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By Mary L. Hardy, MD
Recently, the North American Menopause Society (NAMS) published a position statement of its recommendations for the treatment of menopause-associated vasomotor symptoms. The recommendations are based on the assessment of clinical evidence for efficacy and risk as evaluated by an expert editorial board assembled for this purpose.
The context of the treatment review was established by recapping evidence for prevalence and causality of hot flashes. The epidemiology of hot flashes, the most common and bothersome symptom of peri-menopause, was reviewed and it was noted that in 31% of cases, hot flashes actually precede any alteration in menstrual function. Factors associated with an increased risk of developing significant hot flashes include existence of prior history of moderate-to-severe premenstrual symptoms, warmer ambient temperatures, increased body mass index, smoking, decreased physical activity, and lower socioeconomic status. Etiological considerations such as hormonal and thermoregulatory abnormalities were discussed.
Treatments ranging from lifestyle adjustments through prescription medication were addressed. Evidence for efficacy was balanced against known or perceived risk in considering whether to recommend a given modality. Both the level of evidence (controlled trial, cohort study, anecdotal, etc.) and the consistency of the evidence were considered for each modality evaluated. Short descriptions of the trials considered were given and all material was thoroughly referenced, thus allowing interested readers to peruse the basic literature themselves.
In general, it was recommended to begin with lifestyle adjustments such as lowering external or core body temperature, engaging in regular exercise, losing weight, stopping smoking, or practicing a relaxation technique like diaphragmatic breathing and other interventions of this type. The evidence for non-prescription dietary supplement remedies was thought to be inconclusive for isoflavones from both soy and red clover as well as for herbs such as black cohosh, evening primrose oil, dong quai, licorice, and ginseng. Consideration of the additional detail of the specific trials reviewed gives a more nuanced appreciation for positive trends in the evidence for soy foods and black cohosh as opposed to single negative trials for herbs such as dong quai or ginseng. The final consensus reflects the perception that these products are of low enough risk that use by women who find them helpful should be encouraged. Evidence for vitamin E was not believed to be particularly in favor of treatment, nor did the few identified trials that used acupuncture, a Chinese herbal mixture, or magnet therapy demonstrate utility as they were tested. It is important to note for traditional medicines with very highly individualized treatments using an alternative diagnostic system, most conventional methodology is inadequate unless adapted for this use.
Finally, pharmacologic—both hormonal and non- hormonal—therapies that have shown benefit were reviewed. Non-hormonal therapies that have some demonstrated benefit include particular antidepressants, antihypertensives, anticonvulsants, and an older sedative combination product. No benefit was ascribed to customized hormonal preparations (e.g., compounded estrogens or progesterones).
In summary, this is a very useful review of the prevalence, etiology, and current treatment options for a common menopausal symptom, which may be quite bothersome for some women.
The review is well worth reading. A copy can be found on the NAMS web site (www.menopause.org/hotflashes.pdf) or in the January 2004 Menopause (Vol 11, pp. 11-33).
Dr. Hardy, Medical Director, Cedars-Sinai Integrative Medicine Medical Group, Los Angeles, CA, is on the Editorial Advisory Board of Alternative Therapies in Women’s Health.