Hot flushes 2 2019

Stimulated by Palma et al 2019.[1]

I cannot remember where I found this image, or to whom I should attribute it. My apologies 🙂

This is now my third blog on hot flushes, and the second one this year. Strictly speaking this paper studies climacteric symptoms, rather than simply vasomotor ones, but I’m not sure climacteric is a great word to have in a blog title. Anyway, the study was powered based on vasomotor symptoms, and this appears to have been the primary outcome, although not specifically labelled as such.

Hormone Replacement Therapy

It is a relatively small (n=75) comparative RCT (randomised controlled trial) with 3 parallel arms. It effectively compares acupuncture, HRT and phytoestrogens. I use the term HRT (hormone replacement therapy) but the paper refers to HT (hormone therapy). Perhaps an informed reader will let me know if the R has been dropped officially?

The main outcome was the percentage of women who had an 80% or more reduction in the Greene vasomotor score. This score is measured by adding two items (19 and 20) from the 21 item Greene Climacteric Scale.[2] The scale asks the participant to “Indicate the extent to which you are bothered at the moment by any of these symptoms by placing a tick in the appropriate box.” There are 4 choices for each symptom, and they score from zero to 3: Not at all (0); A little (1); Quite a bit (2); Extremely (3). Item 19 is hot flushes and item 20 is sweating at night. In order to achieve an 80% reduction, the participant must either score 5 or 6 at baseline and 1 at follow up, or zero at follow up and 1 or more at baseline.

Treatment lasted 12 weeks and we don’t hear any details about the acupuncture apart from the qualification of the acupuncturists and that treatments sessions were weekly. The HRT was the lowest routinely used daily dose (conjugated equine oestrogens 0.3mg plus medroxyprogesterone acetate 1.5mg). Phytoestrogens were delivered in the form of oral soy isoflavones (75mg twice a day).


The HRT group was the reference group, and after 12 weeks, 11/25 women taking HRT achieved an 80% or more reduction in the Greene vasomotor score. In the acupuncture group it was 10/24, and 4/23 for the phytoestrogens.

The other outcomes were both the total and the subscales from the Greene Climacteric Scale, as well as a quality of life scale for this population (MenQoL).[3,4] Acupuncture was superior to phytoestrogens in most outcomes, and similar to HRT. Acupuncture was significantly better at 6 months than HRT, but that was after 3 months without either treatment.

I noted above that the dose of HRT was low, but the authors cite evidence that low dose HRT has similar effects as higher dose preparations on vasomotor symptoms.[5]

So we have more pragmatic evidence in favour of acupuncture, but still lack data on clear efficacy over sham. I think the next step should be a large non-inferiority trial against HRT and then we should start looking at SHA (self-home acupuncture).


1         Palma F, Fontanesi F, Facchinetti F, et al. Acupuncture or phy(F)itoestrogens vs. (E)strogen plus progestin on menopausal symptoms. A randomized study. Gynecol Endocrinol 2019;0:1–4. doi:10.1080/09513590.2019.1621835

2         Greene J. Constructing a standard climacteric scale. Maturitas 1998;29:25–31. doi:10.1016/S0378-5122(98)00025-5

3         Lewis JE, Hilditch JR, Wong CJ. Further psychometric property development of the Menopause-Specific Quality of Life questionnaire and development of a modified version, MENQOL-Intervention questionnaire. Maturitas 2005;50:209–21. doi:10.1016/j.maturitas.2004.06.015

4         Hilditch JR, Lewis J, Peter A, et al. A menopause-specific quality of life questionnaire: development and psychometric properties. Maturitas 1996;24:161–75. doi:10.1016/S0378-5122(96)82006-8

5         Utian WH, Shoupe D, Bachmann G, et al. Relief of vasomotor symptoms and vaginal atrophy with lower doses of conjugated equine estrogens and medroxyprogesterone acetate. Fertil Steril 2001;75:1065–79.

Declaration of interests MC