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.

Nonhormonal management of menopause-Associated vasomotor symptoms: 2015 position statement of the North American Menopause Society

https://link.springer.com/content/pdf/10.1016%2Fj.nurt.2007.11.005.pdf

Peripheral Nerve Stimulation for Neuropathic Pain

Objective An overview of the current knowledge on the etiology and treatment of vasomotor symptoms in postmenopausal women.Materials and methods Acknowledged experts in the field contributed a brief assessment of their areas of interest which were combined and edited into the final manuscript.Results Women around the world experience vasomotor symptoms as they enter and complete the menopause transition. Vasomotor symptoms, specifically hot flushes, are caused by a narrowing of the thermoneutral zone in the brain. This effect, although related to estrogen withdrawal, is most likely related to changes in central nervous system neurotransmitters. Peripheral vascular reactivity is also altered in symptomatic women. Estrogen replacement therapy is the most effective treatment for hot flushes. Of the other interventions investigated, selective serotonin and selective norepinephrine reuptake inhibitors and gabapentin show efficacy greater than placebo. Objective monitoring of hot flushes indicates a rob...

Menopausal hot flushes and night sweats: Where are we now?

Menopausal hormone therapy and menopausal symptoms.

Introduction

The International Neuromodulation Society (INS) has determined that there is a need to provide an expert consensus that defines the appropriate use of neuromodulation technologies for appropriate patients. The Neuromodulation Appropriateness Consensus Committee (NACC) was formed to give guidance to current practice and insight into future developments.



Methods

The INS executive board selected members of the international scientific community to analyze scientific evidence for current and future innovations and to use clinical experience to fill in any gaps in information. The NACC used PubMed and Google Scholar to obtain current evidence in the field and used clinical and research experience to give a more complete picture of the innovations in the field.



Results

The NACC has determined that currently approved neurostimulation techniques and technologies have expanded our ability to treat patients in a more effective and specific fashion. Despite these advances, the NACC has identified several additional promising technologies and potential applications for neurostimulation that could move this field forward and expand the applicability of neuromodulation.



Conclusions

The NACC concludes that the field of neurostimulation is an evolving and rapidly changing one that will lead to improved patient access, safety, and outcomes.

The appropriate use of neurostimulation: New and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states

Summary Background Debilitating hot flushes and sleep dysfunction often affect survivors of breast cancer, most notably in those taking anti-oestrogen medications. Conventional treatments have been only partially effective in diminishing these issues, and some have serious risks. We did a pilot study to investigate our hypothesis that stellate-ganglion block can be a safe and effective treatment for hot flushes and sleep dysfunction in this patient population. Methods 13 survivors of breast cancer (in remission) with severe hot flushes and night awakenings were treated with stellate-ganglion block at the anterolateral aspect of the C6 vertebra on the right side under fluoroscopy. Patients recorded hot flushes in a daily diary by use of the Hot-Flash Score, devised by Sloan and colleagues, and night awakenings by use of the Pittsburgh Sleep Quality Index. Both instruments were used 1 week before the procedure [A40] and then weekly after the procedure for 12 weeks. We used the generalised-estimating-equations method to analyse the longitudinal measurements of the number of hot flushes and night awakenings over time. This method is a popular approach to analysing datasets that have repeated measures from the same person, and is robust because it does not need the complete distribution of the outcomes to be specified. This trial is registered on the International Standard Randomised Controlled Trial Number register (ISRCTN14318565). Findings There were no adverse events resulting from the stellate-ganglion block, although patients had temporary Horner's syndrome indicating the effectiveness of the block. Five patients had only one stellate-ganglion block and eight had two stellate-ganglion blocks. The total number of hot flushes decreased from a mean of 79·4 (SD 37·4) per week before the procedure to a mean of 49·9 (SD 39·9) per week during the first 2 weeks after the procedure (p=0·0002). The total number of hot flushes continued to decrease over the remaining follow-up period (weeks 3–12), and stabilised at a mean of 8·1 (SD 5·6) per week (p Interpretation The findings of this study suggest that stellate-ganglion block can provide survivors of breast cancer with relief from hot flushes and sleep dysfunction with few or no side-effects. Long-term relief of symptoms has the potential to improve overall quality of life and increase compliance with anti-oestrogen medications for breast cancer. Funding This study was self funded by the primary authors (EGL and JRJ). There were no additional sponsors for this study.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(08)70131-1.pdf

Effects of stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study

A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD)

Stellate ganglion block may relieve hot flashes by interrupting the sympathetic nervous system.

Objective. To present a novel technique of neuromodulation for the treatment of axial neck pain. Materials and Methods. A case of a patient with history of long-standing axial neck pain with previous cervical spine operation and confirmed discogenic pain is presented. Traditional treatment measures did not provide adequate pain relief. A trial of peripheral subcutaneous field stimulation (PSFS) was performed. Following an excellent response during a week-long trial, a permanent PSFS system was implanted. The patient was followed for nine months after internalization. Results. Seven-day trial of PSFS resulted in complete relief of the patient's pain. This 100% relief of pain continued after the implantation of permanent PSFS system consisting of two quadripolar electrodes, one placed over the paraspinal muscles parallel to midline, and the other positioned horizontally over the ipsilateral trapezius muscle. The patient was gradually weaned off of all opioid medications and continues to report 100% reduction in pain intensity at the nine-month follow-up. Conclusion. PSFS represents a new and promising modality in treatment of axial neck pain. Exact mechanism of the pain relief remains unclear.

Jaydeep R Joshi

Papers

Effects of stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study

A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD)

Stellate ganglion block may relieve hot flashes by interrupting the sympathetic nervous system.

Use of peripheral subcutaneous field stimulation for the treatment of axial neck pain: a case report.

Updated findings on the effects of stellate-ganglion block on hot flushes and night awakenings