Paced respiration for vasomotor and other menopausal symptoms: a randomized, controlled trial

The 2023 nonhormone therapy position statement of The North American Menopause Society

OBJECTIVE

To update the evidence-based Nonhormonal Management of Menopause-Associated Vasomotor Symptoms: 2015 Position Statement of The North American Menopause Society.

METHODS

An advisory panel of clinicians and research experts in women's health were selected to review and evaluate the literature published since the Nonhormonal Management of Menopause-Associated Vasomotor Symptoms: 2015 Position Statement of The North American Menopause Society. Topics were divided into five sections for ease of review: lifestyle; mind-body techniques; prescription therapies; dietary supplements; and acupuncture, other treatments, and technologies. The panel assessed the most current and available literature to determine whether to recommend or not recommend use based on these levels of evidence: Level I, good and consistent scientific evidence; Level II, limited or inconsistent scientific evidence, and Level III, consensus and expert opinion.

RESULTS

Evidence-based review of the literature resulted in several nonhormone options for the treatment of vasomotor symptoms. Recommended: Cognitive-behavioral therapy, clinical hypnosis, selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors, gabapentin, fezolinetant (Level I); oxybutynin (Levels I-II); weight loss, stellate ganglion block (Levels II-III). Not recommended: Paced respiration (Level I); supplements/herbal remedies (Levels I-II); cooling techniques, avoiding triggers, exercise, yoga, mindfulness-based intervention, relaxation, suvorexant, soy foods and soy extracts, soy metabolite equol, cannabinoids, acupuncture, calibration of neural oscillations (Level II); chiropractic interventions, clonidine; (Levels I-III); dietary modification and pregabalin (Level III).

CONCLUSION

Hormone therapy remains the most effective treatment for vasomotor symptoms and should be considered in menopausal women within 10 years of their final menstrual periods. For women who are not good candidates for hormone therapy because of contraindications (eg, estrogen-dependent cancers or cardiovascular disease) or personal preference, it is important for healthcare professionals to be well informed about nonhormone treatment options for reducing vasomotor symptoms that are supported by the evidence.

Effects of health education and progressive muscle relaxation on vasomotor symptoms and insomnia in perimenopausal women: A randomized controlled trial

OBJECTIVES

This study aims to determine the effects of health education (HE) and progressive muscle relaxation (PMR), individually or combined, on vasomotor symptoms and insomnia in perimenopausal women.

METHODS

This study is a single-center, pretest-posttest, randomized controlled trial with a factorial design. The research sample consists of 108 women who were randomly divided into three groups: HE + PMR group (n = 36), PMR group (n = 36) and control group (n = 36). 90 women completed the study. The data were collected in three steps by using instruments of Personal Information Form, Visual Analog Scale and a diary for vasomotor symptoms, Women's Health Initiative Insomnia Rating Scale.

RESULTS

Hot flash and night sweats frequency and severity scores/24 h, the VAS scores for hot flashes and night sweats, and the WHIIRS scores significantly improved more in the intervention groups compared to the control group (p < 0,05). Compared to the group PMR, the group PMR + HE had a greater improvement with larger effect size in all measurements.

CONCLUSIONS

PMR and HE counseling by nurses benefit perimenopausal women who suffer from insomnia and vasomotor symptoms.

PRACTICE IMPLICATIONS

PMR combined with HE or PMR alone is effective in managing vasomotor symptoms and insomnia; therefore, they can easily be integrated into clinical practice.

Behavioral interventions for improving sleep outcomes in menopausal women: a systematic review and meta-analysis

IMPORTANCE

Perimenopausal and postmenopausal women commonly report sleep disruption and insomnia. Behavioral interventions may be safe alternatives for patients who are unwilling to begin pharmacological treatments because of adverse effects, contraindications, or personal preference.

OBJECTIVE

The primary objective is to assess the efficacy of behavioral interventions on sleep outcomes among perimenopausal and postmenopausal women, as measured using standardized scales and objective methods (polysomnography, actigraphy). The secondary objective is to evaluate the safety of these methods through occurrence of adverse events.

EVIDENCE REVIEW

Searches were performed within MEDLINE (OVID interface, 1946 onward), Embase (OVID interface, 1974 onward), Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Web of Science (Core collection) using a search strategy developed in consultation with a health sciences librarian. Title/abstract and full-text screenings were performed in duplicate, and relevant studies were selected based on inclusion and exclusion criteria set to identify randomized controlled trials evaluating the effects of behavioral interventions on sleep quality. Risk of bias assessments were done using the Cochrane Risk of Bias 2 tool, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of the body of evidence. Data were pooled in a meta-analysis using a random-effects model.

FINDINGS

Nineteen articles reporting results from 16 randomized controlled trials were included, representing a total of 2,108 perimenopausal and postmenopausal women. Overall, behavioral interventions showed a statistically significant effect on sleep outcomes (standardized mean difference [SMD], -0.62; 95% confidence interval [CI], -0.88 to -0.35; I2 = 93.4%). Subgroup analyses revealed that cognitive behavioral therapy (SMD, -0.40; 95% CI, -0.70 to -0.11; I2 = 72.7%), physical exercise (SMD, -0.57; 95% CI, -0.94 to -0.21; I2 = 94.0%), and mindfulness/relaxation (SMD, -1.28; 95% CI, -2.20 to -0.37; I2 = 96.0%) improved sleep, as measured using both subjective (eg, Pittsburg Sleep Quality Index) and objective measures. Low-intensity (SMD, -0.91; 95% CI, -1.59 to -0.24; I2 = 96.8) and moderate-intensity exercise (SMD, -0.21; 95% CI, -0.34 to -0.08; I2 = 0.0%) also improved sleep outcomes. No serious adverse events were reported. Overall risk of bias ranged from some concern to serious, and the certainty of the body of evidence was assessed to be of very low quality.

CONCLUSIONS AND RELEVANCE

This meta-analysis provides evidence that behavioral interventions, specifically, cognitive behavioral therapy, physical exercise, and mindfulness/relaxation, are effective treatments for improving sleep outcomes among perimenopausal and postmenopausal women.

Respiratory Physiotherapy Intervention Strategies in the Sequelae of Breast Cancer Treatment: A Systematic Review

Breast cancer treatments can trigger respiratory sequelae. Respiratory physiotherapy helps to eliminate or mitigate the sequelae by optimizing respiratory function. This systematic review aims to synthesize the scientific evidence and assess its quality regarding the use of respiratory physiotherapy in the sequelae of breast cancer. The Cochrane Library, Physiotherapy Evidence Database, PubMed, Web of Science, Scientific Electronic Library Online, Cumulative Index of Nursing and Allied Literature Complete, and Scopus were searched. Study quality was determined using the PEDro scale, STROBE Statement, and Single-Case Experimental Design Scale. Ten studies, six clinical trials, one case study, and three observational studies were selected. The mean methodological quality of the clinical trials was 5.6, that of the case study was 7, and that of the observational studies was 56%. Respiratory physiotherapy has been observed to improve respiratory capacity, lung function, respiratory muscle strength, effort tolerance, dyspnea, fatigue, thoracic mobility, upper limb volume, sleep quality and quality of life, as well as sensitivity to adverse physiological reactions, nausea, vomiting, and anxiety. However, it is not effective for vasomotor symptoms. More clinical trials are needed. These studies should homogenize the techniques used, as well as improve their methodological quality.

Evaluating the Effects of Symptom Monitoring on Menopausal Health Outcomes: A Systematic Review and Meta-Analysis

Evidence suggests that monitoring and appraising symptoms can result in increased engagement in medical help-seeking, improved patient-doctor communication, and reductions in symptom prevalence and severity. To date, no systematic reviews have investigated whether symptom monitoring could be a useful intervention for menopausal women. This review explored whether symptom monitoring could improve menopausal symptoms and facilitate health-related behaviours. Results suggested that symptom monitoring was related to improvements in menopausal symptoms, patient-doctor communication and medical decision-making, heightened health awareness, and stronger engagement in setting treatment goals. Meta-analyses indicated large effects for the prolonged use of symptom diaries on hot flush frequencies. Between April 2019 and April 2021, PsychInfo, EMBASE, MEDLINE, CINAHL, Cochrane, ProQuest, PsychArticles, Scopus, and Web of Science were searched. Eighteen studies met the eligibility criteria and contributed data from 1,718 participants. Included studies quantitatively or qualitatively measured the impact of symptom monitoring on menopausal populations and symptoms. Research was narratively synthesised using thematic methods, 3 studies were examined via meta-analysis. Key themes suggest that symptom monitoring is related to improvements in menopausal symptoms, improved patient-doctor communication and medical decision-making, increased health awareness, and stronger engagement in goal-setting behaviours. Meta-analysis results indicated large effects for the prolonged use of symptom diaries on hot flush frequency: 0.73 [0.57, 0.90]. This review is limited due to the low number of studies eligible for inclusion, many of which lacked methodological quality. These results indicate that symptom monitoring has potential as an effective health intervention for women with menopausal symptoms. This intervention may be beneficial within healthcare settings, in order to improve patient-doctor relations and adherence to treatment regimes. However, findings are preliminary and quality assessments suggest high risk of bias. Thus, further research is needed to support these promising outcomes. Systematic Review Registration Number: https://www.crd.york.ac.uk/prospero/display_record.php?, PROSPERO, identifier: CRD42019146270.

Alternative and non-hormonal treatments to symptoms of menopause

Ovarian function can start to decline a few years before the eventual cessation of the menstrual cycle. The average age of menopause in the UK is 51 years, and it is a retrospective diagnosis after 12 months of amenorrhoea. Women can experience many symptoms such as vasomotor and vulvovaginal symptoms that impact them physically, psychologically, sexually and thus their overall wellbeing. Women may have medical contraindications to hormonal therapy or may prefer non-hormonal or alternative treatments. This review looks at the evidence, efficacy, and safety of a range of complementary or alternative treatments and non-hormonal pharmacological treatments for the treatment of vasomotor symptoms and vulvovaginal atrophy of menopause.

Interventions to Improve Sexual Health in Women Living with and Surviving Cancer: Review and Recommendations

Sexual health concerns, both physical and psychological, are common and represent an unmet need among women with and surviving cancer. Sexual challenges and conditions negatively impact body image, satisfaction, relationships, well-being, and quality of life, yet are widely reported to be under-recognized and undertreated. To guide clinical care and future research on sexual function in women with cancer, we performed a scoping review of interventions for sexual health concerns, including sexual function, body image, genitourinary symptoms, and hot flashes. Relevant publications between 2005 and 2020 were identified by searching PubMed with a combination of medical subject headings and keywords. Articles were included if they focused on the aforementioned topics, were primary research publications, and included female cancer survivors. Studies focusing on women receiving hormone therapy for breast cancer were also included. A total of 91 investigations conducted in the US and abroad were reviewed. Most commonly, interventions included a component of psychoeducation, although pharmacologic, exercise, and other approaches have been evaluated. Many studies have focused on survivors of breast or gynecologic cancer, among other sampling and methodological limitations. These limitations underscore the need for more work on this vital survivorship issue. Recommendations for future research in this area are also offered.

Transcutaneous Auricular Vagus Nerve Stimulation Combined With Slow Breathing: Speculations on Potential Applications and Technical Considerations

OBJECTIVES

Transcutaneous auricular vagus nerve stimulation (taVNS) is a relatively novel noninvasive neurostimulation method that is believed to mimic the effects of invasive cervical VNS. It has recently been suggested that the effectiveness of taVNS can be enhanced by combining it with controlled slow breathing. Slow breathing modulates the activity of the vagus nerve and is used in behavioral medicine to decrease psychophysiological arousal. Based on studies that examine the effects of taVNS and slow breathing separately, this article speculates on some of the conditions in which this combination treatment may prove effective. Furthermore, based on findings from studies on the optimization of taVNS and slow breathing, this article provides guidance on how to combine taVNS with slow breathing.

MATERIALS AND METHODS

A nonsystematic review.

RESULTS

Both taVNS and slow breathing are considered promising add-on therapeutic approaches for anxiety and depressive disorders, chronic pain, cardiovascular diseases, and insomnia. Therefore, taVNS combined with slow breathing may produce additive or even synergistic beneficial effects in these conditions. Studies on respiratory-gated taVNS during spontaneous breathing suggest that taVNS should be delivered during expiration. Therefore, this article proposes to use taVNS as a breathing pacer to indicate when and for how long to exhale during slow breathing exercises.

CONCLUSIONS

Combining taVNS with slow breathing seems to be a promising hybrid neurostimulation and behavioral intervention.

Heart Rate Variability Biofeedback Improves Emotional and Physical Health and Performance: A Systematic Review and Meta Analysis

We performed a systematic and meta analytic review of heart rate variability biofeedback (HRVB) for various symptoms and human functioning. We analyzed all problems addressed by HRVB and all outcome measures in all studies, whether or not relevant to the studied population, among randomly controlled studies. Targets included various biological and psychological problems and issues with athletic, cognitive, and artistic performance. Our initial review yielded 1868 papers, from which 58 met inclusion criteria. A significant small to moderate effect size was found favoring HRVB, which does not differ from that of other effective treatments. With a small number of studies for each, HRVB has the largest effect sizes for anxiety, depression, anger and athletic/artistic performance and the smallest effect sizes on PTSD, sleep and quality of life. We found no significant differences for number of treatment sessions or weeks between pretest and post-test, whether the outcome measure was targeted to the population, or year of publication. Effect sizes are larger in comparison to inactive than active control conditions although significant for both. HRVB improves symptoms and functioning in many areas, both in the normal and pathological ranges. It appears useful as a complementary treatment. Further research is needed to confirm its efficacy for particular applications.

Beyond the bladder: poor sleep in women with overactive bladder syndrome

BACKGROUND

Nocturnal bladder symptoms and sleep disruption commonly coexist in middle-aged and older women. Although sleep disruption is often attributed to nocturnal bladder symptoms in women with overactive bladder syndrome, nonbladder factors also may influence sleep in this population. Many women with overactive bladder are eager to identify nonpharmacologic strategies for both bladder symptoms and sleep disruption, given the potential adverse effects of sedative and anticholinergic bladder medications in this population.

OBJECTIVES

To provide greater insight into the complex relationship between nighttime overactive bladder symptoms and sleep disruption, and to evaluate the effects of a guided slow-paced respiration intervention on sleep outcomes in women with overactive bladder.

STUDY DESIGN

We conducted an ancillary study within a randomized trial of slow-paced respiration in women with overactive bladder symptoms. Ambulatory community-dwelling women who reported ≥3 episodes/day of urgency-associated voiding or incontinence were randomized to use either a portable biofeedback device (RESPeRATE; Intercure, Ltd) to practice guided slow-paced respiration exercises daily for 12 weeks (N=79) or an identical-appearing device programmed to play nonrhythmic music without guiding breathing (N=82). At baseline and after 12 weeks, bladder symptoms were assessed by voiding diary, sleep duration, and disruption were assessed by sleep diary corroborated by wrist actigraphy, and poor sleep quality was determined by a Pittsburgh Sleep Quality Index global score >5.

RESULTS

Of the 161 women randomized, 31% reported at least twice-nightly nocturia, 26% nocturnal incontinence, and 70% poor sleep quality at baseline. Of the 123 reporting any nighttime awakenings, 89% averaged 1 or more nighttime awakenings, and 83% attributed at least half of awakenings to using the bathroom. Self-reported wake time after sleep onset increased with increasing frequency of nocturnal bladder symptoms (P=.01 for linear trend). However, even among women without nocturia, average sleep quality was poor (Pittsburg Sleep Quality Index global score mean of 7.3; 95% confidence interval, 6.0-8.6). Over 12 weeks, women assigned to slow-paced respiration (N=79) experienced modest improvements in mean nocturnal voiding frequency (0.4 fewer voids/night), sleep quality (1.1 point score decrease), and sleep disruption (1.5% decreased wake time after sleep onset). However, similar improvements were detected in the music control group (N=81), without significant between-group differences.

CONCLUSIONS

Many women with overactive bladder syndrome experience disrupted sleep, but not all nocturnal awakenings are attributable to bladder symptoms, and average sleep quality tends to be poor even in women without nocturia. Findings suggest that clinicians should not assume that poor sleep in women with overactive bladder syndrome is primarily caused by nocturnal bladder symptoms. Guided slow-paced respiration was associated with modest improvements in nocturia frequency and sleep quality in this trial, but the results do not support clinician recommendation to use this technique over other behavioral relaxation techniques for improving sleep.

Focusing on fidelity: narrative review and recommendations for improving intervention fidelity within trials of health behaviour change interventions

Background: Interventions to change behaviour have substantial potential to impact positively on individual and overall public health. Despite an increasing focus on health behaviour change intervention research, interventions do not always have the desired effect on outcomes, while others have diluted effects once implemented into real-life settings. There is little investment into understanding how or why such interventions work or do not work. Methodological inadequacies of trials of behavioural interventions have been previously suggested as a barrier to the quality and advancement of behavioural research, with intervention fidelity acknowledged as a key area for improvement. However, there is much ambiguity regarding the terminology and conceptualisation of intervention fidelity and a lack of practical guidance regarding how to address it sufficiently, particularly within trials of complex behavioural interventions. Objectives: This article outlines specific issues concerning intervention fidelity within trials of health behaviour change interventions and suggests practical considerations and specific recommendations for researchers, with examples from the literature presented. Conclusions: Recommendations pertain to (1) clarifying how fidelity is defined and conceptualised, (2) considering fidelity beyond intervention delivery, (3) considering strategies to both enhance and assess fidelity, (4) making use of existing frameworks and guidance, (5) considering the quality and comprehensiveness of fidelity assessment strategies, (6) considering the balance between fidelity and adaptation and (7) reporting the use of fidelity enhancement and assessment strategies and their results. Suggestions for future research to improve our understanding of, and ability to, address fidelity in behaviour change interventions are also provided.

Variation in menopausal vasomotor symptoms outcomes in clinical trials: a systematic review

BACKGROUND

There is substantial variation in how menopausal vasomotor symptoms are reported and measured among intervention studies. This has prevented meaningful comparisons between treatments and limited data synthesis.

OBJECTIVES

To review systematically the outcome reporting and measures used to assess menopausal vasomotor symptoms from randomised controlled trials of treatments.

SEARCH STRATEGY

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to May 2018.

SELECTION CRITERIA

Randomised controlled trials with a primary outcome of menopausal vasomotor symptoms in women and a sample size of at least 20 women per study arm.

DATA COLLECTION AND ANALYSIS

Data about study characteristics, primary vasomotor-related outcomes and methods of measuring them.

MAIN RESULTS

The search identified 5591 studies, 214 of which were included. Forty-nine different primary reported outcomes were identified for vasomotor symptoms and 16 different tools had been used to measure these outcomes. The most commonly reported outcomes were frequency (97/214), severity (116/214), and intensity (28/114) of vasomotor symptoms or a composite of these outcomes (68/214). There was little consistency in how the frequency and severity/intensity of vasomotor symptoms were defined.

CONCLUSIONS

There is substantial variation in how menopausal vasomotor symptoms have been reported and measured in treatment trials. Future studies should include standardised outcome measures which reflect the priorities of patients, clinicians, and researchers. This is most effectively achieved through the development of a Core Outcome Set. This systematic review is the first step towards development of a Core Outcome Set for menopausal vasomotor symptoms.

TWEETABLE SUMMARY

Menopausal hot flushes and night sweats have been reported in 49 different ways in clinical research. A core outcome set is urgently required.

Anxiogenic CO2 stimulus elicits exacerbated hot flash-like responses in a rat menopause model and hot flashes in postmenopausal women

OBJECTIVE

As longitudinal studies determined that anxiety is a strong risk factor for hot flashes, we hypothesized that an anxiogenic stimulus that signals air hunger (hypercapnic, normoxic gas) would trigger an exacerbated hot flash-associated increase in tail skin temperature (TST) in a rat ovariectomy (OVEX) model of surgical menopause and hot flashes in symptomatic postmenopausal women. We also assessed TST responses in OVEX serotonin transporter (SERT) rats that models a common polymorphism that is associated with increased climacteric symptoms in postmenopausal women and increases in anxiety traits.

METHODS

OVEX and sham-OVEX rats (initial experiment) and wildtype and SERT OVEX rats (subsequent experiment) were exposed to a 5-minute infusion of 20% carbon dioxide (CO2) normoxic gas while measuring TST. Postmenopausal women were given brief 20% and 35% CO2 challenges, and hot flashes were self-reported and objectively verified.

RESULTS

Compared to controls, OVEX rats had exacerbated increases in TST, and SERT OVEX rats had prolonged TST increases following CO2. Most women reported mild/moderate hot flashes after CO2 challenges, and the hot flash severity to CO2 was positively correlated with daily hot flash frequency.

CONCLUSIONS

The studies demonstrate that this anxiogenic stimulus is capable of inducing cutaneous vasomotor responses in OVEX rats, and eliciting hot flashes in postmenopausal women. In rats, the severity of the response was mediated by loss of ovarian function and increased anxiety traits (SERT), and, in women, by daily hot flash frequency. These findings may provide insights into anxiety-related triggers and genetic risk factors for hot flashes in thermoneutral environments.

Mind-body interventions for vasomotor symptoms in healthy menopausal women and breast cancer survivors. A systematic review

Mind-body therapies are commonly recommended to treat vasomotor symptoms, such as hot flushes and night sweats (HFNS). The purpose of this systematic review was to evaluate the available evidence to date for the efficacy of different mind-body therapies to alleviate HFNS in healthy menopausal women and breast cancer survivors. Randomized controlled trials (RCTs) were identified using seven electronic search engines, direct searches of specific journals and backwards searches through reference lists of related publications. Outcome measures included HFNS frequency and/or severity or self-reported problem rating at post-treatment. The methodological quality of all studies was systematically assessed using predefined criteria. Twenty-six RCTs met the inclusion criteria. Interventions included yoga (n = 5), hypnosis (n = 3), mindfulness (n = 2), relaxation (n = 7), paced breathing (n = 4), reflexology (n = 1) and cognitive behavioural therapy (CBT) (n = 4). Findings were consistent for the effectiveness of CBT and relaxation therapies for alleviating troublesome vasomotor symptoms. For the remaining interventions, although some trials indicated beneficial effects (within groups) at post-treatment and/or follow up, between group findings were mixed and overall, methodological differences across studies failed to provide convincing supporting evidence. Collectively, findings suggest that interventions that include breathing and relaxation techniques, as well as CBT, can be beneficial for alleviating vasomotor symptoms. Additional large, methodologically rigorous trials are needed to establish the efficacy of interventions on vasomotor symptoms, examine long-term outcomes and understand how they work.

Management of menopausal symptoms in women with gynecologic cancers

OBJECTIVE

Women with gynecologic malignancies will be cured or may become long-term survivors. Management of menopausal symptoms is important in addressing their quality of life. We review the benefit and safety of hormone therapy use in these patients.

METHODS

MEDLINE was searched for studies on menopause management published in English through December of 2016.

RESULTS

Available data suggest that short-term use of hormone therapy in gynecologic cancer patients who do not have an estrogen-dependent malignancy do not adversely impact oncologic outcome and results in improvement of menopausal vasomotor and genitourinary symptoms. Evidence regarding safety of hormone therapy use in women with estrogen-dependent gynecologic malignances is currently lacking.

CONCLUSIONS

Candidates for hormone therapy in gynecologic oncology include women with menopausal symptoms diagnosed with low-grade, early-stage endometrial cancer, cervical, vulvar and vaginal cancer, and ovarian cancer.

Management of Potential Long-Term Toxicities in Breast Cancer Patients

Breast cancer is the most common non-cutaneous malignancy among women, and there are over 3 million breast cancer survivors living in the United States today. Excellent cure rates with modern therapies are associated with substantial toxicities for many women; it is important that health care providers attend to the resulting symptoms and issues to optimize quality of life in this population. In this article, we review management options for potential long term toxicities in breast cancer survivors, with a particular focus on bone health, fertility preservation, premature menopause, cardiac dysfunction, and cognitive impairment.

Evaluating the Sleep Hygiene Awareness and Practice Scale in Midlife Women With and Without Breast Cancer

BACKGROUND AND PURPOSE

Sleep hygiene is one factor that contributes to poor sleep in breast cancer survivors but is poorly measured. The purposes of this study were to (a) evaluate the psychometric properties of the Sleep Hygiene Awareness and Practice Scale (SHAPS) and (b) compare SHAPS scores between midlife women with and without breast cancer.

METHODS

Cross-sectional, descriptive data from a single-blinded, controlled hot flash intervention trial.

RESULTS

194 women (88 breast cancer survivors; 106 menopausal women). Reliability of the three sections of the SHAPS was inadequate with Cronbach's alphas ranging from 0.23 to 0.67. Sleep hygiene practices were modestly correlated with global sleep quality in both groups.

CONCLUSIONS

Findings suggest the SHAPS would need to be revised to be a psychometrically sound measure of sleep hygiene awareness and practice.

Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society

OBJECTIVE

To update and expand The North American Menopause Society's evidence-based position on nonhormonal management of menopause-associated vasomotor symptoms (VMS), previously a portion of the position statement on the management of VMS.

METHODS

NAMS enlisted clinical and research experts in the field and a reference librarian to identify and review available evidence. Five different electronic search engines were used to cull relevant literature. Using the literature, experts created a document for final approval by the NAMS Board of Trustees.

RESULTS

Nonhormonal management of VMS is an important consideration when hormone therapy is not an option, either because of medical contraindications or a woman's personal choice. Nonhormonal therapies include lifestyle changes, mind-body techniques, dietary management and supplements, prescription therapies, and others. The costs, time, and effort involved as well as adverse effects, lack of long-term studies, and potential interactions with medications all need to be carefully weighed against potential effectiveness during decision making.

CONCLUSIONS

Clinicians need to be well informed about the level of evidence available for the wide array of nonhormonal management options currently available to midlife women to help prevent underuse of effective therapies or use of inappropriate or ineffective therapies. Recommended: Cognitive-behavioral therapy and, to a lesser extent, clinical hypnosis have been shown to be effective in reducing VMS. Paroxetine salt is the only nonhormonal medication approved by the US Food and Drug Administration for the management of VMS, although other selective serotonin reuptake/norepinephrine reuptake inhibitors, gabapentinoids, and clonidine show evidence of efficacy. Recommend with caution: Some therapies that may be beneficial for alleviating VMS are weight loss, mindfulness-based stress reduction, the S-equol derivatives of soy isoflavones, and stellate ganglion block, but additional studies of these therapies are warranted. Do not recommend at this time: There are negative, insufficient, or inconclusive data suggesting the following should not be recommended as proven therapies for managing VMS: cooling techniques, avoidance of triggers, exercise, yoga, paced respiration, relaxation, over-the-counter supplements and herbal therapies, acupuncture, calibration of neural oscillations, and chiropractic interventions. Incorporating the available evidence into clinical practice will help ensure that women receive evidence-based recommendations along with appropriate cautions for appropriate and timely management of VMS.

Management of Hormone Deprivation Symptoms After Cancer

Cancer survivors often experience symptoms related to hormone deprivation, including vasomotor symptoms, genitourinary symptoms, and sexual health concerns. These symptoms can occur due to natural menopause in midlife women, or they can be brought on by oncologic therapies in younger women or men. We searched PubMed for English-language studies from January 1990 through January 2016 to identify relevant articles on the management of hormone deprivation symptoms, including vasomotor, genitourinary, and sexual symptoms in patients with cancer. The search terms used included hormone deprivation, vasomotor symptoms, hot flash, vaginal dryness, sexual dysfunction, and breast cancer. This manuscript provides a comprehensive description of data supporting the treatment of symptoms associated with hormone deprivation.

Management of Menopausal Symptoms

Most menopausal women experience vasomotor symptoms with bothersome symptoms often lasting longer than one decade. Hormone therapy (HT) represents the most effective treatment for these symptoms with oral and transdermal estrogen formulations having comparable efficacy. Findings from the Women's Health Initiative and other recent randomized clinical trials have helped to clarify the benefits and risks of combination estrogen-progestin and estrogen-alone therapy. Absolute risks observed with HT tended to be small, especially in younger women. Neither regimen increased all-cause mortality rates. Given the lower rates of adverse events on HT among women close to menopause onset and at lower baseline risk of cardiovascular disease, risk stratification and personalized risk assessment appear to represent a sound strategy for optimizing the benefit-risk profile and safety of HT. Systemic HT should not be arbitrarily stopped at age 65 years; instead treatment duration should be individualized based on patients' risk profiles and personal preferences. Genitourinary syndrome of menopause represents a common condition that adversely affects the quality of life of many menopausal women. Without treatment, symptoms worsen over time. Low-dose vaginal estrogen represents highly effective treatment for this condition. Because custom-compounded hormones have not been tested for efficacy or safety, U.S. Food and Drug Administration (FDA)-approved HT is preferred. A low-dose formulation of paroxetine mesylate currently represents the only nonhormonal medication FDA-approved to treat vasomotor symptoms. Gynecologists and other clinicians who remain abreast of data addressing the benefit-risk profile of hormonal and nonhormonal treatments can help menopausal women make sound choices regarding management of menopausal symptoms.

Device-guided slow-paced respiration for menopausal hot flushes: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of device-guided slow-paced respiration for reducing the frequency and severity of menopausal hot flushes.

METHODS

Perimenopausal or postmenopausal women reporting four or more hot flushes per day were recruited into a parallel-group, randomized trial of slow-paced respiration using a portable guided-breathing device. Women were randomly assigned to use a standard device to practice slowing their resting breathing rate to less than 10 breaths per minute for at least 15 minutes everyday or use an identical-appearing control device programmed to play relaxing nonrhythmic music while monitoring spontaneous breathing. The primary outcome, change in hot flush frequency over 12 weeks, was assessed using data from validated 7-day diaries abstracted by blinded analysts.

RESULTS

Among the 123 participants, mean age was 53.4 (±3.4) years. Women reported an average of 8.5 (±3.5) hot flushes per day at baseline. After 12 weeks, women randomized to paced respiration (n=61) reported an average reduction of 1.8 (95% confidence interval [CI] 0.9-2.6) hot flushes per day (-21%) compared with 3.0 (95% CI 2.1-3.8) hot flushes per day (-35%) in the music-listening group (n=62) (P=.048). Paced respiration was associated with a 19% decrease in frequency of moderate-to-severe hot flushes compared with a 44% decrease with music listening (P=.02).

CONCLUSION

In this randomized trial, women assigned to device-guided slow-paced respiration reported modest improvements in the frequency and severity of their hot flushes, but the paced respiration intervention was significantly less effective than a music-listening intervention in decreasing the frequency and severity of these symptoms.

LEVEL OF EVIDENCE

I.

Insomnia and sleep apnea in midlife women: prevalence and consequences to health and functioning

Sleep disturbance is common during the menopausal transition, with numerous downstream consequences to health and functioning, including reduced quality of life, impaired mental health, and increased physical health morbidity. Insomnia affects approximately 50% of midlife women and is characterized by nocturnal symptoms of difficulties initiating or maintaining sleep (or both) and daytime symptoms that impair occupational, social, or other components of functioning. In addition, approximately 20% of midlife women develop sleep-disordered breathing during the menopausal transition. This commentary summarizes the prevalence, risk factors, and treatment options for each of these sleep disorders in midlife women, with specific focus on first-line treatments for insomnia (cognitive behavioral therapy for insomnia) and sleep-disordered breathing (continuous positive airway pressure) and unique considerations for treating sleep disorders in midlife women. Future directions are also discussed.

Effects of stellate ganglion block on vasomotor symptoms: findings from a randomized controlled clinical trial in postmenopausal women

OBJECTIVE

Uncontrolled intervention studies, including studies involving breast cancer survivors, have demonstrated improvements in vasomotor symptoms (VMS) after stellate ganglion blockade (SGB) with a local anesthetic. This study presents the first randomized sham-controlled trial of SGB for the treatment of VMS.

METHODS

Participants included 40 postmenopausal women, aged 30 to 70 years, with moderate to severe VMS. The study was a randomized sham-controlled trial comparing the effects of SGB versus sham injection on the frequencies of total and moderate to severe VMS, as measured by daily diaries. Image-guided SGB was performed with 5 mL of 0.5% bupivacaine. Sham injection of saline was performed in subcutaneous tissues in the neck. VMS were recorded at baseline and for 6 months thereafter. Objective VMS were recorded using ambulatory sternal skin conductance monitoring during a 24-hour period at baseline and on 3-month follow-up.

RESULTS

There were no significant group differences in overall VMS frequency, but the frequency of moderate to very severe VMS was reduced more in the active group compared with the sham treatment group (event rate ratio, 0.50; 95% CI, 0.35-0.71; P < 0.001). The frequency of objective VMS was also reduced to a greater degree in the SGB group than in the sham group (event rate ratio, 0.71; 95% CI, 0.64-0.99; P < 0.05). There were no study-related serious adverse events.

CONCLUSIONS

SGB may provide effective treatment of VMS in women who seek nonhormonal treatments because of safety concerns and personal preference. The finding that SGB significantly reduces objectively measured VMS provides further evidence of efficacy. A larger trial is warranted to confirm these findings.

Systematic review of sleep disorders in cancer patients: can the prevalence of sleep disorders be ascertained?

Although sleep is vital to all human functioning and poor sleep is a known problem in cancer, it is unclear whether the overall prevalence of the various types of sleep disorders in cancer is known. The purpose of this systematic literature review was to evaluate if the prevalence of sleep disorders could be ascertained from the current body of literature regarding sleep in cancer. This was a critical and systematic review of peer-reviewed, English-language, original articles published from 1980 through 15 October 2013, identified using electronic search engines, a set of key words, and prespecified inclusion and exclusion criteria. Information from 254 full-text, English-language articles was abstracted onto a paper checklist by one reviewer, with a second reviewer randomly verifying 50% (k = 99%). All abstracted data were entered into an electronic database, verified for accuracy, and analyzed using descriptive statistics and frequencies in SPSS (v.20) (North Castle, NY). Studies of sleep and cancer focus on specific types of symptoms of poor sleep, and there are no published prevalence studies that focus on underlying sleep disorders. Challenging the current paradigm of the way sleep is studied in cancer could produce better clinical screening tools for use in oncology clinics leading to better triaging of patients with sleep complaints to sleep specialists, and overall improvement in sleep quality.

Somatosensory amplification and menopausal symptoms in breast cancer survivors and midlife women

OBJECTIVES

Somatosensory amplification is the experience of sensing everyday bodily sensations as intense, agitating, and unpleasant. Using data from menopausal breast cancer survivors and midlife women without cancer, the study purposes were to (1) explore the psychometric properties of the Somatosensory Amplification Scale and (2) to describe somatosensory amplification and its relationship to menopausal symptoms of hot flashes, mood and sleep disturbance.

STUDY DESIGN

This was a cross-sectional, descriptive, correlational study using demographic, e-diary, and questionnaire data from 99 breast cancer survivors and 138 midlife women.

MAIN OUTCOME MEASURES

Somatosensory amplification, hot flashes (frequency, severity, bother, interference, perceived control), mood, and sleep.

RESULTS

Cronbach's alphas for the scale were low. When an 8-item version of the scale was evaluated, alphas improved and item-total correlations remained strong or improved. Midlife women and breast cancer survivors did not have significantly different somatosensory amplification total or item scores after adjusting for group differences in demographics. Somatosensory amplification was significantly correlated with hot flash interference, perceived control over hot flashes, and mood and sleep disturbance in both groups but the patterns of correlations differed slightly between groups and depending on whether the 10-item or 8-item scale was used.

CONCLUSION

Somatosensory amplification may be a relevant concept to assess in relation to the menopausal symptom experience of midlife women with and without breast cancer as it may represent a potential intervention target to improve the menopausal symptom experience.

Risk factors, pathophysiology, and treatment of hot flashes in cancer

Hot flashes are prevalent and severe symptoms that can interfere with mood, sleep, and quality of life for women and men with cancer. The purpose of this article is to review existing literature on the risk factors, pathophysiology, and treatment of hot flashes in individuals with cancer. Electronic searches were conducted to identify relevant English-language literature published through June 15, 2012. Results indicated that risk factors for hot flashes in cancer include patient-related factors (eg, age, race/ethnicity, educational level, smoking history, cardiovascular risk including body mass index, and genetics) and disease-related factors (eg, cancer diagnosis and dose/type of treatment). In addition, although the pathophysiology of hot flashes has remained elusive, these symptoms are likely attributable to disruptions in thermoregulation and neurochemicals. Therapies that have been offered or tested fall into 4 broad categories: pharmacological, nutraceutical, surgical, and complementary/behavioral strategies. The evidence base for this broad range of therapies varies, with some treatments not yet having been fully tested or showing equivocal results. The evidence base surrounding all therapies is evaluated to enhance hot flash treatment decision-making by clinicians and patients.

Strategies used and data obtained during treatment fidelity monitoring

BACKGROUND

Treatment fidelity, also called intervention fidelity, is an important component of testing treatment efficacy. Although examples of strategies needed to address treatment fidelity have been provided in several published reports, data describing variations that might compromise efficacy testing have been omitted.

OBJECTIVES

The aim of this study is to describe treatment fidelity monitoring strategies and data within the context of a nursing clinical trial.

METHODS

A three-group, randomized, controlled trial compared intervention (paced respiration) to attention control (fast, shallow breathing) to usual care for management of hot flashes and other menopausal symptoms. Data from both staff and participants were collected to assess treatment fidelity.

RESULTS

Staff measures for treatment delivery indicated good adherence to protocols. Participant ratings of expectancy and credibility were not statistically different between intervention and attention control; however, the attention control was significantly more acceptable (p < .05). Intervention participant data indicated good treatment receipt and enactment with mean breath rates at each time point falling within the target range. Practice log data for both intervention and attention control indicated lower adherence of once-daily rather than twice-daily practice.

DISCUSSION

Despite strengths in fidelity monitoring, some challenges were identified that have implications for other similar intervention studies.

Description of an Audio-Based Paced Respiration Intervention for Vasomotor Symptoms

Millions of women experience menopause-related hot flashes or flushes that may have a negative effect on their quality of life. Hormone therapy is an effective treatment, however, it may be contraindicated or unacceptable for some women based on previous health complications or an undesirable risk-benefit ratio. Side effects and the unacceptability of hormone therapy have created a need for behavioral interventions to reduce hot flashes. A variety of complex, multimodal behavioral, relaxation-based interventions have been studied with women (n = 88) and showed generally favorable results. However, currently extensive resource commitments reduce the translation of these interventions into standard care. Slow, deep breathing is a common component in most interventions and may be the active ingredient leading to reduced hot flashes. This article describes the content of an audio-based program designed to teach paced breathing to reduce hot flashes. Intervention content was based on skills training theory and music entrainment. The audio intervention provides an efficient way to deliver a breathing intervention that may be beneficial to other clinical populations.