Effect of a yearlong, moderate-intensity exercise intervention on the occurrence and severity of menopause symptoms in postmenopausal women

Symptoms of menopause: hot flushes

Vasomotor symptoms (VMSs) are highly prevalent during the peri- and early postmenopause. They constitute a major driver for patient self-referral for medical care. Although most women will experience an abatement of their VMS by 5 years after their final menses, women with early or surgical menopause may have worse or more persistent symptoms, and up to 16% of naturally menopausal women continue to experience VMS well after their menopause is past. Although estrogen is the most effective known therapy, it is neither appropriate nor desirable for every symptomatic woman, and nonhormonal treatments such as gabapentin, selective serotonin reuptake inhibitors/selective norepinephrine reuptake inhibitors drugs, and the antihypertensives clonidine and alphamethyldopa may be helpful for some women. There is mounting evidence to support the ineffectiveness of many proposed complementary and alternative modalities. This review will highlight the natural history of VMS and the current medical evidence supporting various treatments.

Menopause

Menopause is the time of life when menstrual cycles cease, and is caused by reduced secretion of the ovarian hormones oestrogen and progesterone. Although menopause is a normal event for women, individual experiences vary, and some women seek medical advice for the management of symptoms. Many symptoms have been attributed to menopause, but only vasomotor dysfunction and vaginal dryness are consistently associated with this time of life in epidemiological studies. Other common symptoms such as mood changes, sleep disturbances, urinary incontinence, cognitive changes, somatic complaints, sexual dysfunction, and reduced quality of life may be secondary to other symptoms, or related to other causes. Trials of therapies for vasomotor dysfunction have shown improvements with oestrogen, gabapentin, paroxetine, and clonidine, but little or no benefit with other agents; adverse effects of these treatments must also be considered. Many questions about menopausal transition and its effects on health have not been adequately addressed.

Ethnicity and vasomotor symptoms in postmenopausal women

OBJECTIVE

To determine if there is a difference in the prevalence of vasomotor symptoms between African American and white postmenopausal women.

METHODS

We conducted a cross-sectional study to evaluate baseline vasomotor symptoms in postmenopausal women enrolled in a randomized, placebo-controlled trial of dietary soy supplements. The Menopause-Specific Quality of Life Questionnaire (MENQOL) vasomotor subscale was used to measure vasomotor symptoms, including hot flashes and night sweats.

RESULTS

In total, 104 African American and 112 white postmenopausal women (mean age 56.8 +/- 5.6 years) were studied. A multiple linear regression analysis, which controlled for differences in body mass index (BMI) and dietary fat intake, showed that race and age were significantly and independently associated with vasomotor symptoms, explaining 10% of the variance (p < 0.001). Being African American and younger age were associated with increased vasomotor symptoms.

CONCLUSIONS

The most prevalent postmenopausal symptoms were vasomotor symptoms, which were more bothersome in African American women compared with white women. Factors associated with vasomotor symptoms included race, BMI, and dietary intake of fat calories. Implications for practice include increasing provider awareness to discuss vasomotor symptoms and the need for treatment in postmenopausal African American women. Further research to increase our understanding of racial differences and associated factors that influence the duration and intensity of vasomotor symptoms experienced by postmenopausal women is needed.

Exercise and self-esteem in menopausal women: a randomized controlled trial involving walking and yoga

PURPOSE

To examine the effects of walking and yoga on multidimensional self-esteem and roles played by self-efficacy, body composition, and physical activity (PA) in changes in esteem.

DESIGN

Four-month randomized controlled exercise trial with three arms: walking, yoga, and control.

SUBJECTS

Previously low-active middle-aged women (n=164; M age = 49.9; SD = 3.6).

INTERVENTION

Structured and supervised walking program meeting three times per week for I hour and supervised yoga program meeting twice per week for 90 minutes.

MEASURES

Body composition, fitness assessment, and battery of psychologic measures.

ANALYSIS

Panel analysis within a structural equation modeling framework using Mplus 3.0.

RESULTS

The walking and yoga interventions failed to enhance global or physical self-esteem but improved subdomain esteem relative to physical condition and strength (for walking) and body attractiveness (for both walking and yoga). Over time the effects of PA, self-efficacy, and body fat on changes in physical self-esteem and global esteem were mediated by changes in physical condition and body attractiveness subdomain esteem. Women reporting greater levels of self-efficacy and PA with lower body fat also reported greater enhancements in subdomain esteem.

CONCLUSION

These results provide support for the hierarchic and multidimensional nature of self-esteem and indicate that middle-aged women may enhance certain aspects of physical self-esteem by participating in PA.

The variable response of women with menopausal hot flashes when treated with sertraline

OBJECTIVE

To evaluate the variable response of women when treated with a selective serotonin reuptake inhibitor (sertraline) to decrease hot flashes.

DESIGN

A double-blind, placebo-controlled, crossover trial was conducted in 102 women aged 40 to 65 years who were experiencing hot flashes and not taking any hormone therapy. The original purpose of the study was to evaluate the effectiveness of sertraline for the treatment of hot flashes. After 1 week of baseline hot flash data collection, study participants were randomized to receive placebo or active drug (sertraline 50 mg) for 4 weeks. This intervention was followed by a 1-week washout and crossover to the opposite treatment for 4 weeks. The number and severity of hot flashes were measured.

RESULTS

One hundred two women were enrolled in the study, and 87 completed the study. The average response was a statistically significant but clinically modest reduction in hot flash frequency and hot flash index (frequency x severity). These data on the average response have been previously published. Although the average response was modest, some women responded vigorously, others modestly, and some women actually worsened. This is a post hoc analysis of those data. Percentage of change was divided into three categories of clinical response: women with a clinically significant reduction (>or=30%, n=27), women with a nonsignificant reduction (<30% to none, n=28), and women with an increase (1%-100%, n=32). A vigorous response to sertraline for the treatment of hot flashes was related to activity level, education, and menopausal status.

CONCLUSIONS

Women have markedly variable responses when treated with antidepressants for their hot flashes. We have begun to describe the characteristics of those most likely to respond to treatment with a selective serotonin reuptake inhibitor.

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.

Physical activity and mental health outcomes during menopause: A randomized controlled trial

BACKGROUND

Many women experience detriments in mental health during the menopausal transition. Physical activity may attenuate these adverse outcomes but few studies investigating such effects exist.

PURPOSE

This study examined the effects of a 4-month randomized controlled exercise trial on mental health outcomes in 164 previously low-active middle-aged women (M age = 49.9; SD = 3.6).

METHODS AND RESULTS

Participants completed body composition and fitness assessment and a battery of psychological measures at the beginning and end of a 4-month randomized controlled exercise trial with three arms: walking, yoga, control. The results indicated that walking and yoga were effective in enhancing positive affect and menopause-related QOL and reducing negative affect. Women who experienced decreases in menopausal symptoms across the trial also experienced improvements in all positive mental health and QOL outcomes and reductions in negative mental health outcomes. Whether menopausal symptoms increased or decreased across the trial appeared to be determined in part by whether there were increases or decreases in cardiorespiratory fitness.

CONCLUSIONS

Physical activity appears to enhance mood and menopause-related QOL during menopause, however, other aspects of mental health may be affected only as a result of reduction in menopausal symptoms. Increasing cardiorespiratory fitness could be one way to reduce menopausal symptoms.

Vasomotor symptoms among Japanese-American and European-American women living in Hilo, Hawaii

OBJECTIVE

The Hilo Women's Health Survey was designed and administered to gather baseline data on women's health in Hilo, HI. This randomized, cross-sectional study allowed for a focus on ethnic differences in symptom reporting. The results presented here focus on hot flash and night sweat experience among Japanese-American and European-American women.

DESIGN

Survey packets were mailed to street addresses associated with parcel numbers pulled randomly from Hilo tax maps. Of the 6,401 survey packets delivered to households, 1,824 questionnaires were completed and returned. The results reported here are based on 869 women aged 40 to 60, of whom 249 described themselves to be 100% Japanese and 203 described themselves to be 100% European-American. Logistic regression analyses were used to examine whether the relationship between ethnicity and vasomotor symptoms persisted after controlling for other variables.

RESULTS

European-American participants were more likely to have ever experienced a hot flash as compared with Japanese-American participants (72% vs 53%, P<0.01). During the 2 weeks before the survey, European-American participants were more likely to have experienced hot flashes (P<0.05) and night sweats (P<0.01). In logistic regression analyses, after controlling for age, body mass index, menopause status, level of education, financial comfort, smoking habits, alcohol intake, exercise, use of hormone therapy, and soy intake, European-American women were still significantly more likely to have experienced hot flashes (odds ratio=1.858) and night sweats (odds ratio=2.672).

CONCLUSIONS

The results, based on self-reporting of menopausal symptoms, indicate that Japanese-American women report fewer hot flashes and night sweats than European-American women. Japanese-American women reported a higher intake of soy, but soy intake was not associated with fewer vasomotor symptoms.

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.

Physical Activity And Risk of Hot Flashes among Women in Midlife

OBJECTIVE

Hot flashes commonly affect women during menopause and are among the primary menopausal complaints for which women seek medical treatment. Recent evidence of the potential risks posed by hormone therapies has led to interest in nonhormonal interventions, including physical activity. Studies evaluating the therapeutic effects of physical activity for relief of hot flashes have been limited by small sample size, problems with hot flash classification, and assumptions regarding the timing of risk and effect. The current study evaluated the association between physical activity prior to the time of the last menstrual period (LMP) and hot flashes in a large sample maintaining an appropriate sequence of physical activity and menopausal symptoms.

METHODS

This study included 512 perimenopausal and postmenopausal women who participated in a population-based study of midlife health in the Baltimore metropolitan area. Questionnaires assessed self-reported physical activity levels at various ages as well as frequency and severity of hot flashes. Multiple logistic regression was used to evaluate the association between physical activity prior to LMP and each of the hot flash outcomes.

RESULTS

Highly active women between the ages of 35 and 40 were significantly more likely to report moderate to severe hot flashes (OR = 1.70, p = 0.01) and daily hot flashes (OR = 1.79, p < 0.01) than minimally active women in unadjusted models. Adjustment for age and smoking status did not substantially alter these results.

CONCLUSIONS

Frequent physical activity in midlife may be associated with risk of greater severity and frequency of menopausal hot flashes.

Physical activity and risk of vasomotor symptoms in women with and without a history of depression: results from the Harvard Study of Moods and Cycles

OBJECTIVE

To examine whether physical activity was associated with decreased risk of vasomotor symptoms in a prospective study of women transitioning through menopause.

DESIGN

Hypotheses were evaluated in the Harvard Study of Moods and Cycles, a longitudinal study of women with and without a history of major depression (N = 523). Ordinal logistic regression models were utilized to assess the odds of vasomotor symptoms (none, mild, moderate/severe; Greene Climacteric Scale) associated with physical activity (quartiles of metabolic equivalent-hours per week) at study enrollment and over a 3- to 5-year follow-up period.

RESULTS

No significant associations between physical activity and vasomotor symptoms were observed for the sample as a whole. However, exploratory analyses stratified by depression history revealed that among the 157 women with a lifetime history of major depression, high (odds ratio [OR] = 0.28, 95% CI: 0.09-0.83) or moderately high (OR = 0.33, 95% CI: 0.11-0.99) physical activity proximal to the vasomotor assessment, as well as consistently high (OR = 0.27, 95% CI: 0.10-0.75) or increasing (OR = 0.33, 95% CI: 0.12-0.92) physical activity over the duration of the 3- to 5-year follow-up period was associated with decreased vasomotor symptoms relative to sedentary behavior. No significant associations were observed for women without a history of depression.

CONCLUSIONS

Physical activity may be associated with decreased risk of vasomotor symptoms among women with a history of major depression.

Exercise for overweight or obesity

BACKGROUND

Clinical trials have shown that exercise in adults with overweight or obesity can reduce bodyweight. There has been no quantitative systematic review of this in The Cochrane Library.

OBJECTIVES

To assess exercise as a means of achieving weight loss in people with overweight or obesity, using randomised controlled clinical trials.

SEARCH STRATEGY

Studies were obtained from computerised searches of multiple electronic bibliographic databases. The last search was conducted in January 2006.

SELECTION CRITERIA

Studies were included if they were randomised controlled trials that examined body weight change using one or more physical activity intervention in adults with overweight or obesity at baseline and loss to follow-up of participants of less than 15%.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

The 43 studies included 3476 participants. Although significant heterogeneity in some of the main effects' analyses limited ability to pool effect sizes across some studies, a number of pooled effect sizes were calculated. When compared with no treatment, exercise resulted in small weight losses across studies. Exercise combined with diet resulted in a greater weight reduction than diet alone (WMD -1.1 kg; 95% confidence interval (CI) -1.5 to -0.6). Increasing exercise intensity increased the magnitude of weight loss (WMD -1.5 kg; 95% CI -2.3 to -0.7). There were significant differences in other outcome measures such as serum lipids, blood pressure and fasting plasma glucose. Exercise as a sole weight loss intervention resulted in significant reductions in diastolic blood pressure (WMD -2 mmHg; 95% CI -4 to -1), triglycerides (WMD -0.2 mmol/L; 95% CI -0.3 to -0.1) and fasting glucose (WMD -0.2 mmol/L; 95% CI -0.3 to -0.1). Higher intensity exercise resulted in greater reduction in fasting serum glucose than lower intensity exercise (WMD -0.3 mmol/L; 95% CI -0.5 to -0.2). No data were identified on adverse events, quality of life, morbidity, costs or on mortality.

AUTHORS' CONCLUSIONS

The results of this review support the use of exercise as a weight loss intervention, particularly when combined with dietary change. Exercise is associated with improved cardiovascular disease risk factors even if no weight is lost.

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.

Psychological and social interventions in the menopause

PURPOSE OF REVIEW

Increasingly, menopause research is using knowledge of psychological and social functioning to understand women's experiences of menopause and develop interventions to treat symptoms or reduce risk factors. Clinicians are more aware of the need to take account of psychological processes when discussing treatment choices, risks and quality of life. Here, we review the most recent developments in this area.

RECENT FINDINGS

Group interventions based on a cognitive-behaviour therapy approach that address beliefs about symptoms and teach specific techniques (paced respiration) can reduce the frequency of hot flushes. Studies using a health education framework indicate that information is more salient for women when there are given feedback on their own higher osteoporosis risk status. Finally, there are promising signs that interventions to reduce risk factors can lead to sustained lifestyle change.

SUMMARY

The increasing interest in psychological and social interventions is reflected in the number of new publications, but there are still too few large-scale well controlled studies. Earlier work on treatment decision making, and the factors predicting treatment choices has not been followed by larger studies. Reported research emphasizes the need for clinicians to assess women's beliefs about menopausal symptoms and use this knowledge to develop shared treatment plans.

Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: study of women's health across the nation

OBJECTIVES

We investigated whether vasomotor symptom reporting or patterns of change in symptom reporting over the perimenopausal transition among women enrolled in a national study differed according to race/ethnicity. We also sought to determine whether racial/ethnic differences were explained by sociodemographic, health, or lifestyle factors.

METHODS

We followed 3198 women enrolled in the Study of Women's Health Across the Nation during 1996 through 2002. We analyzed frequency of vasomotor symptom reporting using longitudinal multiple logistic regressions.

RESULTS

Rates of vasomotor symptom reporting were highest among African Americans (adjusted odds ratio [OR]=1.63; 95% confidence interval [CI]=1.21, 2.20). The transition to late perimenopause exhibited the strongest association with vasomotor symptoms (adjusted OR = 6.64; 95% CI = 4.80, 9.20). Other risk factors were age (adjusted OR=1.17; 95% CI=1.13, 1.21), having less than a college education (adjusted OR = 1.91; 95% CI = 1.40, 2.61), increasing body mass index (adjusted OR=1.03 per unit of increase; 95% CI=1.01, 1.04), smoking (adjusted OR=1.63; 95% CI=1.25, 2.12), and anxiety symptoms at baseline (adjusted OR=3.10; 95% CI=2.33, 4.12).

CONCLUSIONS

Among the risk factors assessed, vasomotor symptoms were most strongly associated with menopausal status. After adjustment for covariates, symptoms were reported most often in all racial/ethnic groups in late perimenopause and nearly as often in postmenopause.

Lifestyle factors: are they related to vasomotor symptoms and do they modify the effectiveness or side effects of hormone therapy?

This article reviews and summarizes published literature in order to address the following questions: (1) Are lifestyle factors (alcohol use, cigarette exposure, and physical activity) and body mass index (BMI) related to the occurrence of vasomotor symptoms in perimenopausal and postmenopausal women? (2) Do lifestyle factors or BMI modify the effectiveness or side effects of menopausal hormone therapy (HT)? Information was culled from a nonstructured review of English-language literature. Low levels of alcohol consumption (< or =1 drink per day for women) do not have a measurable effect on occurrence of vasomotor symptoms; whether greater amounts of alcohol intake would promote vasomotor symptoms cannot be addressed by available literature. Most published studies report that active cigarette smoking is positively associated with vasomotor symptoms. However, a large study found that passive (but not active) smoking (i.e., secondhand smoke exposure) was related to vasomotor symptoms. Studies to date do not support a relation between physical activity and vasomotor symptoms. However, rates of vasomotor symptom reporting were low in these studies, potentially limiting the ability to detect an effect of physical activity. Greater BMI is a risk factor for more vasomotor symptom reporting. The scarcity of data that directly address whether lifestyle factors or BMI modify the effects of HT precludes a substantive response to this question at present. Available literature suggests that smoking and greater body weight are risk factors for vasomotor symptoms; women with vasomotor symptoms who smoke may benefit from smoking cessation, and women who are heavier than ideal body weight may benefit from weight reduction. Whether certain behaviors or BMI raise or lower the risks or benefits of HT remains largely unknown and should be the focus of future research.

Hot flashes: behavioral treatments, mechanisms, and relation to sleep

Hot flashes are the most common symptom of the climacteric and occur in about 75% of perimenopausal and postmenopausal women in Western societies. Although hot flashes accompany the withdrawal of estrogen at menopause, the decline in estrogen levels is not sufficient to explain their occurrence. Elevated sympathetic activation acting through central alpha(2)-adrenergic receptors contributes to the initiation of hot flashes, possibly by narrowing the thermoneutral zone in symptomatic women. Hot flashes are then triggered by small elevations in core body temperature acting within this narrowed zone. A relaxation-based method, paced respiration, has been shown in 3 controlled investigations to significantly reduce objectively measured hot flash occurrence by about 50% with no adverse effects. In 6 studies of physical exercise, however, investigators did not find positive effects on hot flashes, possibly because exercise raises core body temperature, thereby triggering hot flashes. Although many epidemiologic studies have found increased reports of sleep disturbance during the menopausal transition, recent laboratory investigations have not found this effect, nor have they found that hot flashes produce disturbed sleep. Therefore, sleep complaints in women at midlife should not routinely be attributed to hot flashes or to menopause.

State of the science: hot flashes and cancer. Part 2: management and future directions

PURPOSE/OBJECTIVES

To critically evaluate and synthesize intervention research related to hot flashes in the context of cancer and to identify implications and future directions for policy, research, and practice.

DATA SOURCES

Published, peer-reviewed articles and textbooks; editorials; and computerized databases.

DATA SYNTHESIS

Although a variety of pharmacologic and nonpharmacologic treatments are available, they may not be appropriate or effective for all individuals.

CONCLUSIONS

The large and diverse evidence base and current national attention on hot flash treatment highlight the importance of the symptom to healthcare professionals, including oncology nurses.

IMPLICATIONS FOR NURSING

Using existing research to understand, assess, and manage hot flashes in the context of cancer can prevent patient discomfort and improve the delivery of evidence-based care.

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.

Menopausal Status, Moderate-Intensity Walking, and Symptoms in Midlife Women

The purpose of this randomized clinical trial study was to determine the effectiveness of a 24-week, home-based, moderate-intensity, walking intervention in improving symptoms (vasomotor, uro-genital/sexual, sleep, psychological, cognitive, physical) experienced by midlife women. One hundred and seventy-three Caucasian and African American women aged 45 to 65 who were not on hormone therapy, had no major signs or symptoms of cardiovascular disease, and were sedentary in their leisure activity were randomly assigned to the moderate-intensity walking group or the nonexercise control group. The exercise prescription was walking at a frequency of 4 times a week for a duration of 20 to 30 minutes. The symptom impact inventory included the frequency, intensity, and bothersomeness of 33 symptoms collected at baseline and 24 weeks. Adherence was measured with a heart rate monitor and exercise log. Average adherence to frequency of walking was 71.6% of the expected walks. After 24 weeks, there were no differences between the walking and control group on change in symptoms. However, multiple regression revealed that frequency of adherence to walking along with change in physical symptoms and menopausal status were significant predictors of change in sleep symptoms. While walking did not improve most symptoms experienced by midlife women, frequency of walking may improve sleep.

Integrative Therapies for Menopause

Menopause is a transitional time for women. This gives practitioners an opportunity to focus on recommending healthy life-style changes. Hormone replacement therapy (HRT) has been the mainstay of therapy for menopausal symptoms. With recent research findings, women and their physicians are seeking alternatives that do not carry the risks associated with HRT. Exercise has been shown to help some women with symptoms of hot flashes, as have relaxation techniques and deep breathing. Dietary changes to incorporate whole foods and soy are thought by some to help with menopausal symptoms, and are recommended because of a positive impact on heart disease and obesity; soy isoflavones may also help with menopausal symptoms. Botanicals such as black cohosh and red clover have been shown in some studies to decrease severity and frequency of hot flashes. We recommend that HRT be prescribed when other measures have failed to adequately control symptoms. Bioidentical hormones are preferred in our practice.

Therapy for Menopausal Symptoms During and After Treatment for Breast Cancer

Breast cancer is the most common newly diagnosed cancer in women. Life-time risk in the US is 1 in 8 (13.2%), in the UK it is 1 in 9 and in Australia it affects 1 in 11 women, of whom approximately 27% will be premenopausal at the time of their diagnosis. Many of these women will experience a sudden menopause as a result of chemotherapy, endocrine therapy or surgical interventions. For these women, the onset of menopausal symptoms is often sudden and severe. The management of such symptoms remains controversial. Women experiencing menopausal symptoms after breast cancer should be encouraged to avoid identifiable triggers for their symptoms and to consider lifestyle modification as a means of controlling those symptoms. When such measures fail, non-hormonal treatments may also be considered. These include clonidine, gabapentin and some antidepressants. Randomised trials have shown a significant difference in the symptom relief associated with various selective serotonin reuptake inhibitors and selective serotonin and noradrenaline (norepinephrine) reuptake inhibitors compared with placebo. Many women elect to use non-prescription complementary therapies to alleviate their menopausal symptoms. Systematic reviews of phytoestrogens have, however, failed to demonstrate significant relief of menopausal symptoms. More than 20 clinical trials have been conducted examining the relationship between postmenopausal hormone replacement therapy and breast cancer recurrence. The majority of these have been observational and have shown no increased risk of recurrence. However, the largest randomised trial that has thus far been conducted was recently halted because of a reported increase in the risk of recurrence amongst users of hormone replacement therapy. Tibolone, a selective tissue estrogen activity regulator, is a compound that exerts clinical effects both by receptor-mediated actions and tissue selective enzyme inhibition, and has been shown in preclinical studies to have different effects to estrogen on the breast. Although tibolone may prove safer than estrogen for long-term use in breast cancer survivors, the results of a large randomised trial are awaited to confirm this.The decision on how best to manage menopausal symptoms must thus be made on an individual basis and after thorough discussion and evaluation of the risks and benefits of each potential intervention.