COMMENTARY

'Alternative' Cures for Hot Flashes: Worthwhile, or a Waste?

Crystal M. Glassy, DO, MPH; Charles P. Vega, MD

Disclosures

March 27, 2014

In This Article

Beyond Phytoestrogens: More Alternative Therapies

Evening primrose oil. Evening primrose oil (Oenothera biennis) is a popular alternative modality for relief of vasomotor symptoms. This plant contains seeds rich in gamma-linoleic acid and cis-linoleic acid, types of omega-3 fatty acids.[17] Adverse effects are rare, but include nausea when not taken with food.

A 6-month randomized trial of 56 women failed to show any benefit for menopausal symptoms when taken at a dosage of 2 mg twice daily.[18] More and larger studies are necessary to determine whether an effect exists. Evening primrose oil is among the most popular alternative therapies used for this purpose.[4] To date, no published data suggest that it is an effective therapy for vasomotor symptoms.

Mind/body therapy. A 2011 study showed that perceived control over vasomotor symptoms was the strongest predictor of severity of these symptoms, making mind/body therapy a potentially potent treatment.[19] "Mind/body therapy" is a term that covers a variety of techniques in which the mind is used to affect bodily function.

Mind/body therapies have been reported to reduce sympathetic and increase parasympathetic activation.[20,21,22,23] They may also improve vasomotor symptoms by reducing body weight and improving depressive symptoms, both of which have been associated with severity of hot flashes.[24] Yoga and tai chi are 2 types of mind/body therapies that have been studied in relation to menopausal symptoms.

Yoga is an ancient discipline that incorporates physical poses, breathing exercises, and meditation to calm the mind and increase physical health. Some studies have suggested an overall reduction in menopausal symptoms of 36%-80% with yoga.[20]

Tai chi is a discipline that uses slow, dance-like movements with deep breathing to achieve mental and physical balance.To date, only 1 study was found of the effect of tai chi on menopausal symptoms. This nonrandomized crossover trial included tai chi and normal lifestyle groups. After 4 months, the groups crossed over for an additional 4 months. Both groups experienced reduction in hot flashes during the tai chi intervention (50% and 42%).[25]

No meta-analyses for mind/body therapies effects on vasomotor symptoms were found. However, a review by Innes and colleagues[24] found that overall good evidence exists for mind/body therapy in the alleviation of menopausal symptoms. These authors point out that meta-analysis was not an appropriate method to evaluate the research on mind/body therapy because of the large amount of heterogeneity present.

Overall, mind/body therapy has reasonable evidence and sound biological plausibility, with few or no adverse effects.

Exercise. Exercise should be considered as a form of treatment for vasomotor symptoms, given its positive effect on overall health and some support in the literature for reduction of hot flashes. It may be that exercise acts through indirect methods to reduce the symptoms of menopause, such as reduction of body weight and positive effects on mood. A study by Thurston and colleagues[26] demonstrated that exercise was effective in reducing hot flashes in women with a history of depression, but not those without such a history.

When obesity and its correlation with vasomotor symptoms are examined, obese women experience more hot flashes then thin women. This holds true despite the theoretical reasoning that thin women would be at increased risk for hot flashes as a result of reduced adipose tissue and aromatase activity, resulting in reduced estrogen production. However, recent evidence supports a model whereby obese women experience more hot flashes because adipose tissue acts as an insulator to prevent heat dissipation.[27] Furthermore, the distribution of body fat and weight fluctuation seems to be an important predictor of vasomotor symptoms. In many studies, a greater waist-to-hip ratio results in an increased frequency of hot flashes.[28,29,30]

In a 2011 Cochrane review looking at exercise for vasomotor symptoms, a soft trend was found for exercise being more effective than no treatment.[31] Further randomized controlled trials are necessary to determine the beneficial evidence of exercise in vasomotor symptoms.

Acupuncture. Acupuncture is the Eastern practice of inserting needles into multiple points on the body for therapeutic purposes. This Chinese medicine philosophy is based on the theory that energy (qi) flows along body meridians. A disruption of flow results in disease.

Acupuncture needles stimulate the qi along meridians and open blocked gates to increase qi and balance (yin and yang). Acupuncture for menopause is based on a condition known as "deficient heat." This is a deficiency in kidney yin that results in "5-palm heat," night sweats, and mental agitation. Acupuncture is aimed at subduing kidney yang.

The Western view on acupuncture proposes that it may reduce vasomotor symptoms by increasing beta-endorphins and inhibiting gonadotropin-releasing hormone (GnRH). The GnRH pulse is believed to be responsible for setting off the neurochemical cascade that leads to hot flashes.[32]

A Cochrane review of 8 studies comparing acupuncture and sham acupuncture found no significant difference in hot flash frequency. However, flashes were significantly less severe in the acupuncture group, albeit with a small effect size.[33] A recent meta-analysis[34] evaluated the long-term effects of acupuncture on vasomotor symptoms in women with breast cancer and men with prostate cancer who had undergone antiestrogen therapy. The analysis found an overall 43.2% reduction in hot flashes with acupuncture. At last follow-up after the end of acupuncture therapy (mean, 5.8 months), the reduction was sustained in 89% of patients.

Acupuncture is generally considered safe; major adverse events are exceptionally rare and are usually associated with unlicensed and poorly trained acupuncturists.[35] Major and infrequent complications include transmission of disease, needle fragments left in the body, nerve damage, and organ injury.[36] Local complications include bleeding, contact dermatitis, infection, pain, and paresthesia.[36]

Black cohosh. Black cohosh is a plant native to North America that is traditionally used by Native Americans for menstrual irregularities and childbirth.[37] Many studies have evaluated the plant's rhizome for its effects on menopausal symptoms. The German health authorities and the World Health Organization endorse black cohosh for the relief of menopausal symptoms at typical dosages of 40-160 mg/day (usually taken in 2 divided doses).[38]

Black cohosh is believed to act centrally as a serotonin partial agonist.[39] Previously, the plant was thought to stimulate estrogen activity as an isoflavone. However, a variety of animal models have shown that black cohosh does not have estrogenic actions.[40]

Numerous trials of black cohosh have had mixed results. A Cochrane review stated that insufficient evidence exists to support the use of black cohosh for menopausal symptoms.[41] The Cochrane authors cited uncertainty regarding the quality of identified trials, particularly with respect to allocation concealment and handling of incomplete outcome data. Moderate heterogeneity existed among studies, and therefore results should be interpreted cautiously. A popular German combination of black cohosh with St. John's wort showed a 50% reduction in menopause rating compared with placebo.[42]

The most common side effects of black cohosh are gastrointestinal, musculoskeletal, and connective tissue symptoms. A few cases of hepatitis and hepatic failure have been reported, but causal evidence is insufficient.[43] Many of these studies and reports do not address the question of impurities and adulterants with respect to black cohosh products and hepatotoxicity risk.[44]

Nonpharmacologic Relief of Vasomotor Symptoms: Conclusions

Many women use nonpharmacologic therapies for menopausal symptoms, and clinicians should be aware of the evidence for and risks associated with these therapies. Most modalities entail minimal risk and may be beneficial in improving quality of life. Consistently, the existing literature recommends additional studies to assess the effectiveness of these treatments.

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