Postmenopausal women's usage of complementary and alternative medicine and its relationship to sexual function: A cross‐sectional study in southeastern Iran

Abstract Background and Aims Sexual dysfunction is one of the most common problems in postmenopausal women that affect their lives. Due to the widespread disadvantages and age limit of drug and hormone therapy, the demand for complementary and alternative medicine (CAM) methods has increased. Methods This was a descriptive‐analytical study. A total of 297 postmenopausal women who were referred to health centers in Kerman, southeastern Iran, were selected during the years 2020–2021. The use of CAM and sexual function were examined by Complementary and Alternative Medicine Questionnaire and the Female Sexual Function Index, respectively. Data were collected through a combination of face‐to‐face and online forms. Results More than half of the participants used at least one type of CAM in the preceding year for any general reason. The mean satisfaction score for CAM use was 21.7 ± 5.84; Most reasons of use were for improving quality of life, improving physical function, reducing sleep disorders, improving mood status, reducing vasomotor symptom, and improving sexual function, respectively. Most reasons of use were related to sexual dysfunction. Specifically, the mean score for sexual function was 17.96 ± 7.50 which was lower than the scale's midpoint of 28. According to different subscales of sexual function, 52.9% of participants had good desire, 49.5% good arousal, 34.7% good lubrication, 56.9% good orgasm, and 2% had no pain, and 52.5% were satisfied with their sexual function. There were no significant differences between CAM users and nonusers about sexual functions and all its subscales. Conclusion There were no significant differences between CAM users and nonusers about sexual functions and all its domains. Further research in different communities with different health systems is recommended to investigate the relationship between CAM and sexual function among postmenopausal women.


| INTRODUCTION
Menopause refers to the permanent cessation of menstruation for a minimum of 12 consecutive months, which occurs due to a lack of estrogen and is not linked to any underlying medical condition. 1 All these changes can lead to difficulty sleeping, a reduced sex drive (libido), urinary incontinence, palpitations, osteoporosis, recurrent urinary tract infections (UTIs), vaginal dryness and pain, 2 mood changes, such as low mood or anxiety and depression. 3 In some societies today, 95% of women enter this stage. This population is projected to reach 1.2 billion by 2030, with an annual increase of 47 million new cases. 4 In Iran, it is expected that in 2021 there would be about 5 million women of menopausal age due to the aging of the population. 5 As a woman ages and goes through natural menopause, her sexuality is adversely affected, particularly in terms of libido, arousal, orgasm, desire, and sexual activity. 6 Sexual dysfunction, one of the most common problems affecting postmenopausal women, significantly impacts their quality of life and can negatively affect selfesteem, contribute to the development of depression and stress, and impact marital satisfaction. [7][8][9] The prevalence of sexual dysfunction among women has been reported at up to 63%, which exceeds this rate after menopause and reaches 68%-86%. 9 This population had increasingly attracted public, pharmaceutical, and medical attention. 10 To prevent and treat sexual dysfunction and reduce menopausal symptoms during menopause in women, pharmacological methods such as hormonal and nonhormonal methods, complementary and alternative medicine (CAM) are used. 5,6,11 While hormone replacement therapy is effective in addressing urogenital problems and improving sexual function, concerns about its long-term use and potential risks, such as cancer and venous thromboembolism, have led women to seek nonpharmacological alternatives. 12 Therefore, women's concern about the consequences of these treatments has led their tendency to nonpharmacological methods such as CAM, which, in addition to have fewer side effects, is also more cost-effective. 11,[13][14][15] CAM is a treatment that falls outside of mainstream healthcare that has shown through science to be safe and effective. 16 Studies have shown varying prevalence rates of CAM use among menopausal women, ranging from 9.8% to 76% in different countries, with Asian countries exhibiting higher figures in recent years. 17 In Iran, this prevalence is 42%. 18 Özcan  Given the increasing population of postmenopausal women, their common symptoms and complications, and the limitations and potential risks associated with drug and hormone therapies, there is a growing demand for CAM interventions. However, the types of CAM used are influenced by societal, historical, and occasionally religious factors, 25 Furthermore, there is a lack of sufficient evidence on the use of CAM specifically in Iran.
Therefore, it is necessary to investigate the utilization of various

| Study type and setting
This was a cross-sectional descriptive-correlational study. Postmenopausal women who were referred to health centers in Kerman were studied from 2020 to 2021. The city of Kerman is the capital of Kerman province, which is located in the southeast of Iran. Health centers are the first level of providing health services to the people 26 and the city of Kerman has 47 health centers. Of these 47 health centers, 31 collaborated with researchers.

| Sample size and sampling
The sample size was estimated at 267 using Cochran's formula for an infinite population in accordance with the study's primary objective (Z = 1.96, d = 0.06). The convenience sampling method was used.
Inclusion criteria included the age range of 50-60 years old, the spouse being alive, having mental health (no history of mental disorders, bipolar, depression, postpartum depression), and at least 12 months passed since the last menstrual period. 14,27 Exclusion criteria included having a history of hysterectomy or surgery that led to abnormal menopause.
In this Project, data were collected through both online sampling form and face-to-face form. In the face-to-face form, a total of 220 questionnaires were given out to postmenopausal women referring to Kerman health centers, of which 189 were returned (a response rate of 85.9%), and 36 were excluded due to not being eligible. In the online sampling form, of 450 postmenopausal women who were contacted, 191 questionnaires were completed (a response rate of 12.44%), and 47 questionnaires were excluded for not having the inclusion criteria. All in all, a total of 297 samples were included in the study. The total response rate was 56.71%.

| Demographic characteristics and background form
This form included the participant and her spouse's age, length of marriage, menopause age, level of education, number of children, occupation, and history of chronic diseases. Also, there were nine questions to measure satisfaction with using complementary medicine, including accessibility, ease of use, harmlessness, noninterference with daily activities, worries about interaction with other treatments, feeling good after using the treatment, suggestion of this method to others, and costeffectiveness. This part is scored on a five-point Likert scale (4 = very satisfied, 3 = satisfied, 2 = dissatisfied, 1 = very dissatisfied, and 0 = no comment). The satisfaction score varied from 0 to 36. The higher the score, the greater the satisfaction. The content validity index of the questionnaire was confirmed by 10 faculty members trained in CAM. Also, its reliability was determined by a pilot study on 30 people of the target population who used CAM.

| CAMQ
The Cronbach's α was reported as 0.77. 28 In another study, Dehghan et al. did some minor revisions on the questionnaire; They reported the content validity index of the questionnaire as 0.96, and for the internal consistency Cronbach's α coefficient was 0.85. 25 In the present study, the Cronbach's α coefficient was obtained 0.74.  30 In the present study, the Cronbach's α coefficient was obtained 0.94.

| Data collection
Due to the prevalence of corona, this study employed a mixedmethods approach. Sampling was done in both face-to-face and online forms in an 8-month period from January until August 2021.
All participants were informed of the study goals and their voluntary participation. Informed consent was obtained. Sampling was done after receiving health services so that there would be no disruption in the service delivery process for these women and they would have enough time to answer the questionnaire. If the subjects were illiterate, a questionnaire was read to them. In the online form, questionnaires were prepared and given out via social networks like Telegram, Whatsapp, and SMS. The researcher, after receiving the contact numbers of postmenopausal women from health centers, identified the eligible individuals and invited them by telephone call to participate in the study. The objectives of the research, its implementation method, and how to fill out an online questionnaire were explained. If they wished to participate in the study, they were asked to sign and read the written consent form by referring to a link on the consent form. Then the link to the questionnaire was sent to eligible postmenopausal women.

| RESULTS
The participants' average age was 54.99 ± 3.08 years. The majority of those who took part in the survey were educated yet unemployed.
Only 4% of the individuals had no children. Nearly half of those who took part in the study had a history of chronic illness (Table 1) There were no significant differences between CAM users and nonusers regarding sexual functions and all its domains (Table 3).
Among the study variables, only the duration of marriage, number of children, history of diabetes, and history of other chronic diseases were associated with CAM use (Table 1). For further analysis, these variables were included in a logistic regression model. The results showed that participants with no history of other chronic diseases used CAM 3.53 times (95% confidence interval for odds ratio: 2.01-6.20) more than participants with a history of other chronic diseases. In addition, the other variables were no longer associated with CAM use.

| DISCUSSION
The aim of this study was to investigate the use of CAM and its relationship with sexual function among postmenopausal women referring to health centers in Kerman.
The results of the present study showed that more than half of menopausal women used at least one type of CAM in the last year.
About half of the participants used prayer, almost a third herbal medicine, less than a quarter relaxation and meditation, and the least used methods were wet cupping, acupressure, acupuncture, and homeopathy, respectively. Arentz et al. in Australia showed that more than almost three quarters of women with polycystic ovary syndrome reported using complementary medicines, usually dietary supplements and herbal supplements. 31 Witteman et al. found that more than three quarters of women with UTI used complementary or selfcare strategies in addition to standard treatment, and almost more than half used CAM/self-care strategies to manage vaginal symptoms. Cranberries (51.9%), vitamin C (43.8%), and D-mannose (32.7%) were the most often reported UTI-related dietary supplements. 32 The types and patterns of CAM use are socioculturally determined and are generally influenced by society, history, and occasionally religion. 25 This study was different from our study in terms of samples, measures, and cultural factors. In Iran, the majority of people are Muslims, and religious practices such as praying and meditating are the daily practices of the Muslim people of Iran. 25 Also, due to the historical background of the use of complementary medicine, the use of complementary medicine is common in Iran.
The results of the present study showed that the sexual function of menopausal women was lower than the index's midpoint which was unfavorable. Yağmur et al. in Turkey revealed that the prevalence of sexual disorders was high among menopausal women, and almost more than half of their participants were below the cutpoint score and unfavorable. 33 Pérez-Herrezuelo et al. in Spain, 34

and in Iran,
Safaei et al. 32 and Jamili et al. 35 showed that almost three quarters, almost three quarters, and more than three quarters of menopausal      supervision; writing-original draft; writing-review and editing.

ACKNOWLEDGMENTS
We would like to thank the women who participated in the study.
The approved research project code was 99000487.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

ETHICS STATEMENT
The ethical committee of Kerman University of Medical Sciences approved the study (IR. KMU. REC.1399.444). After approval, permission was issued to the management of the Health Care Centers. Some oral information, including the goals and objectives of the study, the confidentiality and anonymity of the data, and that the participants were free to withdraw from the study at any time were provided by the researchers. Then written informed consent was taken individually. All methods were carried out in accordance with relevant guidelines and regulations and Declaration of Helsinki.

TRANSPARENCY STATEMENT
The lead author Asma Ghonchehpour affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.