Acupuncture and hot flashes – a winning combination

There have been a lot of naysayers of late with regards to acupuncture. However, one of the largest studies to date examining its impact on menopausal hot flashes has been completed. The results? Acupuncture plus self-care can significantly reduce hot flashes and improve quality of life during menopause!

In the  ACUFLASH study, researchers randomized 399 postmenopausal women (1 year since last menstrual period) regularly experiencing at least 7 hot flashes daily to acupuncture or no treatment. Moxibustion was used at the practitioner’s discretion and sessions could also be extended by two weeks (from 12 weeks), if needed.  Although the practitioners met beforehand to discuss possible diagnoses and recommended treatment points, all treatment was individualized. Both groups of patients also received self care recommendations, which consisted of a one-page information leaflet on care of menopausal symptoms (e.g. soy, herbs, physical activity and relaxation techniques) which they were free to add at their own discretion.

Overall, the mean frequency of hot flashes declined by 48% in women receiving acupuncture compared with 28% of women using self-care methods only. This means that 50% of women receiving acupuncture experienced a 50% or greater reduction in how often their hot flashes occurred, compared to 16% of women using self-care. Significant reductions were also seen in hot flash intensity. Additionally, the acupuncture group reported significant improvements in vasomotor, sleep, and somatic symptoms over the course of the study.

The researchers have pointed out that previous studies (which have shown mixed results) have relied on smaller numbers of patients, have used  sham needles that did not penetrate the skin,  and have relied on a standardized practice. In contrast (and in keeping in line with the edicts of eastern  medicine) ACUFLASH practitioners individualized treatment according to patients’ needs. This may help to account for the positive results.

I have long argued for a need to modify western methods so that aspects of eastern practice that both make it unique and also form its foundation, may remain intact. This study remained true to the practice of acupuncture while also insuring that certain scientific tenets were followed. I  am hopeful  that the size of the study coupled with its approach, will open the door for future studies and provide an evidence-based path for women who choose a non-pharmacologic approach to menopause.

Wednesday Bubble: Sham?

Today’s Bubble troubles me because it’s a bit personal. You see; I want to believe.

Reporting in the Climacteric journal of the International Menopause Society, researchers say that a thorough review of scientific studies examining acupuncture and hot flashes failed to reveal any specific effects.  So, is acupuncture no more effective than sham acupuncture, i.e. placebo?

In this report, which appeared in the February 2009 edition of the journal, researchers searched studies published in 17 databases in different languages. Of the six well-designed trials that were ultimately included in their review, four compared regular acupuncture with sham acupuncture, in which a practitioner will insert needles on acupuncture points that are not relevant for treating hot flashes. The results: none of these trials showed any benefit of acupuncture in terms of frequency or severity of hot flashes.

Only one trial showed any favorable effects: this particular study tested acupuncture against needles that were place on non-relevant points but not inserted into the skin.

So, what can we conclude from these findings?

The researchers say that controlled studies, in which the environment is scientifically designed to mimic real life, fail to show any specific effects of acupuncture for controlling hot flashes. However, they do not appear to believe that this is the end all to be all. Instead, they call for more rigorous trials to further investigate the use of acupuncture for hot flashes.

Perhaps the ACUFLASH trial will shed more light.

What are your experiences with acupuncture? Have you used it specifically to treat hot flashes?

She’s got moxi

Have you heard of or experienced moxibustion? Moxibustion is a technique used during acupuncture in which mugwort (or artemsia vulgaris) is burned to warm certain regions or acupuncture points. It can be direct (in which the moxa is placed directly on the acupuncture point) and indirect (in which the moxa is palced approximately 1 to 2 cm above the acupuncture point). The purpose of moxibustion is to encourage better blood and energy flow through the area to promote healing.

A study in the March 13 advanced online edition of Menopause suggests that moxibustion plus acupuncture can reduce both the frequency and severity of hot flashes.

In this study, researchers randomly assigned 51 women, ages 45 to 60 years who experienced at least 5 moderate to severe hot flashes daily to:

• 14 sessions of indirect moxibustion plus acupuncture at points consistent with evidence from clinical practice experience
• 14 sessions of indirect moxibustion plus acupuncture at points consistent with evidence from published literature
• no treatment

To ensure that researchers were able to distinguish between general improvements and improvements resulting from treatment, all study participants had to go through a 1-week period during which time they used not treatments at all.

Study findings showed that compared with no treatment at all, women in both moxibustion groups experienced significantly reductions in hot flash frequency (roughly 60% in both groups), and continuous reductions in hot flash severity through the fourth week of the study (by as much as 50%). 10 participants experienced side effects due to the moxi smoke (e.g. fatigue, stomach upset, flare-up and headaches ) and 5 reported burns to their skin).

Notably, women receiving moxibustion along points directed by published literature also experienced more improvements in quality of life scores, particularly as they related to symptoms and psychosocial issues.

This study appears to indicatethat moxibustion may help to enhance acupuncture’s effect on hot flashes during the menopause. Clearly, more studies with larger samples are needed.

What’s your sleep number?

[Rembrandt van Rijn, Sleeping Woman, 1658]

On a scale of 1 to 5 would you say that your sleep number (the quality of your sleep) is:

1. nonexistent, I never sleep
2. occasional, I sleep one or two nights a week
3. obstructed, I sleep but I wake up regularly throughout the night
4. pretty good, I rarely wake up
5. great, I typically sleep through the night

If you are like most peri- post menopausal women, it’s likely that you rate the quality of your sleep about a “3. ” In fact, a review in the journal Current Neurology and Neuroscience Reports suggests that 28% to 64% of peri- or postmenopausal women have some form of sleep disturbances that may aggravated by sleep apnea, periodic limb movements syndrome (restless leg syndrome) and psychological distress (anxiety, major depression).

One of the primary causes of sleep disruption during menopause is declining estrogen levels, which increase peripheral and central temperature, dilate blood vessels and lead to hot flashes. Unfortunately data also suggest that  hot flashes double the time spent awake although ironically, they often follow rather than proceed awake times.

More good news: both sleep apnea and periodic limb movements syndrome increase with age. Menopausal women are espeically at risk due to declining progesteron levels and increased body mass index (and associated increases in neck circumference). Both sleep apnea (in which the airways become partially or totally obstructed) and periodic limb movements obviously interefere with sleep quality. In fact, sleep researchers have documented apnea, restless leg syndrome or both in up to 53% of women between the ages of 44 and 56.

The evidence is less certain for mood disturbances and sleep, although studies have shown clear links between reproductive hormonal changes and clinical depression in women going through menopause. What’s more, women in menopause who are clinically depressed have reported more frequent and longer times awake than those who do not have any mood disturbances.

Steps to take

I’ve written previously on this issue and there are a variety of non-pharmacologic steps that might improve sleep quality including standardized herbs and acupuncture.

Hypnosis, relaxation techniques that include breathing and/or biofeedback) may also assist. These strategies are part of a larger approach called cognitive-behavioral therapy for insomnia (CBT-I) which in a small study, was found to significantly improve anxiety, depression, partner relationships, sexuality and hot flashes in menopausal women.

Notably, the benefit of HRT for sleep/mood disturbances remains unclear and studies are inconclusive.

As with any issue associated with menopause, it’s critical to speak to a health practitioner about the issue so that the course of therapy can be safely individualized and personalized.

What about you? How’s your sleep? And what are you doing about it?

ACUFLASH

Researchers are studying whether or not Traditional Chinese Medicine acupuncture care plus self-care can effectively relieve hot flashes.

The ongoing study, known as the ACUFLASH trial, is examining acupuncture as a complete treatment package, a standardized (rather than haphazard) approach in which following diagnosis, the patient receives treatment in specific points. Each practitioner is also free to add individualized points to treat other symptoms related to the menopause, such as depression, anxiety and  insomnia. Treatment will comprise up to 10 sessions over 12 weeks, and may also include soy, dietary supplements and herbal medicine.

Study participants will receive either acupuncture treatment as described or self care alone (over the counter drugs, self-provided interventions such a soy and herbal supplements). Participants may also  use any additional care such as massage or prescribed medications but these interventions will be followed up, registered, and analyzed accordingly.

Traditional Chinese Medicine Acupuncture uses diagnostic methods according to principes of Traditional Chinese Medicine. Acpunture is believed to affect the autonomic and central nervous systems which directly influence hot flash activity.

Early data looking at patient experiences demonstrates that many women receiving acupuncture treatment have reported substantial impact in terms of a reduction in the frequency and severity of their hot flashes both during the day and at night. They also report better sleep, and improvements in mood.

Sounds very promising, doesn’t it? What’s your experience with acupuncture? Care to share?

More great news about needles

Tis the Season for needles…pine and otherwise!

Norwegian researchers are reporting that acupuncture plus self-care can reduce the frequency of hot flashes substantially in postmenopausal women! Now that’s a gift I can get my arms around!

In this study, published in the December 4 advanced, online edition of Menopause, 267 postmenopausal women who experienced at least 7 hot flashes every 24 hours for at least 7 consecutive days received:

1) 10 acupuncture treatments plus an informational brochure on self-care for menopause symptoms, or

2) An informational brochure on self-care for menopause symptoms only

The results showed that hot flash frequency decreased by 50% over 24 hours in women receiving acupuncture compared to those who only received self-care instructions. The researchers aso noted significant improvements in vasomotor (e.g. night sweats) , sleep and emotional/psychological  symptoms among women receiving acupuncture.

I’ve written about the value of acupuncture for hot flashes and improved sleep quality previously. I’m glad to see that more evidence is accruing supporting this wonderful, safe modality to improve menopausal symptoms.

The American Association of Acupuncture and Oriental Medicine is also an excellent source for more information and help finding a qualified practitioner.

Navigating the Maze, Part 2

In my last post, I wrote about navigating the maze of perimenopause symptoms and treatments. This is a continuation of an interview I had with NYC-based acupuncturist and Chinese Medicine Specialist, Elaine Stern.

When I last left off, we were discussing useful Western herbs for addressing perimenopausal symptoms.

Are there other herbs than black cohosh that are helpful for perimenopausal symptoms?

Chaste tree berry is a very useful herb for perimenopause since it targets the “luteal phase” of the menstrual cycle. It helps the body become more efficient in terms of ovulation and progesterone production, and may be useful for women experiencing irregular cycles or PMS symptoms.

You mentioned nutrition earlier. How is this different than herbal medicine? Afterall, we’re taking supplements, right?

Nutrition, like acupuncture and herbal medicine, is a fairly diverse field. However, unlike the literature has not caught up with its practice. It’s also confusing because we may read the newspaper one week and see a study saying we should take vitamin X, and then the next week, see that it’s been linked to cancer.

When it comes to nutrition, it’s important to understand the body’s physiology and biochemisty and focus on nutrients to increase natural function and actions. With regards to perimenopause, you may recall that we discussed the build-up of excess estrogen. Vitamin B6 has been shown to be very important in helping the liver clear the estrogen out of the body. While things like diet are undoubtedly the most efficient way to obtain B6, well, the way that we eat and the way that our food is grown can interfere with the ability to get as much as is needed. With a little extra, we can assist the body’s ability to clear the estrogen, thereby addressing water retention and other PMS symptoms.

Do women need to stay on treatment the entire menopausal transition?

Well, it’s important to stay on some sort of program for a period of time. This will vary from person to person.

What should women look for in a practitioner?

With Chinese medicine and acupuncture, the practitioner should be licensed and have national board certification. If their specialty is nutrition, it’s helpful to inquire about education and experience. And most of all, find out if the practitioner has a specific interest or area of practice that focuses on gynecology and internal medicine.

Anything else you’d like to add?

I want reiterate that herbal and nutritional products are completely unregulated and there’s a huge variety in quality. Whatever you can learn about the way that a product is manufactured and with what type of oversight, the better. So, I’d recommend that women look at the labeling for buzzwords like “standardized,” “good manufacturing of products,” things like that, but with the knowledge and understanding that there is no oversight with regards to the marketing of these substances. Again, this is a good reason to see a practitioner, at least to get started as he or she can be useful for creating a program and guide you to good sources for herbs and nutritional products.

Finally, this is medicine. Women need to understand that they are tinkering with their hormonal balance and even if the products aren’t toxic, it’s important to look beyond the symptoms and understand what’s going on physiologically. So, I truly believe in the importance of speaking to someone who can understand your individual changes and then recommend something. At the very least, women should see someone at least once to insure that they are on the right track.

Navigating the Maze, Part 1

I always enter mazes with great anticipation. The thrill of navigating the corners and moving forward without interruption, the intellectual aspect of the “game,” and the forced retracing of steps when I hit a wall.

Maybe we should think about perimenopause like that? Anticipate, analyze, and step back each time we hit a wall.

I spoke with New York City-based acupuncturist and Chinese Herbal Medicine specialist Elaine Stern last week. We talked about common perimenopause complaints, what’s actually going on in our bodies, and with the proper guidance, steps that might be taken.

I learned a few things and hope that you will also. Please note that it is neither mine nor Elaine’s intention to provide medical advice or replace personal consultation with a private practitioner. Rather, we hope that our conversation will help you understand some of the the changes you may be going through.

p.s. Because our conversation was so lengthy, I’ve broken it into two parts.

What are the primary perimenopausal complaints that you see consistently in your practice?

There are a core group of complaints that are very common. Beginning in perimenopause, women start to have a lot more PMS, and more mood swings that worsen just before the period and sometimes don’t get better right away after, as they did previously. Sleep disturbances may occur, especially in the second half of the cycle. Note that these peripheral problems are influenced by hormonal changes.

What exactly do you mean when you say the problems are “influenced by” hormonal changes?

From the time women reach age 36 or 37, they begin to ovulate less often, i.e. instead of 11 or 12 times a year, maybe they’re ovulating nine or 10 times. By the time they get to age 45, they might be ovulating every two or three months. Women’s hormones, that is, estrogen and progesterone, have an important relationship with one another and keep one another in check. A decline in ovulation means a decline in progesterone production, leaving, for all intents purposes, an imbalance.

What happens as a result of this imbalance?

Women in perimenopause may have a low progesterone level, which leaves the estrogen in relative excess in comparison. If the estrogen is in excess in relation to progesterone, the body tends to retain water, metabolism slows, and the liver becomes more sluggish and this affects the digestive system. They may gain weight because they are not burning food as efficiently. Estrogen stimulates breast cells, meaning that breasts may feel more tender than usual. Additionally, it stimulates endometrial growth, so periods may be heavier. And because estrogen stimulates the nervous system, it can also cause anxiety.

What types of treatment do you recommend for women experiencing these types of symptoms?

I believe it’s important to consider three modalities: acupuncture, herbal medicine, and nutrition.

So, let’s talk about acupuncture. Why is it helpful and what are the drawbacks, if any?

Acupuncture is helpful for women in perimenopause because it has a very good effect on the regulatory system; it smooths things out so to speak. It can help lessen anxiety, promote the immune system and can even out digestive problems. It helps rebalance areas that are out of balance. But what it can’t do is reverse the process of moving towards menopause. And you have to go quite regularly to keep the effects going.

Meaning what? Do you have to continue treatments throughout the entire menopause?

Well, this is why I find it helpful to combine herbs and acupuncture. Because herbs stay in the system all the time, they can keep a woman at an optimal level or balance in between acupuncture sessions.

Speaking of herbs, the whole issue can be very confusing for lots of women. One study may say that they are effective,and another, that they’re not. And, there’s often a lot of product selection. Can you clear up the mystery?

It’s important to separate the idea of Chinese herbs and Western herbs. Simply speaking, Chinese herbs are based on a system of Chinese medicine diagnosis. So, they are prescibed in combinations that treat these diagnostic categories. In other words, there is no one-to-one correspondence between a single herb and a single symptom. Because they are almost always combined, you can’t simply pick something off the shelf.

Western herbs, on the other hand, tend to be targeted towards specific problems. And there are good ones available for menopause.

Can you touch upon some of those?

Well, for example, black cohosh is a terrific herb. It’s not as strong as hormones but its track record is very good. While there are some studies that show it’s not very effective and others that show it is quite effective, I think that that has to do with how the studies were done. The other issue is quality of product and the lack of regulation.

Then, how do you choose when you go to the drugstore or health store?

That’s one reason to see a practitioner. A good practitioner will have examined the studies and will understand a bit about the marketplace. In this way, she or he will be able to direct you to a good product.

But if you live in a rural setting and don’t necessarily have access to a good practitioner, what are your options?

Almost all the studies that have shown good results have been conducted using a particular blend. We refer to these herbs as “standardized” because they are created using a percentage of one or two specific ingredients that are essential to creating an effect.

Where can you learn more about which products have been used in studies?

I recommend looking at Medline or even searching for “standardized X extract” on the American Botanical Council websites. A simple rule of thumb is that the least expensive product is not always going to be the best. While it’s hard to generalize, if you can find the product that was used in studies, well, it’s a great start.

Tomorrow, I’ll post the rest of this interview, which includes more information on Western herbs, a brief discussion about nutrition, and some overall advice.

Needles anyone?

According to a study in Holistic Nursing Practice, acupuncture directed at menopausal-specific sites can substantially alleviate hot flashes and sleep disturbances. Too good to be true? I think that this is a topic that deserves a lot more attention. Stay tuned!