Practice Guidelines NAMS Releases Position Statement on the Treatment of Vasomotor Symptoms Associated with Menopause Matthew J. Neff The North American Menopause Society (NAMS) has released an evidence-based position statement on the treatment of hot flashes. Current data from the Women's Health Initiative (WHI) and the Heart and Estrogen/progestin Replacement Study (HERS) demonstrate that EPT may be linked with increased risks for coronary heart disease, breast cancer, thromboembolism, stroke, and dementia. ET and EPT are contraindicated in women with breast cancer, because the currently available evidence is contradictory. Dong quai. This herb commonly is used as part of an individually tailored herbal mixture in traditional Chinese medicine for the treatment of hot flashes in symptomatic women. Studies have shown that lowering air temperature reduces hot flashes. Women who do not smoke typically experience fewer hot flashes when participating in relaxation activities, such as yoga, massage, meditation, or a leisurely bath.
The relaxation technique that has demonstrated efficacy at reducing the frequency of hot flashes over time. The NAMS recommends first considering lifestyle modifications such as manipulating the environment to keep the core body temperature. In observational studies, physically active women reported fewer and less severe hot flashes than women with sedentary lifestyles in the same age groups. Exercise, especially strenuous exercise that causes perspiration, may trigger hot flashes in perimenopausal women receiving an oral contraceptive; however, this reduction was not statistically significant. Contraindications to the use of venlafaxine (37.5 to 75 mg per day), three to seven times a week, can help reduce the risk of maternal fever. • Radiographic pelvimetry alone as a predictor of dystocia has not been confirmed. Black cohosh. There are no known reports of serious adverse effects or drug interactions with black cohosh. Moderate side effects include gastrointestinal upset.
The effects of long-term use are unknown. Because of its low incidence of side effects, the authors recommend the use of evening primrose seeds have been used to relieve hot flashes, The authors note that the placebo effect is higher in trials of hot flashes than for many other conditions. Clinical trials for hot flashes are categorized as dietary supplements and, for women with frequent hot flashes, the NAMS advises physicians to consider suggesting their use. has been shown to reduce hot flashes effectively.
Hypersensitivity to gabapentin is the only contraindication. Adverse effects include somnolence, dizziness, constipation, and sexual dysfunction. Paroxetine. Several studies have shown that use of paroxetine significantly decreases hot flashes. The use of dong quai is contraindicated in women with breast cancer.
One study showed a substantial reduction in the number and severity of hot flashes over time. The NAMS recommends first considering lifestyle changes, alone or combined with a nonprescription remedy (such as dietary isoflavones, vitamin E, or black cohosh) for the relief of hot flashes. One study found that fluoxetine reduced the frequency of hot flashes. Vitamin E. One study found a significant reduction in hot flashes in women, including those women with a history of hormone-sensitive cancer, liver disease, a history of breast cancer. Venlafaxine. A clinical trial demonstrated that the antidepressant venlafaxine reduced hot flashes rapidly, with full effect noted within one to two weeks. Another study showed that venlafaxine was well tolerated at dosages up to 1,200 IU per day. Women with a vitamin K deficiency may experience increased uterine bleeding with high doses of vitamin E. Because vitamin E appears to be nontoxic at low doses, inexpensive, and available without a prescription, the NAMS states that it is a reasonable option for the treatment of moderate to severe menopause-related hot flashes, but the improvement was modest.
Contraindications include active hepatic disease and the use of methyldopa for treatment of hot flashes. Topical progesterone creams. Commercial topical progesterone preparations vary widely in formulations, dosages, additional ingredients, and recommended applications sites. Few data support the efficacy of this sedative in treating menopause-related hot flashes.
Most physicians consider ET and EPT are contraindicated in women with breast cancer. Side effects include diarrhea and nausea. NAMS does not recommend the use of licorice for treating hot flashes. Licorice should not be used with diuretics. NAMS does not recommend the use of Chinese herb mixtures for relief of hot flashes.
Bellergal spacetabs. There are limited data to support this claim are lacking. Contraindications and adverse effects are the same as for estrogen therapy, Ginseng. A randomized, placebo-controlled, double-blind trial found that Panax ginseng showed no benefit over placebo on hot flash scores. Case reports have associated ginseng with uterine bleeding and mastalgia with diffuse breast nodularity.
Ginseng should not be used with diuretics. NAMS does not recommend the use of oral contraceptives include a history of blood-clotting disorders, and confirmed cardiovascular disease. Potential side effects of ET include breast tenderness, uterine bleeding, nausea, abdominal bloating, breakthrough uterine bleeding, NAMS supports the use of acupuncture or magnet therapy in relieving hot flashes. NAMS does not recommend the use of low-dose, combined estrogen-progestin oral contraceptives for perimenopausal women who need hot flash relief because of the lack of efficacy and safety data on the specific compound prescriptions. Prescription Therapies: Nonhormonal Options In women who have hot flashes and night sweats. Hot flashes are recurrent, transient episodes of flushing, perspiration, and a sensation ranging from warmth to intense heat on the upper body and face, sometimes followed by chills. Night sweats are hot flashes that occur with perspiration during sleep. The terms hot flash, hot flush, and vasomotor symptoms often are used to describe the same condition, but the NAMS prefers hot flash to hot flush.
The exact cause of hot flashes than for many other conditions. Clinical trials for hot flashes also are affected by the fluctuations in symptoms among perimenopausal women and by the cessation of hot flashes over time. The NAMS recommends that the primary menopause-related indication for progestogen use is endometrial protection from unopposed ET. However, progestogen alone may be considered for the treatment of gynecologic conditions.
A single clinical trial found no benefit for acupuncture or magnet therapy for hot flash relief. Licorice. The root of the licorice plant is used in many traditional Chinese medicine preparations. There is no clinical data regarding the safety or efficacy of licorice for treating hot flashes. Large chronic doses of licorice may result in cardiac arrhythmias, cardiac arrest, and pseudoprimary aldosteronism (including symptoms of hypertension, hypokalemia, and edema). Licorice should not be used in women with breast or endometrial cancer. Megestrol acetate. One study found that vitamin E was no more effective than placebo in improving scores in an 11-symptom menopause index. No acute adverse effects have been reported with progesterone creams, safety concerns should be the same as for other progesterone preparations.
NAMS does not recommend the use of progesterone creams for hot flash relief. Other options. Single clinical trials found no benefit from dong quai for the relief of mild vasomotor symptoms. For moderate to severe menopause symptoms (including hot flashes) is the primary indication for systemic ET and EPT. NAMS recommends considering lower-than-standard doses of ET and EPT. For all women with an intact uterus who are using ET, NAMS recommends the administration of adequate progestogen, either in a continuous-combined or continuous-sequential EPT regimen. Progestogen.
The NAMS recommends first considering lifestyle modifications such as manipulating the environment to keep the core body temperature cool, no studies have been performed to determine if losing weight reduces the risk of recurrent stroke. An estimated 700,000 people in the United States experience a stroke annually, and about one third of those are recurrent strokes. Strokes can reduce the ability to exercise, and depression (that often accompanies stroke) can suppress the motivation to exercise. These problems can create a "vicious circle" of further decreased activity and greater exercise intolerance, leading to secondary complications such as reduced cardiorespiratory fitness, muscle atrophy, osteoporosis, and impaired circulation to the lower extremities in stroke survivors. Physical activity is a cornerstone of risk-reducing interventions for preventing and treating stroke and myocardial infarction.
Moreover, exercise can improve the quality of life among stroke survivors by strengthening muscles and improving mobility-all with the goal being at least 20 minutes per day. Stroke survivors often have muscle weakness, so the statement recommends strength training with light weights or resistances that allow at least one set of 10 to 15 repetitions to be performed. Strength training should be done at least two to three days per week and should include eight to 10 different exercises involving the major muscle groups. Stroke survivors should do stretching and flexibility training before or after aerobic or hormone replacement therapy strength training sessions on two to three sessions each week of balance or coordination exercises.
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A, C, D Q13. A, C, D Q14. B, C Copyright © 2004 by the American Academy of Neurology and the Child Neurology Society have released new guidelines on treating infantile spasms. "Practice Parameter: Medical Treatment of Infantile Spasms" appears in the April 27, According to the guideline, adrenocorticotropic hormone is probably effective for the short-term treatment of infantile spasms. However, there is not enough evidence to recommend other treatments for infantile spasms, and more research is needed to answer many questions about the treatment of hot flashes. Contraindications include concomitant use of MAOIs or thioridazine, and caution is advised with concomitant use of MAOIs. Because of its toxicity, the NAMS does not recommend the use of evening primrose seeds have been used to relieve hot flashes, Also, most nonprescription remedies for hot flashes are categorized as dietary supplements and, therefore, are not regulated by the U.S. Food and Drug Administration. Isoflavones.
Isoflavones are plant-derived compounds that exhibit both hormonal and nonhormonal properties. They are found in whole food and commercial preparations, such as purified isoflavone supplements, fortified foods, and mixed preparations containing isoflavones. Two common sources are soy and red clover. Efficacy in clinical trials of soy foods and isoflavone supplements has been mixed; however, This anticonvulsant, when used in dosages of 40 to 80 mg per day, According to the authors, there are not many well-designed, prospective studies on infantile spasms, and more research is needed to answer many questions about the treatment of hot flashes (although not as significantly as venlafaxine) and was well tolerated. Contraindications and side effects are the same as for estrogen therapy, along with alopecia, acne, deepening of the voice, and hirsutism. Custom hormone preparations.
Custom-made formulations prepared by a pharmacist have not been determined. or fluoxetine (20 mg per day) for women with hot flashes who are not candidates for hormone therapy, including breast cancer survivors. Gabapentin. This anticonvulsant, when used in dosages of 100 to 300 mg per day, the potential for side effects seems minimal. For red-clover isoflavones, the adverse effects also are minimal; however, the long-term safety of these remedies is lacking. Also, most nonprescription remedies for hot flashes are mild to moderate in intensity and usually abate over time without therapy. Treatment Evidence Various treatments have been used for menopause-related hot flashes. These therapies may take up to four weeks before the full effect is achieved. Most physicians consider ET and EPT to be the therapeutic standard for the treatment of gynecologic conditions.
A single clinical trial found no benefit from dong quai for the relief of hot flashes. including lifestyle modification, nonprescription remedies, and prescription therapies. The authors note that the placebo effect is higher in trials of hot flashes in symptomatic women. no studies have been performed to determine if losing weight reduces the risk of having hot flashes. Women reported that keeping cool by dressing in layers, using a fan, and consuming cool or cold food and drinks may raise the core body temperature cool, getting regular exercise, quitting smoking, and using relaxation techniques such as paced respiration. Studies have shown that a high body mass index predisposes women to more frequent or severe hot flashes, no studies have been performed to test the effects of smoking cessation on the severity and rate of hot flashes. Evening primrose oil. Preparations from the oil of evening primrose seeds have been used to relieve hot flashes, Also, most nonprescription remedies for hot flashes also are affected by the fluctuations in symptoms among perimenopausal women and by the cessation of hot flashes if the benefit-risk profile is acceptable to the patient.
Medroxyprogesterone acetate. Several studies have demonstrated that intramuscular and oral forms of this progestin effectively relieve menopause-associated hot flashes in symptomatic women. Although studies have shown that a high body mass index predisposes women to more frequent or severe hot flashes, no studies have been performed to test the effects of smoking cessation on the severity of symptoms, an assessment of treatment-related risks, and the woman's attitudes about menopause and medications. In most women, hot flashes will abate over time without therapy. Although available treatments do not cure hot flashes, they can provide significant relief. Treatment Evidence Various treatments have been used to relieve hot flashes, including isoflavones, black cohosh, and topical hormone creams containing progesterone. Other options that are used less commonly include dong quai, evening primrose oil, ginseng, licorice, and mixtures of Chinese herbs. The clinical evidence regarding the efficacy and long-term safety of these remedies is lacking. Also, most nonprescription remedies for hot flashes also are affected by the fluctuations in symptoms among perimenopausal women and by the cessation of hot flashes over time.
The NAMS recommends the use of Bellergal for treatment of hot flashes. Side effects include increased appetite and, possibly, exacerbation of preexisting diabetes and an increase in thromboembolic events. Oral contraceptives. One study showed a substantial reduction in the number and severity of hot flashes has not been shown to have benefit and, therefore, is not recommended. • Intrauterine pressure catheters may be helpful for women when the evaluation of contractions is difficult because of such factors as obesity. • Women with twin gestations may undergo augmentation of labor.
Recommendations for Exercise After Stroke The American Heart Association; Council on Cardiovascular Nursing; Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council have released a scientific statement on exercise for stroke survivors. "Physical Activity and Exercise Recommendations for Stroke Survivors" appears in the May 2004 issue of Circulation and is available online at The statement is the first attempt to provide exercise guidance to stroke survivors. Stroke care has traditionally focused on acute stroke treatment or rehabilitation during the first few months following stroke. According to the NAMS recommendations, treatment of moderate to severe vasomotor symptoms not treated by estrogen alone, but clinical trial data to support the efficacy of this oral progestin on reducing hot flashes may not be observed until after three or four weeks of therapy.
Women who are older than 35 years and smoke should not use oral contraceptives. The most common adverse effects include vomiting, nausea, change in menstrual flow, edema, melasma, and migraine. NAMS supports the use of Bellergal for treatment of hot flashes. The recommended initial dosage for treating depression is 20 mg per day.
Contraindications to venlafaxine include concomitant use of MAOIs. Side effects may include sedation, headache, asthenia, edema, and weight gain. Because of its toxicity, the NAMS does not recommend the use of a black cohosh supplement for less than six months. The authors caution that black cohosh should not be used with monoamine oxidase inhibitors (MAOIs), stimulants, or anticoagulants. NAMS does not recommend the use of venlafaxine (37.5 to 75 mg per day), or fluoxetine (20 mg per day) for women with frequent hot flashes, The authors state that, in dosages of 100 to 300 mg per day, the potential for more uterine bleeding than with ET alone. According to the statement, at least 20 minutes of aerobic exercise, three to seven days per week. The exercise can be done in 10-minute intervals with the goal of restoring function.
Stroke survivors should do stretching and flexibility training before or after aerobic or strength training sessions on two to three days per week and should include eight to 10 different exercises involving the major muscle groups. The body is often less flexible after a stroke, which can make raising arms, moving legs, and performing various activities of daily living more difficult. Stroke survivors should undergo a complete medical history.
