Jillian Capodice, LAc looks at clinical trials examining hot flashes menopausal women and ways traditional herbal medicine can alleviate symptoms.

by  Jillian L. Capodice, LAc

Menopause is defined as the cessation of menstruation >12 months due to decline in female ovarian function.  The average age of menopause is 51 years among American women.  The period that precedes the cessation of menstruation and is often characterized by menstrual cycle irregularity is called perimenopause (1). 

Basic physiology of perimenopause subsequent to menopause is based on shortened menstrual intervals that are affected by fluctuations in hormone levels including a characteristic reduction in inhibin and estradiol and an increase in follicle-stimulating hormone (FSH) (1).  It is important to note that the transition of perimenopause and menopause are not themselves diseases rather they are the normal course of events that occur as a woman ages from a reproductive to a non-reproductive age (2). 

Symptoms that are often experienced by women during perimenopause and/or menopause include hot flashes, night sweating, headaches, irregular bleeding, vaginal dryness, and sleep disturbances. While some woman may experience one or all of theses symptoms, it is possible that a woman may not be affected greatly or never experience any of the abovementioned symptoms.

In Traditional Oriental Medicine (TOM), menopause is also defined as the cessation of menstruation for at least 12 months (2).  Perimenopause is also characterized similarly and is commonly called “climacteric” syndrome in TOM [again perimenopause is also similarly defined as the period that spans 2-4 years prior to and following menopause] (2).

Traditional Chinese Medical pathology often characterizes the aforementioned symptoms into patterns and includes common zang-fu diagnoses such as: decline of the kidney (shen) function and weakening of both kidney yin and yang.  Other zang-fu diagnoses often include pathologic contributions from the waning or stagnation of liver blood (xue), heart qi, stasis, deficiency of blood, or dampness (shi).

Common conventional treatment for hot flashes includes estrogen therapy.  Other treatments under investigation include the use of antidepressants such as venlafaxine and gabapentin, vitamin E (approximately 400–800 IU/day), and consumption of soy-based products or other phytoestrogens and botanicals.  Finally acupuncture and moxibustion have been proposed as potential treatments for hot flashes.  Below, I will briefly discuss the results of two current clinical trials.

Recent Clinical Trials of Acupuncture and Moxibustion for Hot Flashes in Post Menopausal Women

1.  Borud EK, Alraek T, White A, et al. The Acupuncture on Hot Flushes Among Menopausal Women (ACUFLASH) study, a randomized controlled trial. Menopause. 2009 May-Jun; 16(3): 484-93

Objective: To assess acupuncture plus self-care versus self-care alone on ameliorating hot flashes and health-related quality of life (QOL) in postmenopausal women experiencing hot flashes.

Methods: A multicenter, randomized, controlled trial with two parallel arms

Inclusion:  Postmenopausal women experiencing >7 or more hot flashes per 24 hours over seven consecutive days.
Intervention: Acupuncture Group: 10 acupuncture treatment sessions and advice on self-care versus Control Group:  Advice on self-care only.

Measures:
– Frequency and severity (0-10 scale) of hot flashes (by daily diary)
– Change in health-related (QOL) measured by the Women’s Health Questionnaire
– Calcitonin gene-related peptide was assessed at baseline and 12 weeks

Results:
– Decrease in hot flash frequency to 5.8 per 24 hours in the acupuncture group (n = 134) and 3.7 per 24 hours in the control group (n = 133) (P < 0.001)
– Decrease in hot flash intensity by 3.2 units in the acupuncture group and 1.8 units in the control group, (P < 0.001)
– The acupuncture group experienced statistically significant improvements in the vasomotor, sleep, and somatic symptoms dimensions of the Women’s Health Questionnaire versus the control group
– No statistical significance in calcitonin gene-related peptide excretion (urine)

Conclusions: Acupuncture plus self-care may contribute to a reduction in hot flashes and increased QOL in post-menopausal women experiencing hot flashes.

2.  Park JE, Lee MS, Jung S, et al. Moxibustion for treating menopausal hot flashes: a randomized clinical trial. 1: Menopause. 2009 Jul-Aug; 16(4): 660-5.

Objective: To determine if moxibustion can relief hot flashes experienced by post-menopausal women

Methods:  Randomized clinical trial into 3 groups:
– Moxibustion 1 (5 moxibustion pillars at acupuncture points CV 12, CV4 and bilateral ST 36)
– Moxibustion 2 (5 moxibustion pillars at GV4, CV4, CV 6 and bilateral to UB 23)
– Control (waiting list)

Measures:
– Frequency and severity of hot flashes
– Quality of life using the Menopausal-Specific Quality of Life Scale and the Menopause Rating Scale

Results: 
– Statistical reduction in the severity and frequency of hot flashes in the moxibustion group versus the control (P=0.0003)
– Statistically significant difference in Menopausal-Specific Quality of Life Scale scores between the moxibustion group versus control ((p=0.0018)

Conclusions: Moxibustion may reduce both the frequency and severity of menopausal hot flashes as compared with those in on a waiting list control.

Comment: The above two clinical trials demonstrate that acupuncture versus advice only and moxibustion versus a waiting list control may be helpful in relieving hot flash frequency or severity.  For other recent analyses read a recent systematic review: Lee MS, Shin BC, Ernst E. Acupuncture for treating menopausal hot flushes: a systematic review.  Climacteric. 2009 Feb; 12(1): 16-25.

In conclusion, more research needs to be done in order to test potential mechanisms of action of acupuncture, the physiology of menopausal hot flashes and quantitative assessments of any potential treatment for hot flashes.

Traditional Herbal Medicine

Even though the clinical evidence is primarily on acupuncture and moxibustion as potential treatment strategies, there are many formulas in the traditional Materia Medica that have classic application and indication for the treatment of hot flashes related to classic menopausal symptoms. 

Classic Chinese herbal formulas common symptoms related to menopause include:
• Er xian tang:  Kidney yin and yang deficiency
• You gui wan:  Kidney yang deficiency
• Zhi bai di huang wan:  Kidney yin deficiency
• Zuo gui yin: Kidney yin and blood deficiency with empty heat

Conclusion
TOM including acupuncture, moxibustion and herbal medicine (traditional and modern formulations) all represent viable treatment options for the treatment of symptoms experienced by women during perimenopause and after menopausal transition.  At present, more research needs to be done on all treatments (conservative and complementary) and factors including co-morbid conditions, concomitant medications and safety and efficacy of all strategies needs to be assessed. 

References
1.  Harrison’s Principles of Internal Medicine, 17th Edition.  McGraw Hill.
2. Giovanni Maciocia.  Obstetrics and Gynecology in Chinese Medicine, Chapter 58.  Churchill Livingston Press 1998. 


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