Chinese herbal medicine for menopausal symptoms

Language models for data extraction and risk of bias assessment in complementary medicine

Large language models (LLMs) have the potential to enhance evidence synthesis efficiency and accuracy. This study assessed LLM-only and LLM-assisted methods in data extraction and risk of bias assessment for 107 trials on complementary medicine. Moonshot-v1-128k and Claude-3.5-sonnet achieved high accuracy (≥95%), with LLM-assisted methods performing better (≥97%). LLM-assisted methods significantly reduced processing time (14.7 and 5.9 min vs. 86.9 and 10.4 min for conventional methods). These findings highlight LLMs' potential when integrated with human expertise.

Effectiveness and safety of East Asian herbal medicine for menopausal insomnia: a systematic review and meta-analysis

Background: Menopausal insomnia significantly impacts the quality of life in women. East Asian herbal medicines (EAHMs) have been traditionally used in Asian countries, but their efficacy and safety require systematic evaluation. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of EAHM for treating menopausal insomnia. Methods: A comprehensive literature search was conducted across 10 electronic databases from inception until 19 July 2023. Randomized controlled trials (RCTs) investigating EAHM for menopausal insomnia were included. Two reviewers independently screened studies, extracted data, and assessed the risk of bias using the Cochrane risk of bias tool. The primary outcome was sleep quality, insomnia severity, and sleep architecture. Secondary outcomes included total effective rate (TER), menopausal symptoms, and adverse effects. Meta-analysis was conducted using a random-effects model, and the results were calculated as mean differences (MDs) or risk ratios (RRs) and their 95% confidence intervals (CIs). Also, the certainty of evidence was assessed using the GRADE approach. Results: A total of 70 RCTs involving 6,035 participants met the inclusion criteria. The most frequently used EAHMs were modified Suan Zao Ren Tang, and the most frequently used herbal component was Zizyphus jujuba Miller var. spinosa Hu ex H. F. Chou [Rhamnaceae; Zizyphi Semen]. Compared with sedative-hypnotics, EAHM significantly improved sleep quality, as measured by the Pittsburgh Sleep Quality Index (PSQI) (MD -2.18, 95% CI -2.56 to -1.80), and reduced menopausal symptoms, as assessed by the Kupperman Index (MD -4.92, 95% CI -6.03 to -3.80). Similar results were seen when EAHM was added to sedative-hypnotics. When EAHM was additionally used in sedative-hypnotics, similar benefits were shown for PSQI (MD -2.46, 95% CI -3.09 to -1.82) and the Kupperman Index (MD -4.64, 95% CI -5.07 to -4.21). EAHM was generally safer than sedative-hypnotics, with significantly fewer adverse reactions (RR 0.15, 95% CI 0.07-0.34). However, the certainty of evidence was moderate to low. Conclusion: EAHMs, alone or with sedative-hypnotics, may be effective and safe for improving sleep quality and managing menopausal symptoms. Future studies should include diverse populations, rigorous methodologies, and explore mechanisms of action to confirm these findings. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?], identifier [CRD42023446708].

Acupuncture for comorbid depression and insomnia in perimenopause: A feasibility patient-assessor-blinded, randomized, and sham-controlled clinical trial

Background and objective

Whilst acupuncture is widely used for treating psychosomatic diseases, there is little high-quality evidence supporting its application in comorbid perimenopausal depression (PMD) and insomnia (PMI) which are common complaints during climacteric. This feasibility, patient-assessor-blinded, randomized, sham-controlled clinical trial addresses this gap by investigating the efficacy and safety of acupuncture on depressed mood and poor sleep in women with comorbid PMD and PMI.

Methods

Seventy eligible participants were randomly assigned to either real-acupuncture (RA) or sham-acupuncture (SA) groups. Either RA or SA treatment were delivered in 17 sessions over 8 weeks. The primary outcomes for mood and sleep were changes on 17-items Hamilton Depression Rating Scale (HAM-D₁₇) and Pittsburgh Sleep Quality Index (PSQI) scores, from baseline to 16-week follow-up. Secondary outcome measures involved anxiety symptoms, perimenopausal symptoms, quality of life, participants' experience of and satisfaction with the acupuncture treatment. Blood samples were taken to measure reproductive hormone levels. Intention-To-Treat and Per-Protocol analyses were conducted with linear mixed-effects models. The James' and Bang's blinding indices were used to assess the adequacy of blinding.

Results

Sixty-five participants completed all treatment sessions, and 54 and 41 participants completed the eight- and 16-week follow-ups, respectively. At post-treatment and 8-week follow-up, the RA group showed a significantly greater reduction in PSQI scores than the SA group did; although the reduction of HAM-D₁₇ scores in RA group was significant, the change was not statistically different from that of SA. There were no significant mean differences between baseline and 16-week follow-up in either HAM-D₁₇ or PSQI in either group. There were no significant between-group differences in serum reproductive hormone levels. All treatments were tolerable and no serious adverse events were reported, and the blinding was successful.

Conclusion

Acupuncture is safe and can contribute to clinically relevant improvements in comorbid PMD and PMI, with satisfactory short-and medium-term effects. Whether the anti-depressive benefit of acupuncture is specific or non-specific remains to be determined. No evidence was found for any longer-term benefit of acupuncture compared to sham at 16 weeks. Further research is required to elucidate mechanisms underlying the short to medium term effects of acupuncture.

Sensitivity-to-change and predictive validity of the Cervantes Short-Form (C-SF) questionnaire in postmenopausal women

OBJECTIVES

To explore, for the first time, the ability of the Cervantes Short-Form (C-SF) questionnaire to detect and to predict meaningful changes (sensitivity-to-change and predictive validity) in women with menopausal symptoms receiving any therapeutic management under routine medical care.

METHODS

Postmenopausal women included in a registry study were the source of data. Sensitivity-to-change was explored by assessing the responses of C-SF to different type of treatment management: no treatment, natural therapies or systemic hormonal therapy (SHT). Predictive validity assessed the ability of baseline score to predict the reduction in the impact of menopausal symptoms in C-SF scoring equal or higher than one time its minimally important difference (MID) of improvement (response rate).

RESULTS

A total of 245 women were enrolled. C-SF score was significantly reduced (better QoL) with SHT by 10.62 points versus no change or 2.32 point by natural therapies or no treatment, respectively (p < 0.001 in both cases). Women declaring better improvement after treatment showed higher significant reduction in C-SF score versus those with no self-perceived improvement or impairment: -12.49 point versus +1.06 and +12.71, respectively (p < 0,01 in both cases). Responder rate showed a significant lineal growing trend with higher C-SF scoring at baseline in women who received SHT: higher scoring showed higher response rates (lineal Chi² = 15.9, p < 0.001), but not in the case of receiving natural therapies or no treatment.

CONCLUSIONS

C-SF was shown to be sensitive-to-change when postmenopausal QOL status changes due to mainly systemic hormonal treatment, therefore, supporting the utilization of this instrument to monitor response to treatment. Likewise, pre-treatment scoring in C-SF was able to predict woman's QOL meaningful response with hormonal treatment.

Estimation of placebo effect in randomized placebo-controlled trials for moderate or severe vasomotor symptoms: a meta-analysis

OBJECTIVE

The Food and Drug Administration guidance recommended that for the indication of vasomotor symptoms (VMS), studies should enroll participants with minimum of seven to eight moderate to severe VMS per day at baseline, and coprimary endpoints should be the mean change in frequency/severity at weeks 4 and 12. This study aimed to estimate placebo effects in randomized controlled trials (RCTs) fulfilling this guidance.

METHODS

PubMed was searched using the following terms: "vasomotor symptom or hot flash or hot flashes or hot flash or hot flashes [title/abstract]," "menopause or climacteric," "RCT or randomized controlled or randomized controlled," "placebo [title/abstract]," and "frequency or severity." Inclusion criteria were as follows: (1) placebo controlled RCTs, (2) enrolling women with moderate or severe VMS with a minimal frequency more than seven to eight times per day or 50 times per week, and (3) efficacy measurements including mean change in VMS frequency from baseline at week 12. A random-effects model was used in the meta-analysis.

RESULTS

Seventeen studies were included for the estimation of VMS frequency reduction and 13 studies for severity. Estimated change of VMS frequency in placebo arms was -5.44 times per day (95% CI, -5.81 to -5.07 times per day) at week 12. For VMS severity, the estimated change at week 12 was -0.36 (95% CI, -0.46 to -0.27).

CONCLUSION

Substantial and consistent placebo effects were observed in RCTs for VMS treatment. These data suggest a reduction of 5.44 times per day in frequency and 0.36 in severity might be observed as a placebo effect.

System-level investigation of anti-obesity effects and the potential pathways of Cordyceps militaris in ovariectomized rats

BACKGROUND

Cordyceps species have been used as tonics to enhance energy, stamina, and libido in traditional Asian medicine for more than 1600 years, indicating their potential for improving reproductive hormone disorders and energy metabolic diseases. Among Cordyceps, Cordyceps militaris has been reported to prevent metabolic syndromes including obesity and benefit the reproductive hormone system, suggesting that Cordyceps militaris can also regulate obesity induced by the menopause. We investigated the effectiveness of Cordyceps militaris extraction (CME) on menopausal obesity and its mechanisms.

METHODS

We applied an approach combining in vivo, in vitro, and in silico methods. Ovariectomized rats were administrated CME, and their body weight, area of adipocytes, liver and uterus weight, and lipid levels were measured. Next, after the exposure of MCF-7 human breast cancer cells to CME, cell proliferation and the phosphorylation of estrogen receptor and mitogen-activated protein kinases (MAPK) were measured. Finally, network pharmacological methods were applied to predict the anti-obesity mechanisms of CME.

RESULTS

CME prevented overweight, fat accumulation, liver hypertrophy, and lowered triglyceride levels, some of which were improved in a dose-dependent manner. In MCF-7 cell lines, CME showed not only estrogen receptor agonistic activity through an increase in cell proliferation and the phosphorylation of estrogen receptors, but also phosphorylation of extracellular-signal-regulated kinase and p38. In the network pharmacological analysis, bioactive compounds of CME such as cordycepin, adenine, and guanosine were predicted to interact with non-overlapping genes. The targeted genes were related to the insulin signaling pathway, insulin resistance, the MARK signaling pathway, the PI3K-Akt signaling pathway, and the estrogen signaling pathway.

CONCLUSIONS

These results suggest that CME has anti-obesity effects in menopause and estrogenic agonistic activity. Compounds in CME have the potential to regulate obesity-related and menopause-related pathways. This study will contribute to developing the understanding of anti-obesity effects and mechanisms of Cordyceps militaris.

Cochrane systematic reviews on traditional Chinese medicine: What matters-the quantity or quality of evidence?

BACKGROUND

Systematic reviews on traditional Chinese medicine (TCM) are constantly increasing. However, if these reviews are to be of practical value, the evidence needs to be relevant, valid, and adequately reported. Cochrane Systematic Reviews (CSRs) are considered as high-quality systematic reviews that can inform health care decision making. Our aim was to provide an overview of the scope, findings, quality and impact of CSRs on the benefits and harms associated with TCM interventions for the treatment and prevention of disease to provide new information for clinical practice and future research.

METHODS

The Cochrane Database of Systematic Reviews was searched up to May 2021, and descriptive characteristics were extracted. The correspondence between the questions asked in the CSRs and the available evidence, conclusions and certainty of findings (according to GRADE assessment), methodological quality (AMSTAR 2), and impact (Altmetric Attention Score [AAS], total citations by guideline, and total citations in Web of Science [WoS]) of CSRs were extracted. Tabular and graphical summaries of these descriptive characteristics were constructed.

RESULTS

Of 104 CSRs on TCM identified, 70 diseases belonged to 16 disease systems and contained 1642 primary studies with 157,943 participants. Interventions included Chinese herbal medicine (n = 70), acupuncture (n = 28), TCM exercises (n = 4), and moxibustion (n = 2). Among 1642 primary studies, 662 studies included an intervention group treated with at least one TCM therapy and 980 studies included a combination of therapies. Promising outcomes from the 104 CSRs were divided into endpoint outcomes (34 diseases), doctor- or patient-reported outcomes (27 diseases), and surrogate outcomes (37 diseases). Despite the presence of promising outcomes, only 5/104 CSRs drew overall positive conclusions, 42 CSRs concluded the evidence was insufficient, and 54 failed to draw firm conclusions. GRADE assessments were reported in 41.3% of the CSRs, and the ratings were mostly low or very low. Comparing the questions asked and results obtained, there was frequently a lack of information about specific outcomes. Only 16 CSRs obtained results for all outcomes listed in the methods section. According to AMSTAR 2, 51 CSRs (49.0%) were of low quality. The total number of citations in the WoS was 2135 (mean ± SD: 20.8 ± 21.2), and 38.5% of the CSRs had been cited in guidelines 95 times.

CONCLUSION

Although TCM is commonly used, evidence of its effectiveness remains largely inconclusive. Rigorous high-quality trials are needed to support the performance of high-quality reviews and to increase the evidence base. It is critical to emphasize quality over quantity in future TCM research.

Update on hormone therapy for the management of postmenopausal women

Hormone therapy (HT) has been used in postmenopausal women for decades in clinical practice. With further analysis and newer studies, the benefits and risks of HT have been repeatedly verified and discussed. HT is recommended for the treatment of vasomotor symptoms (VMS), genitourinary syndrome of menopause (GSM) and the prevention of osteoporosis. However, the precise association between HT and the risks of cardiovascular diseases, venous thromboembolism, neurodegenerative diseases, breast cancer, and endometrial cancer remains controversial. Therefore, determining how to take advantage of and control the risks of HT by adjusting the initiation time, regimen, and duration is crucial. Recent studies have indicated that HT is not related to the risk of all-cause, cardiovascular, or breast cancer mortality although it might increase the incidence of some chronic diseases. For symptomatic postmenopausal women under the age of 60 without contraindications, early initiation of HT is safe and probably has a mortality benefit over the long term. Initiating HT close to menopause at the lowest effective dose is more likely to have maximal benefits and the lowest risks. Transdermal and vaginal HT may have a lower risk, but recent evidence suggests additional clinical benefits of oral HT formulations in relieving VMS and preventing osteoporosis. The pooled cohort risk equation for atherosclerotic cardiovascular disease (ASCVD) and the free app named Menopro can be used to perform individual risk assessments. In addition, Chinese herbal medicines have benefits in alleviating hot flashes, depression, and menopausal symptoms, although further data are needed to strongly support their efficacy. Acupuncture and electroacupuncture have definite efficacy in the treatment of postmenopausal symptoms with few adverse effects, so they are a reasonable option as an alternative therapy for high-risk women. This review discusses the history of, guidelines on, and strategies for HT in order to make suggestions based on the most up-to-date evidence for the management of postmenopausal women.

Comparative Utility of Acupuncture and Western Medication in the Management of Perimenopausal Insomnia: A Systematic Review and Meta-Analysis

Background

Many women with perimenopausal insomnia (PMI) have sought alternative therapies such as acupuncture because of concerns about risks associated with hormone replacement therapy (HRT) and/or psychotropic drugs. This systematic review aimed to clarify if acupuncture alone or combined with standard Western pharmacotherapy (HRT and/or psychotropic drugs) is more effective in ameliorating PMI in comparison to pharmacotherapy alone.

Methods

Randomized controlled trials (RCTs) of PMI treatment via acupuncture alone or combined with Western pharmacotherapy versus Western pharmacotherapy were searched for from eleven databases from inception to March 2020. Cochrane criteria were followed.

Results

Fifteen studies involving 1410 women were analyzed. Meta-analysis indicated that acupuncture significantly reduced the global scores of Pittsburgh Sleep Quality Index (PSQI) [MD = −2.38, 95% CI (−3.38, −1.37), p < 0.01] and Kupperman Index [MD = −5.95, 95% CI (−10.68, −1.21), p = 0.01], compared with hypnotics. Acupuncture combined with hypnotics was more effective than hypnotics alone in decreasing PSQI scores [MD = −3.13, 95% CI (−5.43, −0.83), p < 0.01]. Too few RCTs were available to investigate the clinical efficacy differences between acupuncture and HRT/psychotropic drugs other than hypnotics.

Conclusions

Despite limited evidence, in comparison to hypnotics, acupuncture was associated with significant improvements in PMI, and reductions of other menopausal symptoms. This finding suggests that acupuncture may be a useful addition to treatment for PMI.

Herbal Medicines (Danggui Liuhuang Decoctions) for Management of Menopausal Symptoms: A Systematic Review of Randomized Controlled Trials

Danggui Liuhuang (DLH) decoctions are traditional herbal medicines that are widely used for menopausal symptoms. The objective of this systematic review was to investigate evidence of the efficacy of DLH decoctions for menopausal symptoms. Fifteen databases were searched from inception until 29 May, 2020. We included randomized controlled trials (RCTs) testing any type of DLH decoction. All RCTs investigating DLH decoctions or modified DLH decoctions were included. The methodological quality of the RCTs was evaluated using Cochrane’s risk of bias assessment tool. We measured the certainty of evidence (CoE) according to the GRADE approach. A total of five RCTs met all of the inclusion criteria and were analyzed. The included RCTs had unclear risks of bias in most domains. Based on studies using the Kupperman index for the measurement of menopausal symptoms, DLH decoctions may have ameliorative effects on menopausal symptoms equivalent to those of conventional drug therapies, but we are very uncertain (MD 3.03, 95% CI −3.17 to 9.25, two studies, very low CoE). Compared with conventional drug therapies, DLH decoctions may reduce hot flashes (MD 0.17, 95% CI 0.28 to 0.06, three studies, low CoE). The difference in the response rate between treatments is very uncertain (risk ratio 1.1, 95% CI 1.07 to 1.25, three studies, very low CoE); the results may indicate that compared with drug therapy, DLH decoction therapy elicits responses in 84 more cases per 1000 cases. In conclusion, there is limited evidence that DLH decoctions improve menopausal symptoms equivalently compared with conventional drug therapies. However, the studies had unclear risks of bias, and the CoEs were very low in general. Additional large and rigorous studies are needed.

A qualitative study of classical Chinese medicine in community health focusing on self-care: practitioner and staff perspectives

Introduction

Classical Chinese medicine (CCM) encompasses many simple lifestyle recommendations which can be adopted into daily routines in support of short and long-term health outcomes. The rise in non-communicable diseases (NCDs) globally in recent decades has led to a need for cost-effective and scalable health care interventions to address lifestyle risk for NCDs in the community. This analysis explores the experience of staff and practitioners delivering a CCM community health care program designed to improve health behaviors in the community in rural Scotland.

Methods

A qualitative study employed semi-structured interviews with a sample of program practitioners and staff (n = 7). Informants were asked to share their experience in delivering the CCM program. Emergent themes were identified via analysis using the Framework Approach.

Results

Themes emerged from the data in three key areas: Cultural challenges within the local region; Integration with the existing local health care network; and Team dynamics, co-creation and communication integrity.

Conclusion

This study highlights the importance of accessibility, integration, networking, secure funding and team unity in the context of community health program delivery, as well as noting a diversity of practice among Chinese medicine practitioners. CCM concepts may hold potential for integration into community health, however, further research is warranted.

Jie-Yu Pill, A Proprietary Herbal Medicine, Ameliorates Mood Disorder-Like Behavior and Cognitive Impairment in Estrogen-Deprived Mice Exposed to Chronic Unpredictable Mild Stress: Implication for a Potential Therapy of Menopause Syndrome

Jie-Yu Pill (JYP) is a proprietary herbal medicine initially developed to treat menstrual mood disorders. This study sought to determine whether JYP could alleviate menopausal psychiatric symptoms in ovariectomized (OVX) mice, an animal model of estrogen deprivation, exposed to chronic unpredictable mild stress (CUMS) and the underlying mechanisms in comparison with estrogen therapy. The OVX+CUMS mice were treated with 0.3 mg/kg estradiol (E₂), 2.5 g/kg or 5 g/kg JYP for 36 days, and tested in multiple behavioral paradigms. Serum, uterus, and brain tissues were collected for the measurement of hypothalamus-pituitary-ovarian axis (HPO) and hypothalamus-pituitary-adrenal (HPA) axis hormones, γ-aminobutyric acid (GABA), glutamate, neurotrophins, and estrogen receptors. JYP and E₂ had comparable efficacy in reducing anxiety- and depression-like behavior and cognitive impairment of the OVX+CUMS mice. E₂ strikingly increased ratio of uterus to body weight of the OVX+CUMS mice, but JYP did not. Both agents suppressed HPO-axis upstream hormones, inhibited HPA-axis hyperactivity by reinstating hypothalamic GABA, restored hippocampal and prefrontal glutamate contents and its receptor expression in the OVX+CUMS mice. While JYP and E₂ protected against decreases in hippocampal and prefrontal neurotrophins and estrogen receptors of the OVX+CUMS mice, unlike E₂, JYP had no significant effects on these biomarkers in the uterus. These results suggest that JYP has comparable efficacy in ameliorating mood disorder-like behavior and cognitive impairment induced by a combination of estrogen deprivation and chronic stress in association with certain differential uterus-brain mechanisms compared to estrogen therapy. JYP may be a potential therapy for menopause-associated psychiatric disorders.

Perceptions of using herbal medicines for managing menopausal symptoms: a web-based survey of Korean medicine doctors

Background

Most women experiencing menopause have sought out traditional treatment options to relieve their symptoms. The aim of this study, which used a web-based survey, was to investigate perceptions of Korean medicine doctors (KMDs) on managing menopausal symptoms with herbal medicines.

Methods

We developed and then sent a questionnaire via email to a total 497 KMDs in obstetrics and gynecology affiliated with the Society of Korean Medicine. The questionnaire consisted of three categories and a total of 26 items focusing on major menopausal symptoms, prescriptions, pattern identification, and background characteristics.

Results

Out of the 497 KMDs, we received responses from 48 doctors, a response rate of 9.7%. The most common symptoms of menopausal disorder perceived by responded KMDs were hot flashes (22.9%), sleep disorders (18.2%), systemic fatigue (12.5%), and sweating (12.0%). The herbal medicines reported to be the most effective when treating patients with menopausal disorders were Jiawei shaoyao-san (12.5%), Jiawei guipi-decoction (11.8%). The responding KMDs recommended one to two months of treatment for female menopausal disorder, using two to three doses of herbal medicine per day in combination with traditional Korean medicine (KM) therapies such as acupuncture, moxibustion, cupping, and pharmacopuncture.

Conclusion

The results of this survey may provide information about doctor’s perceptions on using herbal medicines to manage patient’s menopausal symptoms. Future studies should be done with a larger sample size to overcome the limitation of this study and to examine how KM is used for treating menopausal symptoms in clinical practice.

Non-concealed placebo treatment for menopausal hot flushes: Study protocol of a randomized-controlled trial

Background

Beneficial effects of placebos are high in double-blind hot flush trials. Studies in various conditions suggest that honestly prescribed placebos may elicit symptom improvement.

Objective

To determine whether open label placebo (OLP) treatment is efficacious in alleviating hot flushes among peri- and postmenopausal women.

Methods/design

In this assessor-blinded, randomized-controlled trial, n = 100 women experiencing five or more daily hot flushes of at least moderate severity and bothersomeness are assigned 1:1 to a 4-week OLP treatment or no treatment. To explore the duration and maintenance of placebo effects, the OLP group is randomized a second time to either discontinue or continue the OLP treatment for another 4 weeks. All participants receive a briefing about placebo effects and study visits at baseline, post-treatment (4 weeks), and follow-up (8 weeks, OLP group only). Qualitative interviews about subjective experiences with the OLP treatment are conducted.

Primary outcomes are differences between the OLP and the no-treatment group in the hot flush composite score (frequency × severity), and bothersomeness of hot flushes as assessed with the Hot Flush Rating Scale at post-treatment. Secondary outcomes include hot flush frequency, health-related quality of life, global improvement, and the number of responders at post-treatment. Data are analyzed by fitting (generalized) linear mixed models. An exploratory analysis of maintenance and duration is performed including follow-up data.

Discussion

This trial will contribute to the evaluation of OLP treatments in clinical practice and further our understanding about the magnitude of placebo effects in hot flush treatments.

Trial registration

Clinicaltrials.gov, NCT03838523. Retrospectively registered on February 12th, 2019. The first patient was enrolled on October 10th, 2018.

Understanding the complex relationships underlying hot flashes: a Bayesian network approach

OBJECTIVE

The mechanism underlying hot flashes is not well-understood, primarily because of complex relationships between and among hot flashes and their risk factors.

METHODS

We explored those relationships using a Bayesian network approach based on a 2006 to 2015 cohort study of hot flashes among 776 female residents, 45 to 54 years old, in the Baltimore area. Bayesian networks were fit for each outcome (current hot flashes, hot flashes before the end of the study, hot flash severity, hot flash frequency, and age at first hot flashes) separately and together with a list of risk factors (estrogen, progesterone, testosterone, body mass index and obesity, race, income level, education level, smoking history, drinking history, and activity level). Each fitting was conducted separately on all women and only perimenopausal women, at enrollment and 4 years after enrollment.

RESULTS

Hormone levels, almost always interrelated, were the most common variable linked to hot flashes; hormone levels were sometimes related to body mass index, but were not directly related to any other risk factors. Smoking was also frequently associated with increased likelihood of severe symptoms, but not through an antiestrogenic pathway. The age at first hot flashes was related only to race. All other factors were either not related to outcomes or were mediated entirely by race, hormone levels, or smoking.

CONCLUSIONS

These models can serve as a guide for design of studies into the causal network underlying hot flashes.

Chinese herbal medicine for postpartum constipation: a protocol of systematic review and meta-analysis

INTRODUCTION

Constipation is one of the most common gastrointestinal symptoms in postpartum mothers. The choice of treatments for postpartum constipation remains a challenging clinical problem. Chinese herbal medicine has become increasingly popular as an alternative therapy for constipation. This systematic review aims to evaluate the efficacy and safety of Chinese herbal medicine for postpartum constipation.

METHODS AND ANALYSIS

We will search PubMed (1946 to present), EMBASE (1974 to present), Cochrane Central Register of Controlled Trials (all years), Web of Science (1900 to present), Chinese Biomedical Literatures Database (1978 to present), China National Knowledge Infrastructure (1979 to present) and WANFANG data (1998 to present) to identify any eligible study. No restriction will be put on the language, publication date or status of the study. The primary outcome will be the spontaneous bowel movement. Secondary outcomes will be stool consistency, quality of life, transit time, relief of constipation symptoms and adverse events. We will perform the meta-analysis when more than one trial examines the same intervention and outcomes with comparable methods in similar populations. If the heterogeneity is not significant statistically (p>0.10 or I2<50%), the fixed-effect model will be built to estimate the overall intervention effects. Otherwise, the random-effect model will be used to provide more conservative results.

ETHICS AND DISSEMINATION

No ethical issues are foreseen because no primary data will be collected. The results will be published in a peer-reviewed scientific journal.

PROSPERO REGISTRATION NUMBER

CRD42018093741.

The Management of Menopausal Symptoms in Women Following Breast Cancer: An Overview

The improved detection and successful treatment of breast cancer, resulting in better survival rates, has led to an increasing number of women living with the effects of treatment modalities and their long-term consequences. Menopausal symptoms following breast cancer can occur at an earlier age, be more severe and significantly influence a woman's overall wellbeing, in particular, sexual function, quality of life and adherence to treatment. There is a dearth of good quality evidence on the safest and most effective treatment options available for these women, and this article aims to summarize the current available treatments. Pertinent to these women is general advice, such as avoidance of triggers, and lifestyle modifications. Following which, non-pharmacological interventions, including cognitive behavior therapy (CBT), hypnosis, acupuncture, stellate ganglion nerve block and complementary agents, are discussed. Pharmacological therapies and their safety profile in these high-risk women are then examined; namely, menopausal hormone therapy, progestogens, antidepressants (selective serotonin reuptake inhibitors and selective noradrenaline reuptake inhibitors), gabapentin, clonidine and intra-vaginal dehydroepiandrosterone (DHEA). Finally, neurokinin 3 receptor antagonists, promising new agents for the treatment of troublesome menopausal vasomotor symptoms, are discussed.

Herbal medicine (Danggui Liuhuang decoction) for managing menopausal symptoms: A protocol of systematic review of randomized clinical trials

BACKGROUND

Danggui Liuhuang (DLH) decoction is a traditional herbal medicine that is widely used in East Asia to treat menopausal symptoms. Most of the available clinical trials that investigated DLH decoction have been included in this review. The objectives of this protocol are to provide the information of how to evaluate the effectiveness and safety of DLH decoction for the treatment of menopausal symptoms.

METHODS AND ANALYSIS

Fourteen databases will be searched from inception until February 2018. We will include randomized controlled trials (RCTs) testing any type of DLH decoction. All RCTs investigating DLH decoction or modified DLH decoction will be included. The methodological quality of the RCTs will be evaluated using the Cochrane's risk of bias assessment tool.

ETHICS AND DISSEMINATION

The full systematic review will be published in a peer-reviewed journal. The review will also be disseminated electronically and in print. Updates of the review will be conducted to inform and guide healthcare practice and policy.

TRIAL REGISTRATION NUMBER

PROSPERO 2017 CRD42017079189.

A Herbal Formula HT051, a Combination of Pueraria lobata and Rehmannia glutinosa, Prevents Postmenopausal Obesity in Ovariectomized Rats

Menopause is strongly associated with an increased risk of metabolic dysfunctions due to the decline in estrogen. Here, we hypothesized that dietary HT051, containing the roots of Pueraria lobata and Rehmannia glutinosa, has beneficial effects on ovariectomized (OVX) rats by regulating lipid metabolism. Forty-eight female Sprague-Dawley rats were randomly divided into 4 groups: sham-operated (Sham), OVX, OVX with low-dose HT051 supplementation, and OVX with high-dose HT051 supplementation. The rats were fed with a modified AIN-93G diet or an HT051-containing modified AIN-93G diet for 8 weeks. Body weight, fat mass, and serum levels of total cholesterol, triglyceride, glucose, alanine transaminase, and aspartate transaminase decreased in HT051-fed OVX rats. Dietary HT051 supplementation significantly decreased the mRNA expression of lipogenesis-related genes, including sterol regulatory element-binding protein 1c and fatty acid synthase, and increased the mRNA expression of β-oxidation-related genes, including peroxisome proliferator-activated receptor and carnitine palmitoyl transferase 1 in the liver of OVX rats. Moreover, the expression of genes involved in adipogenesis and inflammation was significantly lower in the adipose tissue of OVX rats fed with HT051 than in the OVX group. These findings suggest that HT051 may be a potential natural alternative for the management of postmenopausal metabolic dysfunctions.

Efficacy and side effects of chinese herbal medicine for menopausal symptoms: a critical review

This study evaluates 23 (9 Chinese and 14 non-Chinese) randomized controlled trials for efficacy and side effects of Chinese herbal medicine on menopausal symptoms. Menopause was diagnosed according to western medicine criteria in all studies while seven Chinese studies and one non-Chinese study further stratified the participants using traditional Chinese medical diagnosis "Zheng differentiation." Efficacy was reported by all 9 Chinese and 9/14 non-Chinese papers. Side effects and adverse events were generally mild and infrequent. Only ten severe adverse events were reported, two with possible association with the therapy. CHM did not increase the endometrial thickness, a common side effect of hormone therapy. None of the studies investigated long-term side effects. Critical analysis revealed that (1) high-quality studies on efficacy of Chinese herbal medicine for menopausal syndrome are rare and have the drawback of lacking traditional Chinese medicine diagnosis (Zheng-differentiation). (2) Chinese herbal medicine may be effective for at least some menopausal symptoms while side effects are likely less than hormone therapy. (3) All these findings need to be confirmed in further well-designed comprehensive studies meeting the standard of evidence-based medicine and including Zheng-differentiation of traditional Chinese medicine.