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January 23, 2003

Pins & needles

Can acupuncture help relieve common menopausal symptoms in breast cancer patients and survivors?

When Susan M. Cohen joined Pitt’s nursing faculty last fall, she came with the belief — as well as with scientific evidence from recent clinical trials to back it up — that acupuncture could relieve the bothersome discomfort associated with menopause.

Cohen, associate professor in the Department of Health Promotion and Development, was principal investigator on two pilot studies, “The Impact of Acupuncture on Perimenopausal Symptoms” (1997-1998, funded by Yale University) and “Use of Acupuncture for Menopausal Symptom Relief” (1999-2001, funded by the Donaghue Medical Foundation), both of which showed that acupuncture held promise in relieving typical menopause-related discomfort.

Although the studies involved a small number of subjects, 17 and 35 respectively, Cohen said hot flashes, for example, decreased by 50 percent among the groups who received acupuncture compared to other groups in the studies.

Building on those studies with a larger number of participants, Cohen received a $685,350 grant from the National Cancer Institute (NCI), for a three-year study titled “Menopausal Symptom Relief for Women With Breast Cancer.” The randomized, placebo-controlled clinical trial is examining the use of acupuncture for managing menopausal symptoms in women who experience menopause following, or as the result of, chemotherapy treatment for breast cancer.

“This study has to do with symptoms secondary to treatment, in this case, studying women between the ages of 35 and the normal age of menopause, which in this country is about 51,” Cohen said. “Once they go through chemotherapy for breast cancer, a high proportion of women go into menopause. Below 35, they don’t tend to do that. So, menopause in this group of women is in fact a consequence of their cancer treatment, which is why the NCI was interested in this.”

In recent years, hormone replacement therapy (HRT) has been the most common treatment for menopausal symptoms such as headaches, hot flashes, insomnia and anxiety, Cohen said. But recent data has raised some red flags about HRT.

“Last year, for example, the NIH halted one part of a Women’s Health Initiative trial, because there was a small but real increase of risk for breast cancer for the women who undergo hormone replacement therapy,” Cohen said.

She said her interest in alternative medicine, including acupuncture, is long-standing, partly driven by her career-long research interest in the intersection of women’s lives and their health, as well as her experience treating menopausal women as a nurse practitioner.

While on the Yale faculty (1995-2000), she taught a course in alternative therapies, including acupuncture, herbs and Reiki, which is Japanese form of therapeutic touch involving smoothing the body to induce relaxation and relieve stress.

She also was influenced by a 1995 Swedish study on acupuncture published in the journal Menopause.

“I first came at this from a slightly different standpoint [from the Swedish study], which was that I had been interested in non-hormonal remedies for menopause symptoms, because among women who were breast cancer survivors, many did not want to take estrogen out of concern about potential for other health problems, and many women didn’t like the side effects of hormones,” she said.

Acupuncture, the centuries-old Chinese medicine technique of puncturing the body with two-inch needles at particular points called meridians, is said by its supporters, including Cohen, to relieve stress, cure allergies, promote relaxation and release hormones, such as endorphins, the body’s natural painkillers.

Skeptics within the Western medical world abound. “But that’s essentially changing,” Cohen said. “The Western medical community used to be much more resistant. There will always be people who have a negative view, but I feel as we get more studies, people are becoming much more open to the possibility that acupuncture holds some promise.

“Plus, quite frankly,” she continued, “consumers in the United States are using all kinds of alternative or complementary therapy. It’s increased significantly and it’s much more widely accepted. Now, in the West you find trained acupuncturists all over, really, including on the Pitt medical faculty.”

But chiefly, Cohen said, the way to bridge the skepticism gap is to apply Western medical principles to the study of ancient Eastern techniques.

“People like me have said, ‘Okay, this has been used for well over 1,000 years by thousands of people in China, Japan, Korea — there’s got to be something going on here. So, let’s figure out a way to put it into a Western scientific model for testing.”

That means applying the standard Western methodology of the scientific method. “It’s the same thing we learn in science class in junior high: You ask a question; we then say how are we going to go about answering this question; we then look to see if anyone else has asked this question, and what they have found out. Eventually, in the Western scientific tradition, we design a research study that controls as many of the elements of the question as possible, which is how we get to what we call the randomized clinical trial.”

In her current NCI study, Cohen has concluded the first year’s work, gathering data on 27 women divided into three groups of nine. She is recruiting eligible participants for years two and three, expecting to recruit 81 subjects in all. Subjects commit to 12, 20-30 minute sessions over eight weeks, with three months of periodic follow-up evaluations. Acupuncture sessions are performed by a state-licensed acupuncturist. “Most women who get the acupuncture fall asleep during the session,” she said.

(For more information on Cohen’s study, call 412/624-4597.)

In the trial, one group gets acupuncture at points specific to menopausal symptoms, such as hot flashes, she said. “We know which points those are, because they are identified in traditional Chinese medicine.”

A second group gets acupuncture at points different from those identified points, with no overlap at all, she said. “That’s the control group.”

A third group gets “enhanced usual care, which includes educational sessions related to increasing the overall health of a mid-life woman,” which is the so-called placebo group in the study, she said.

Results of the trial are not expected to be released until the study’s conclusion in April 2004.

Cohen also is preparing funding proposals for two related studies, one on the relaxing and pain-relieving effects of “mindfulness meditation,” a meditating technique developed by Jon Cabot Zin of Massachusetts, and the other study on monitored exercise and its increased production of pain-killing natural endorphins.

Both trials will focus on how relaxation interacts with pain relief, she said. “These are extensions to understanding other non-pharmacological methods to relieve bothersome menopausal changes,” she said.

A longer-term goal is to find alternatives to medication that increase people’s ability to manage chronic conditions, such as rheumatoid arthritis, and other ailments like migraines and headaches, she said.

“Once you learn how to structure your exercise, you can do it yourself, so it’s about self-care. That’s the model that within nursing we’re very interested in,” she said.

Ultimately, alternative medicine techniques could lower health care costs, Cohen said. “We hope to show by some of these clinical trials that non-pharmacological methods are viable, so that eventually insurance companies will be willing to pay for them.

“Medications can only do so much. When you think about high blood pressure, for example, we certainly have medications that bring down high blood pressure, but we also know that if we lose weight, exercise and don’t smoke, we’re likely to use none or a smaller amount of medication, and prevent some other side effects.”

—Peter Hart

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