Increasingly, our patients ask us about alternatives to prescription drugs for managing common conditions. This issue of American Family Physician features an article about nonhormonal therapies for hot flashes¹—a concern we regularly encounter in our patients who are navigating the menopausal transition. Other health concerns physicians are commonly asked about include lowering lipids without drug therapy; managing cancer symptoms using alternative modalities; and treating hypertension, heart failure, angina, and diabetes using nutrients or herbal therapies.

Most physicians are not comfortable treating a disease or managing symptoms such as hot flashes without clear data to support a given intervention. We are properly wary of instituting, or even supporting, a patient’s use of an “alternative” or “complementary” treatment unless we can be convinced that the research to support it is sound. More and more we see articles in major journals supporting what previously have been considered “alternative” therapies, yet we are slow to change our ways. We seem much more comfortable trying an “alternative” use of a prescription drug—such as a selective serotonin reuptake inhibitor (SSRI) for hot flashes—than an herb or nutrient with which we have less experience, such as soy or black cohosh. As Dr. Carroll points out in her article,¹ there is relatively similar evidence for the effectiveness of SSRIs and soy isoflavones for reduction of hot flashes (approximately a 60 percent reduction in hot flashes on average for both treatments), yet fewer side effects occur with the soy interventions. What is our hesitation to incorporate useful nonconventional therapies into our practice?

One problem we have is how to find a reliable nutritional supplement or herb, as these products are not standardized or overseen by any government entity. A resource that can be useful to at least determine proper potency and lack of unwanted additives in nutritional products is available online athttp://www.consumerlab.com. This subscription service independently evaluates herbal and nutritional products and regularly publishes the results of these evaluations on its Web site. The Cochrane Database of Systematic Reviews (http://www.cochrane.org/reviews/index.htm) also has many abstracts that can be accessed without charge on numerous herbal, nutritional, and other unconventional therapies, such as acupuncture for headache² and massage for low back pain.³ The National Library of Medicine’s PubMed Web site (http://www.ncbi.nlm.nih.gov) provides easy access to medical literature about any topic. The National Institutes of Health’s National Center for Complementary and Alternative Medicine Web site (http://nccam.nih.gov) has continuously expanding resources to educate physicians and the public about research results regarding therapies heretofore considered unconventional or “alternative.”

Something we do not often realize is that even the “standardized” pharmaceutical agents that are heavily regulated by the U.S. Food and Drug Administration (FDA) are not identical batch to batch or pill to pill. The FDA allows a range of potency from 90 to 110 percent for any given name-brand drug, and 80 to 125 percent for generics.⁴ How many of us are aware of this?

Most physicians that I have talked with would like to see abandonment of the phrase “alternative medicine,” and I agree with them. We need to speak in terms of medicine that works (or at least has enough research to support its current safety and effectiveness) and medicine that does not. We have a problem, however, in that an inbred bias exists to promote the use of the therapies with which we are familiar—largely drugs and surgery—and we too often ignore the ones with which we are less comfortable, even when the data are poor for the former and supportive for the latter. A good example is the wealth of data, and even meta-analyses, supporting the use of certain nutrients such as policosanol to lower cholesterol⁵ and saw palmetto to improve symptoms in benign prostatic hyperplasia.⁶ We tend to downplay the dangers of pharmaceutical agents, such as statins for lipid lowering, because they are the mainstays of recommended therapy and we feel safe, in a therapeutic and medicolegal sense, in continuing to use them as our preferred treatment. Yet we often could produce results approaching those of standard therapy, with fewer side effects, by taking the nutritional approach. Why are we hesitant? Our clinical guidelines recommend statins early in treatment, and insurance reimburses for prescriptions but not usually for nutritional supplements.

We have many obstacles to the use of “alternative therapies” in our practices—financial, institutional, longstanding pro-pharmaceutical bias, and insufficient information at our fingertips about the safety and effectiveness of the alternatives. However, more and more of our patients want us to overcome these challenges and help them follow a path to health that includes less-toxic nutrients and herbs when appropriate, combining the best scientific knowledge with an open mind.