A comparison of acupuncture and oral estradiol treatment of vasomotor symptoms in postmenopausal women

Acupuncture for treating hot flushes in men with prostate cancer: a systematic review

GOALS OF WORK

The goal of the study was to assess the effects of acupuncture as a treatment for hot flushes in prostate cancer (PC) patients.

MATERIALS AND METHODS

The literature was searched using 14 databases with dates ranging from their inceptions to December 2008 and without language restrictions. All clinical studies of any type of acupuncture in PC patients were included. Their main outcome measures had to be vasomotor symptoms. Their methodological quality was assessed using the modified Jadad score.

RESULTS

Six studies met all the inclusion criteria. One randomised clinical trial compared the effects of manual acupuncture with acupuncture plus electro-acupuncture. The other five studies were uncontrolled observational studies and therefore had limitations.

CONCLUSION

The evidence is not convincing to suggest acupuncture is an effective treatment for hot flush in patients with PC. Further research is required to investigate whether acupuncture has hot-flush-specific effects.

Study Protocol: effects of acupuncture on hot flushes in perimenopausal and postmenopausal women - a multicenter randomized clinical trial

Background

Hot flushes are the most frequent climacteric symptom and a major cause of suffering among menopausal women. The condition negatively influences many aspects of women's lives. To date, conventional hormone replacement therapy (HRT) is considered the most effective treatment for hot flushes. However, HRT is associated with a host of negative side effects. Complementary and alternative medical (CAM) approaches have been employed to relieve symptoms and to avoid these side effects. Acupuncture is one of the most strongly preferred CAM treatments for many diseases, causing few serious adverse effects, and is frequently used in Korea.

We aim to evaluate the effectiveness of Traditional Korean Acupuncture (TKA) in conjunction with usual care, compared to usual care alone, on hot flushes in perimenopausal and postmenopausal women in Korea.

Methods

This study consists of a multi-center randomized controlled trial with 2 parallel arms. Participants included in the study will meet the following criteria: 1) a documented daily average hot flush score ≥ 10 for one week prior to the screening visit 2) not taking HRT and other pharmaceutical therapies which might affect hot flushes or other vasomotor symptoms.

While maintaining usual care, the treatment group will receive acupuncture 3 times a week, for a total of 12 sessions over 4 weeks. The control group will receive usual care alone during the same period. Post-treatment follow-up will be performed one month after completing 12 sessions of acupuncture.

Discussion

This trial will provide evidence for the effectiveness of acupuncture as a treatment for hot flushes. The primary endpoint in both groups is a change in hot flush score from baseline to week 4 and/or week 8. As the secondary endpoint, we will employ the Menopause Rating Scale (MRS), a health-related quality of life questionnaire. Further analysis will examine the frequency, severity and difference in symptoms for daytime vs. nighttime hot flushes, sub-domain analysis of MRS, and participants' expectations of acupuncture treatment.

Trial registration

Current Controlled Trials ISRCTN49335612

Acupuncture for the treatment of hot flashes in breast cancer patients, a randomized, controlled trial

Acupuncture has been used to treat the problem of hot flashes in healthy postmenopausal women. The object of this study was to investigate the efficacy of acupuncture in women with breast cancer suffering from hot flashes as a result of anti-oestrogen medication. In a prospective, controlled trial, 59 women suffering from hot flashes following breast cancer surgery and adjuvant oestrogen-antagonist treatment (Tamoxifen) were randomized to either 10 weeks of traditional Chinese acupuncture or sham acupuncture (SA). Mean number of hot flashes at day and night were recorded prior to treatment, during the treatment period as well as during the 12 weeks following treatment. A validated health score (Kupperman index) was conducted at baseline, at the end of the treatment period and at 12 weeks following treatment. During the treatment period mean number of hot flashes at day and night was significantly reduced by 50 and almost 60%, respectively from baseline in the acupuncture group, and was further reduced by 30% both at day and night during the next 12 weeks. In the sham acupuncture group a significant reduction of 25% in hot flashes at day was seen during treatment, but was reversed during the following 12 weeks. No reduction was seen in hot flashes at night. Kupperman index was reduced by 44% from baseline to the end of the treatment period in the acupuncture group, and largely maintained 12 weeks after treatment ended. No corresponding changes were seen in the sham acupuncture group. Acupuncture seems to provide effective relief from hot flashes both day and night in women operated for breast cancer, treated with Tamoxifen. This treatment effect seems to coincide with a general health improvement measured with the validated Kupperman index.

Auricular acupuncture: a novel treatment for vasomotor symptoms associated with luteinizing-hormone releasing hormone agonist treatment for prostate cancer

OBJECTIVES

To evaluate the role of auricular acupuncture (AA) in men receiving luteinizing-hormone releasing hormone (LHRH) analogues for carcinoma of the prostate, as vasomotor symptoms can affect the quality of life in such men, and similar symptoms in postmenopausal women have been successfully treated with AA.

PATIENTS AND METHODS

In all, 60 consecutive patients with prostate cancer and on LHRH agonist treatment (median age 74 years, range 58-83) consented to weekly AA for 10 weeks. The validated 'Measure Yourself Concerns and Well-Being' questionnaire (a six-point scale to assess symptom severity) was used to assess concerns and well-being before and after treatment.

RESULTS

All men completed the treatment with no adverse events recorded, apart from transient exacerbation of symptoms in two men; 95% of patients reported a decrease in the severity of symptoms, from a mean 5.0 to 2.1 (Student's t-test, P < 0.01).

CONCLUSIONS

The symptomatic improvement was at levels comparable with that from pharmacotherapy, and cost analysis showed AA to be a viable alternative. Larger randomized studies are needed to fully evaluate AA against more conventional treatments, and these are planned.

Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicenter trial

OBJECTIVE

To evaluate the effects of electro-acupuncture (EA) and hormone therapy (HT) on vasomotor symptoms in women with a history of breast cancer.

METHODS

Forty-five women were randomized to EA (n = 27) for 12 weeks or HT (n = 18) for 24 months. The number of and distress caused by hot flushes were registered daily before, during and up to 24 months after start of treatment.

RESULTS

In 19 women who completed 12 weeks of EA, the median number of hot flushes/24 h decreased from 9.6 (interquartile range (IQR) 6.6-9.9) at baseline to 4.3 (IQR 1.0-7.1) at 12 weeks of treatment (p < 0.001). At 12 months after start of treatment, 14 women with only the initial 12 weeks of EA had a median number of flushes/24 h of 4.9 (IQR 1.8-7.3), and at 24 months seven women with no other treatment than EA had 2.1 (IQR 1.6-2.8) flushes/24 h. Another five women had a decreased number of flushes after having additional EA. The 18 women with HT had a baseline median number of flushes/24 h of 6.6 (IQR 4.0-8.9), and 0.0 (IQR 0.0-1.6; p = 0.001) at 12 weeks.

CONCLUSION

Electro-acupuncture is a possible treatment of vasomotor symptoms for women with breast cancer and should be further studied for this group of women.

Practical clinical guidelines for assessing and managing menopausal symptoms after breast cancer

BACKGROUND

The purpose of this study was to provide practical, evidence-based guidelines for evaluating and treating common menopausal symptoms following breast cancer.

METHODS

Literature review of the causes, assessment and management of menopausal symptoms in breast cancer patients.

RESULTS

A number of nonhormonal treatments are effective in treating hot flashes. Whether pharmacological treatment is given will depend on the severity of symptoms and on patient wishes. For severe and frequent hot flashes, the best data support the use of venlafaxine, paroxetine and gabapentin in women with breast cancer. Side-effects are relatively common with all these agents. For vaginal dryness, topical estrogen treatment is the most effective but the safety of estrogens following breast cancer is not established. There are limited data on effective treatments for sexual dysfunction during menopause.

CONCLUSION

Menopausal symptoms after breast cancer should be evaluated and managed as warranted using a systematic approach and may benefit from multidisciplinary input.

Two modes of acupuncture as a treatment for hot flushes in men with prostate cancer--a prospective multicenter study with long-term follow-up

BACKGROUND

Hot flushes are common and distressing among men with castrational treatment for prostate cancer. Of the few treatments, most have side effects.

OBJECTIVE

Assess changes in hot flushes of electrostimulated (EA) and traditional acupuncture (TA).

DESIGN, SETTING, AND PARTICIPANTS

Thirty-one men with hot flushes due to prostate cancer treatment were recruited from three urological departments in Sweden, from 2001 to 2004.

INTERVENTION

Thirty-one men were randomized to EA (12 needle points, with 4 electrostimulated) or TA (12 needle points) weekly for 12 wk.

MEASUREMENTS

PRIMARY OUTCOME

number of and distress from hot flushes in 24 h and change in "hot flush score." Secondary outcome: change in 24-h urine excretion of CGRP (calcitonin gene-related peptide).

RESULTS AND LIMITATIONS

Twenty-nine men completed the treatment. Hot flushes per 24 h decreased significantly, from a median of 7.6 (interquartile range [IQR], 6.0-12.3) at baseline in the EA group to 4.1 (IQR, 2.0-6.5) (p=0.012) after 12 wk, and from 5.7 (IQR, 5.1-9.5) in the TA group to 3.4 (IQR1.8-6.3) (p=0.001). Distress by flushes decreased from 8.2 (IQR, 6.5-10.7) in the EA group to 3.3 (IQR, 0.3-8.1) (p=0.003), and from 7.6 (IQR, 4.7-8.3) to 3.4 (IQR, 2.0-5.6) (p=0.001) in the TA group after 12 wk, (78% and 73% reduction in "hot flush score," respectively). The effect lasted up to 9 mo after treatment ended. CGRP did not change significantly. Few, minor side effects were reported.

LIMITATIONS

small number of patients; no placebo control, instead a small group controlled for 6 wk pretreatment.

CONCLUSIONS

EA and TA lowered number of and distress from hot flushes. The hot flush score decreased 78% and 73%, respectively, in line with or better than medical regimens for these symptoms. Acupuncture should be considered an alternative treatment for these symptoms, but further evaluation is needed, preferably with a non- or placebo-treated control group.

Acupuncture in managing menopausal symptoms: hope or mirage?

There is an increased interest amongst women in seeking alternatives for hormone replacement therapy because of their fear of side-effects. It is claimed that acupuncture is effective for curing menopausal symptoms, and to be a safe treatment in the hands of well-trained and qualified practitioners. About one million acupuncture treatments are given in the National Health Service and two million privately each year in England for various indications. However, because its mechanism of action is not fully understood in physiological terms, acupuncture is considered by many clinicians to be of no value. This article reviews the currently available evidence as regards the effectiveness and safety of acupuncture in treating menopausal symptoms.

Randomized, controlled trial of acupuncture for the treatment of hot flashes in breast cancer patients

PURPOSE

To determine the immediate and long-term effects of true acupuncture versus sham acupuncture on hot flash frequency in women with breast cancer.

PATIENTS AND METHODS

Seventy-two women with breast cancer experiencing three or more hot flashes per day were randomly assigned to receive either true or sham acupuncture. Interventions were given twice weekly for 4 consecutive weeks. Hot flash frequency was evaluated at baseline, at 6 weeks, and at 6 months after initiation of treatment. Patients initially randomly assigned to the sham group were crossed over to true acupuncture starting at week 7.

RESULTS

The mean number of hot flashes per day was reduced from 8.7 (standard deviation [SD], 3.9) to 6.2 (SD, 4.2) in the true acupuncture group and from 10.0 (SD, 6.1) to 7.6 (SD, 5.7) in the sham group. True acupuncture was associated with 0.8 fewer hot flashes per day than sham at 6 weeks, but the difference did not reach statistical significance (95% CI, -0.7 to 2.4; P = .3). When participants in the sham acupuncture group were crossed over to true acupuncture, a further reduction in the frequency of hot flashes was seen. This reduction in hot flash frequency persisted for up to 6 months after the completion of treatment.

CONCLUSION

Hot flash frequency in breast cancer patients was reduced following acupuncture. However, when compared with sham acupuncture, the reduction by the acupuncture regimen as provided in the current study did not reach statistical significance. We cannot exclude the possibility that a longer and more intense acupuncture intervention could produce a larger reduction of these symptoms.

Exercise for vasomotor menopausal symptoms

BACKGROUND

Evidence suggests that a high proportion of perimenopausal and early postmenopausal women will experience some menopause symptoms, hot flushes being the most common. The effects caused by falling levels of estrogen may be alleviated by hormone replacement therapy (HRT) but there has been a marked global decline in the prescription and use of HRT due to concerns about the risks and benefits of HRT; consequently many women are now seeking alternatives. As large numbers of women are choosing not to take HRT, it is increasingly important to identify evidence based lifestyle modifications, which can have a positive effect on menopausal symptoms.

OBJECTIVES

To examine the effectiveness of any type of exercise intervention in the management of vasomotor menopausal symptoms (hot flushes and night sweats) in perimenopausal and postmenopausal women.

SEARCH STRATEGY

Searches of the following electronic bibliographic databases were performed to identify randomised controlled trials: The Cochrane Library (CENTRAL) (Wiley Internet interface) 2006 Issue 2, MEDLINE (Ovid) 1966-May week 4 2006, EMBASE (Ovid) 1980-week 21 2006, PsycINFO (Ovid) 1967-May week 5 2006, Science Citation Index and Social Science Citation Index (Web of Science) 1900-June 2006 and 1956-June 2006 respectively, CINAHL (Ovid) 1982-May week 4 2006, SPORT Discus (ERL WebSPIRS) 1830-2006/04.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which any type of exercise intervention was compared to other treatments or no treatment in the management of menopausal vasomotor symptoms in symptomatic perimenopausal and postmenopausal women.

DATA COLLECTION AND ANALYSIS

Nineteen reports were deemed potentially eligible, but of these only one met the inclusion criteria and three authors independently extracted data from this trial.

MAIN RESULTS

Only one very small trial, which compared exercise with HRT, was available for inclusion in this review. Based on within-group analyses the study authors concluded that both interventions were effective in reducing vasomotor symptoms. Between-group trial analyses conducted by reviewers showed that the HRT group experienced significantly fewer hot flushes compared to the exercise group at follow-up.

AUTHORS' CONCLUSIONS

Only one very small trial involving symptomatic women has assessed the effectiveness of exercise in the management of vasomotor menopausal symptoms. Exercise was not as effective as HRT in this trial. We found no evidence from randomised controlled trials on whether exercise is an effective treatment relative to other interventions or no intervention in reducing hot flushes and or night sweats in symptomatic women. No conclusions regarding the effectiveness of exercise as a treatment for vasomotor menopausal symptoms could be made due to a lack of trials.

Effect of acupuncture on pubertal development of rats and rabbits at different developmental stages

Physiological and endocrine studies on sexual development in animals and effects of acupuncture on sexual development are limited. Therefore, we investigated the effect of electro-acupuncture (EA) on the arcuate nucleus (Arc) and release of gonadotropin-releasing hormone (GnRH) in animals at different developmental stages. In Experiment 1, EA stimulation (30 Hz) was performed for 30 min per day in EA group of rabbits for 48 days, while the control group (mature rabbits) was not given EA. Arc discharges in those two groups were measured after the 48-day treatment. Arc discharge was also measured in the pre-pubertal group (as control) without EA treatment. Then, all three groups were treated with transient EA for 30 min and Arc discharges were determined again. In Experiment 2, EA (3 Hz) at the same acupoints or non-acupoints as that in the rabbits was performed for 20 min per day in different developmental group of Sprague-Dawley rats for 10 days. GnRH mRNA expression in the hypothalamus of rats was determined using RT-PCR and real-time PCR. The serum sexual hormone, sperm count, and body weight was measured. The results showed that the Arc discharge (P<0.01), testosterone (T) (P<0.01) and sperm count (P<0.01) in male rabbits were reduced by repeated EA. However, the body weight of rabbits was not changed after EA compared to the control in Experiment 1. In Experiment 2, GnRH mRNA expression in rats of the early pubertal group (EPG) and adult group (AG) were significantly depressed after repeated EA at acupoints (P<0.01). The sexual hormones were negatively influenced by repeated EA during puberty. Sperm count was reduced significantly after repeated EA at time of puberty (P<0.01). Repeated EA did not influence body weight of rats (P>0.01) and structures of the gonadial tissues during development. The results suggested that repeated EA is a good option that can be considered for regulating the function of the hypothalamus-pituitary-gonad (HPG) axis during puberty.

Follow-up after treatment for breast cancer in young women

The majority (80%) of breast cancers are diagnosed in women over the age of 50; only 5% will be in their 20s and 30s. These women have specific needs that include genetic counselling, psychological support, advice with regard to fertility and pregnancy issues and information on coping with treatment-related morbidity. The primary purpose of follow-up is often regarded as the early detection of recurrence as well as the detection of second primary tumours. Rather than concentrating solely on detecting cancer recurrence, clinicians need to be more susceptive to symptoms related to treatment morbidity and to the information needs of their patients. This paper outlines the specific issues listed above that need to be addressed in follow-up clinics and highlights interventions that may help improve the value of follow-up appointments and quality of life for young women with breast cancer.

Family Medicine Physicians′ Advice about Use of Nonconventional Modalities for Menopausal Symptom Management

AIMS

This study explores the beliefs and practices of family medicine physicians regarding the use of nonconventional modalities for menopausal symptom management.

METHODS

Anonymous self-administered questionnaires were distributed to faculty and residents from eight participating family medicine residency programs around Florida, with an overall response rate of 66% (212 respondents). The survey explored what physicians report about patterns of patient inquiries and their responses to patients' inquiries about nonconventional modalities for specific menopausal symptoms and what physicians' report on their advice to patients about using specific herbs and supplements for menopausal symptom relief.

RESULTS

Behavioral approaches were encouraged more than herbal therapies, acupuncture, and body therapies for the treatment of most of the menopausal symptoms. However, the most frequent response category was No advice. Resident physicians were significantly more likely than faculty to encourage acupuncture. Faculty physicians were more likely than residents to recommend particular herbal remedies. The majority of the respondents believed there was not sufficient evidence for recommending any of the herbs and supplements listed.

CONCLUSIONS

These data reveal some important trends about how family medicine physicians respond to nontraditional approaches for menopausal symptom management. Because family medicine physicians typically receive some training in behavioral and psychotherapeutic approaches and there is some evidence for the effectiveness of behavioral strategies in menopausal symptom management, it is not surprising that they are more likely to endorse these approaches. Most family medicine physicians, however, have little or no training in the other nonconventional modalities, and our data show that these modalities received lower levels of endorsement, suggesting that physicians are not clear on their advantages or disadvantages.

Acupuncture for postmenopausal hot flashes

OBJECTIVE

To determine whether individually tailored acupuncture is an effective treatment option for reducing postmenopausal hot flashes and improving quality of life.

METHODS

In a randomized, placebo-controlled pilot study, 29 postmenopausal participants averaging at least seven moderate to severe hot flashes per 24h, with a baseline estradiol concentration of less than 50 pg/mL and a normal TSH level, were randomized to receive 7 weeks (nine treatment sessions) of either active acupuncture or placebo acupuncture (placebo needles that did not penetrate the skin at sham acupuncture points). Participants recorded hot flashes in logs that were reported daily. Global indices of the severity and frequency of hot flashes were derived from the participants' daily logs.

RESULTS

Participants receiving the active treatment had a greater reduction in hot flash severity (24.5+/-30.7%) compared to those receiving placebo (4.4+/-17.1%, P=0.042). Within group repeated measures analyses of variance revealed a significant reduction in hot flash severity in the active (P=0.042), but not in the placebo treatment group (P=0.15). Although there was no significant group difference in the reduction of hot flash frequency between the active (42.4+/-32.2%) and placebo groups (32.0+/-26.5%; P>or=0.352), within group repeated measures analyses of variance revealed that the reduction was statistically significant in both groups (P<or=0.001).

CONCLUSIONS

Standardized, individually tailored acupuncture treatment was associated with significantly greater decrease in the severity, but not the frequency, of hot flashes, in symptomatic postmenopausal women when compared to placebo acupuncture of equal duration. Future, larger scale, studies are needed.

Non-hormonal treatments for menopausal symptoms

Increasing numbers of women are requesting non-hormonal treatments for menopausal symptoms. Estrogen-containing HRT is the most effective treatment for menopausal symptoms in healthy women but is contraindicated for some women and avoided by many others. This review will assess the evidence regarding the safety and efficacy of non-hormonal treatments for menopausal symptoms. Relatively few high quality studies have addressed this issue, almost all have only addressed the treatment of hot flushes and there are few long-term data.

Endocrine Effects of Breast Cancer Treatment

OBJECTIVES

To discuss long-term physical effects of treatment for breast cancer including effects on reproductive, bone, sexual health, and related women's issues.

DATA SOURCES

Research articles, abstracts, literature reviews.

CONCLUSION

Long-term effects of treatment have become increasingly prevalent in breast cancer survivors. The most common are effects on reproductive, bone, and sexual health.

IMPLICATIONS FOR NURSING PRACTICE

Long-term effects of treatment can have a significant negative impact on the long-term health and QOL of women with breast cancer. Oncology nurses are well-positioned to anticipate and address the reproductive and endocrine consequences of breast cancer treatment.

Psychological well-being improves in women with breast cancer after treatment with applied relaxation or electro-acupuncture for vasomotor symptom

The aim of this study was to evaluate the effect of applied relaxation and electro-acupuncture (EA) on psychological well-being in breast cancer-treated women with vasomotor symptoms. Thirty-eight breast cancer-treated postmenopausal women with vasomotor symptoms were included in the study. They were randomized to either treatment with electro-acupuncture (EA) (n = 19, three of them with tamoxifen) or applied relaxation (AR) (n = 19, five of them with tamoxifen) over a 12-week study period with six months follow-up. Vasomotor symptoms were registered daily. A visual analog scale was used to assess climacteric symptom, estimation of general well-being was made using the Symptom Checklist, and mood using the Mood Scale. These were applied during treatment and at follow-up. In total 31 women completed 12 weeks of treatment and six months of follow-up. Hot flushes were reduced by more than 50%. Climacteric symptoms significantly decreased during treatment and remained so six months after treatment in both groups. Psychological well-being significantly improved during therapy and at follow-up visits in both groups. Mood improved significantly in the electro-acupuncture treated group. In conclusion psychological well-being improved in women with breast cancer randomized to treatment with either AR or EA for vasomotor symptoms and we therefore suggest that further studies should be performed in order to evaluate and develop these alternative therapies.

Hot flash therapies in breast cancer survivors

More than 86% of those diagnosed with invasive breast cancer are expected to survive for >/= 5 years after their diagnosis. Approximately 75% of postmenopausal women who had breast cancer report experiencing hot flashes. More than 90% of young survivors also experience hot flashes, which can be more severe and long lasting, with iatrogenic ovarian ablation or antiestrogen therapy. There are numerous options for the treatment of hot flashes. Not one treatment fits all. Some treatments are generally more effective than others, and each has different side effects. This review is meant to provide the basic information needed to make a decision about the best treatment for a breast survivor experiencing hot flashes.

A randomized controlled pilot study of acupuncture for postmenopausal hot flashes: effect on nocturnal hot flashes and sleep quality

OBJECTIVE

To assess the effectiveness of acupuncture on postmenopausal nocturnal hot flashes and sleep.

DESIGN

Prospective randomized placebo-controlled study.

SETTING

Stanford University School of Medicine and private acupuncture offices.

INTERVENTION(S)

Active or placebo acupuncture was administered for nine sessions over seven weeks.

MAIN OUTCOME MEASURE(S)

Severity and frequency of nocturnal hot flashes from daily diaries and Pittsburgh Sleep Quality Index (PSQI).

PATIENT(S)

Twenty-nine postmenopausal women experiencing at least seven moderate to severe hot flashes daily, with E(2) <18 pg/mL and FSH 30.0-110.0 IU/L.

RESULT(S)

Nocturnal hot-flash severity significantly decreased in the active acupuncture group (28%) compared with the placebo group (6%), P=.017. The frequency of nocturnal hot flashes also decreased in the active group (47%, P=.001), though it was not significantly different from the placebo group (24%, P=.170; effect size = 0.65). Treatment did not differentially influence sleep; however, correlations between improvements in PSQI and reductions in nocturnal hot flash severity and frequency were significant (P<.026).

CONCLUSION(S)

Acupuncture significantly reduced the severity of nocturnal hot flashes compared with placebo. Given the strength of correlations between improvements in sleep and reductions in nocturnal hot flashes, further exploration is merited.

Treatment of hot flushes in breast and prostate cancer

Hot flushes, the most common health problem reported by menopausal-age women, can lead to significant morbidity and affect the social life, ability to work and sleep pattern of the sufferer. Women treated for breast cancer and men receiving androgen ablation for prostate cancer experience hot flushes that are more frequent, severe and longer lasting than those experienced by the general menopausal population. In women with breast cancer, hot flushes can result from chemotherapy-induced menopause, hormonal therapy, or ovarian suppression. In men with prostate cancer, hot flushes occur after surgical or medical castration. Hormone replacement therapy with oestrogen-based compounds has been a mainstay of treatment for hot flushes during the perimenopausal period. However, recent studies have shown that, in healthy menopausal women, hormone replacement therapy is associated with an increased risk of breast cancer, myocardial infarction, thrombo-embolic events and stroke. Thus, identifying nonhormonal agents that can control hot-flush symptoms is essential to the quality of life of a growing population of cancer survivors. The most promising agents act on the CNS and include selective serotonin reuptake inhibitors, as well as venlafaxine and gabapentin.

Symptoms and Treatment in Cancer Therapy‐Induced Early Menopause

Young women with breast cancer often experience early menopause as a result of the therapy for their malignant disease. The sudden occurrence of menopause resulting from chemotherapy, oophorectomy, radiation, or gonadal dysgenesis frequently results in hot flashes that begin at a younger age and may occur at a greater frequency and intensity than hot flashes associated with natural menopause. Hormone therapy relieves symptoms effectively in 80%-90% of women who initiate treatment. This therapy, however, is generally contraindicated in estrogen-dependent cancers, such as breast cancer, because of the potentially increased risk for recurrence. Many agents have been investigated as potential means for alleviating hot flashes in survivors of breast cancer, such as progestagens, clonidine, gabapentin, and anti-depressants. Several complementary and alternative medicines frequently used by patients have also been studied. These include black cohosh, phytoestrogens, homeopathy, vitamin E, acupuncture, and behavior strategies. To support the use of one of more of these nonpharmacological or pharmacological options in the treatment of hot flashes in breast cancer patients, more evidence from well-controlled clinical trials is needed. In particular, soundly based scientific research with complementary and alternative medicine therapies is lacking. Pharmacological treatments appear to be more beneficial than nonpharmacological treatments. This article reviews the current literature to assess the epidemiology and diagnosis of hot flashes and the nonpharmacological and pharmacological options for the treatment of hot flashes, in breast cancer patients in particular. When specific treatment options have not been evaluated in breast cancer patients specifically, published data on the management of hot flashes with this modality in healthy postmenopausal women are described.

Acupuncture and self acupuncture for long-term treatment of vasomotor symptoms in cancer patients--audit and treatment algorithm

INTRODUCTION

Since hormone replacement therapy given for long periods is now recognised to produce serious side effects, patients with troublesome vasomotor symptoms are increasingly using non-hormonal treatment including acupuncture. Several randomised controlled trials have shown that acupuncture reduces menopausal symptoms in patients experiencing the normal climacteric. It may have this effect by raising serotonin levels which alter the temperature set point in the hypothalamus. Vasomotor symptoms can be extreme in breast cancer patients and patients with prostate cancer who are undergoing anticancer therapy. The safety of some herbal medicines and phytoestrogens has been questioned, as they could potentially interfere adversely with the bioavailability of tumouricidal drugs. A previous study reports short term benefit from acupuncture, and the aim of this report is to describe our approach to long term treatment.

ACUPUNCTURE APPROACH

After piloting several approaches, six weekly treatments were given initially at LI4, TE5, LR3 and SP6 and two upper sternal points, but avoiding any limb with existing lymphoedema or prone to developing it. If there were no contraindications, patients were given clear instructions on how to perform self acupuncture using either semi-permanent needles or conventional needling at SP6, weekly for up to six years, for long term maintenance.

AUDIT METHODS AND RESULTS

A retrospective audit of electronic records was carried out by a doctor not involved in treatment. A total of 194 patients were treated, predominantly with breast and prostate cancer. One hundred and eighty two patients were female. The number of pre-treatment hot flushes per day was estimated by the patient: in the 159 cases providing adequate records, the mean was 16 flushes per day. Following treatment, 114 (79%) gained a 50% or greater reduction in hot flushes and 30 (21%) a less than 50% reduction. Treatment was abandoned in those who responded poorly or not at all. The duration of treatment varied from one month to over six years with a mean duration of nine months. Seventeen patients (9%) experienced minor side effects over the six year period, mostly minor rashes; one patient described leg swelling but this was likely to be due to a concurrent fracture.

CONCLUSION

Acupuncture including self acupuncture is associated with long-term relief of vasomotor symptoms in cancer patients. Treatment is safe and costs appear to be low. An algorithm is presented to guide clinical use. We recommend the use of self acupuncture with needles at SP6 in preference to semi-permanent needles in the first instance, but poor responders use indwelling studs if they fail to respond adequately to self acupuncture with regular needles. Point location may be of less importance than the overall 'dose', and an appropriate minimum dose may be required to initiate the effect.

A Review of Non-Hormonal Options for the Relief of Menopausal Symptoms

The climacteric syndrome involves a variety of symptoms such as profuse sweating, insomnia, memory loss, decreased sexual drives, joint aches, and anxiety. However, amongst these symptoms, hot flashes and sweats are generally considered the hallmark and result in the majority of the medical consultations for this condition. Hot flashes are known to respond readily to placebo, which alone decreases their frequency by 20-40%. In the ideal setting of clinical trials, with optimal patient selection and compliance, estrogen therapy reduces hot flashes by about 70-80%; this is twice as effective as placebo. However, estrogen is unable to be universally used, either because of contraindications or because of an unwillingness of women to take it. Furthermore, hot flashes may persist in spite of adequate estrogen replacement, and physicians are often faced with the dilemma of finding something to administer in place of, or in addition to, estrogen to improve symptoms. The most commonly used non-hormonal alternatives for climacteric symptoms are neurotransmitter modulators such as serotonin reuptake inhibitors and gabapentin. These are, at best, approximately half as effective as estrogen for the relief of menopausal symptoms, and are only marginally better than placebo.Complementary treatment, particularly over-the-counter phytotherapeutic extracts, are very popular and women often try a variety of such products before resorting to conventional medicine. Preparations containing isoflavones, such as soy extract and red clover or extracts from evening primrose or cimicifuga (black cohosh, Actaea racemosa, syn. Cimicifuga racemosa), in variable doses are very popular for the treatment of hot flashes. The scientific support for their efficacy certainly does not equal their popularity.Non-hormonal treatments for menopause are not as effective as estrogens in relieving hot flashes, but may have a role in therapy for women who have contraindications to gonadal steroid use.

Other complementary and alternative medicine modalities: acupuncture, magnets, reflexology, and homeopathy

We sought to evaluate evidence for the benefits and risks of acupuncture, magnets, reflexology, and homeopathy for menopause-related symptoms. Search strategies included electronic searches of online databases (PubMed, PsycINFO, Medline), direct searches of target journals, and citation-index searches. A total of 12 intervention studies were identified for review. Complementary and alternative medicine (CAM) treatments resulted in few side effects. The design, study populations, and findings across acupuncture studies varied. In uncontrolled studies, acupuncture improved subjective measures of hot flash frequency and vasomotor, somatic, physical, and psychological symptoms; however, improvements were not consistent. Controlled studies of acupuncture yielded even less consistent findings. Overall, controlled studies of acupuncture did not reliably improve hot flashes, sleep disturbances, or mood when compared with nonspecific acupuncture, estrogen therapy, or superficial needling. Homeopathy significantly improved subjective measures of hot flash frequency and severity, mood, fatigue, and anxiety in uncontrolled, open-label studies. Controlled studies of magnets and reflexology failed to demonstrate any increased benefit of treatment over placebo. There is a need for additional investigations of acupuncture and homeopathy for the treatment of hot flashes and other menopausal symptoms. However, existing evidence does not indicate a beneficial effect of magnets or reflexology in the treatment of hot flashes and other menopausal symptoms. Understanding whether, for whom, and how these interventions work is crucial to building the evidence base needed to evaluate any potential for these CAM therapies in the management of menopause-related symptoms.

Applied relaxation and oral estradiol treatment of vasomotor symptoms in postmenopausal women

OBJECTIVE

The aim was to evaluate and compare the effects of applied relaxation and oral estradiol treatment on hot flushes, mood and psychological wellbeing in postmenopausal women.

PATIENTS AND METHODS

In a prospective study, 30 postmenopausal women with vasomotor symptoms were randomized to applied relaxation or oral estradiol treatment during 12 weeks with 6 months follow-up. Number and severity of flushes were registered daily and Kupperman's Index and a general estimate of climacteric symptoms, Mood Scale and Symptom Check List were completed at baseline, 4, 8 and 12 weeks of treatment, and 3 and 6 months after therapy.

RESULTS

After 12 weeks of treatment, the number of flushes/24 h decreased significantly over time in both treatment groups. In the group receiving applied relaxation, the mean number of flushes/24 h decreased from 6.0 (95% CI 4.5-7.6) to 3.0 (95% CI 2.1-3.9) after 12 weeks of treatment. The mean number of flushes/24 h was 1.7 (95% CI 0.7-2.5) at 6 months follow-up; i.e. a 72% decrease. In the estrogen group, the mean number of flushes/24h decreased from 8.4 to 0.8; i.e a 90% decrease in the number of flushes after 12 weeks of treatment. The significant change in flushes reached after 12 weeks of treatment and remained to 6 months after end of treatment in both groups. Estrogen therapy reduced flushes significantly faster than applied relaxation. General climacteric symptoms according to the Visual Analogue Scale and the Kupperman's Index decreased significantly over time in both groups. General mood (Mood Scale) increased significantly in the estrogen group, but not in the group receiving applied relaxation. Psychological wellbeing according to Symptom Checklist, increased significantly from baseline to 12 weeks in both groups.

CONCLUSIONS

We suggest that applied relaxation may be used as an alternative treatment of vasomotor symptoms for postmenopausal women but should be further evaluated.

Acupuncture: role in comprehensive cancer care--a primer for the oncologist and review of the literature

In recent studies, patients have reported an increased use of complementary and alternative medicine (CAM). Acupuncture is a popular complementary therapy for patients with cancer. This article will provide current cancer treatment providers with information on acupuncture as well as the research conducted on cancer symptoms and side effects of cancer treatments. Antiemetic studies are the most prevalent and contain the most promising results. Several studies have found that acupuncture significantly reduces the number of emesis (vomiting) episodes for patients receiving chemotherapy. While studies on pain control vary due to the heterogeneity of pain, there are few studies investigating pain caused from cancer and the removal of cancerous tumors. These studies, while promising, provide basic results that need further investigation for more definitive results. Although relatively few studies have been done on anxiety and depression, several researchers have found acupuncture to be just as effective as or more effective than antidepressants for patients without cancer. Studies on breathlessness, while small, have shown acupuncture to have a significant positive effect on chronic obstructive pulmonary disease, breathlessness associated with end-stage cancer, and asthma. Researchers studying xerostomic individuals who have received salivary gland irradiation found significant positive results in salivary flow rates compared to baseline. Patients with hot flashes due to hormonal imbalance may benefit from the use of acupuncture. A recent pilot study showed improvement of chronic postchemotherapy fatigue following acupuncture treatments. Many individuals with cancer have turned to acupuncture because their symptoms persisted with conventional treatments or as an alternative or complement to their ongoing treatments. Despite the immense popularity in the community, few large randomized trials have been conducted to determine the effects acupuncture has on cancer symptoms and side effects of treatments. A majority of the current studies have shown beneficial effects that warrant further investigation with large trial sizes.

Management of menopausal symptoms in patients with breast cancer: an evidence-based approach

Increasing numbers of women have menopausal symptoms after treatment for breast cancer. These symptoms can result directly from cancer treatments (such as oophorectomy, ovarian suppression, chemotherapy-induced ovarian failure, and antioestrogens), as a spontaneous event, or after discontinuation of hormone-replacement therapy. The onset of menopausal symptoms after treatment for breast cancer can have a long-lasting effect on quality of life, body image, sexual function, and self esteem. Hormone-replacement therapy that contains oestrogen is the most effective treatment for menopausal symptoms in healthy women. However, evidence from one randomised controlled trial suggests that use of hormone replacement therapy after breast cancer raises the risk of recurrence and of new primary breast cancer. As the incidence of breast cancer increases and survival continues to improve, the number of women with menopausal symptoms will probably rise. Safe and effective non-hormonal treatments for severe menopausal symptoms after breast cancer are urgently needed. Few studies have addressed the management of menopausal symptoms after breast cancer, and the quality of studies is generally poor. Progestagens, and selective inhibitors of serotonin and norepinephrine reuptake seem to offer reasonable symptom palliation, but the long-term effectiveness and safety of these preparations is not known. We propose that the management of menopausal symptoms in patients with a history of cancer requires a patient-centred, but multidisciplinary, approach.

Treatment of menopausal symptoms post-Women's Health Initiative: refinement of existing treatments and development of new therapies

Menopause is a normal life transition for women. More than 80% of women experience some symptoms at menopause and > 25% of women in western countries seek treatment for a variety of symptoms that accompany this transition. In addition, there are certain chronic disease processes that accelerate after the menopausal transition. Hormone replacement therapy (HRT) with various combinations of oestrogen and progesterone compounds has been the mainstay of treatment for menopausal symptoms, as well as theoretical reduction in acceleration of certain chronic diseases after menopause. After the publication of the results of the Women's Health Initiative study in June 2002, the safety of HRT, as well as its effectiveness in decreasing various chronic diseases, was challenged. New formulations of hormone therapy, as well as new treatments, are evolving to aid the reduction of menopausal symptoms and long-term risks of common chronic disease processes that accelerate after the menopause.

Treatment of menopausal symptoms: what shall we do now?

During the past few years, many women and doctors have revised their opinions of hormone replacement therapy (HRT) for menopausal symptoms, and a substantial number of individuals have discontinued its use because of concerns about side-effects. Numerous alternatives to HRT are promoted, and assessment of the quality of evidence about the safety and effectiveness of these compounds can be difficult. In this Review, we summarise the data from studies addressing the efficacy, risks, and benefits of frequently prescribed treatments, and offer evidence-based clinical guidelines for the management of menopausal symptoms. Although few comparative studies exist, oestrogen alone or combinations of oestrogen and progestagen are likely to be the most effective treatments for menopausal hot flushes and vaginal dryness. Tibolone is as effective as HRT, however, and might also improve libido. For those who wish to avoid hormonal treatments, there are few effective options. Selective serotonin reuptake inhibitors might be effective in the very short term (less than 12 weeks) and are well tolerated. There is not enough evidence that any of the complementary therapies available are any better than placebo for menopausal vasomotor symptoms, and few safety data exist.