1.  Introduction {#sec0005}
===============

Menopause, defined as the permanent cessation of ovarian function, usually signals the end of a woman's menstrual periods.[@bib0005] The main symptoms of menopause are hot flashes, night sweats, sleep problems, mood disorders, weight gain, loss of sexual desire, and declines in cognitive functioning.[@bib0010] These symptoms cause intense discomfort and a substantial reduction in quality of life.  Women have been looking for alternative treatment options to relieve their symptoms because of the side effects of hormone replacement therapy.[@bib0015] Above all, herbal medicine is a popular choice.[@bib0015], [@bib0020] Its effectiveness and long-term safety, however, have not been adequately researched.[@bib0025] There are few clinical studies supporting the usage of herbal medicines for managing menopausal symptoms.  In addition, there have been very few surveys to gather opinions about using herbal medicine in the treatment of menopausal disorders from clinicians who are involved in the clinical treatment of these disorders. 

The aim of this study was to explore the perceptions Korean medicine doctors (KMDs) have about using herbal medicines to treat menopausal symptoms. 

2.  Methods {#sec0010}
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2.1.  Study design {#sec0015}
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This study involved a cross-sectional study with a web survey of KMDs regarding their perceptions of the major menopausal symptoms and prescribing Korean medicine. 

2.2.  Participants and recruitment {#sec0020}
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This survey was conducted between May 25 and June 7, 2016.  We developed and sent a questionnaire to a total of 497 members of the Society of Korean Medicine obstetrics and gynecology regardless of sex, age, or residence. 

2.3.  Development of survey questionnaire {#sec0025}
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We developed the questionnaire using information from relevant literature found in electronic databases and from classical medical texts.  We used PubMed, OASIS, classical literature, and clinical traditional Korean medicine literature to extract information about major menopausal symptoms and herbal prescriptions.  We derived items of 22 major menopausal symptoms and 19 herbal prescriptions.  We then completed a draft of the questions for the survey ([Fig.  1](#fig0005){ref-type="fig"}).  We formed an expert panel to review the draft with four experts from Korea Institute of Oriental Medicine and four members of the Society of Korean Medicine Obstetrics and Gynecology.  We finalized the draft based on their opinions and got approval from the Society of Korean Medicine Obstetrics and Gynecology to use the final form (Supplement 1).Fig.  1Questionnaire development process. Fig.  1

2.4.  Variables {#sec0030}
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The survey questionnaire included the following key variables (Supplement 1):1)Major symptoms of menopausal disorders and herbal prescriptions used to treat them2)The pattern identification and the herbal prescription used according the stages of menopausal disorders3)The doses of herbal medicines for women with menopausal disorders4)General characteristics of respondents (age, sex, region, etc.) 

2.5.  Data sources/measurement {#sec0035}
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We surveyed licensed KMDs of the Society of Korean Medicine Obstetrics and Gynecology through Survey Monkey (<https://ko.surveymonkey.com>). 

2.5.  Statistical analysis {#sec0040}
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The frequency analysis of each item in the survey was performed using Microsoft Excel 2016.  Descriptive statistics were conducted for each of the percentage distributions using each category of data. 

2.7.  Ethical considerations {#sec0045}
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The ethical review committee of the Semyung University approved this study (SMU-EX-2019-06-001).  The survey was conducted on a voluntary basis, and the participants agreed to the use of the collected data for scientific purposes. 

3.  Results {#sec0050}
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3.1.  General characteristics {#sec0055}
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Out of the initial 497 KMDs who were sent the survey, we received responses from only 48 doctors, a response rate of 9.7%.  The general characteristics of the respondents are shown in [Table 1](#tbl0005){ref-type="table"}.Table 1Demographic characteristics of respondents (n = 48).Table 1ClassificationTotal (n = 48)n%Sex Male1327.1 Female1020.8 No response2552.1  Age (years) 20--2936.3 30--391020.8 40--49918.8 50--5912.1 No response2552.1  Duration of clinical experience Under 5years816.7 Over 5 under 10years48.3 Over 10 under 15years510.4 Over 15years612.5 No response2552.1  Place of work KM hospital1327.1 KM clinic918.8 No response2654.2  Specialist of KM and Gynecology Yes1735.4 No612.5 No response2552.1[^2]

3.2.  Perceptions about the major symptoms of menopausal women {#sec0060}
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The most common symptoms of menopausal disorder perceived by KMDs who responded were hot flashes (22.9%), sleep disorders (18.2%), systemic fatigue (12.5%), sweating (12.0%), joint pain/low back pain (6.3%), and depression (5.7%) ([Table 2](#tbl0010){ref-type="table"}).Table 2Perception on the major symptoms of menopausal disorder. Table 2Symptoms*n*%Circulatory system Hot flush4422.9 Hot hands and feet42.1 Cold hands and feet21.0 Dry mouth31.6 Bitter taste10.5 Palpitation94.7 Sweating2312.0  Nervous system Insomnia3518.2 Memory lapses21.0 Depression115.7 Anxiety31.6  Reproductive system Vaginal dryness21.0  Urinary system Pollakisuria21.0 Urinary incontinence10.5   Musculoskeletal system Systemic fatigue2412.5 Joint inflammation /backache126.3 Gonalgia / shoulder pain31.6  Sense organs Numbness in hand and feet31.6 Skin sensibility10.5  Alimentary system Poor appetite10.5  Metabolic system Gain weight63.1[^3]

3.3.  Main pattern identification and herbal medicines according to stages of menopausal disorder {#sec0065}
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[Table 3](#tbl0015){ref-type="table"} shows responses to the main pattern identification and the herbal prescriptions given for menopausal disorders according to the stage of the condition.  The major patterns of symptoms doctors identified for the pre, peri and postmenopausal phases, respectively, were liver qi stagnation (27.1%), kidney yin deficiency (20.8%), and kidney yin deficiency (20.8%).  The most frequent herbal remedies prescribed for the pre, peri and postmenopausal phases, respectively, were Jiawei shaoyao-san (Gami soyo-san, 31.3%), Jiawei guipi-decoction (Gami gwibi-tang, 16.7%), and Liuwei dihuang-decoction (Yukmi jihwang-tang, 16.7%).Table 3The major pattern identification and herbal medicines for different stages of menopausal disorder. Table 3Pre-menopausePeri-menopausePost-menopause*n*%*n*%*n*%Pattern IdentificationLiver qi depression816.712.100.0Liver qi stagnation1327.148.324.2Phlegm-dampness00.000.024.2Kidney yang deficiency24.212.124.2Yin deficiency24.21020.81020.8Dual deficiency of the heart-spleen48.324.2510.4Non-interaction between the heart and kidney48.3918.836.3Other24.224.212.1No response1327.11939.62347.9\
  Prescription (Chinese name/Korean name)Jiawei quipi decoction (Gami gwibi-tang)1122.9816.7714.6Jiawei shaoyao-san (Gami soyo-san)1531.3714.636.3Danggui shaoyao-san (Dangguijakyak-san)12.112.100.0Chaihu yugan-san (Sihoukgan-san)12.100.000.0Wendan decoction (Ondam-tang)00.012.124.2Liuwei dihuang decoction (Yukmijihwang-tang)12.1612.5816.7Liuyu decoction (Yukwool-tang)36.312.100.0Erxian decoction (Yiseon-tang)00.024.212.1Other36.336.348.3No response1327.11939.62347.9

3.4.  Dose of herbal medicine for women with menopausal disorder {#sec0070}
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The most recommended dose of herbal medicine per day was three doses (29.2%), followed by two doses (20.8%) and the mean duration of treatment with herbal medicine was four weeks (18.8%), followed by eight weeks (12.5%), and six weeks (10.4%) ([Table 4](#tbl0020){ref-type="table"}).  The most frequent concomitant treatment with herbal medicine was acupuncture (47.9%), followed by pharmacopuncture (27.1%), moxibustion (27.1%), cupping (20.8%), and electroacupuncture (12.5%).Table 4Recommended regimen of HM for managing menopausal disorder. Table 4Dose of HM*n*%Number of doses Once a day00.0 Twice a day1020.8 Three times a day1429.2 No response2450.0  Treatment duration 2 weeks12.1 3 weeks12.1 4 weeks (1 month)918.8 5 weeks00.0 6 weeks510.4 7 weeks00.0 8 weeks (2 months)612.5 3 months12.1 More than 4 months12.1 No response2450.0  Combined treatment with HM[a](#tblfn0005){ref-type="table-fn"} Acupuncture2347.9 Parmacopuncture1327.1 Electro-acupuncture612.5 Moxibustion1327.1 Cupping1020.8 Chuna12.1 KM for physical therapy48.3 Other12.1 No response2450.0[^4][^5]

4.  Discussion {#sec0075}
=============

We investigated the perception of using herbal medicines to manage menopausal symptoms with a questionnaire developed through literature reviews and experts' opinions.  The results of the pilot survey shows that Jiawei guipi-decoction (Gami gwibi-tang) is widely used to alleviate neuropsychiatric and digestive issues related to menopausal symptoms --- including insomnia, chest discomfort, hot flashes, loss of appetite, and lethargy caused by dual deficiency of the heart and spleen.[@bib0030] Liuwei dihuang-decoction (Yukmi jihwang-tang) is used to treat menopausal symptoms caused by kidney deficiency such as blushing (hot flashes), chest discomfort, and heat sensations in the chest, palms, and soles.  With a patient's increasing age, the stage of the condition showed a pattern of shifting toward deficiency syndromes, such as kidney yin deficiency, a non-interaction between the heart and kidney, rather than liver qi depression and liver qi stagnation, and this shift in the pattern was reflected in the use of prescriptions.[@bib0035], [@bib0040], [@bib0045]

There are two similar studies which investigated herbal medicines for menopausal symptoms.[@bib0050], [@bib0055] One study analyzed a nationwide prescription database to investigate the prescription patterns of Chinese herbal products for menopausal symptoms, in Taiwan.[@bib0050] The other study analyzed survey results on the frequency of KM for menopausal symptoms.[@bib0055] Our results of the major herbal medicines prescribed for menopausal symptoms (Shaoyao-san, Guipi-decoction) are similar to those found in Taiwan and the previous Korean survey.  However, some herbal medicines in Korea are different from Taiwan.  Comparing our study to these two studies, we have provided more information about the pattern identification and the herbal medicines that were prescribed for different menopausal stages as well as information about the dosages of these herbal medicines. 

There were limitations to this study.  First, the response rate was too low to make generalizations.  Second, half of the participants did not fully complete the questionnaire; they left the open-ended questions unanswered. 

The questionnaire that we developed, and the results of this pilot survey provide valuable information about the usage of herbal medicines in managing menopausal symptoms.  However, we may not be able to generalize because the size of our sample was not large enough to be representative.  Future studies should be done with more participants, and the results should be confirmed in clinical practice. 

Author contributions {#sec0095}
====================

JHJ, HWL, JC, JAL, and MSL conceptualized this study.  JHJ, JC, JAL, MSL drafted, made the revisions and created the final version of questionnaire.  JHJ, JC, HWL, HYG made the web version and performed the survey.  JHJ, HWL, and MSL wrote the original draft.  JC, TYC, JAL, HYG critically commented on the manuscript.  All authors approved the final version. 

Conflict of interest {#sec0080}
====================

The authors declare that they have no competing interests. 

Funding {#sec0085}
=======

This study is supported by the Korea Institute of Oriental Medicine (K162921, K17292, and K17043).  The funder had no role in this study. 

Ethical statement {#sec5090}
=================

The ethical review committee of the Semyung University approved this study (SMU-EX-2019-06-001).  The survey was conducted on a voluntary basis, and the participants agreed to the use of the collected data for scientific purposes. 

Data availability {#sec0090}
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Data will be made available on request. 

Supplementary material {#sec0105}
======================

The following are Supplementary data to this article:

Developed questionnaire can be found, in the online version, at doi:<https://doi.org/10.1016/j.imr.2019.08.004>. 

[^1]: Equally contributed. 

[^2]: KM: Korean medicine. 

[^3]: Duplicated responses were allowed. 

[^4]: HM: herbal medicine; KM: Korean medicine. 

[^5]: Duplicated responses were allowed.