy complications

• Irregular bleeding in menstrual cycle

• Change in volume of menstrual bleed

• Purulent vaginal discharge

• Abdominal and lower back discomfort prior to menstrual bleed

• Stress building up due to studies

ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE

Nil

• Pattern of premenstrual symptoms have stopped indicating lack of ovulation

• Bowel motion less than three times a week

• Increased weight gain and acne with associated menstrual changes

• Excess caffeine foods

• Lack of exercise

• New boyfriend and sexual relations

• New relationship may have potential to effect Gia’s studies

• Excess body waxing due to hirsutism

REFERRAL REFERRAL REFERRAL

• Medical investigation to rule out serious endocrine causes of hirsutism and symptoms of virilisation

• Medical investigations for change in menstrual cycle, abdominal and lower back discomfort

• Musculoskeletal assessment for lower back pain

• Test for sexually transmitted diseases

• Education about contraception options

• Dietary assistance to balance food intake

• Massage for relaxation

• Student counsellor for time management issues

TABLE 5.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1, 2, 6–12, 65]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Examine genitalia and note secondary sex characteristics	May indicate functional or endocrine disorder
Pelvic, vaginal, abdominal examination	Check for bulging uterus, ovaries can be palpable in PCOS, abdominal rebound tenderness, overactive bowel sounds, genital deformities, signs of trauma
Musculoskeletal examination	Back strain, trauma, deformities, inflammation
Human chorionic gonadotropin (HCG) blood test/radioimmunoassay (RIA)	Pregnancy, ectopic pregnancy
Vaginal smear	Evaluation of cervical mucus will indicate if ovarian oestrogen is being produced
Cervical smear	Detect cervical cancer
CA-125 serum marker	Ovarian cancer, endometriosis, pelvic inflammatory disease
Chlamydia cervical culture Cervical gonorrhoea culture	Sexually transmitted diseases
Full blood count	Rule out infection, tumour, inflammation, anaemia
Blood lipids	Increased possible risk for cardiovascular disease connected with PCOS [26–29]
Progesterone level	Test 7 days before menstruation to determine if ovulation has occurred; low serum progesterone level in anovulatory cycles
Oestradiol	Normal: PCOS, weight loss, excess exerciseRaised: pregnancy, ovarian tumour, testicular tumour, adrenal tumourLow: PCOS, polycystic ovarian disease, ovarian failure, anorexia nervosa, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal hyperplasia, menopause, Turner’s syndrome, failing pregnancy, fetal death
Oestrone	Elevated in PCOS due to peripheral conversion
FSH (follicle-stimulating hormone)	Normal: PCOS, pregnancy, anorexia, weight loss, excess exerciseRaised: ovarian failure, menopauseLow: polycystic ovarian disease, anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
LH (luteinising hormone): due to pulsatile action of this hormone it may not be accurately measured on one random sample	Normal: pregnancy, anorexia, weight loss, excess exerciseRaised: PCOS, polycystic ovarian disease, ovarian failure, menopauseLow: anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
PRL (prolactin): common in secondary amenorrhoea to be raised	Normal: ovarian failure, anorexia, weight loss, excess exercise, adrenal tumour/hyperplasiaRaised: PCOS (mildly), hypothyroidism, Cushing’s syndrome, pregnancy, amenorrhoeaLow: pituitary destruction from tumour
Testosterone	Normal: ovarian failure, anorexia, weight loss, excess exercise, hypothyroidism, pregnancyRaised: PCOS, Cushing’s syndrome, adrenal tumour/hyperplasia, testicular tumour, ovarian tumourLow: corticosteriod use
SHBG (sex hormone-binding globulin)	Low SHBG would indicate the presence of elevated levels of free androgens
Thyroid function testTSH, T4, T3	TSH (thyroid-stimulating hormone) increased in hypothyroidism
Fasting blood glucose test	Raised levels can indicate diabetes mellitus, Cushing’s syndrome
HOME TESTS:
Basal body temperature	Normally drops 24–36 hours after menses begins; with endometriosis there is often a delay in basal body temperature to the second or third day of menses; a decrease indicates preovulation and an increase of 5 degrees occurs after ovulation; monitors thyroid function
Ovulation prediction kits	Detects increase in urinary luteinising hormone (LH) excretion 24–36 hours prior to ovulation
IF NECESSARY:
Progesterone withdrawal test	To determine if oestrogen is being produced in the body
17-hydroxyprogesterone	Elevated in congenital adrenal hyperplasia (classic early onset) and after stimulation tests can reveal late onset
Androgens: androstenedione and dehydroepiandrosterone sulphate	Elevated in PCOS and significantly so in congenital adrenal hyperplasia and virilising tumours; androstenedione is a precursor to cortisol, aldosterone, testosterone and oestrogen; will indicate possible adrenal tumour, ovarian tumour or Cushing’s syndrome
Serum cortisol blood test	Will determine Cushing’s syndrome possible adrenal tumour and stress levels
Abdominal and pelvic x-ray/ultrasound	Most accurate diagnosis of PCOS, ovarian mass, ovarian cyst or tumour, retroverted uterus, tubo-ovarian abscesses, fibroids, trauma; intestinal obstruction
Laparoscopy and biopsy/culdoscopy	Primary diagnostic technique for endometriosis by visualising the lesions
Endometrial, vaginal and cervical biopsies	Detect cancer; during luteal phase (10–12 days after ovulation) to determine inadequate luteal phase production or action of progesterone
Transvaginal ultrasonography	To determine cause of excess and random menstrual bleeding (menometrorrhagia) such as dysfunctional uterine bleeding or cancer
Brain scan CT/MRI	Pituitary tumour
Back x-ray, CT scan and MRI	Degenerative disc disease, disc prolapse, ankylosing spondylitis, Paget’s disease, osteoporosis

Confirmed diagnosis

Gia and polycystic ovarian syndrome with anovulatory menstrual cycle and physiologic leukorrhOea

Gia is 24 years of age and has come to the clinic for help with a series of symptoms associated with an irregular menstrual cycle. Gia is most concerned about acne, increasing facial and body hair, a vaginal discharge and a change to premenstrual symptoms. Gia is coming to the end of her studies to be a teacher and admits her current lifestyle includes a lot of computer work, lack of exercise, quick meals and consuming more chocolate, cola and energy drinks to get through. She has been craving sugar and has gained weight in the past seven months. Gia has a new boyfriend and enjoys seeing him up to four evenings a week. She is looking for alternative approaches to the oral contraceptive pill for helping her menstrual symptoms.

Gia was referred for a series of medical investigations and has been diagnosed with polycystic ovarian syndrome. Gia has classic symptoms of amenorrhoea, lower abdominal pain, backache, hormonal acne, sugar cravings, weight gain and increased facial and body hair (hirsutism). Multiple cysts develop on the ovaries causing increased production of androgens. Due to low levels of follicle-stimulating hormone, excess androgens are converted to testosterone rather than oestrogen. PCOS is a metabolic condition commonly associated with insulin resistance and glucose intolerance. Due to increased levels of insulin there is a decrease in SHBG, which binds increasing free androgens. A propensity to gain weight and develop obesity will make the underlying androgen increase and insulin resistance worse.

Amenorrhoea and oligomenorrhoea associated with symptoms of virilisation, such as acne and hirsutism, develop slowly and steadily shortly after menarche for many young women. Symptoms of PCOS can begin to become very uncomfortable in the second and third decade, affecting fertility and can influence the development of hypertension, hyperlipidaemia and cardiovascular disease. It is believed that a majority of women who do not ovulate regularly have polycystic ovarian syndrome.

General references used in this diagnosis: 2, 7, 9–11, 59, 60, 62

Prescribed medication

• Oral contraceptive pill [61]

Gia wants to try natural therapies to correct her hormonal balance at this stage. In view of the recommendation to take the oral contraceptive pill, it is important to work collaboratively with Gia’s doctor to ensure her condition is monitored. Her treatment program should be reviewed in eight weeks and then again four to six weeks later. If no change has occurred after 12–16 weeks Gia should be encouraged to consider other treatment options.

TABLE 5.9 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Dietary recommendations to support hormonal balance and improve glycaemic control, which is essential in managing PCOS • Lifestyle recommendations to improve glycaemic control and control PCOS symptoms • Physical treatment suggestions to help improve hormonal balance • Herbal tonic or tablets to support ovarian function and hormonal balance • Herbal tea to support hormonal balance and glycaemic control • Supplemental nutrients to improve glycaemic control

• Dietary recommendations to improve nutrition, general health and to reduce the risk of type 2 diabetes and cardiovascular disease

• Supplemental nutrients to improve nutrient and antioxidant status, as well as to support cardiovascular health

• Recommendation for Gia to lose weight to improve general health and reduce the risk of type 2 diabetes and cardiovascular disease

• Lifestyle recommendations to help reduce Gia’s stress levels

• Herbal tonic and tea containing nervine and adaptogenic herbs to help support Gina’s stress response

• Supplemental multivitamin to help support Gia’s stress response

NB: Blood pressure and serum potassium should be monitored while Gia is taking the herbal tonic or tablets due to licorice content; dandelion leaf has been added to the herbal tonic and tea to reduce the risk of hypokalaemia and hypertension [14, 19, 20]; dietary recommendation to reduce sodium intake and increase potassium intake while taking herbal tonic or tablets [14, 19, 20]

• Review use of chaste tree if menstrual irregularity worsens [14]

• Ensure Gia is using appropriate contraception while taking the herbal tonic or tablets due to pregnancy contraindications for schisandra [23, 24] and thuja [23]

• If Gia decides to try the oral contraceptive pill, a review of her herbal medicine will be required to ensure there are no negative drug/herb interactions

Treatment aims

• Normalise hormonal balance [14, 27] and restore normal menstrual cycle [14, 27, 48].

• Reduce and manage symptoms of elevated androgens [14, 27, 48].

• Support Gia’s ovarian function [14, 48] and maintain her fertility for the future [14, 26, 27].

• Help Gia lose weight and ensure she stays within normal BMI [26, 27, 48].

• Support Gia’s stress response [26, 30].

• Improve Gia’s diet and lifestyle [26, 27, 50].

• Improve insulin sensitivity [14, 26, 27, 50] and prevent potential progression to type 2 diabetes [15, 26, 27, 48].

• Support Gia’s antioxidant status [28] and cardiovascular health [26–29, 48, 58].

Lifestyle alterations/considerations

• Gia will benefit from regular exercise to help reduce her stress levels [32, 33] and improve her symptoms [26, 50]. Exercise should include both strength training and aerobic exercise [31], which will help reduce body fat and improve skeletal muscle mass and strength. This in turn will improve glucose control [26, 31].

• Gia will benefit from a weight-reduction program to bring her back into normal BMI range [26, 27, 50] but should avoid crash dieting and short-term weight loss [26].

• Gia may find relaxation therapies such as meditation, yoga, tai chi or autogenic (self-relaxation) training helpful to reduce her stress levels [26, 33].

• If Gia is a smoker she should quit [26].

Dietary suggestions

• Encourage Gia to follow a low GI and GL diet to improve glucose control [14–18, 35, 36] and improve her skin [34]. Dietary measures are essential for the management of polycystic ovarian syndrome [14, 26, 29, 35, 50].

• Encourage Gia to reduce consumption of saturated [14, 26, 35, 50] and trans fats [26] and increase consumption of monounsaturated fats [35, 36] and omega-3 fatty acid-rich foods. Omega-3 oils confer a range of benefits for general and reproductive health in women [38] and can improve glucose metabolism [37, 38].

• Encourage Gia to increase consumption of fibre from low GI sources [14, 26, 35, 36]. Soluble fibre can reduce postprandial glucose response and improve glycaemic control [16, 17, 36].

• Gia’s diet should be high in antioxidant-rich foods such as low GI whole grains, fruit, vegetables and legumes [14, 16–18, 26, 28].

• Encourage Gia to consume phyto-oestrogen-containing foods [14]. Lignans can increase levels of SHBG and reduce the biological activity of androgens [14, 41]; they also have a positive effect on ovulation and hormonal balance [14, 39].

• Gia should reduce or eliminate alcohol consumption [26] and significantly reduce her intake of caffeine [26].

• Encourage Gia to eat foods high in B-group vitamins, zinc, chromium, potassium, magnesium and vanadium. These are essential minerals for blood glucose regulation [14, 16–18].

• Encourage Gia to reduce her sodium intake and increase potassium intake while she is taking the herbal tonic or tablets [14, 19, 20].

• Encourage Gia to regularly include cinnamon in her diet to help with glucose control [40].

Physical treatment suggestions

• Gia is likely to benefit from a course of electro-acupuncture [41, 42]. Repeated electro-acupuncture can induce regular ovulation and reduce androgen levels in women with PCOS [41] and positively alter ovarian neuroendrocrine status [42].

• Gia may find massage therapy beneficial in helping reduce her stress levels [43, 44].

• Hydrotherapy: hot sitz baths or full baths are indicated for supressed menses [52, 53]. Taking a shallow cold sitz bath and placing the feet in a hot foot bath simultaneously eases pelvic congestion [52]. Alternatively have hot foot bath with a cold compress on the sacrum (if the feet are warm there is no need to heat the pelvic area – the cold will push blood back into the pelvic organs while the feet keep the core body temperature warm) [57].

• For acute period pain spray the pelvic area with a hot hand shower for two minutes, then alternate and spray with cold water for one minute (repeat three times) [54]. Place a hot compress/fomentation on the back during menstrual pain [54]. Apply a warm castor oil pack on the abdomen/pelvic area for menstrual cramps and constipation [54].

• For constipation place a hot compress on the abdomen, then cover in plastic with a hot water bottle/heating pad on top for 12 minutes, followed by cold mitten friction for 30 seconds (repeat process three times) [54].

• Weekly contrasting treatments between menses with a hot fomentation on the back and abdomen for 15 minutes, followed by 30-second cold mitten friction. Next, apply heat to the pelvic area and back for another 15 minutes, repeat the cold mitten friction with client in the side lying position (repeat alternating procedure three times) then follow with an abdominal massage [54].

• Constitutional hydrotherapy: lumbar wrap [53, 55].

• Use a facial steam treatment to clean the skin, followed by an oatmeal face pack [56]. Finish with a cold shower on the face [52].

TABLE 5.10 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

Herb	Formula	Rationale
Paeonia Paeonia lactiflora	60 mL	Inhibits testosterone synthesis [14, 24]; enhances aromatase enzymes thereby promoting conversion of oestradiol from testosterone [14]; normalises ovarian function [14]; skeletal muscle relaxant [24]; combined with licorice, paeonia exerts a beneficial effect in PCOS [14, 19, 20, 24, 47] by improving LH:FSH ratio [14, 19, 24], reducing testosterone levels [14, 19, 20, 24, 47] and improving oestradiol to testosterone ratio [14, 24, 47]
Licorice Glycyrrhiza glabra	30 mL	Oestrogenic properties [14, 19]; adrenal tonic [19, 20]; antioxidant [19, 20]; beneficial in stress [19, 20]; mild laxative [19, 20]; beneficial in PCOS when combined with paeonia [14, 19, 20, 24, 47] – see above
Dandelion leaf Taraxacum officinale	40 mL	Diuretic [14, 20]; liver tonic [20]; rich source of potassium [14, 20]; beneficial to reduce the risk of hypokalaemia and hypertension from long-term use of licorice in herbal tonic or tablets [14]
Black cohosh Cimicifuga racemosa	20 mL	Reduces LH secretion [19, 20]; indicated for use in ovarian dysfunction [21] and PCOS [20]
Schisandra Schisandra chinensis	50 mL	Antioxidant [19, 23]; nervine tonic [23, 24]; adaptogenic [19, 23, 24]; hepatoprotective [19, 24]; improves mental, physical and sensory performance [24]; to support liver function [24, 48]
Supply:	200 mL	Dose: 5 mL 3 times daily

Chaste tree (Vitex agnus castus) 1000 mg tablet once daily

Beneficial for the treatment of latent hyperprolactinaemia [19, 20] and corpus luteum insufficiency [19, 20, 45]; beneficial in PMS [19, 20]; some women may experience a worsening of menstrual irregularity with chaste tree, so its use should be reviewed if this occurs with Gia [14]

TABLE 5.11 HERBAL TEA

Alternative to herbal liquid if Gia prefers a tea
HERB	FORMULA	RATIONALE
Paeonia root Paeonia lactiflora	2 parts	See above
Licorice root Glycyrrhiza glabra	1 part	See above
Black cohosh root Cimicifuga racemosa	1 part	See above
Hops Humulus lupulus	1 part	Mild sedative [23, 45]; oestrogenic action [19, 46]; anti-androgenic action [45, 46]; beneficial where stress and nervous tension accompanies PCOS [14]
Cinnamon bark powder Cinnamomum cassia	½ part	Antioxidant [19]; hypoglycaemic [40]; enhances insulin sensitivity [19]; traditionally used for female reproductive disorders [19]
Dandelion leaf Taraxacum officinale	1 part	See above

Infusion: 1 tsp per cup – 3–4 cups daily

TABLE 5.12 TABLET ALTERNATIVE TO HERBAL LIQUID: MAY IMPROVE COMPLIANCE

HERB	DOSE PER TABLET	RATIONALE
Paeonia Paeonia lactiflora	852 mg	See above
Licorice Glycyrrhiza glabra	847 mg	See above
Black cohosh Cimicifuga racemosa	300 mg	See above
Thuja Thuja occidentalis	250 mg	Traditionally used to support glandular function and to treat abnormal growths [49]

Dose: 2 tablets twice daily

TABLE 5.13 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
High-potency practitioner-strength multivitamin, mineral and antioxidant supplement providing therapeutic levels of B-group vitaminsDosage as per manufacturer’s instructions	To ensure adequate levels of essential nutrient and antioxidants given Gia’s current poor dietary intake; to reduce oxidative stress [28]; B-group vitamins are required for glucose metabolism [22, 19]; increased need for B-group vitamins during times of excessive stress [22, 19]; to support Gia’s cardiovascular health [28, 51]; PCOS is associated with increased risk of cardiovascular disease [28, 58]
Supplement providing a daily dose of 200 µg chromium [16, 22] and 400 mg elemental magnesium [22]	Chromium enhances the effects of insulin [22, 25]; reduces skeletal muscle insulin resistance [16]; improves glucose control [16, 22, 25]; magnesium deficiency aggravates insulin resistance [16, 19, 25]; supplemental magnesium improves glucose tolerance [25] and insulin sensitivity [19, 22, 25]
Omega-3 fish oil 3000 mg daily [19]	Beneficial to improve Gia’s reproductive health [38] and to improve glucose metabolism [37, 38]

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Endometriosis

Case history

Cathy Hall is 29 years old and has come to the clinic for natural help with her hormonal problems. She recently saw her doctor who advised her to take the oral contraceptive pill, but Cathy doesn’t think there is any point in taking it because she is not currently sexually active. Cathy explains that her parents always used natural therapies for the family’s health when she was growing up and she would like to continue to use natural therapies, partly in their memory but also because she has had positive outcomes with natural therapies in the past. Her parents were killed in a motor vehicle accident nearly four years ago. Her aunt (her father’s much younger sister) is only seven years older than Cathy and is happily married with three children. Cathy and her aunt are more like sisters than aunt and niece, and Cathy tells you since her parents died she considers her aunt to be her closest family member. Cathy spends a lot of time at her aunt’s house because she feels welcome and at home there.

Cathy’s main complaint is irregular and painful periods. She has had problems with irregular periods for the past five years, which has worsened in recent years. This concerns her because she never used to have problems with her cycle. Cathy tells you she knows when her period is coming because she experiences back pain two to three days before her period starts, which increases in intensity the day before her period and also during the bleed. Last month Cathy’s aunt took her to the family GP when Cathy was experiencing the premenstrual pain. The doctor did a pelvic and abdominal examination and ordered blood tests. The blood tests showed there was no anaemia, infection or inflammation and the doctor diagnosed her with endometriosis and prescribed the oral contraceptive pill along with ibuprofen. Cathy didn’t think to tell her doctor she sometimes has mid-cycle pain and was too embarrassed to tell him that sometimes she notices blood coming from her rectum during her period. Cathy describes the pain as dull and constant, which sometimes becomes severe. She also tells you that her digestion is ‘out of balance’, with alternating episodes of constipation and diarrhoea. During her period her bowel motions tend to be watery. Premenstrually she feels bloated, teary and generally awful. Cathy has not been sexually active for over four years and is beginning to lose hope that she will ever meet the right person, particularly because she doesn’t feel like socialising much these days due to her health problems.

Cathy works as a night shift cleaner and is on her feet for the whole shift. When she has her period she finds it very difficult to manage at work, and she is concerned that she may lose her job soon because she has called in sick so often in the past few months. She knows her shift team leader is getting fed up with the amount of time she is taking off and the pressure it puts on other team members, which she feels really bad about.

Cathy tells you she had considered becoming a nurse when she was much younger, and cleaning was only meant to be a short-term job for a few years to help her save up money so she could study. Eleven years later she is still there and beginning to wonder whether she will ever study. Cathy explains that her father was a member of Australia’s ‘stolen generation’ of Aboriginal children and, in the years just prior to his death, he reconnected with the remote community he originally came from. When she talked about becoming a remote area nurse and working in his community, it made her dad very happy and proud. She confesses she sometimes wonders whether the desire to work as a remote area nurse is really her dream or her father’s dream for her.

TABLE 5.14 COMPLAINT

Analogy: Skin of the apple

Complaint: Define the presenting complaint and symptoms; understand the complaint

Menstrual pain

AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset Menstrual problems started 5 years ago and are worsening Timing Pain occurs prior to her period and during her menstrual bleed Exacerbating factors Have you noticed anything that makes your symptoms worse? If I’m standing up for a lot of time and doing hard physical work. Relieving factors Have you noticed anything that makes your symptoms better? Ibuprofen, rest and heat packs. Location and duration Can you tell me where you experience the pain and how long it lasts? Lower back before my period and then in my lower abdomen and down into my legs during my period. It starts to get better in the last couple of days of my period. Rating scale Can you rate your pain on a scale of 10, with 1 being no pain and 10 being the worst pain you have ever had? Before my period, the back pain is probably a 5 or 6 and sometimes during my period it gets to an 8.

TABLE 5.15 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
Does anyone else in your family have similar problems?	I don’t think so.
Trauma and pre-existing illness
Have you ever had trauma to your abdominal or pelvic area?	No.
Recreational drug use
Do you ever take recreational drugs?	Not for years.
Surgery and hospitalisation
Have you ever had surgery or been in hospital?	No.
Occupational toxins and hazards
What kind of cleaning chemicals do you use at work?	A few. I always wear gloves and sometimes a mask if it smells really bad. I haven’t really asked my boss much about the chemicals we use.
Infection and inflammation
Have you noticed your bowel motions floating in the toilet bowl with mucus? (inflammation, pancreatic disorder)	Not that I’ve noticed, sometimes they seem to float more.
Stress and neurological disease
Do you experience more diarrhoea in times of emotional stress? (nervous diarrhoea with no presence of blood or mucus in stool)	Yes, I’m scared I might lose my job because I’ve taken so much time off work. Maybe that would be a good thing because it would make me go back to study.
Eating habits and energy
Tell me about your daily diet and energy levels.	Cathy’s diet consists of significant amounts of refined carbohydrates, animal protein and smaller amounts of whole grains, fruit and vegetables. She doesn’t eat fish often and knows she should drink more water. She has about three cups of coffee a day, and more when she is working.She says her energy levels are good most of the month but not good during her period.

TABLE 5.16 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Support systems
Apart from your aunt, who would you go to for support?	My older brothers, and my mother’s family.
Emotional health
How do you feel you are emotionally at the moment?	I’m better than I was a few years ago, but I still get really sad sometimes when I think of my children (if I ever have any) not having grandparents.
Stress release
When you feel stressed what do you do?	Sometimes I go for a swim or a bike ride and sometimes I talk to my aunt, we’re really close.
Family and friends
Tell me more about your other family.	I am very close to my brothers but neither lives close. I have some friends from work I go out with sometimes and I still keep in touch with a couple of friends from school.
Education and learning
What do you understand about your menstrual problems and what might be causing them?	I don’t really understand it. Maybe if I studied nursing I would understand it better. I think maybe there is something to do with stress since it got much worse after my parents passed away.
Long-term goals
Do you have any long-term goals?	I don’t know, maybe I’m a bit confused about my life and what I’m supposed to be doing. I think I want to study nursing, but maybe I’m only thinking that because I know it would make dad happy and I don’t want to be a cleaner for the rest of my life. I think I’d like to have a family like my aunt, but there isn’t anyone special in my life right now and sometimes I think there never will be.
Has not been well since
How do you feel your parent’s death has impacted your health?	I think the stress has made my periods worse since the pain got really bad after their accident. I think I struggle with depression sometimes too because of it.

TABLE 5.17 CATHY’S SIGNS AND SYMPTOMS

Waist circumference

No abnormality detected (NAD)

TABLE 5.18 RESULTS OF MEDICAL INVESTIGATIONS [1–4, 7, 10, 11]

TEST	RESULT
Pelvic and abdominal examination	Tender on palpation
Urinalysis	NAD
Human chorionic gonadotropin (HCG) to test pregnancy, ectopic pregnancy	Negative
Full blood count	NAD
ESR	Raised
Progesterone level	Test 7 days before menstruation revealed ovulation Result: low reading
Oestradiol	Raised: pregnancy, ovarian tumour, testicular tumour, adrenal tumour, endometriosis [45] *Ruled out:* Normal result: PCOS, weight loss, excess exercise Low: PCOS, polycystic ovarian disease, ovarian failure, anorexia nervosa, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal hyperplasia, menopause, Turner’s syndrome, failing pregnancy, fetal death
FSH (follicle-stimulating hormone)	Normal result: PCOS, pregnancy, anorexia, weight loss, excess exercise, endometriosis *Ruled out:* Raised: ovarian failure, menopause Low: polycystic ovarian disease, anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
LH (luteinising hormone): due to pulsatile action of this hormone it may not be accurately measured on one random sample	Normal result: pregnancy, anorexia, weight loss, excess exercise, endometriosis *Ruled out:* Raised: PCOS, polycystic ovarian disease, Ovarian failure, menopause Low: anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
PRL (prolactin): common in secondary amenorrhoea to be raised	Normal result: ovarian failure, anorexia, weight loss, excess exercise, adrenal tumour/hyperplasia, endometriosis *Ruled out:* Raised: PCOS (mildly), hypothyroidism, Cushing’s syndrome, pregnancy, amenorrhoea Low: pituitary destruction from tumour
Testosterone	Normal: ovarian failure, anorexia, weight loss, excess exercise, hypothyroidism, pregnancy, endometriosis *Ruled out:* Raised: PCOS, Cushing’s syndrome, adrenal tumour/hyperplasia, ovarian tumour Low: corticosteriod use
SHBG (sex hormone-binding globulin)	Normal result: low SHBG would indicate the presence of elevated levels of free androgens
CA-125 serum marker	Raised: can indicate ovarian cancer, endometriosis, pelvic inflammatory disease
Abdominal and pelvic x-ray/ultrasound [61]	Revealed no acute cholecystitis, aortic aneurysm, acute appendicitis, PCOS, ovarian mass, ovarian cyst or tumour, retroverted uterus, tubo-ovarian abscesses, fibroids, trauma
Laparoscopy and biopsy/culdoscopy	Positive for endometriosis lesions
Cervical pap smear	Regular check for cervical cancer

TABLE 5.19 UNLIKELY DIAGNOSTIC CONSIDERATIONS [1–5, 7, 9, 55]

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Ovarian, pituitary or adrenal tumour: will affect androgen levels, produce symptoms of irregular cycles, lower abdominal pain [59]	Full blood count NAD; no changes in smell or taste, headaches mentioned indicating a brain tumour; no significant increased facial hair, depression, weight gain
Abdominal aneurysm Phlebitis of iliac veins and inferior vena cava: deep pain in lumbosacral region; can cause acute pain if likely to rupture; steady pain; pain on standing, aching in the groin; history of taking the OCP could be risk factor	Usually indicated in older age groups; unknown if Cathy has previously taken the OCP; abdominal ultrasound clear
Neoplasm: spinal cord, lumbar, Hodgkin’s lymphoma, metastatic carcinoma, myeloma, haematoma	Full blood count NAD; no history of primary cancer
OBSTRUCTION AND FOREIGN BODY
Intestinal obstruction (bowel cancer, adhesions, hernias): abdominal distension and pain	Abdominal ultrasound showed no obstructions; no vomiting or weight change
DEGENERATIVE AND DEFICIENCY
Anaemia	Full blood count NAD
INFECTION AND INFLAMMATION
Inflammatory bowel disease: Crohn’s disease, diverticulitis, ischaemic colitis, regional ileitis, amoebic colitis, autoimmune granulomatous colitis; ESR raised	No sign of anaemia of chronic disease; abdominal ultrasound did not reveal signs of bowel inflammation
Pelvic inflammatory disorder: abdominal pain, could be from a sexually transmitted disease; causes abdominal pain; irregular periods, lower backache; ESR raised	Purulent vaginal discharge, need to be sexually active; physical exam revealed no motion of cervix
Appendicitis/Meckel’s diverticulum: intermittent lower abdominal pain, constipation; common age group	Abdominal ultrasound showed no signs of inflammation at appendix
Cystitis: abdominal pain, ESR raised	Urinalysis NAD
ENDOCRINE/REPRODUCTIVE
Diabetes: anovulatory cycles	Urinalysis NAD
Hypothyroidism: cause of secondary amenorrhoea due to hyperprolactinaemia and endocrine disorder; anovulatory cycles sadness, fatigue, constipation	Thyroid function tests revealed no abnormality; no weight gain, increased facial and body hair (hirsutism), weight gain; no skin and hair changes mentioned; no significant temperature intolerance or visible goitre noted
Pregnancy: irregular periods; missed periods; most common cause of secondary amenorrhoea; can present with vaginal discharge and pelvic/abdominal pain [59]	Negative HCG blood test; can present with fever; may have signs of breast tenderness and may have morning sickness
Ectopic pregnancy: irregular periods; can present with no pain (rare) and can leak over several days slowly; may be missed; common cause of secondary amenorrhoea; usually associated with severe and acute abdominal pain, abdominal fullness, increased desire to urinate; may have signs of fever and dull headaches	Negative HCG blood test
Primary dysmenorrhoea: period pain and watery stools with menstrual bleed [53, 58]	Period pain usually begins with menarche and is often associated with no pelvic abnormality, nausea vomiting, headache and dizziness
Twisted uterine fibroids and polyps: twisted fibroids can cause symptoms of severe dysmenorrhoea, heavy bleeding, back pain and sometimes vaginal discharge	Usually maintains normal cycle unless submucosal or nearly extruded; causes uterine enlargement; usually causes menorrhagia (blood loss of 80 mL per day and lasting more than 7 days); fibroids form due to excess oestrogen; unless twisted, fibroids do not usually present with pain
Anovulatory bleeding: irregular bleeding that appears to be menstrual although no ovulation has occurred; can be associated with both short and long cycles; blood volume can be excessive but irregular [51]	Usually no significant premenstrual symptoms reported to show evidence of regular association with menses cycle; bleed is painless; physical findings will often include hirsutism, acne, and indicate PCOS; hormonal tests revealed ovulation is occurring
Polycystic ovarian syndrome (PCOS): extremely common cause of secondary amenorrhoea; anovulatory cycles; irregular menstrual cycles, lower abdominal pain	No signs of significant hormonal acne, increased facial and body hair (hirsutism), sugar cravings, weight gain; hormonal levels did not show raised androgens
Ovarian disease: premature menopause often due to autoimmune disease; menses beginning to change; can present with symptoms of menopause and irregular periods	No hot flushes; blood tests did not reveal hormone levels as menopausal
Adenomyosis (benign invasion of endometrium into myometrium)	Common complaint that often does not cause symptoms; more often in late reproductive years; heavy bleeding common
Retroverted uterus (congenital): pelvic pain	Abdominal ultrasound showed uterus not retroverted

TABLE 5.20 CONFIRMED DIAGNOSIS [1–4]

CONDITION	RATIONALE
Secondary dysmenorrhea (acquired due to a pathology)	Period pain begins several years after menarche and is due to a pelvic abnormality
Endometriosis	Irregular periods, severe episodes of pain before and during menstrual bleed, bleeding from the bowel, lower back pain; pain on passing a bowel motion; period pain becomes worse with every cycle; pelvic and lower back pain
Test results	Laparoscopy revealed endometrial lesions; ESR blood test raised; raised oestradiol levels; low progesterone reading

Case analysis

TABLE 5.21 POSSIBLE FURTHER DIFFERENTIAL DIAGNOSIS [1–4, 6, 9, 55]

Not ruled out by tests/investigations already done
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
TRAUMA AND PRE-EXISTING ILLNESS
Causal factor: Trauma: recent curettage, foreign body insertion, sexual abuse, aggressive masturbation	Pelvic and lower back pain; rectal bleeding	No history of pregnancy or sexual abuse revealed at this stage
Causal factor: Trauma: strains, sprains, tear, herniated disc, fracture, disc prolapse	Work strain and lower back pain; standing for long periods of time at work
Congenital disorders: spina bifida, scoliosis, spondylolisthesis	Lower back pain
FUNCTIONAL DISEASE
Irritable bowel syndrome	Symptoms fluctuate between constipation and diarrhoea; bloating, abdominal distension and pain	Pain not necessarily relieved by passing a bowel motion
Causal factor: Faulty posture	Strain and standing for long periods of time at work
Haemorrhoids	Rectal bleeding	Unsure whether the bleeding is mixed in the stools or from the rectum
Colon polyps	Bleeding, changes in bowel habit, pain in passing a stool	Unsure of the colour of blood and stools
Anal fissures	Painful bowel motions, rectal bleeding; lower back pain	Unsure whether Cathy’s bleeding is mixed in the stools or from the rectum
DEGENERATIVE AND DEFICIENCY
Degenerative and deficiency diseases: osteomalacia, osteoporosis, osteoarthritis, lumbar spondylosis [56]	Lower back pain, physical strain at work; lumbar spondylosis can be symptomless or cause progressive spinal pain and stiffening; ESR blood reading raised	No diagnosed risk factors such as inflammatory bowel disease, vitamin D deficiency; no known familial tendency for osteoarthritis or osteoporosis at this stage
INFECTION AND INFLAMMATION
Inflammatory lower back pain: fibromyositis, osteomyelitis, spinal, tubo-ovarian or rectal abscess, myelitis, ankylosing spondylitis	Lower back pain; ESR raised	Requires further investigation
ENDOCRINE/REPRODUCTIVE
Infertility	May be a secondary issue from endometriosis due to distortion of pelvic cavity, impaired ovum pick up and tubal transport mechanisms, increased incidence of luteal phase dysfunction, trapped oocyte, increased peritoneal prostaglandin production and/or increased peritoneal macrophage activity	No history of attempting to become pregnant; unknown at this time
Premenstrual syndrome	Feels teary, bloated and swollen 1–12 days before period; experiences a dull pelvic ache, abdominal bloating	Symptoms not necessarily ameliorated after menses begins
Ovulatory bleed: check basal body temperature – will be biphasic and fluctuate, indicating ovulation has occurred	Feels emotional, premenstrual symptoms such as ovulation pain (mittelschmerz) and mood changes	Has a bleed mid-cycle as well as regular menses and ovulation has occurred; usually spotting or a light bleed at the time of ovulation, regular cycle
Dsyfunctional uterine bleeding (DUB): [60] endometrial hyperplasia, PCOS, from taking exogenous oestrogen; endocrine dysfunction not associated with inflammation, tumour or pregnancy	Usually causes unpredictable frequency and amount of bleeding	No use of exogenous oestrogen reported; menorrhagia (heavy bleed with regular cycle) is common but the interval between periods is usually shorter
AUTOIMMUNE DISEASE
Coeliac disease	Fluctuation between constipation and diarrhoea, feels bloated; abdominal pain	No indication symptoms become worse with diet
STRESS AND NEUROLOGICAL DISEASE
Psychogenic back pain	Cathy is not happy with her employment
Depression	Lack of social support, unhappy in employment, not confident she could have a relationship
Posttraumatic stress disorder	Parents’ sudden death 4 years ago changed her life significantly; stress can contribute to premenstrual symptoms [54, 57]
Anxiety	Cathy spends most of her time with her aunt; lack of social network; Cathy is worried about how her health is affecting her employment
Low self-esteem	Cathy does not believe she will meet the right person to have a relationship with

Working diagnosis

Cathy and endometriosis

Cathy is a young woman showing signs of low self-esteem and depression after the death of her parents four years ago. Cathy has experienced worsening reproductive symptoms that suggest endometriosis. This is a benign disease where functioning endometrial tissue is present in sites outside of the uterine cavity. Endometriosis is usually confined to the surfaces of intra-abdominal organs, most commonly the ovaries, posterior broad ligament, posterior cul-de-sac and the uterosacral ligaments. Less commonly it can be found in the small and large bowel, ureters, bladder, vagina, surgical scars and pleural cavity. A retrograde flow of menstrual tissue through the fallopian tubes may cause intra-abdominal endometriosis and lymphatic and circulatory systems may contribute to endometriosis reaching more distant areas in the body. It often develops for women aged 25–45 years who are menstruating and there may be family inheritance pattern and/or late child-bearing. Clinical symptoms that develop include secondary dysmenorrhoea, irregular periods and infertility. Symptoms of endometriosis can range from being asymptomatic to incapacitating pain that can occur after several years of pain-free periods. If endometrial lesions are in the large bowel or bladder symptoms can worsen at the time of menses to include pain on passing a bowel motion, rectal bleeding, abdominal bloating or pain on urination. Bleeding from the endometrial tissue is believed to set up an inflammatory process that causes adhesion formation.

General references used in this diagnosis: 1–4, 45

TABLE 5.22 DECISION TABLE FOR TREATMENT PRIOR TO REFERRAL

Complaint	Context	Core
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Acute herbal tea or tonic to be taken during the menstrual bleed. • Lifestyle and self-care practices to help manage acute pain • Physical therapy recommendations to help manage acute pain

• Dietary recommendations to improve general health, hormonal balance and to reduce inflammation

• Lifestyle and self-care practices to improve health and wellbeing and help improve reproductive health

• Lifestyle recommendations to address underlying emotional/psychological issues

• Physical therapy suggestions to support Cathy’s stress response and emotional health

TABLE 5.23 DECISION TABLE FOR REFERRAL [1–5, 8, 9]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Blood from the rectum during menstruation	• Experiences back pain before her period	• Cathy does not believe she can have an intimate relationship
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Cathy did not feel comfortable to let her GP know about the rectal bleeding	• Back pain is significant enough to be affecting her employment responsibilities • Digestion is not optimal and Cathy experiences both constipation and diarrhoea episodes	• Cathy has concerns about her job security • Spending more time at her aunt’s house than her own home
REFERRAL	REFERRAL	REFERRAL
• Referral to a GP for another opinion on the bleeding	• Suggest musculoskeletal assessment • Suggest digestive assessment	• Suggest Cathy seeks counselling to deal with underlying anxiety and emotional problems

TABLE 5.24 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–4, 7, 10, 11, 56]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Musculoskeletal assessment	Deformity, joint movement/pain or swelling, muscle wasting or weakness, gait abnormalities, structure of spine and movement, general posture
Neurological assessment	Assess speech, language, facial expression, neck stiffness, orientation, memory, judgement and reasoning, cranial nerves, motor function (reflexes and tone), coordination, sensory function of skin, joints and temperature feeling, general observation of mood and behaviour
Stool test	Rule out parasitic infections and occult blood that suggests possible diagnosis of diverticulosis, ulcers, polyps, inflammatory bowel disease, and GI tumour, haemorrhoids, H. pylori; if acidic stools are passed it indicates lactose intolerance
Basal body temperature	Normally drops 24–36 hours after menses begins; with endometriosis there is often a delay in basal body temperature to the second or third day of menses [3]
IF NECESSARY:
Sigmoidoscopy	Haemorrhoids, polyps, anal fissures, irritable bowel syndrome, Crohn’s disease
Back x-ray, CT scan and MRI	Degenerative disc disease, disc prolapse, ankylosing spondylitis, Paget’s disease, osteoporosis
Serum alkaline phosphatase, plasma calcium, serum phosphate, serum 25-hydroxyvitamin D3	Osteomalacia, Paget’s disease

Confirmed diagnosis

Cathy has endometriosis with premenstrual syndrome.

Prescribed medication

• Oral contraceptive pill [52]

Cathy has chosen not to take the OCP at this stage, preferring to try natural therapies first. It is imperative that Cathy’s case is managed collaboratively with her GP to ensure appropriate and effective monitoring and treatment of her condition.

TABLE 5.25 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Continue with lifestyle and self-care practices for acute pain management as necessary • Continue with physical therapy recommendations for acute pain management as necessary • Continue with acute herbal tea or tonic as required during the menstrual bleed; acute formula reviewed after three months • Continue with dietary recommendations to improve reproductive health and hormonal balance and to reduce inflammation • Continue with nutritional supplements to reduce inflammation and regulate hormone balance; to be reviewed after 3 months NB: Cathy’s vitamin and mineral levels should be monitored to ensure her levels stay within normal range; supplementation dosage can be reviewed if necessary

• Continue with lifestyle and self-care practices to improve general health and wellbeing and reproductive system health

• Continue with dietary recommendations to improve general health, nutrition, hormonal balance and manage food allergies or intolerances (if present)

• Continue with physical therapy suggestions to improve general health, enhance detoxification and improve hormonal balance and reproductive health

• Herbal tonic or tea with hormonal balancing, detoxification, anti-inflammatory, immunomodulatory and spasmolytic action; to be reviewed after three months; dong quai in Cathy’s herbal tonic is contraindicated in heavy menstrual bleeding so her menstrual bleeding should be monitored to ensure there are no problems; reformulate tonic if necessary and review formula after four months of treatment

• Nutritional supplements to modulate the immune response, improve digestive health and hepatic detoxification; to be reviewed after 3 months

• Recommendation for counselling to help Cathy deal with her grief and anxieties

• Multivitamin support for general health and nervous system support

• Regular exercise, massage, acupuncture, meditation and visualisation exercises

• Self-care help to increase relaxation and cleansing

Lifestyle alterations/considerations

• Encourage Cathy to take up regular exercise [15].

• Functional breathing exercises [46].

• Cathy may benefit from counselling to deal with the grief associated with the loss of her parents and to work through issues surrounding her desire to study nursing.

• Cathy should avoid using tampons. There is a link between the long-term use of tampons and endometriosis [33].

• Encourage Cathy to minimise her exposure to environmental toxins and xeno-oestrogens, which have been implicated in the development of a variety of hormonal imbalances and reproductive problems [33, 34].

• Skin brushing to encourage circulation and detoxification [40].

• Suggest Cathy uses stress-management techniques such as meditation and visualisation exercises [15].

• Encourage wider social support and group activities that interest Cathy [15].

Dietary suggestions

• Reduce consumption of sugar, dairy foods and red meat [9].

• Increase consumption of soluble fibre [9] and omega-3 essential fatty acids [9, 15].

• Eliminate or significantly reduce consumption of caffeine [25] and alcohol [26].

• Increase consumption of indole-3 carbinole-containing foods (cruciferous vegetables), which help modify oestrogen metabolism [9, 24, 49] and foods that enhance phase 2 liver function to support oestrogen clearance [9, 15]. Adding turmeric to food can help increase bile secretion and decrease inflammation [9, 17, 19].

• Increase consumption of phytoestrogen-rich foods and lignans, which can competitively inhibit endogenous oestrogen and help improve hormonal balance [9, 47, 48].

• Consider a withdrawal challenge followed by an elimination/rotation diet for Cathy. Women with endometriosis have a higher incidence of allergies [27].

• Encourage Cathy to eat a whole-food diet containing plenty of antioxidant-rich foods [28, 29].

Physical treatment suggestions

• Cathy may benefit from a course of acupuncture to assist with hormonal balance and stress management [35].

• Hydrotherapy: for acute period pain spray the pelvis area with a hot hand shower for two minutes, then alternate and spray with cold water for one minute (repeat three times) [40]. Apply a hot compress/fomentation on the back during menstrual pain [40]. Place a warm castor oil pack on the abdomen/pelvic area for menstrual cramps and abdominal discomfort [40].

• A hot foot bath will stimulate menstrual bleed [42].

• Hot sitz baths will ease pain and stimulate menstrual bleed [42, 43].

• Between periods, apply weekly contrasting treatments with a hot fomentation on the back and abdomen for 15 minutes, followed by 30-second cold mitten friction. Next, apply heat to the pelvic area and back for another 15 minutes, repeat cold mitten friction with the client in the side lying position (repeat alternating procedure three times) then follow with an abdominal massage [40].

• Constitutional hydrotherapy: lumbar wrap [41, 44].

Herbal formula (1:2 liquid extracts)

Given the complex aetiology of, and symptom management required for, this condition, it is likely to be necessary to provide Cathy with two different formulas. One to be taken during her period to assist with symptom relief, and the other to be taken the rest of the month to balance hormones and address underlying causes.

TABLE 5.26 HERBAL TONIC TO BE TAKEN DURING THE MONTH

HERB	FORMULA	RATIONALE
Dong quai Angelica sinensis	40 mL	Anti-inflammatory [15, 16]; regulates uterine function [15, 16]; traditionally used for dysmenorrhoea [17, 18]; contraindicated if there is a tendency to excessive bleeding or heavy menstrual bleeding [18]
Paeony Paeonia lactiflora	55 mL	Antispasmodic [15, 18]; anti-inflammatory [15, 18]; traditionally used for dysmenorrhoea [15, 18]
Calendula Calendula officinalis	20 mL	Spasmolytic [20]; anti-inflammatory [19, 20]; emmenagogue [20]; antioxidant [19]; immunomodulator [19]
Schisandra Schisandra chinensis	45 mL	Nervine [18]; tonic [18]; adaptogenic [18, 19]; liver tonic [18, 19]; antioxidant [19]; anti-inflammatory [19]; used for improving liver function and improve the detoxifying capacity of the liver [18]; improves mental, physical and sensory performance [18]; indicated for use in hormonal disorders related to oestrogen excess [15]
Ginger Zingiber officinale	10 mL	Anti-inflammatory [17, 19]; antioxidant [19]; immunomodulator [19]; anxiolytic [19]; circulatory stimulant [17]; traditionally used for dysmenorrhoea [17, 19]
Rosemary Rosemarinus officinalis	30 mL	Hepatoprotective [19]; anti-inflammatory [19]; antioxidant [19, 36]; increases oestrogen metabolism [19, 22]; circulatory stimulant [36]
Supply:	200 mL	Dose: 5 mL 3 times daily

Chaste tree (Vitex agnus castus) 1000 mg daily (2 mL of 1:2 liquid extract or as a tablet)

Enhances development of corpus luteum and can correct relative progesterone deficiency [17], and in conditions such as endometriosis where oestrogen imbalance is involved [23]

TABLE 5.27 ‘ACUTE’ HERBAL FORMULA TO BE TAKEN DURING THE BLEED

HERB	FORMULA	RATIONALE
Cramp bark Viburnum opulus	30 mL	Spasmolytic [15]; mild sedative [21]
Corydalis Corydalis ambigua	60 mL	Analgesic [18]; sedative [18]; used for organ pain, blood stasis and dysmenorrhoea [18]
Pasque flower Pulsatilla vulgaris	10 mL	Spasmolytic [20, 37]; analgesic [20, 37]; sedative; traditionally used for inflammation or painful conditions of the female reproductive tract [20, 37]
Supply:	100 mL	Dose: 5 mL 3–5 times daily as required during menstrual period

TABLE 5.28 HERBAL TEAS

Alternative to liquid herbal tonic if Cathy prefers a tea Daily formula
HERB	FORMULA	RATIONALE
Calendula flowers Calendula officinalis	½ part	See above
Black cohosh root Cimicifuga racemosa	1 part	Uterine tonic [17, 20]; antispasmodic [17, 20]; traditionally used for dysmenorrhoea [17, 20]
False unicorn root Chamaelirium luteum(cultivated/plantation source)	1 part	Uterine tonic [20, 36]; oestrogen modulating [20, 36]; traditionally used for dysmenorrhoea [20, 36]
Chaste tree berries Vitex agnus castus	1 part	See above
Ginger root Zingiber officinale	½ part	See above

Decoction: 1 cup 3 times daily

TABLE 5.29 HERBAL TEA

‘Acute’ herbal formula to be taken during the bleed; alternative to liquid herbal tonic if Cathy prefers a tea
HERB	FORMULA	RATIONALE
Cramp bark Viburnum opulus	1 part	See above
Pasque flower Pulsatilla vulgaris	1 part	See above
Wild yam root Dioscorea villosa	1 part	Spasmolytic [19, 20]; anti-inflammatory [19, 20]; autonomic nervous system relaxant [19]; indicated for dysmenorrhoea and uterine pain [19, 20]

Decoction: 1 cup four times daily during menstrual bleed as required

TABLE 5.30 NUTRITIONAL SUPPLEMENTS

Omega-3 fish oil 3 × 1000 mg capsule twice daily [38]	Anti-inflammatory [19, 30, 38, 39]; suppress production of pro-inflammatory cytokines [19]; regulates inflammatory prostaglandin formation [38, 39]; regulates prostaglandin imbalance [30]; indicated for use in dysmenorrhoea [19]
High-potency practitioner-strength women’s multivitamin, mineral and antioxidant supplement containing therapeutic doses of B-group vitamins, beta carotene and selenium [9, 15] Daily dose as recommended by manufacturer	Women with endometriosis have lower antioxidant levels [28]
Vitamin E 500–800 IU daily [15, 19, 39]	Reduces adhesion formation [31]; aids removal of debris in pelvic fluid via white cells [32]; regulates oestrogen ratio [8]
Vitamin C 6000 mg daily in divided doses [9, 38]	Antioxidant [19, 38, 39]; increases cellular immunity and decreases capillary wall fragility [9, 19, 38]; high doses of vitamin C may help reduce pain [38]
Supplement providing approx 1000 mg choline bitartrate and 1000 mg of dl-Methionine or cysteine 3 times daily [9] May be necessary to support detoxification if tests provide evidence of exposure to toxic chemicals or heavy metals	Lipotrophics; supports liver detoxification functions and aids with removal of oestrogen metabolites and environmental toxins [9, 38, 39]

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Menopause

Case history

Maggie Lefevre, 49, has come to the clinic with symptoms of fatigue and hot flushes. Maggie has been experiencing increasing fatigue over the past 12 months and flushes for the past three months. During the day the flushes don’t particularly bother her, although she gets a bit sweaty and uncomfortable in bed at night, which is disturbing her sleep.

Maggie and her husband Rene live on a small property where they grow organic produce for the restaurant market. Maggie tells you she met Rene while she was travelling in Europe 27 years ago and they married 25 years ago. For many years they travelled the world and enjoyed a nomadic lifestyle and finally settled down in Australia 13 years ago to grow vegetables and start a family. Unfortunately they weren’t able to have a baby. Maggie realises now they probably left it too late to start a family when she was 36 and sometimes wishes they had settled down earlier, although Rene wasn’t ready to stop travelling before then even though she was ready to settle down in her early 30s. Maggie does have regrets about this, which are intensifying now that she realises her time for having children has passed.

Maggie’s cycle has been changing in the past few years. For as long as she can remember her period lasted for around six days and she had a very regular 28-day cycle. Since she turned 47 her cycle has become irregular and usually only lasts 25–26 days. Her bleed has also changed and she gets a couple of days of spotting before her bleed and when it does start it is heavy for about 36 hours and has clots in it; the bleed then tapers off very quickly and is usually all over by the third or fourth day. Maggie is also noticing vaginal dryness and now needs to use lubricants during intercourse.

When asked about her menstrual and reproductive history, Maggie tells you she has no history of menstrual problems although she had an abortion at the age of 22 when she first met Rene. She has been thinking a lot about missed opportunities recently.

Maggie is also noticing changes to her body; her breasts are starting to sag and her skin is getting dryer and she has put on about 2 kg in the past three years even though she doesn’t think her diet or lifestyle have changed. Maggie confesses she is a little concerned about losing her youthful looks. Rene is 10 years older than her but is still very vital and good looking. Maggie quickly adds that Rene has given her no reason to be concerned about this but she is aware he comes into contact with a lot of beautiful younger women in the course of his business. She also feels she is more emotional than she used to be.

Maggie feels her diet is very good. Rene worked as a chef for many years and they mostly eat the organic food they grow on their farm. She drinks wine occasionally and has never smoked.

Maggie has been to her doctor who did some blood tests and told her she is perimenopausal. Although she is still ovulating, her hormone levels are dropping. Maggie’s doctor referred her to your clinic when she told him she would prefer natural therapies for her symptoms. Maggie feels natural therapies are more in keeping with her lifestyle as an organic farmer.

TABLE 5.31 COMPLAINT

Analogy: Skin of the apple

Complaint: Define the presenting complaint and symptoms; understand the complaint.

Hot flushes

Fatigue

AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset When did you first begin to experience the flushes and fatigue? The flushes have been happening for about 3 months and I’ve been feeling tired for about 12 months. Timing

When and how often do you experience the flushes?

When do you feel fatigue?

I feel the flushes during the day, but they don’t particularly bother me. They’re more of a problem at night because they are disturbing my sleep.

I’m feeling tired generally, but since the flushes started it’s really hard to get out of bed in the morning because I don’t feel refreshed.

Exacerbating factors Is there anything that makes your symptoms worse? If the weather is warm I notice the flushes more, and it is always worse at night. I’m tired all the time, but I guess it’s probably worse in the morning until I have a coffee. Relieving factors Is there anything that makes your symptoms better? Not really. I suppose if I could get better sleep at night I might not feel so tired in the morning.

TABLE 5.32 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Surgery and hospitalisation
Have you every had surgery or been in hospital?	I had a pregnancy termination when I was 22. Rene and I had just met and when I found out I was pregnant we both felt we weren’t ready to have a child.
Supplements and side effects of medication
Do you take any supplements or medications?	Not usually. I started taking a multivitamin a couple of months ago to see if it would help improve my energy. It did seem to help, but in the past couple of months I’ve been feeling really tired.
Endocrine/reproductive
Tell me about your menstrual cycle.	For most of my adult life it has been really regular, every 28 days. In the last couple of years it has changed and now it comes every 25 or 26 days and the bleed is much lighter and it doesn’t last as long. The other thing that has changed is that in the first couple of days I get clots, but no pain.
Stress and neurological disease
Do you feel stressed or anxious at the moment?	I have started to notice I’m feeling more anxious, particularly in the week before my period. That never used to happen. I’m also feeling a bit anxious about how my body is going to change after menopause.

TABLE 5.33 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Daily activities
Describe your daily routine.	We usually get up around 5.30 to get the vegetables ready to take to the market. Breakfast is at 7 and then we usually work around the house or farm all day if we don’t have to go out. I stay home more than Rene. We eat dinner around 6 and are in bed by 9 or 9.30.
Stress release
How do you manage your stress?	I don’t usually feel stressed, except for the last few months. Walking or working in the gardens usually helps.
Occupation
Do you enjoy your work?	Yes, we’re both doing what we always wanted to do.
Family and friends
Do you spend much time with family and friends?	My sister and her family live close and we have lots of friends in the local area. We have quite an active social life.
Home life
How are things at home?	Rene and I have always gotten along really well, and he has always been a wonderful husband. There is a little more stress at the moment because I get tired and irritable. Sometimes I worry that he might find somebody else more attractive as I get older, but there’s never been any problems like that.
Action needed to heal
How do you think I can help you?	I was hoping for some dietary and lifestyle suggestions, and perhaps some herbs to help. I’m willing to try whatever you suggest.
Long-term goals
What are your long-term goals?	I hope we can stay doing what we’re doing for as long as possible.

TABLE 5.34 MAGGIE’S SIGNS AND SYMPTOMS

TABLE 5.35 RESULTS OF MEDICAL INVESTIGATIONS [2, 7–11, 13]

TEST	RESULTS
Pelvic, vaginal, abdominal examination	No bulging uterus, rebound tenderness, overactive bowel sounds, genital deformities, signs of trauma
Human chorionic gonadotropin (HCG) blood test/radioimmunoassay (RIA)	No sign of pregnancy or ectopic pregnancy
Full blood count	NAD
CRP/ESR	NAD
Blood cholesterol	Normal range
Female – progesterone level	Low serum progesterone level
Female – oestradiol (the major from of oestrogen in the blood and urine)	Low: PCOS, polycystic ovarian disease, ovarian failure, anorexia nervosa, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal hyperplasia, menopause, Turner’s syndrome, failing pregnancy, fetal death
FSH (follicle-stimulating hormone)	Raised: ovarian failure, menopause
LH (luteinising hormone)	Raised: PCOS, polycystic ovarian disease, ovarian failure, menopause
PRL (prolactin): common in secondary amenorrhoea to be raised	Normal: ovarian failure, anorexia, weight loss, excess exercise, adrenal tumour/hyperplasia, menopause
Testosterone	Normal: ovarian failure, anorexia, weight loss, excess exercise, hypothyroidism, pregnancy, menopause
Thyroid stimulating hormone	Normal range
Liver function test	Normal range
Cervical smear	Cervical cancer, request STD swabs
Basal body temperature: normally drops 24–36 hours after menses begins; a decrease indicates preovulation and an increase of 5 degrees occurs after ovulation; monitors thyroid function	Revealed pattern of biphasic temperature although temperature had only slight fluctuation

TABLE 5.36 UNLIKELY DIAGNOSTIC CONSIDERATIONS

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Neoplasms: vaginal, uterine cancer, ovarian, adrenal, pituitary; irregular vaginal bleeding in perimenopausal women; can be acyclic with symptoms of menopause [69]	Can be profuse menstrual flow (metrorrhagia); oestradiol was low, CRP normal
INFECTION AND INFLAMMATION
Cirrhosis or hepatitis: irregular menses, mood swings, fatigue	Liver function test NAD
SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION
Medications: vaginal bleeding	Several drugs can cause altered menstrual bleeding; Maggie is taking no medication
Progesterone-breakthrough bleeding: when a high-dose progesterone drug is administered	Low progesterone; no drug hormonal drug therapy has been taken
ENDOCRINE/REPRODUCTIVE
Pregnancy: spotting can precede haemorrhage/spontaneous abortion, irregular periods; until complete menopause still can fall pregnant and experience complications of pregnancy	Pregnancy blood test negative, oestradiol not raised, FSH/LH was raised, prolactin levels normal
Polycystic ovarian syndrome (PCOS): irregular menstrual cycle, weight gain; can present with anovulatory irregular menstrual bleeding	Oestradiol reading was low; FSH was raised; prolactin levels normal; testosterone normal
Hypothyroidism: irregular periods, weight gain and fatigue	FSH/LH was raised; prolactin levels normal; no physical symptoms such as skin or hair changes reported; no constipation, depression, temperature intolerance or visible goitre noted; thyroid-stimulating hormone not raised
Cushing’s disease: can present with anovulatory irregular menstrual bleeding and weight gain	FSH/LH was raised; prolactin levels normal; testosterone normal; no physical symptoms such as a moon-shaped face, hirsutism, acne, frontal balding of hair, hypertension, oedema; urinalysis NAD and indicating no glucose intolerance or diabetes
Diabetes: weight gain, fatigue	Urinalysis and fasting blood glucose NAD
Adult-onset adrenal hyperplasia: can present with anovulatory irregular menstrual bleeding	FSH/LH was raised; testosterone normal
Cervical dysplasia: intermenstrual spotting	Cervical smear negative
Uterine fibroids and polyps: heavy bleeding, spasmodic period pain	Often maintains normal cycle unless submucosal or nearly extruded; causes uterine enlargement; usually causes menorrhagia (blood loss of 80 mL per day and lasting more than 7 days); fibroids form due to excess oestrogen; usually symptoms of severe dysmenorrhoea, back pain and sometimes vaginal discharge
Endometriosis: can have profuse or minimal bleeding; irregular menstrual cycle, intermenstrual spotting, infertility	Oestrogen dominance is more common in younger reproductive years; usually has associated symptoms such as severe episodes of pain before and during menstrual bleed, bleeding from the bowel, lower back pain; no vaginal discharge mentioned; oestradiol levels were low
Dysfunctional uterine bleeding (DUB): [69] endometrial hyperplasia, PCOS, from taking exogenous oestrogen; endocrine dysfunction (not associated with inflammation, tumour or pregnancy) anovulatory hormone related bleeding is most common; intermenstrual bleeding	Often presents with menorrhagia (heavy bleed with regular cycle) but interval between periods is shorter to appear irregular [81]; no use of exogenous oestrogen reported; usually causes bleeding that is unpredictable regarding amount and frequency; tests do not reveal an endocrine disorder; oestradiol low
Oestrogen-breakthrough bleeding – 2nd type	Oestrogen levels are well above threshold causing endometrium to become hyperplastic and outgrow blood-borne hormone supply; degeneration of endometrium with prolonged and irregular bleeding occurs; low oestradiol test
Progesterone-withdrawal bleeding: can occur when oestrogen therapy continued and progesterone stopped; also when progesterone is administered to test endogenous oestrogen	Often in PCOS; only occurs when there is an oestrogen-primed endometrium, not likely with low oestradiol; no hormonal drug therapy has been taken
Anovulatory bleeding: irregular cycle, spotting before bleed; menses can be profuse, unexpected and painless; check basal body temperature will not fluctuate (monophasic)	Maggie experiences premenstrual symptoms; slight biphasic temperature fluctuation indicated ovulation still occurring and not stopped completely

Case analysis

TABLE 5.37 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [2, 7–9, 11, 13]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
FUNCTIONAL DISEASE
Chronic fatigue syndrome: fatigue for at least 6 months that has no physical basis, psychoses, bipolar affective disorder, eating disorder or organic brain disease	Severe disabling fatigue affects both mental and physical functioning for at least 6 months; sleeping more, depression, crying spells	Need to define whether Maggie experiences fatigue after exertion and she experiences muscular and mental fatigue for at least 24 hours before some level of recovery; need to define if fatigue improves during the day; need to define if Maggie experiences at least two neurological/cognitive manifestations of chronic fatigue syndrome such as impaired concentration and muscle weakness
Functional fatigue –depression [66]	Tiredness that has lasted several months	Need to define if the feeling of fatigue improves during the day
Physiologic fatigue	Can be caused by depression, caffeine, alcohol, excess sleep, intense emotions; diagnostic studies to date are within normal limits with signs of menopause; symptoms present with changes in self-esteem, social difficulties or overall mood; perimenopausal symptoms may be associated with sleep disturbance [67]	Symptoms present as less than 14 days duration
Organic fatigue	Tired, sleep disturbances, no major physical abnormalities	Need to determine if the feeling of fatigue worsens during the day
DEGENERATIVE AND DEFICIENCY
Osteoporosis: risk much higher after menopause [72]	Oestrogen levels dropping causing perimenopausal symptoms; asymptomatic often unless have accident to indicate low bone density	Check family history of osteoporosis
ENDOCRINE/REPRODUCTIVE
Ovarian disease: premature menopause often due of autoimmune disease	Menses beginning to change; LH and FSH raised and oestradiol low, prolactin and testosterone levels normal; can present with symptoms of menopause	Maggie is in the typical age group for perimenopause
Ovulatory bleed: usually spotting or light bleed at time of ovulation, regular cycle	Feeling emotional, premenstrual symptoms; basal body temperature is still biphasic and fluctuates slightly, indicating ovulation has occurred
Oestrogen-withdrawal bleeding: causes intermenstrual bleeding; the endometrium proliferates and becomes unstable when oestrogen drops below the threshold when not in the secretory phase (luteal phase) or in the absence of progesterone	Common cause of irregular bleeds in perimenopausal women due to low progesterone and oestrogen drops; bleed is not necessarily prolonged and profuse
Oestrogen-breakthrough bleeding – 1st type: when oestrogen levels are low but constant causing sections of endometrium to degenerate	Causes spotting of blood, can be symptom of perimenopause towards complete menopause	Common when taking low-dose OCP and in PCOS
Premenstrual staining in ovulatory cycle	Gets spotting up to 7 days before menses
STRESS AND NEUROLOGICAL DISEASE
Mixed anxiety and depressive disorder [66]	Depressive disorder often associated with an experience of loss; grief for not having had children; feeling more emotional, anxious about her body changes, symptoms of fatigue, or intense sadness; numerous physical complaints associated with depression	Has not mentioned significant incapacity to continue daily activities

TABLE 5.38 CONFIRMED DIAGNOSIS [3, 5, 11]

CONDITION	RATIONALE
Perimenopausal	Irregular menstrual cycle, fatigue, feeling emotional, hot flushes, weight gain
Test results	Low progesterone and oestradiol; raised FSH/LH

Working diagnosis

Maggie and menopause [2, 7–9, 11, 13, 19, 64, 65]

Maggie has been referred by her GP for natural therapies to aid symptoms of perimenopause. Blood tests have confirmed Maggie’s hormone levels are dropping which is causing her symptoms of hot flushes, weight gain, fatigue and emotional changes. Maggie reveals in her consultation that not only is she experiencing physical complaints associated with the early stages of menopause, but is also experiencing enormous regret about not having had children. She blames the constant travel she and her husband Rene enjoyed over the years. She feels Rene was not ready to settle down when she was ready and still able to have a family. Maggie has also been feeling more worried about changes to her physical appearance and her attractiveness to Rene. Maggie is generally feeling uncomfortable, is going through a major life transition and is focusing on many regrets.

Menopause means the cessation of menstrual periods and usually occurs naturally between the ages of 45 and 55. During the late fourth decade FSH (follicle-stimulating hormone) and then LH (luteinising hormone) concentrations secreted by the anterior pituitary gland begin to rise as the ovarian follicle supply reduces. Oestrogen levels fall and the menstrual cycle pattern is changed to reduce the chances for ovulation to occur.

During this physical transition women either may experience irregular scanty periods that fluctuate over time, or can have a very sudden cessation of periods. Secondary causes of premature menopause may include surgical procedures to the ovaries, from ovarian disease or from radiotherapy to the ovaries. Additionally it is possible for women to experience premature menopause after a significant emotional shock or physical trauma.

Features of oestrogen deficiency include hot flushes, vaginal dryness and atrophy of the breasts, loss of libido, depression, weight gain and loss of mental focus and concentration. Postmenopausal health complications include a reduction in bone density and reduced protection against ischaemic heart disease.

Menopause is an important and completely natural life stage that often inspires reflection about the reproductive years of life. Women may experience profound changes and can feel the physiological and emotional affects of menopause to be unfamiliar and unsettling. On the other hand, menopause may also be a positive transition into a new phase of life that no longer involves the potential of child-bearing. The experience of menopause varies enormously between women and is best approached as an individual journey in which similar physiological changes are experienced.

TABLE 5.39 DECISION TABLE FOR TREATMENT PRIOR TO REFERRAL

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Dietary and lifestyle recommendations to reduce severity and incidence of hot flushes and other symptoms associated with perimenopause • Physical therapy suggestions to provide relief from hot flushes and improve sleep • Herbal tea, tonic or tablet to alleviate or reduce hot flushes and improve other symptoms associated with perimenopause such as sleep disturbance and fatigue • Supplemental nutrients to reduce perimenopausal symptoms

• Dietary and lifestyle recommendations to support Maggie’s general health and wellbeing, improve energy and reduce the risk of conditions such as cardiovascular disease, osteoporosis and breast cancer

• Dietary and lifestyle recommendations to maintain weight within healthy BMI range

• Lifestyle recommendations and herbal tonic with adaptogenic properties to help support healthy adrenal function

• Herbal tonic and tablets to help reduce breast cancer risk

• Supplemental nutrients to support general health and reduce the risk of cardiovascular and other disease

• Supplemental minerals to support bone health and reduce the risk of osteoporosis

• Lifestyle and physical therapy recommendations to reduce the symptoms of anxiety and depression

• Recommendation for Maggie to try relaxation therapies

• Recommendation for Maggie to seek counselling to help her deal with issues surrounding infertility and ageing

• Herbal tea, tonic or tablet with anxiolytic, antidepressant and sleep-enhancing actions

TABLE 5.40 DECISION TABLE FOR REFERRAL [2, 7–9, 12, 13]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
Nil	• Fatigue began prior to hot flushes by several months indicating it could be from a functional disorder such as depression [67]	• Body image becoming an issue now that she is beginning menopause • Regrets about not having had children prior to menopause
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
• Hot flushes are disturbing sleep	• Reduced oestrogen increases the risk of osteoporosis	• Regrets about the impact of previous lifestyle choices on child-bearing • Indication of resentment towards Rene for not wanting to stop travelling to settle down and have children when Maggie was still able to get pregnant
REFERRAL	REFERRAL	REFERRAL
Nil	• Bone density test to assess osteoporosis risk • Mental health assessment to assess risk of depressive illness	• Counselling to address Maggie’s issues of childlessness, her feelings towards Rene and going through menopause

TABLE 5.41 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [2, 6–8, 10, 11, 13, 71]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Referral for counselling	Emotional assessment and support
DEXA bone density test	To ascertain the health of her bones and assess what age she is likely to be when she crosses the ‘fracture threshold’ (this will also give an indication of how much support she needs to maintain or improve bone density)
Basal body temperature: normally drops 24–36 hours after menses begins; a decrease indicates pre-ovulation and an increase of 5 degrees occurs after ovulation; monitors thyroid function	Keep monitoring pattern of biphasic temperature to see if in some months there is a monophasic pattern emerging, although temperature had only slight fluctuation; monitor sub-clinical thyroid dysfunction
IF NECESSARY:
Pelvic ultrasound	Cervical cancer, uterine fibroids, PCOS
Anti-nuclear antibody blood test	Autoimmune disease causing ovarian failure
Progesterone withdrawal test	To determine whether oestrogen is still being produced
Laparoscopy	Rule out endometriosis
Endometrial, vaginal and cervical biopsies	Detect cancer; during luteal phase (10–12 days after ovulation) to determine inadequate luteal phase production or action of progesterone
Brain CT scan/MRI	Rule out pituitary adenoma

Confirmed diagnosis

Perimenopause and organic fatigue not caused by chronic depression.

Prescribed medication

• Hormone replacement therapy, which Maggie has chosen not to take [68]

TABLE 5.42 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Continue with dietary and lifestyle recommendations to reduce severity and incidence of hot flushes and other symptoms associated with perimenopause • Continue with physical therapy suggestions to provide relief from hot flushes and improve sleep • Continue with herbal tea, tonic or tablet to alleviate or reduce perimenopausal symptoms • Continue with supplemental vitamins to reduce perimenopausal symptoms NB: If Maggie decides to take prescribed HRT the herbal tea, tablet or tonic will need to be reviewed and reformulated; Maggie’s condition should be managed collaboratively with her GP to ensure her treatment program is effective and appropriate

• Continue with dietary and lifestyle recommendations to support Maggie’s general health and wellbeing, and reduce the risk of cardiovascular disease, osteoporosis and breast cancer

• Continue with dietary and lifestyle recommendations to maintain weight within healthy BMI range

• Continue with lifestyle recommendations and herbal tonic to support adrenal function and reduce breast cancer risk

• Continue with supplemental nutrients to support general health and reduce risk of conditions such as cardiovascular disease and to support bone health

• Continue with lifestyle and physical therapy recommendations to reduce symptoms of anxiety and depression

• Continue to recommend relaxation therapies and counselling

• Continue with herbal tea, tonic or tablet to help with anxiety, depression and sleep

Treatment aims

• Minimise the impact of reduced oestrogen on Maggie’s physical and mental health [14–17, 19].

• Provide relief from or reduction of Maggie’s physical symptoms: fatigue, hot flushes, sleep disturbance and vaginal dryness [14–17].

• Support Maggie’s adrenal glands. Her adrenal glands will be involved in oestrogen production following menopause [15, 17, 18] so it is important to ensure their continuing healthy function.

• Support Maggie’s bone health and reduce her risk of developing osteoporosis [14–17].

• Support Maggie’s cardiovascular health and reduce her risk of developing cardiovascular disease [14–17].

• Assist Maggie to maintain her BMI within normal range.

• Support Maggie’s mental and emotional health during her transition to menopause [17, 19, 26].

• Support Maggie’s health and wellbeing during the perimenopausal period and focus on wellness and disease prevention in her postmenopausal years [14–17].

Lifestyle alterations/considerations

• Encourage Maggie to be physically active every day. Daily physical activity reduces her risk of breast cancer [20]. Daily exercise is also associated with reduced depression and anxiety [14, 16, 21, 22, 29], improved sleep [15, 23] and reduced risk of cardiovascular disease [24]. Exercise may also reduce hot flushes [16, 31].

• Encourage Maggie to include weight-bearing exercise such as walking or strength training in her daily routine. Weight-bearing exercise supports bone health [16, 17, 25], reduces bone mineral loss [17, 25] and reduces fracture risk [25], and can help her to maintain healthy weight [43].

• Encourage Maggie not to eat a very low calorie diet in an effort to lose weight. It may reduce her metabolic rate as the body seeks to conserve energy [4, 16]. Instead encourage her to increase exercise to help maintain her weight in the normal BMI range [43].

• Maggie may gain benefit from relaxation and stress-management therapies such as meditation, yoga and autogenic (self-relaxation) training [28, 56].

• Encourage Maggie to work through her issues surrounding infertility and ageing. Perimenopausal and menopausal women are at significantly greater risk of experiencing depression and anxiety [19, 26] and she is likely to gain benefit from psychological counselling [27, 28, 30].

Dietary suggestions

• Encourage Maggie to increase her intake of dietary phyto-oestrogens [14–17, 55]. Chickpeas and soybeans are particularly good sources of isoflavones [14] along with split peas, mung beans, lentils, broad beans, alfalfa, flax seed and rye. Consuming isoflavone-rich food is associated with reduced hot flushes [17, 34, 36, 37] and vaginal dryness [17, 34, 37] as well as a lower risk for breast cancer [17, 35–37] and cardiovascular disease [14, 36, 37, 40]. Soy has a positive effect on bone health and can help prevent osteoporosis [14, 17, 36, 37, 39].

• Maggie’s diet should include sufficient amounts of essential minerals for bone health including calcium, magnesium, silica, boron, zinc, manganese, copper and vitamins C, D and A [14–17].

• Maggie will benefit from a mostly vegetarian Mediterranean diet comprising a high consumption of legumes, fruits, vegetables and whole grains, moderate consumption of alcohol and low consumption of animal protein [16, 17, 38, 42].

• Maggie should ensure she consumes a wide variety of antioxidant-rich whole foods [14–17, 38, 62].

• Maggie should minimise consumption of saturated fats and avoid trans fats [15, 16, 38]. She should increase consumption of omega-3 fatty acids to promote cardiovascular, mental and bone health [14–17, 41].

Physical treatment suggestions

• Maggie may find massage helpful to improve her emotional health and sense of wellbeing [32].

• Acupuncture may reduce Maggie’s anxiety [28, 33], improve her sleep [33, 44] and reduce hot flushes [44].

• Hydrotherapy: tread in cold water daily (especially first thing in morning and just before bed) [56, 58]. Kneel or briefly sit in cold water to decrease hot flushes and increase energy [56]. Cold sock treatment at night to bring down heat from the upper body [57]. A salt-water hot sponge bath before bed [56]. Neutral baths [57].

• Constitutional hydrotherapy for balancing internal heat in the body [57, 59, 60].

TABLE 5.43 HERBAL TEA

Alternative to herbal liquid tonic if Maggie prefers a herbal tea
HERB	FORMULA	RATIONALE
Sage leaf Salvia officinalis	1 part	Antihidrotic [17, 36, 46]; traditionally used to reduce sweating [17, 36]; beneficial for night sweats and hot flushes [17, 36]
Passionflower Passiflora incarnata	1 part	Anxiolytic [36, 46, 48]; sedative [36, 48]; hypnotic [36, 46, 48]
Zizyphus seed Zizyphus spinosa	2 parts	Sedative [17, 49]; hypnotic [49]; traditionally used for night sweats accompanied by anxiety and insomnia [17, 49]

Infusion: 1 tsp per cup – 1 cup 3–4 times daily; may be consumed cold if preferred

TABLE 5.44 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

HERB	FORMULA	RATIONALE
Black cohosh Cimicifuga racemosa	30 mL	Reduces hot flushes [17, 36, 45, 51]; improves menopausal symptoms [36, 45, 51]; protective against breast cancer [51]
St John’s wort Hypericum perforatum	60 mL	Nervine [17, 36, 45]; antidepressant [17, 36, 45]; beneficial in emotional symptoms associated with menopause [17, 51]; superior results in alleviating menopausal mood disorders when combined with black cohosh [51]
Shatavari Asparagus racemosus	60 mL	Tonic [48, 61]; adaptogenic [48, 61]; sexual tonic [48, 61]; traditionally used in menopause [61]
Zizyphus Zizyphus spinosa	50 mL	See above
Supply:	200 mL	Dose: 8 mL twice daily

TABLE 5.45 TABLET ALTERNATIVE TO HERBAL LIQUID: MAY IMPROVE COMPLIANCE

HERB	DOSE PER TABLET	RATIONALE
Black cohosh Cimicifuga racemosa	250 mg	See above
St John’s wort Hypericum perforatum	700 mg	See above
Wild yam Dioscorea villosa	800 mg	Oestrogenic action [36, 53]; steroidal saponins in wild yam may help alleviate symptoms of oestrogen withdrawal [36, 53]
Lavender Lavandula angustifolia	300 mg	Anxiolytic [36, 48]; improves sleep [36]; antidepressant [46, 48]

Dose: 1 tablet at lunchtime, two in the evening

TABLE 5.46 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
High-potency practitioner-strength mineral supplement for bone health containing calcium, magnesium, zinc, manganese, boron, silica, vitamins D and K Dose as per manufacturer’s recommendation, taking into account dietary intake	To provide essential nutrients for bone health [14–17]; particularly indicated if bone densiometry indicates reduced bone density [14, 36, 47]
High-potency practitioner-strength multivitamin, mineral and antioxidant supplement providing therapeutic levels of essential micronutrients Dose as per manufacturer’s recommendation	To ensure Maggie has optimal levels of essential nutrients and antioxidants to support general health and wellbeing and help reduce the risk of conditions more likely to occur in the postmenopausal years such as cardiovascular disease and cancer [62, 63]
Vitamin E 800 IU daily [36, 54]	Reduces menopausal hot flushes [16, 36, 54]; reduces cardiovascular risk [14, 36, 47, 50]