Chill Out: A Good Treatment for Hot Flashes?
Chill Out: A Good Treatment for Hot Flashes?
By Mary L. Hardy, MD
Associate Director, UCLA Center for Dietary
Supplement Research: Botanicals
Medical Director, Cedars-Sinai Integrative
Medicine Program, Los Angeles, CA
Dr. Hardy is on the scientific advisory board for Pharmavite and Herbalife.
Hot flashes are the most common and bothersome symptom for most women in menopause. In a national probability survey of menopausal women, 70% reported experiencing hot flashes; this was the main symptom that caused survey respondents to seek treatment from their physicians.1 Frequency, duration, and severity of hot flashes vary greatly among women, but most have hot flashes of mild-to-moderate intensity for several years around the onset of menopause. An unfortunate minority of women, about 20% by some estimates, experiences hot flashes for up to 15 years.2 Estrogen is one of the few therapies proven to decrease hot flashes. However, since the termination of the Women’s Health Initiative study, many women and their health care providers have rejected this option. This has left us in the position of actively seeking other safe, effective therapies.
Lifestyle factors, some of which are modifiable, such as weight or smoking, have been associated with a higher risk of more severe hot flashes. Other unmodifiable factors, such as race and family history, also predict a higher rate and intensity of symptoms.2 Further, it has been observed that more severe hot flashes are associated with depression and have responded to selective serotonin reuptake inhibitor therapy.3 Paroxetine has been used successfully to treat anxiety disorders as well as depression and suggests a role for serotonin in the genesis of vasomotor symptoms in menopausal women. This observation reinforces many of our clinical impressions—that mood may play a role in the severity and/or bothersomeness of hot flashes. Since many complementary and alternative therapies (CAM) have shown benefit in the management of both anxiety and depression, it could be postulated that these therapies or lifestyle interventions could be helpful in treatment, especially if anxiety could be correlated with severity of menopausal symptoms.
Association Between Anxiety and Hot Flashes
Four hundred thirty-six women were followed prospectively for six years beginning early in
perimenopause.4 The group was selectively enrolled so that there were equal numbers of white and black women, a significant choice as menopausal symptoms reportedly are worse in African Americans.2 Data were collected about menstrual history, height, weight, smoking history, age, and ethnicity. Mood was assessed using the Zung Anxiety Index (Zung) and hot flashes were assessed based on number and severity using a daily diary. Hormonal levels were checked as well.
This cohort of women (mean age at the end of study = 47 years) was enrolled at a relatively early stage of menopause. By the end of the six-year observation period, 48% were still pre- or perimenopausal and 32% were in the early transition state. Hot flashes were prevalent from the beginning of the trial (32% reported regular flashes) and increased in frequency as expected during the observation period (47% symptomatic at the end). Sixty-two percent of the women reported at least one episode of hot flashes during the course of the study and 39% stated that these were severe, with 20% having daily symptoms. These observations confirm that vasomotor symptoms are prevalent even in the earliest stages of menopause.
Based on the Zung scores, the women were classified as experiencing low, medium, or high anxiety symptoms. Although anxiety decreased in all groups over the time of the trial, the frequency and severity of hot flashes was strongly positively correlated with the level of anxiety (P < 0.001). Moderately anxious women were three times more likely to experience hot flashes and severely anxious women were five times more likely. A higher degree of anxiety also predicted greater severity and frequency of hot flashes (P < 0.001). On the other hand, hormone levels (follicle-stimulating hormone, luteinizing hormone, estradiol) were not correlated with anxiety level, but were correlated as expected with the presence of hot flashes. African-American race and later stage of menopause also showed an increased rate of vasomotor symptoms. The association of degree of depression with severity of hot flashes was present in the unadjusted analysis, but this finding disappeared when the analysis was adjusted for depression. Thus, it appears from this cohort, that the driving factor in increasing the rate and severity of hot flashes was anxiety not depression. Causality remained multifactorial, however, as hot flashes also were observed to be associated with menopausal stage, hormone levels, and race.
Relaxation Training for Anxiety
Understanding the strength of the association between anxiety and severity of menopausal symptoms, allows us to identify women at greater risk and also gives us a sense of which CAM therapies might benefit these high-risk women. At least three recent reports have shown the benefit of relaxation training on hot flashes.4-6 A small group of women was trained for one hour a week over 12 weeks in applied relaxation
training.5 A significant reduction in hot flash frequency was seen over the next six months as the women continued to practice. Similarly, another group of women in early menopause with frequent hot flashes (five or more/24 hours) were trained in relaxation response, while a control group did not receive this
instruction.6 The treatment group reported reduced severity of hot flashes; however, anxiety, tension, and depression also were reduced significantly (all
P < 0.05), an important finding in light of Freeman’s work. A recent publication describes a program that integrates an understanding of the complex causality of hot flashes into a holistic program addressing relaxation, lifestyle modification, coping skills, and group
support.4 This kind of program provides a model for the rationale and types of supportive therapies we can offer to women during their menopausal transition. It appears that they are particularly useful to anxious women, who are at higher risk of more severe symptoms. Good results do not seem to require a long term of complex training, just continued practice.
When we advise hot flashing patients to chill out and teach them how to do it, we may be modifying the underlying progress of their condition as well as modifying immediate symptoms. Recommending training in relaxation therapy to menopausal women experiencing hot flashes should provide lasting benefit, both for their physical symptoms as well as their mood. v
References
1. Singh B, Hardy M, et al. Unpublished data; 2001.
2. Stearns V, et al. Hot flushes. Lancet 2002;360:1851-1861.
3. Stearns V, et al. Paroxetine controlled release in the treatment of menopausal hot flashes: A randomized controlled trial. JAMA 2003;289:2827-2834.
4. Freeman EW, et al. The role of anxiety and hormonal changes in menopausal hot flashes. Menopause 2005;12:258-266.
5. Wijma K, et al. Treatment of menopausal symptoms with applied relaxation: A pilot study. J Behav Ther Exp Psychiatry 1997;28:251-261.
6. Irvin JH, et al. The effects of relaxation response training on menopausal symptoms. J Psychosom Obstet Gynaecol 1996;17:202-207.
Associate Director, UCLA Center for Dietary Supplement Research: Botanicals Medical Director, Cedars-Sinai Integrative Medicine Program, Los Angeles, CA Dr. Hardy is on the scientific advisory board for Pharmavite and Herbalife. Hot flashes are the most common and bothersome symptom for most women in menopause. In a national probability survey of menopausal women, 70% reported experiencing hot flashes; this was the main symptom that caused survey respondents to seek treatment from their physicians.1 Frequency, duration, and severity of hot flashes vary greatly among women, but most have hot flashes of mild-to-moderate intensity for several years around the onset of menopause. An unfortunate minority of women, about 20% by some estimates, experiences hot flashes for up to 15 years.2 Estrogen is one of the few therapies proven to decrease hot flashes. However, since the termination of the Womens Health Initiative study, many women and their health care providers have rejected this option. This has left us in the position of actively seeking other safe, effective therapies.Subscribe Now for Access
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