By Judith Balk, MD, FACOG
The standard treatment for menopausal symptoms, especially vasomotor instability, has been hormone replacement therapy (HRT). Vasomotor symptoms, such as hot flashes and night sweats, respond quickly and dramatically to estrogen preparations. Because vasomotor symptoms can be disruptive and affect quality of life, many perimenopausal and postmenopausal women choose to take HRT to ease their symptoms. However, with the recent findings of the Women’s Health Initiative (WHI) study,1 HRT use has been questioned by both health care providers and patients. Several mind-body approaches may be effective in alleviating symptoms, especially in those patients for whom HRT is no longer an option.
Summary of WHI Findings
The WHI study was halted early because of an increased risk of breast cancer in the group receiving a combination medication of estrogen/progestin compared to women in the placebo group.1 The risks that were higher in the HRT group included an increased risk of stroke, heart disease, blood clots, and breast cancer. The benefits to the hormones included reductions in hip fracture and colon cancer. The risk of breast cancer began to increase after two years of hormone use, whereas the risk of heart disease began to increase immediately after hormones were started.
The conclusion reached by WHI was that long-term HRT use (at least in the form used in the study) was associated with more risks than benefits. Because of these findings, alternatives to HRT are needed. Although short-term hormone use could be considered for treating menopausal symptoms, many women are concerned about taking hormones and are interested in other approaches.
Allopathic Non-Hormonal Medications
Several allopathic medications—including venlafaxine, fluoxetine, and clonidine—have been studied for treatment of meno- pausal symptoms.2-4 The benefits of these medications tend to be modest (i.e., they can give some improvement in the hot flashes but they do not approach estrogen’s effectiveness). These agents are non-hormonal; thus, they are not thought to increase the risk of breast cancer. Side effects can include dry mouth, insomnia, dizziness, somnolence, and nausea. Drug interactions also can limit their use. Although these agents can be used successfully, other approaches can minimize side effects and drug interactions.
Physiology of the Hot Flash
Hot flashes are the most frequently reported meno- pausal symptom, causing predictable physiological changes.5 Most likely caused by a decrease in the set point in the thermoregulatory system in the brain, hot flashes are accompanied by decreases in estrogen and increases in cortisol, heart rate, and skin temperature.
Hot flashes may be considered an overdrive of the sympathetic nervous system—they are similar to the stress response, but not identical to it. In a hot flash, vasodilation of the vessels in the skin occurs, which is why the face tends to get red. In the stress response, vessel vasoconstriction, not vasodilation, occurs.
Mind-Body Techniques— Physiology and Clinical Trials
Relaxation. If the hot flash is a manifestation of the sympathetic nervous system being in overdrive, is it possible to reduce this sympathetic overdrive and hence reduce hot flashes?
Mind-body approaches, specifically the relaxation response, can be used to reduce the stress response, reduce catecholamines, and help balance the autonomic nervous system. If the physiological correlates of the hot flash can be controlled using mind-body approaches, perhaps the symptoms of the hot flash can be reduced as well.
Some women report that hot flashes increase during times of stress. Physiologically, this may represent a mechanism that includes central (specifically hypothalamic) noradrenergic and opioid activity.6 It is not understood fully whether women under stress are more likely to notice and report hot flashes, or whether there is a true increase in the frequency, but the issue has been studied.6
Twenty-one postmenopausal women with at least six hot flashes daily were recruited for physiological monitoring during stressful and non-stressful sessions. During the stress session, women were exposed to stressful stimuli such as a paced arithmetic task, loud noise, and a stressful film. The non-stress session included listening to music and reading pleasant magazines.
To ascertain if a reporting bias exists, subjects were asked to report when they had hot flashes, and these reports were compared to the physiological changes that were occurring within the subject at the time of the reported hot flash. There were 43% more objective hot flashes recorded during the stress session than during the non-stress session, and there were 47% more subjective hot flashes during the stress session. Hot flash accuracy was equal in both sessions; the laboratory stress did not sensitize women to their physiological states and did not contribute to mislabeling somatic sensations as hot flashes. In conclusion, stress does increase the frequency of hot flashes.
Stress Management Techniques. Because stress increases the frequency of hot flashes, stress reduction techniques may decrease the frequency of hot flashes. An early pilot study investigated the use of a multiple component self-control program for menopausal hot flashes.7
Four menopausal women served as their own controls over a six-month period. After a three- to four-week baseline period, subjects received 10 sessions of training in a variety of stress and temperature control techniques, such as relaxation, self-suggestions of cool thoughts, and temperature feedback. The reductions in number of hot flashes between the last two weeks of baseline and the last two weeks of training ranged from 41% to 90% for the four subjects, and treatment gains were maintained at the six month follow-up.
Relaxation and Additional Interventions. A larger study on the effects of relaxation response training on menopausal symptoms found similar results.8 In this study of 33 postmenopausal women, subjects were randomized to one of three groups: relaxation response, a reading intervention in which patients read for 20 minutes daily (the attention control group), or control in which patients received no intervention training. Both intervention groups experienced psychological benefits, such as reduction in depression in the relaxation group and anxiety in the reading group. However, only the relaxation response group demonstrated significant reductions in hot flash intensity.
These authors concluded that daily elicitation of the relaxation response led to significant reductions in hot flash intensity and the concurrent psychological symptoms of tension-anxiety and depression.
A study of six menopausal subjects demonstrated that the behavioral technique called applied relaxation also reduced menopausal symptoms.9 The purpose of applied relaxation is to teach a coping skill that will enable rapid relaxation. It has multiple components, such as progressive relaxation and cue-controlled relaxation, and has been used to treat both anxiety disorders and somatic disorders such as headache. Subjects received group instruction one hour per week over a 12-week duration. The frequency of hot flashes was monitored from baseline through six months after training. The number of hot flashes decreased during this period in all subjects, ranging from 59% to 100% reduction, with the mean of 73% reduction.
Relaxation training also was studied under conditions of heat-induced hot flashes.10 Peripheral heating has been shown to elicit hot flashes in postmenopausal women but not in premenopausal women. Subjects received either relaxation training or a control procedure and then were subjected to heat stress to induce hot flashes. Latency to hot flash onset during heat stress was increased significantly in relaxation subjects but not in controls. Similarly, hot flash frequency was significantly reduced in relaxation subjects but not in control subjects.
Breathing Techniques. Slow, deep breathing has been hypothesized to modulate sympathetic activation; as such, this type of breathing may decrease hot flashes. One study randomized symptomatic postmenopausal women to either paced respiration (slow deep breathing), muscle relaxation, or a-wave electroencephalographic biofeedback (placebo control).11 Subjects under- going paced respiration had abdominal and thoracic chest excursions recorded. They were instructed to breathe at 6-8 cycles/min and to increase the amplitude of the abdominal tracing. Twenty-four hour ambulatory monitoring detected hot flashes at baseline and after completion of the last treatment session. Hot flash frequency decreased significantly for the paced respiration group, but not for the other two groups. Thus, training in slow, deep breathing alone will result in a significant reduction in the occurrence of menopausal hot flashes.
Few risks exist with relaxation techniques. Some subjects may have emotional distress with certain techniques such as guided imagery, if the imagery is unpleasant to that subject. Autogenic training, where the arms and legs typically are imagined to be warm and heavy, likely would not be helpful in alleviating menopausal symptoms, given that the sensation of warmth is unpleasant for women experiencing hot flashes.
Mind-body approaches, such as relaxation response training and slow, deep breathing, can reduce the frequency of hot flashes. For women who choose not to use HRT, or for women who have unsatisfactory results on hormones, the addition of mind-body skills training can improve their menopausal symptoms and the psychological distress that often comes with these troublesome symptoms.
Dr. Judith Balk is an Assistant Research Professor at the University of Pittsburgh in Pittsburgh, PA.
1. Rossouw JE, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321-333.
2. Loprinzi CL, et al. Venlafaxine in management of hot flashes in survivors of breast cancer: A randomised controlled trial. Lancet 2000;356;2059-2063.
3. Loprinzi CL, et al. Phase III evaluation of fluoxetine for treatment of hot flashes. J Clin Oncol 2002;20: 1578-1583.
4. Nagamani M, et al. Treatment of menopausal hot flashes with transdermal administration of clonidine. Am J Obstet Gynecol 1987;156:561-565.
5. Swartzman LC, et al. The menopausal hot flush: Symptom reports and concomitant physiological changes. J Behav Med 1990;13:15-30.
6. Swartzman LC, et al. Impact of stress on objectively recorded menopausal hot flushes and on flush report bias. Health Psychol 1990;9:529-545.
7. Stevenson DW, Delprato D. Multiple component self-control program for menopausal hot flashes. J Behav Ther Exp Psychiatry 1983;14:137-140.
8. Irvin JH, et al. The effects of relaxation response training on menopausal symptoms. J Psychosom Obstet Gynaecol 1996;17:202-207.
9. Wijma K, et al. Treatment of menopausal symptoms with applied relaxation: A pilot study. J Behav Ther Exp Psychiatry 1997;28:251-261.
10. Germaine LM, Freedman RR. Behavioral treatment of menopausal hot flashes: Evaluation by objective methods. J Consult Clin Psychol 1984;52:1072-1079.
11. Freedman RR, Woodward S. Behavioral treatment of menopausal hot flushes: Evaluation by ambulatory monitoring. Am J Obstet Gynecol 1992;167:436-439.