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Menopause. 2004 Jan-Feb;11(1):11-33 Publication Type: Practice Guideline
Treatment of menopause-associated vasomotor symptoms: position statement of The North American Menopause Society.
North American Menopause Society.
North American Menopause Society, Cleveland, OH 44101, USA.
OBJECTIVE: To create an evidence-based position statement regarding the treatment of vasomotor symptoms associated with menopause. DESIGN: The North American Menopause Society (NAMS) enlisted clinicians and researchers acknowledged to be experts in the field of menopause-associated vasomotor symptoms to review the evidence obtained from the medical literature and develop a document for final approval by the NAMS Board of Trustees. RESULTS: For mild hot flashes, lifestyle-related strategies such as keeping the core body temperature cool, participating in regular exercise, and using paced respiration have shown some efficacy without adverse effects. Among nonprescription remedies, clinical trial results are insufficient to either support or refute efficacy for soy foods and isoflavone supplements (from either soy or red clover), black cohosh, or vitamin E; however, no serious side effects have been associated with short-term use of these therapies. Single clinical trials have found no benefit for dong quai, evening primrose oil, ginseng, a Chinese herbal mixture, acupuncture, or magnet therapy. Few data support the efficacy of topical progesterone cream; safety concerns should be the same as for other progestogen preparations. No clinical trials have been conducted on the use of licorice for hot flashes. Among nonhormonal prescription options, the antidepressants venlafaxine, paroxetine, and fluoxetine and the anticonvulsant gabapentin have demonstrated some efficacy for treating hot flashes and were well tolerated. Two antihypertensive agents, clonidine and methyldopa, have shown modest efficacy but with a relatively high rate of adverse effects. For moderate to severe hot flashes, systemic estrogen therapy, either alone (ET) or combined with progestogen (EPT) or in the form of estrogen-progestin oral contraceptives, has been shown to significantly reduce hot flash frequency and severity. Clinical trials have associated ET/EPT with adverse effects, including breast cancer, stroke, and thromboembolism. Several progestogens (both oral and intramuscular formulations) have shown efficacy in treating hot flashes, including women with a history of breast cancer, although no definitive data are available on long-term safety in these women. CONCLUSIONS: In women who need relief for mild vasomotor symptoms, NAMS recommends first considering lifestyle changes, either alone or combined with a nonprescription remedy, such as dietary isoflavones, black cohosh, or vitamin E. Prescription systemic estrogen-containing products remain the therapeutic standard for moderate to severe menopause-related hot flashes. Recommended options for women with concerns or contraindications relating to estrogen-containing treatments include prescription progestogens, venlafaxine, paroxetine, fluoxetine, or gabapentin. Clinicians are advised to enlist women's participation in decision making when weighing the benefits, harms, and scientific uncertainties of therapeutic options. Regardless of the management strategy adopted, treatment should be periodically reassessed as menopause-related vasomotor symptoms will abate over time without any intervention in most women.
Maturitas. 2004 May 28;48(1):19-25 Publication types: guideline, practice guideline
Climacteric medicine: European Menopause and Andropause Society (EMAS) statements on postmenopausal hormonal therapy.
Skouby SO, Barlow D, Samsioe G, Gompel A, Pines A, Al-Azzawi F, Graziottin A, Hudita D, Rozenberg S; European Menopause and Andropause Society (EMAS).
Frederiksberg Hospital, Ob/Gyn, Ndr Fasanvej, 200 F Copenhagen, Denmark. email@example.com
Hormonal therapy (HT) is one of the most frequently prescribed drug regimens for women after the age of 50 years. HT has been developed progressively since the 1960s to provide estrogen to those women (a) who require relief of symptoms which have resulted from reduced circulating estrogen or (b) to act as an anti-resorptive agent to counteract the effect of the increased bone turnover which occurs with falling menopausal estrogen levels and which results in loss of bone mass leading to postmenopausal osteoporosis. However, a large number of women pass through the menopausal transition without experiencing distress as a result of the natural fall in estrogen hormone levels and since the introduction HT has been thought to be associated with a number of health benefits that have been tested in clinical trials but not substantiated. In women experiencing distressing climacteric symptoms double-blind randomised controlled clinical trials with a variety of HT regimens have shown that HT of any type provides symptom relief with no alternative treatment of similar effect. The dose and regimen of HT need to be individualised and in general the appropriate dose is dependent on the menopausal age. Women experiencing urogenital estrogen deficiency symptoms require long-term treatment which is most easily achieved with local estrogen. With the perspective provided by the most recent epidemiological findings not least from the estrogen only arm of the Women's Health Initiative Study (WHI) EMAS supports research activities generating HT with new compositions including lower doses and a wider range of progestins in order to positively affect the balance of clinical benefit and risk. Currently, however, individualized and appropriate prescription of the available HT products together with life-style management will sustain possibilities for beneficial effects on climacteric symptoms, quality of life and degenerative diseases after the menopause.
Sports Med. 2004;34(11):753-778
Exercise for health for early postmenopausal women: a systematic review of randomised controlled trials.
Asikainen TM, Kukkonen-Harjula K, Miilunpalo S.
UKK Institute for Health Promotion Research, Tampere, Finland. firstname.lastname@example.org
Women who pass menopause face many changes that may lead to loss of health-related fitness (HRF), especially if sedentary. Many exercise recommendations are also relevant for early postmenopausal women; however, these may not meet their specific needs because the recommendations are based mainly on studies on men. We conducted a systematic review for randomised, controlled exercise trials on postmenopausal women (aged 50 to 65 years) on components of HRF. HRF consists of morphological fitness (body composition and bone strength), musculoskeletal fitness (muscle strength and endurance, flexibility), motor fitness (postural control), cardiorespiratory fitness (maximal aerobic power, blood pressure) and metabolic fitness (lipid and carbohydrate metabolism). The outcome variables chosen were: bodyweight; proportion of body fat of total bodyweight (F%); bone mineral density (BMD); bone mineral content (BMC); various tests on muscle performance, flexibility, balance and coordination; maximal oxygen consumption (V-dotO(2max)); resting blood pressure (BP); total cholesterol (TC); high-density lipoprotein-cholesterol; low-density lipoprotein-cholesterol; triglycerides; blood glucose and insulin.The feasibility of the exercise programme was assessed from drop-out, attendance and injury rates. Twenty-eight randomised controlled trials with 2646 participants were assessed. In total, 18 studies reported on the effects of exercise on bodyweight and F%, 16 on BMD or BMC, 11 on muscular strength or endurance, five on flexibility, six on balance or coordination, 18 on V-dotO(2max), seven on BP, nine on lipids and two studies on glucose and one on insulin. Based on these studies, early postmenopausal women could benefit from 30 minutes of daily moderate walking in one to three bouts combined with a resistance training programme twice a week. For a sedentary person, walking is feasible and can be incorporated into everyday life. A feasible way to start resistance training is to perform eight to ten repetitions of eight to ten exercises for major muscle groups starting with 40% of one repetition maximum. Resistance training initially requires professional instruction, but can thereafter be performed at home with little or no equipment as an alternative for a gym with weight machines. Warm-up and cool-down with stretching should be a part of every exercise session. The training described above is likely to preserve normal bodyweight, or combined with a weight-reducing diet, preserve BMD and increase muscle strength. Based on limited evidence, such exercise might also improve flexibility, balance and coordination, decrease hypertension and improve dyslipidaemia.
J Physiol Anthropol Appl Human Sci. 2004 Sept;23(5):143-8
A 12-week structured education and exercise program improved climacteric symptoms in middle-aged women.
Department of Medical Humanities, Yamaguchi University School of Medicine, Ube, Japan. email@example.com
In the present study, 40- to 60-year-old women with climacteric symptoms were placed on a 12-week structured education and exercise program to ascertain the effects of this program on climacteric symptoms, quality of life (QOL), and attitude towards exercise. A total of 35 women served as subjects. Twenty women were enrolled in an educational and exercise program that involved learning about menopause and participating in physical activity at least three times a week (Group E). For comparison, the other 15 women did not participate in this program and were instructed to refrain from exercising during study period (Group C). The effects of the 12-week interventional program on climacteric symptoms, QOL, and attitude towards exercise were thereby investigated. The program demonstrated significant effects on climacteric symptoms in terms of Kupperman index and psychosomatic symptoms, especially paresthesia and nervousness. In other words, climacteric symptoms improved significantly in Group E. Furthermore, scores for QOL and attitude towards exercise improved in Group E after the 12-week program; however, these trends did not reach statistical significance. Hence, the 12-week structured education and exercise program was shown to be effective in alleviating climacteric symptoms.
Menopause. 2004 Jul-Aug;11(4):382-388
Effect of a yearlong, moderate-intensity exercise intervention on the occurrence and severity of menopause symptoms in postmenopausal women.
Aiello EJ, Yasui Y, Tworoger SS, Ulrich CM, Irwin ML, Bowen D, Schwartz RS, Kumai C, Potter JD, McTiernan A.
Fred Hutchinson Cancer Research Center, Division of Public Health Sciences, Cancer Prevention Research Program, Seattle, WA 98109, USA.
OBJECTIVE: To evaluate the effect of moderate-intensity exercise on the occurrence and severity of menopause symptoms. DESIGN: A yearlong, randomized, clinical trial, conducted in Seattle, WA, with 173 overweight, postmenopausal women not taking hormone therapy in the previous 6 months. The intervention was a moderate-intensity exercise intervention (n = 87) versus stretching control group (n = 86). Using logistic regression, odds ratios comparing exercise with controls were calculated at 3, 6, 9, and 12 months for menopause symptoms and their severity. RESULTS: There was a significant increase in hot flash severity and decreased risk of memory problems in exercisers versus controls over 12 months, although the numbers affected were small. No other significant changes in symptoms were observed. CONCLUSIONS: Exercise does not seem to decrease the risk of having menopause symptoms in overweight, postmenopausal women not taking hormone therapy and may increase the severity of some symptoms in a small number of women.
Maturitas. 2004 Jun 15;48(2):97-105
Vasomotor symptoms and quality of life in previously sedentary postmenopausal women randomised to physical activity or estrogen therapy.
Lindh-Astrand L, Nedstrand E, Wyon Y, Hammar M.
Division of Obstetrics and Gynaecology, Department of Molecular and Clinical Medicine, Faculty of Health Sciences, University Hospital, S-581 85 Linkoping, Sweden.
OBJECTIVE: To assess if regular physical exercise or oral oestradiol therapy decreased vasomotor symptoms and increased quality of life in previously sedentary postmenopausal women. SETTING: A prospective, randomised trial at a University Hospital. METHODS: 75 postmenopausal, sedentary women with vasomotor symptoms were randomised to: exercise three-times weekly over 12 weeks (15 women), oral oestradiol therapy for 12 weeks (15 women) and 45 women to three other treatment arms. Results from the exercise and oestradiol groups are presented here. The effects on vasomotor symptoms and wellbeing were assessed with logbooks and validated questionnaires. RESULTS: Ten women fulfilled 12 weeks of exercise. The number of flushes was rather unchanged in five women and decreased to 28% (range 18-42%) of baseline in the other five women. Five of the ten women continued to exercise another 24 weeks, thus in all 36 weeks. The mean number of flushes decreased by about 50% in these five women (from 6.2/24 to 3.2 flushes/24 h at 36 weeks). In the same group a score made as the product of reduction in number and severity of flushes decreased by 92% at 12 weeks, 75% at 24 weeks and 72% at 36 weeks compared with baseline. In the estrogen group flushes decreased from 8.4 to 0.8
(P<0.001) after 12 weeks of therapy and remained at this level after 36 weeks. Well-being according to different measurements improved significantly in both groups, albeit more markedly in the estrogen group. CONCLUSIONS: Apart from many other health benefits regular physical exercise may decrease vasomotor symptoms and increase quality of life in postmenopausal women, but this has to be further evaluated scientifically. Exercise should be introduced gradually to ensure compliance.
J Clin Nurs. 2004 May;13(4):447-54
Menopausal women: perceiving continuous power through the experience of regular exercise.
Jeng C, Yang SH, Chang PC, Tsao LI.
School of Nursing, Taipei Medical University, Taipei, Taiwan, ROC.
BACKGROUND: Menopausal women are at high risk for cardiovascular diseases and osteoporosis. However, for so long, women have devoted much of their time and energy to family, children, and work such that they could not regularly exercise. There are few studies addressing the experiences of Taiwanese women who regularly exercise. OBJECTIVES: The aim of this study was to explore the experiences of regularly exercising, defined as thoughts or actions by menopausal women who did not regularly exercise before menopause, but who now exercise regularly. DESIGN: A grounded theory research design was used. METHODS: In-depth interviews were undertaken with a purposive sampling of 12 menopausal women who began to do regular exercises after menopause and who have continued exercising for more than 6 months. The constant comparative method was used to analyse the interview data. RESULTS: 'Perceiving Continuous Power' was the core category during the process of regularly exercising. Every participating woman perceived that her body and mind were filled with continuous power including the subcategories of 'Overcoming the initial discomfort', 'Experiencing Benefits to Body and Mind' and 'Broadening' during the process. 'Awareness of Health Crisis', which included the subcategories of 'Cureless Chronic Disease', 'Mood Swings', and 'Conflict on Medication', was identified as occurring when these women first began regularly exercising. Throughout the process of perceiving continuous power, women experienced the following interactive behaviour categories: 'Exercise Selection' with subcategories of 'Self-Evaluation', 'Seeking and Fitting', 'Comparing' and 'Health Becoming' with the subcategories of 'Releasing Health Crisis', 'Regaining Flowering Life', and 'Self-Fulfilling'. CONCLUSIONS: Regular exercises provided continuous power for menopausal women. RELEVANCE TO CLINICAL PRACTICE: The experiences with exercise we uncovered in this study can provide a reference for nurses to guide menopausal women with their regular exercise plans.
West J Nurs Res. 2003 Apr;25(3):274-88; discussion 289-93
Physical activity alone and in combination with hormone replacement therapy on vasomotor symptoms in postmenopausal women.
Li S, Holm K.
Loyola University, Chicago, Illinois, USA.
The purposes of this study were (a) to examine the influence of physical activity alone, and in combination with, hormone replacement therapy (HRT) on vasomotor symptoms and (b) to identify factors that are predictive of vasomotor symptoms at menopause. A total of 239 postmenopausal women completed a modified Women's Health Assessment scale, a Usual Physical Activity questionnaire, and a Health History and Demographic questionnaire. It was found the inactive women without HRT experienced more vasomotor symptoms than women with HRT, regardless of their levels of physical activity. Physical activity, however, may be synergistic to HRT, as a trend was noted that within the same HRT-non-HRT groups, active women tended to report fewer vasomotor symptoms than inactive women, although the difference did not reach statistical significance. In addition, sociodemographic and health-related variables had limited predictive power for vasomotor symptoms.
Am J Epidemiol. 2004 Jun 15;159(12):1189-99
Lifestyle and demographic factors in relation to vasomotor symptoms: baseline results from the Study of Women's Health Across the Nation.
Gold EB, Block G, Crawford S, Lachance L, FitzGerald G, Miracle H, Sherman S.
Department of Epidemiology and Preventive Medicine, University of California School of Medicine, Davis, CA 95616-8648, USA. firstname.lastname@example.org
Results of recent trials highlight the risks of hormone therapy, increasing the importance of identifying preventive lifestyle factors related to menopausal symptoms. The authors examined the relation of such factors to vasomotor symptoms in the multiethnic sample of 3,302 women, aged 42-52 years at baseline (1995-1997), in the Study of Women's Health Across the Nation (SWAN). All lifestyle factors and symptoms were self-reported. Serum hormone and gonadotropin concentrations were measured once in days 2-7 of the menstrual cycle. After adjustment for covariates using multiple logistic regression, significantly more African-American and Hispanic and fewer Chinese and Japanese than Caucasian women reported vasomotor symptoms. Fewer women with postgraduate education reported vasomotor symptoms. Passive exposure to smoke, but not active smoking, higher body mass index, premenstrual symptoms, perceived stress, and age were also significantly associated with vasomotor symptoms, although a dose-response relation with hours of smoke exposure was not observed. No dietary nutrients were significantly associated with vasomotor symptoms. These cross-sectional findings require further longitudinal exploration to identify lifestyle changes for women that may help prevent vasomotor symptoms.
Am J Obstet Gynecol. 2003 Dec;189(6):1646-53
Menopause-related symptoms: what are the background factors? A prospective population-based cohort study of Swedish women (The Women's Health in Lund Area study).
Li C, Samsioe G, Borgfeldt C, Lidfeldt J, Agardh CD, Nerbrand C.
Department of Obstetrics and Gynecology, Lund University Hospital, Lund, Sweden.
OBJECTIVE: The purpose of this study was to analyze the influence of sociodemographic characteristics and environmental factors on self-reported menopause-related symptoms among middle-aged Swedish women. STUDY DESIGN: Women who were born in the years 1935 to 1945 and who were living in the Lund area of southern Sweden were investigated. Each woman completed a generic questionnaire and underwent a personal interview that pertained to sociodemographic characteristics, lifestyle, and current health-related problems. With these background factors, the frequency and intensity of hot flushes and vaginal dryness were determined; risk factor analysis was evaluated with the use of the multiple regression models. RESULTS: There were 6917 participants, with a response rate of 64%. A lower risk for hot flushes was related to older age, high education, and vigorous physical exercise. The major risk factors for vasomotor complaints were current weight gain, part-time employment, oophorectomy, unhealthy lifestyle, and concomitant health problems. Light smoking, late age of menopause, higher education, and excessive weight reduced the risk of vaginal dryness. However, older age, marriage, and chronic diseases negatively affected vaginal complaints. The background factors had less impact on symptoms in women who used hormone replacement therapy. CONCLUSION: Sociodemographic characteristics, lifestyle, and concomitant health problems appear to be important modifiable determinants for menopause-related symptoms.