Integrative medicine is a whole-person, holistic approach that combines evidence-based complementary modalities, lifestyle approaches, and Western medicine to comprehensively treat patients. Women are the highest users of integrative modalities in the United States, and women’s health conditions commonly benefit from an integrative approach. This study presents evidence-based integrative medicine for common women’s health conditions.
Key points
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Integrative therapies are evidence-based and offered alongside conventional medication and surgery for common gynecologic conditions.
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For dysmenorrhea, mild exercise, mind–body therapies, calcium, magnesium, and ginger are recommended.
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For polycystic ovary syndrome, nutrition, sleep, stress management, exercise, and supplements including myoinositol, vitamin D, n-acetyl-cysteine, and chromium help restore menses and improve metabolic profile.
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For premenstrual syndrome, vitex, magnesium, and calcium, along with mind–body movement, nutrition, and stress management are evidence-based modalities.
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Several evidence-based and emerging integrative therapies for endometriosis, such as nutrition, sleep, stress management, acupuncture, low-dose naltrexone, melatonin, curcumin, and vitamin D, can alleviate symptoms.
| CBT | cognitive behavioral therapy |
| CBT-I | cognitive behavioral therapy for insomnia |
| EPA | eicosapentanoic acid |
| IL | interleukin |
| IM | integrative medicine |
| LDN | low-dose naltrexone |
| MBSR | mindfulness-based stress reduction |
| NAC | N-acetyl cysteine |
| NSAIDs | nonsteroidal anti-inflammatories |
| PCOS | polycystic ovarian syndrome |
| PFPT | pelvic floor physical therapy |
| PMDD | premenstrual dysphoric disorder |
| PMS | premenstrual syndrome |
Introduction
Integrative medicine (IM) is a whole-person, healing-oriented approach to health care. It integrates complementary and alternative therapies with conventional Western medicine utilizing nutrition, exercise, mind–body therapies, spiritual healing, manual medicine, herbs, supplements, and other systems of medicine (traditional Chinese medicine and Ayurveda) with pharmacotherapy and surgery. Several common women’s health conditions are amenable to an integrative approach, including dysmenorrhea, premenstrual syndrome (PMS), polycystic ovarian syndrome (PCOS), and endometriosis.
Dysmenorrhea: Integrative Approaches and Therapeutic Insights
Introduction
Dysmenorrhea occurs in 50% to 90% of women of reproductive age and is a significant cause of morbidity. The condition commonly presents with nausea, vomiting, headaches, muscle cramps, low back pain, fatigue, insomnia, and diarrhea. Given the underlying mechanism of inflammation, dysmenorrhea is a prime target for integrative therapies such as nutrition, supplements, mind–body interventions, exercise, and acupuncture.
Nutrition
Patients with dysmenorrhea can benefit from nutritional interventions that address inflammatory mediators. An anti-inflammatory or Mediterranean-style diet pattern rich in magnesium, calcium, and omega-3 fatty acids improves symptoms. Omega-3 fatty acids obtained by supplementation or eating cold-water fish 2 to 3 times per week are effective at decreasing inflammation and pain, and supplementing with omega-3 fatty acids can reduce the amount of ibuprofen needed compared to placebo. Sugars, fried foods, and other processed foods should be avoided as they increase inflammation and can worsen dysmenorrhea. Dietary changes must be implemented throughout the cycle rather than during menses to confer the most benefit.
Supplements
Supplementation with calcium, magnesium, and ginger addresses inflammation and the propagation of pain signals in the myometrium. Magnesium has been studied in several pain syndromes due to its antagonistic action at the N- methyl- d -aspartate receptor, with blockade of this receptor can prevent central sensitization and hypersensitivity. Moreover, it is postulated that women with dysmenorrhea have lower levels of magnesium. Magnesium is also helpful for treating bloating and menstrual migraine. Migraine prophylaxis is achieved with all forms of magnesium, with at 400 to 600 mg daily. It should be taken during the luteal phase, and further benefits may be noted with continuous use. Magnesium is a simple and cost-effective supplement that improves pain scores and addresses the associated symptoms of dysmenorrhea.
Calcium reduces premenstrual pain by inhibiting uterine muscle contraction. Increases in dairy consumption are inversely associated with dysmenorrhea, illustrating the utility of nutritional interventions or supplementation. Effective doses range between 1000 and 1200 mg daily. Calcium should be taken continuously throughout the cycle.
Adding vitamin D to calcium supplementation further reduces symptoms of dysmenorrhea due to its inhibition of prostaglandin synthesis. When calcium and magnesium are combined, a calcium-to-magnesium ratio 2:1 is preferred (1200 mg calcium to 600 mg magnesium).
Ginger, Zingiber officinale , is effective at treating dysmenorrhea due to its modulating effect on prostaglandin synthesis via arachidonic acid inhibition. Ginger’s anti-inflammatory properties reduce pain and the need for medications. At 1 to 2 g daily, ginger is more effective than placebo and equivalent to nonsteroidal anti-inflammatories (NSAIDs). This herb is a helpful adjunct in the treatment of dysmenorrhea owing to its anti-inflammatory action and inhibition of multiple hormonal symptoms. Table 1 lists the supplements for dysmenorrhea, adverse effects, and recommended dosages.
| Supplement | Indications | Potential Adverse Effects | Recommended Dose |
|---|---|---|---|
| Calcium | Cramps | Caution in renal disease | 1000–1200 mg per day |
| Magnesium | Cramps, bloating, migraine, and constipation | Diarrhea, nausea, hypotension, confusion, and caution in renal disease | 400–600 mg per day |
| Ginger | Nausea and headaches | Diarrhea, reflux, stomach pain, and increased bleeding risk | 1–2 g per day |
Mind–body
Mind–body interventions such as mindfulness, yoga, Tai Chi, Qigong, and breath regulation can alter dysmenorrhea’s underlying mechanisms and associated inflammation. These practices decrease perception of pain and help manage stress.
Exercise
While yoga exerts positive effects via the mind–body connection, aerobic exercise helps patients manage pain and improves well-being through other mechanisms. Exercising at varying intensities at least 3 times weekly for 45 to 60 minutes decreased pain. Notably, moderate-intensity to high-intensity exercise modulates pain via anti-inflammatory cytokines and reduced the release of prostaglandins. Low-intensity exercise such as yoga or walking decreases the secretion of cortisol, a hormone that can increase the production of prostaglandins. However, patients benefit from exercise regardless of the intensity or chosen activity.
Acupuncture
Acupuncture is known to improve dysmenorrhea. In 13 randomized controlled clinical trials, acupuncture and moxibustion relieved pain and had fewer adverse events than controls. However, timing the treatments before menses resulted in more significant reductions in pain scores than at the onset of menses. Given its efficacy and safety profile, acupuncture should be considered in for dysmenorrhea.
Clinics care points
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A balanced diet rich in fruits, vegetables, whole grains, and fish, such as the anti-inflammatory or Mediterranean diet, can reduce symptoms.
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Omega-3 fatty acid supplementation or increased consumption of cold-water fish (2–3 times per week) offers anti-inflammatory benefits.
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Magnesium (400–600 mg daily) and calcium (1000–1200 mg daily) supplementation addresses deficiencies and alleviates pain, especially during the luteal phase. Consider adding vitamin D.
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Ginger (1–2 g per day) has anti-inflammatory properties and effectiveness comparable to NSAIDs.
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Mind–body interventions can help manage pain and reduce stress.
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Regular aerobic exercise (at least 3 times weekly for 45–60 minutes) reduces symptoms.
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Acupuncture before the onset of menses can result in significant pain relief.
Polycystic Ovarian Syndrome
Introduction
PCOS is a common disorder in women’s health, affecting 6% to 10% of premenopausal women, with endocrinologic, metabolic, and reproductive implications. The diagnosis is classically made if 2 of the 3 Rotterdam Criteria are met (oligo-ovulation or anovulation, hyperandrogenism, and ultrasound findings), but individual presentations can be heterogeneous, with increasing recognition of other complications, including elevated cardiovascular disease risk, sleep apnea, infertility, and a high prevalence of mental or psychological health conditions. Addressing the driving factors of PCOS by reducing circulating insulin, improving insulin sensitization, balancing ovarian androgen production, and addressing stress and inflammation is key to improving patient outcomes, and the focus of integrative therapies.
Nutrition
A low-glycemic diet increases insulin sensitivity and improves metabolic parameters and reproductive health. The recommended dietary pattern is plant-forward, heavy in nonstarchy vegetables, low-glycemic fruits, and low in processed foods. It incorporates healthy fats or proteins to minimize blood sugar spikes and promote satiety. It also supports a healthy microbiome with adequate fiber (40 g/d) and prebiotics. Impaired glucose tolerance is common in PCOS, and continuous glucose monitors may play a future role in management by allowing patients to identify patterns in glucose swings and develop a sense of empowerment.
Exercise and mind–body
Physical activity meeting the recommended guidelines of 150 to 200 minutes of moderate-intensity exercise per week can reduce markers of inflammation, promote weight maintenance, improve body composition and metabolic parameters, and regulate sleep, appetite, and mood. Mind–body approaches address comorbid anxiety, depression, and stress and benefit mood, quality of life, and weight management. Studied modalities include cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), yoga, and progressive muscle relaxation. ,
Supplements
The literature supports the use of several supplements in PCOS. Chromium is a mineral that improves insulin sensitization and resistance in both PCOS and diabetes and is typically dosed at 200 μg daily. Inositol at 3 to 4 g divided daily can improve hyperandrogenism, insulin sensitization, fasting insulin, ovarian function, and spontaneous or augmented fertility outcomes. Vitamin D deficiency is prevalent in patients with PCOS, especially those with comorbid obesity, and supplementation may improve metabolic disturbances and the success of ovulation induction. N-acetyl cysteine (NAC) is an antioxidant used in multiple conditions to address oxidative stress, inflammation, and hepatic detoxification. In PCOS, it decreases the inflammatory burden, improves insulin sensitivity, and supports fertility by increasing ovulation, oocyte quality, and odds of successful live birth. , , Doses studied for PCOS are typically around 600 mg 2 to 3 times daily. Table 2 lists the supplements used for PCOS, adverse effects, and recommended dosages.
| Supplement | Indications | Potential Adverse Effects | Recommended Doses |
|---|---|---|---|
| Vitamin D | PCOS, hyperlipidemia, and elevated testosterone | Nausea, vomiting, and constipation | 3200–7000 IU daily |
| Inositol | PCOS | Nausea and diarrhea | 3–4 g daily |
| NAC | PCOS and infertility | Nausea, vomiting, and diarrhea | 1200–1800 mg daily, divided doses |
| Omega-3 fatty acids | PCOS and hyperlipidemia | Fish aftertaste, nausea, and diarrhea | 2–3 g daily |
| Chromium | PCOS, obesity, elevated testosterone, and insulin resistance | Headaches, insomnia, mood changes, and caution in liver or kidney disease | 200–400 μg daily |
Acupuncture
The benefits of acupuncture in PCOS include improved ovulatory function and fertility, hormonal regulation with decreased hyperandrogenism and hypothalamus-pituitary-ovarian axis effects, healthy insulin and lipid metabolism, and improved stress and psychological comorbidities. ,
Clinics care points
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A low glycemic-index diet rich in nonstarchy vegetables, low-glycemic fruits, healthy fats, and proteins can improve PCOS. Highlight the importance of fiber and prebiotics in supporting a healthy microbiome.
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Physical activity consistent with recommended guidelines (150–200 minutes of moderate-intensity weekly exercise) improves metabolic parameters and overall well-being.
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Refer for CBT or MBSR as needed.
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Inositol (3–4 g daily) can improve hyperandrogenism and insulin sensitivity.
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Vitamin D (3200–7000 IU daily) addresses deficiency and improves metabolic health.
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N-acetylcysteine (600–1800 mg daily, divided doses) has antioxidant properties and supports ovulation and fertility.
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Chromium (200–400 μg daily) enhances insulin sensitivity.
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Omega-3 fatty acids (2–3 g daily) have potential cardiovascular benefits.
Premenstrual Syndrome: Integrative Strategies for Management
Introduction
PMS consists of a constellation of symptoms that can vary in intensity and severity during the late luteal phase of the menstrual cycle. The syndrome affects up to 40% of menstruating women, and 90% of women experience premenstrual symptoms. Premenstrual dysphoric disorder (PMDD) involves symptoms that are greater in severity, and 8% of women are diagnosed with this condition. Addressing PMS not only improves well-being and quality of life but can also be life-saving because some women with PMS and PMDD are at a greater risk of suicide. The etiology of PMS is unknown, and treatment of the disorder often involves hormonal manipulation or antidepressants. Due to the significant burden and the complexity of symptoms affecting multiple organ systems, PMS is a prime target for integrative treatment strategies.
Nutrition
A Western dietary pattern is associated with a higher frequency of PMS symptoms, while a healthy and traditional plant-forward diet pattern has an inverse correlation with the syndrome. Intermittent fasting can decrease cortisol during the luteal phase and improve symptoms. Sugars, simple fats, fried foods, coffee, and alcohol positively correlate with symptoms. Although women typically crave carbohydrates during the luteal phase due to the effect on serotonin levels, a diet rich in fruits, vegetables, and fiber can reduce PMS symptoms. A whole-food, plant-forward dietary pattern addresses underlying inflammation and abnormal oxidative activity. Nutritional considerations are essential for improving the symptoms of PMS as part of an integrative approach.
Supplements
Although several supplements are marketed for the treatment of PMS symptoms, few high-quality studies confirm their efficacy. Calcium has good-quality evidence for preventing the symptoms of PMS, such as bloating, anxiety, and cramping. Calcium levels are lower in those with symptoms, and supplementation can decrease the syndrome’s incidence. A suggested mechanism for the low calcium levels is related to estrogen’s antagonistic effect on serum calcium levels and receptors. Fluctuating levels of estrogen can also affect the binding of serotonin at its receptor, resulting in mood symptoms typical of PMS. A dose of 1200 mg daily from combined food and supplement sources appears most effective. Calcium citrate is best absorbed, compared with other forms.
Patients with PMS and PMDD often have lower serum magnesium levels. Magnesium supplementation can correct these deficiencies and has helped control symptoms of anxiety, irritability, bloating, mastalgia, and cramping at a dose of 300 to 600 mg per day; combining magnesium and vitamin B6 at 50 mg daily is more effective than magnesium alone. However, studies on magnesium have been conflicting, so more robust evidence is needed.
Chaste tree berry, or Vitex agnus-castus , appears to be a safe and effective supplement for symptoms of PMS and PMDD. This native Mediterranean plant has been used to treat several gynecologic disorders for centuries, including irregular menstruation and PMS. V agnus-castus operates as a dopamine agonist at the hypothalamic-pituitary axis. This results in more robust gonadotropin-releasing hormone signaling, increasing luteinizing hormone secretion and progesterone. Progesterone’s effects may prolong the luteal phase in some patients, particularly those with an otherwise unexplained short luteal phase. Due to the dopamine agonist effects, it may interact with antipsychotics. It is particularly effective for mastalgia but can also improve irritability, anxiety, and bloating. A typical dose is 500 mg of crude herb or 50 mg extract daily, and results are typically seen after 3 months of continuous use.
Saint John’s wort, Hypericum perforatum , is a supplement that has a similar mechanism of action to the selective serotonin reuptake inhibitor class of medications, and it alleviates the depressive symptoms of PMS and PMDD. Similar to antidepressants, it is more effective if taken continuously. The combination of H perforatum and V agnus-castus is more effective than placebo at treating the symptoms of PMS. This supplement has several drug interactions and can cause photosensitivity. Table 3 lists the supplements used for PMS, adverse effects, and recommended dosages.
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