Menopause strategies: Finding Lasting Answers for Symptoms and Health: eliminating hot flashes--still not a slam dunk!

T ype Balternative hot flash treatment[ in your search engine and it will call up an extraordinary range of suggestions. For example, the Prevention Web site article B14 Natural Remedies for Hot Flashes,[ published in April 2012, recommends hypnosis, flax seed, focusing on the positive, exercise, and yoga. Many of these options have appeal, but is there evidence? The Menopause Strategies: Finding Lasting Answers for Symptoms and Health (MsFLASH) Clinical Trials Network was formed Bto create a network of scientists who are highly knowledgeable about the menopausal transition and experienced in the conduct of women_s health trials. [ This multisite effort was funded by the National Institute on Aging, among others, in the hope of promoting Bprogress in identifying effective remedies for vasomotor symptoms (VMS) in women experiencing the menopausal transition. [ These scientists have produced some strong work and have published studies of escitalopram and its effects on VMS, two methods articles, and four articles summarizing their somewhat disappointing but nevertheless worthy look at the effects of omega-3, exercise, and yoga on VMS. Three of these articles are included in this month_s issue of Menopause. The methods summary states that BTesting the efficacy of behavioral and complementary and alternative medicine (CAM) treatments was a priority for the MsFLASH Network because these treatments are widely available, acceptable, low risk, and provide many additional health benefits. [ A 3 2 factorial design was used in the 12-week study reported here. Exercise, yoga, and omega-3 were compared in a randomized placebo-controlled study, where the participants not receiving a physical intervention were taking active or placebo pills and therefore could reasonably expect a benefit. Reed et al were presumably hoping to demonstrate a reduction in VMS because all three of these nonprescription options have been recommended in lay literature and some medical literature. Yoga performed the best. The data did not show a decrease in VMSVeither in frequency or in botherVamong women practicing yoga for 12 weeks. However, 66% of them reported that they were satisfied with their hot flash relief, and the group had measurably improved insomnia. The participants reported that they wanted to continue practicing yoga. Unfortunately, there is no information on what they actually did in the subsequent months and years. Exercise likewise did not show an overall decrease in VMS in the intervention group (previously sedentary women) compared with controls. Interestingly, white women had significantly fewer VMS at the end of the study period, whereas black women had no change in VMS. There was also a trend toward a significant effect on women who were more fit at baseline. As in other studies, exercise improved sleep and mood, as assessed by study tools. Again, the women expressed a desire to continue exercising, suggesting that they experienced positive effects from their effort. No differences in VMS frequency, VMS bother, or any of the secondary measures of sleep and mood were demonstrated in the group that took omega-3 compared with the group that took placebo. Ensrud et al published the results of the Menopause Quality of Life survey of their participants in another venue. Again the yoga group recorded improvements in multiple domains, whereas the exercise group showed only some physical improvements. The participants taking omega-3 could not be distinguished from those taking placebo by this measure. The overall negative results beg the question, BWhat are the flaws in these studies? [ Demonstrating a therapeutic effect on VMS is notoriously challenging, but the MsFLASH group has been thoughtful and systematic in its approach and has taken much care to standardize performance across sites. One does wonder, BWhat would motivate a woman experiencing two hot flashes a day (the study minimum, although the mean was ultimately 7.4/24 h) to commit to participation in this effort? [ Almost 900,000 letters were sent to age-appropriate women. Seven thousand women (less than 1%) responded, and 355 were ultimately randomized. This is a rarified group and may not be representative of women who seek medical care for menopause symptoms. The authors pointed out that their reliance on participant self-report is a weakness. However, it has been argued that self-report is key in assessing the management of VMS because symptom relief is what women are looking for. Furthermore, there is the question, BWith respect to the exercise regimen, was it the right one or did the study last long enough? [ It is interesting to note that the women who started out fitter benefitted more from exercise. Could there be a threshold of fitness for VMS effects? This theory is supported by a study showing regular exercise to be negatively correlated with menopause symptoms.