What is the difference between the
terms "climax", "menopause" and "climacteric syndrome"?
Does it make sense to treat a naturally occurring phenomenon? And what are the
dangers when medicines are taken from climacteric syndrome?
In
the beginning you should understand the terms. For example, the word
"climax" (from the Greek kλῖμαξ - staircase) is indicated in the physiology
of the natural period of a woman's life, characterized by the extinction of the
functions of the reproductive system that occurs due to age-related changes. As
a synonym also used the word "menopause", "climacterim",
"climacterical period". On average, it occurs in about 50 years, but
the individual can vary greatly. In itself, the phenomenon of menopause
(climacterical period) often runs quietly enough and takes time from 1 to 5
years. During this period, the character and decreases the frequency of menstruation,
go manifestations of premenstrual tension and other typical manifestations of
hormonal activity. Gradually comes "postmenopausal period"
(postmenopause). At the same time, some women experience menopause is very
hard, in violation of the blood pressure, nervous disorders and other symptoms.
It is a condition that accompanies menopause, usually called "climacteric
syndrome" or “female climacteric
syndrome" (FCS). In addition to being highly
expressed disorders is accompanied by a neuro-psychiatric, vegetative-vascular
and metabolic disorders to be treated. Thus, if climacterim (menopause) – is a
physiological condition, FCS – this disease [1, 2].
At
the same time, are still no uniform classification of the FCS and it is not
separately stands out to the ICD-10, semi-officially entering the section N95.1
«Menopause and menopausal status of the woman." And this is the source of
many inaccuracies and mistakes in the assessment of the status and purpose of the
relevant drug treatment.
Epidemiology. It is recognized that the FCS is
quite common among women of all countries and regions of the world. At the same
time, due to lack of clear criteria for concepts and its symptoms statistics is
very different in different authors. Thus, according to Kulakov et al. [1] it
is observed in 60-80% of women and is more common in menopause before the age
of 50 years (the so-called "early menopause", relating to ICD-10
heading to E28.3 «Primary ovarian insufficiency"). According to other
authors have observed FCS 25-55% of women, and can vary depending on the living
conditions and health. At the same time, various publications agree that
certain climacteric symptoms of different severity point not less than 80% of
women. However, seek medical help no more than 10-15% of them [2, 3].
Determining
the frequency of FCS difficult ambiguity of his interpretations. So, if there
are uterine bleeding, it is under the heading of N92 «Excessive bleeding in the
premenopausal period." A number of researchers linking the FCS with
periodic symptoms of cerebral ischemia, diagnose diagnose this condition by
category G46 «Syndrome brainstem stroke" and I60-I67 «Other
cerebrovascular disorders." When taking into account the frequency and
severity of characteristic for clinical manifestations of the "hot
flashes" FCS rate reaches 64-73%, but is estimated by category R23.2
«Excessive flashes". And, actually, it is classified in this category FCS
in practice (see below). Summing up, it should be noted that such a crushing
pathology clearly reduces the overall incidence of the FCS and it can be
assumed that the frequency of it in practice higher [3-5].
There
are racial and national differences in the frequency of occurrence of the FCS,
as well as their differences over the years. For example, in Russia in 1980 FCS
observed in 37.7% of women in 1994 - 42.4 at%, and in 2002 - is 60-80%, whereas
in Japan, this index does not exceed 36%. In general, one or the other symptoms
of the FCS (often hot flashes, sweating, irritability, sleep disorders and
related mood changes) is seen in 40-80% of women. FCS has a tendency to flow
long and almost 50% of women continued for more than 15 years after menopause.
The highest frequency and the intensity of its manifestations observed during
the first 2-3 years of menopause [2, 4].
Symptoms
of the FCS, in spite of their diversity can be combined into three groups:
- vegetative-vascular, the most typical FCS - hot flashes and sweating - from single to 30 per day. There is also increasing pressure (from situational lability to severe hypertension), vegetative-vascular crises
- neuropsychiatric feature nearly everyone, but the nature and severity of them depend on the severity of autonomic symptoms and personality characteristics - weakness, dizziness, fatigue, irritability, sleep disturbances, depression. May develop depression: a sense of despondency, depressed mood with anxiety about their health or the fear of death (especially in crises with severe palpitations, choking), the frequent occurrence of questions about the meaning of life, self-worth, etc. Fixing on your condition may become a leading, especially in individuals with anxiety and doubtful character.
- endocrine-metabolic, which develop over time - vaginal dryness, itching, burning, pain during sexual intercourse. Decreased muscle tone in the crotch, there may be violations of urination up to incontinence when you laugh, cough. The weakening of the pelvic floor prolapse gives the walls of the uterus and vagina. Because of the changing nature of metabolism increases weight, adipose tissue accumulates in the waist area, changes the function of the thyroid gland, develop diabetes, become brittle bones (developing of osteoporosis), changing the look - the skin loses its elasticity, wrinkles appear.
Table
1 shows the frequency of symptoms in patients with FCS on collecting data N.L.
Szymanowski [4]. Of all of them are only temporary vasomotor (hot flashes and
sweats). However, 75% of women vegetovascular and neuropsychiatric disorders
appear simultaneously, and 25% - over a short (up to 0.5 years) interval. In
this second clinical manifestations preceded the FCS, and vasomotor appeared
later and became dominant in the next following year [2, 5].
The
severity of menopausal syndrome is estimated by the number of
vegetative-vascular attacks (hot flashes).
- Mild - the number of hot flashes is not more than 10 a day with good performance status and conservation of disability.
- Moderate - 10-20 hot flashes. A deterioration of general condition, performance, headaches, pain in the heart.
- Severe - the number of hot flashes as high as 20 or more (sometimes more than 80 a day), accompanied by other symptoms, leading to partial or complete loss of ability to work.
Duration of symptoms FCS - to 5 years - 35% of women with
55% - 5-10, and more than 10 years - 10% of women.
Table 1.
The averaged values of occurrence of climacteric symptoms in women aged
45 to 54 years
Complications of the FCS. During menopause, women represent
a high risk category for the development of various diseases. However, some of
them are considered as a direct complication of the FCS. It should be
emphasized that the choice of treatment strategy of the FCS, the choice of
drugs and their dosages, according to the latest data, should be held not so
much on the severity of symptoms, symptoms of menopause, and depending on the
degree of development of such complications. In this regard, a special place is
the importance of adequate diagnosis of the state of a patient with CS.
The
highest incidence of FCS complications has various diseases of the heart and
blood vessels, especially arterial hypertension
(its frequency increases 7 times), ischemic heart disease (aged 50-59 years,
this figure is tripled. Menopausal
cardiomyopathy in third place among the complications and is
characterized by a variety of pain in the heart and heart rhythm disturbances.
typically, the pain is localized to the left of the sternum, in the apex of the
heart. Its duration may be hours, days, months, and the intensity varies with
the gain in the night. Exacerbations occur in spring and autumn. Pain, unlike
angina of coronary artery disease, is not provoked by physical exertion, but is
accompanied by severe autonomic reactions characteristic of the FCS (sweating,
hot flashes, palpitations, numbness of extremities, chills, breathing rhythm
disturbances, dizziness, polyuria). Acceptance of antianginal drugs and
nitroglycerin had no effect on cardialgia. It should be noted that unlike most
other diseases described the group as well as other forms of cardiomyopathy,
climacteric has a very favorable prognosis [2, 6-8].
The
incidence of breast cancer,
and ovarian and endometrial cancer increases with
age, and (at statistics aged 39 years - Cancer develops in one of the 231 women
(the risk is less than 0.5%), from 40 to 59 - 1 in 25 (4% risk), from 60 to 79 - 1 in 15 (7% risk). risk of developing cancer of
the female reproductive processes associated with a reduction in the scope of
the immune system, and a leading role in this is hormonal imbalance with
increased levels of estrogen in the blood. growth of the cells of the glandular
tissue of the breast is stimulated by estrogen. premenopausal and
postmenopausal women, many women remain high estrogen levels (especially in
obesity, since it occurs in adipose tissue estrogen synthesis of male sex
hormones) that have a stimulating effect on the proliferation of the
endometrium. Without progesterone secretion that leads to hyperplasia of the
endometrium, the emergence of cancer of the uterus and mammary glands. This
state persists for admission outside of estrogen (hormone replacement therapy -
HRT) FCS. And this, and so far unresolved problems of pharmacotherapy, we will
detail further. However, in practice, the groups increased risk of oncological
at the beginning of menstruation at an early age and late menopause (longer
exposure to estrogens), and long-term hormone replacement therapy, obesity,
liver pathology (violation of metabolism of steroid hormones) and some others.
Thyroid dysfunction is seen in 23,2-36% of the patients
at the time of menopause, but more often subclinical. And in the form of
decreased with the development of hypothyroidism. Dysfunction of two and three
times to increase the frequency characteristic manifestations of the FCS [5,
9].
Mental disorders that appear during menopause are
manifold. For example, among depressions that reach the frequency of 20-60%, we
can distinguish three types: the climacteric, psychogenic and endogenous. The
first common in premenopausal (39-50 years old) and are characterized by a
depressed mood with tearfulness, decreased interest in the self and the
environment, decreasing the activity, a sense of age, fear of impending old age
with anxious fears for his health. The second type - psychogenic depression -
occurs after a significant psychological trauma, and does not depend on the
severity of the FCS. But as time evolves hypochondriacal symptoms
(soul-searching, self-hypnosis). In some cases, there are suicidal thoughts
against a pessimistic assessment of the future. Endogenous depression during menopause
is characterized by depressed mood, loss of previous interests, decreased
energy and activity, decreased self-esteem and self-confidence (up to the idea
of self-blame and self-deprecation).
Severity of depression in most cases does not depend on the severity of
symptoms of the FCS [10, 11].
Urogenital disorders include a complex of complications
associated with the development of atrophic processes in the lower third of the
urinary tract, mucous membranes of the vagina muscles, ligaments and muscles of
the pelvic floor. In perimenopause, they are found in 10% of cases, and by 55
years - 50% of women, ie increased to 5 times. Violations of urine passage
contribute to the emergence of infectious lesions of the urinary tract, which
are a separate issue. On it you can read more here. For the manifestations of
the first phase is characterized by: frequent night urination, violating sleep,
frequent urination, urgency with urge incontinence or without urinary
incontinence (during exercise, coughing, sneezing, laughing, sharp movements
and weight lifting), dysuria (painful urination) etc. [6-8, 12].
Osteoporosis is a systemic skeletal disease
characterized by low bone mass and microstructural damage bone tissue leading
to enhanced bone fragility and susceptibility to fracture. Its frequency in the
developed countries is 25-35%. Rate of bone fractures in women 50-54 years of
age and older increased 4-7 times as compared to young and among them,
osteoporosis is found in 70% of cases. It is believed that the lack of sex
hormones, particularly in the first five years of menopause, greatly
accelerates the loss of bone mass. With the increase in a woman's lifetime risk
of developing osteoporosis and fractures increases. On the clinic and treatment
of osteoporosis details can be read here.
Treatment of menopausal symptoms. The current standard treatment of FCS,
despite a number of unresolved problems while using it is HRT. For this
purpose, hormones, making up for the lack of estrogen in the body. They have an
impact on all components of the FCS, the arresting vasomotor (hot flashes,
sweating), psycho-emotional (anxiety, irritability, tearfulness), urogenital
(dryness, itching and burning of the vagina) and metabolic (weight gain,
brittle bones, a change of skin turgor) violation. Simultaneously with HRT
symptomatic therapy is often used (see below). Duration of treatment - from 3
months to 5 years or more.
Preparations
containing only estrogen administered to women whose uterus has been removed,
along with the neck. Everyone else should receive combination therapy, which
consists of an additional progestins are necessary to protect against
endometrial hyperplasia. This therapy can be administered in two modes: 1)
Cyclical - in the first 14 days of taking estrogen alone, and in the next 14
days - estrogens and progestins. Under such a regime will menstrualnopodobnye
selection (similar to the usual monthly) 1 every 28 days, and 2) Continuous -
every day appointed and estrogens and progestins. These selections in this case
will not, but in the first few months they are possible - this body is set to a
new one for him hormones.
HRT
is administered as tablets, transdermal gel, patch, or combinations thereof.
Selection of the type and mode of admission is made individually. In this case,
it is better to start hormone replacement therapy at the first signs of
depletion of ovarian function and appearance of the FCS. The longer the time
passed since the last menstrual period, the smaller the body is the estrogen
receptor and thus would be less effect preparations. The best is the beginning
of HRT no later than the year after the last menstrual period and not later
than 6-8 years. If the treatment was started on time, the effect of the drugs
kept all the reception and is independent of age.
Used
for hormone replacement therapy drugs are shown in Table 2. However, it
should be noted that historically were created substantial differences the use
of drugs of different types in different countries of the world. For example,
the U.S. market is almost entirely focused on the use of conjugated hormones,
and in Europe they are almost not used.
Table 2.
Preparations for hormone replacement
therapy of climacteric syndrome
Note: * - indicates only drugs used for hormone replacement therapy
Combination
products have their own features (indications). For example, Klimen intended
for reception the presence of symptoms of hyperandrogenism: oily and porous skin,
hirsutism and hypertrichosis, deepening of the voice, etc. For the postmenopausal
period the FCS recommended a two-phase Divitren or single-phase Kliogest. And
in a similar situation, with a focus on pre-treatment of osteoporosis, is
positioned Tibolone, which lacks most of the characteristic hormonal side
effects. However, having certain advantages, certain drugs has little effect on
other manifestations of the FCS and its symptoms.
There
are slight differences in the effect depending on the route of administration
(forms thereof). Transdermal administration forms of drugs are advantageous
because exclude hepatic metabolism and lower doses of hormones 0.05-0.1 mg /
day. In addition, virtually eliminated their effect on blood coagulation. At
the same time, there is a belief that the oral route of administration of
estrogen is more effective for the correction of lipid metabolism. Vaginal
administration demonstrated a greater effect in the urogenital disorders
(candles with estriol).
In
the absence of contraindications duration of HRT use is not restricted.
Treatment interruptions do not need it.
Contraindications to HRT are based on the potential side effects of the drugs used,
the adverse effects (immediate and chronic) on individual organs and systems.
Specifically, they include (including history):
- Vaginal bleeding obscure genesis
- Acute severe liver disease
- Acute deep vein thrombosis
- Acute thromboembolic disease, hereditary and acquired thrombophilia transferred embolism or thrombosis of deep veins of the extremities.
- Porphyria
- Breast and endometrial cancer.
Side effects and complications of
HRT are also
closely related to the above mentioned side effects, and are caused by a
hormonal effect of the drugs. Thus it is necessary to stress once again that,
to date a number of important aspects of its implementation remain unresolved.
Often the side effects of HRT is more severe than the symptoms of the FCS,
which is the reason for not further therapy. In a number of cases are reported
and more serious complications. In general, these effects can be divided into
the following groups:
- CNS - headache, migraine, mood changes;
- Reproductive system - pain and an increase in the density of the mammary glands (including on mammograms), changes in libido, vaginal bleeding, endometrial hyperplasia;
- Gastrointestinal tract - dyspepsia, nausea, spasm of smooth muscles of the digestive tract;
- Cardio-vascular system - thrombosis and thromboembolism, increased blood pressure;
- Other - weight gain, edema, hirsutism, and allergic reactions.
HRT
considered unfavorable with regard to increasing the risk of cancer. In
particular, the fourth symposium of the International Menopause Society (IMS)
in December 2003 to discuss this observational studies and RCTs information
regarding breast cancer on the
back of it. There was a significant increase in the incidence of this type of
cancer. In addition to this unfavorable trend was set against the background
incidence of hormone replacement therapy for coronary heart disease, stroke and
pulmonary embolism. As a result, even then have been questioned by many
clinical indications for HRT, which was previously positioned as a
"rejuvenation of the body" in order to reduce the incidence of it is
from these pathologies. In particular, observational study to 1084110 British
women's national screening program for the prevention of breast disease showed
that all types and modes of HRT caused an increased risk of developing breast
cancer. The risk is significant in the first year of its use, and reduced from
1 year after cessation of HRT. But then stored until 5 years of age. It was
more in the ratio of 5 to 19 using an estrogen-progestin combinations and generally
estimated by the authors in the amount of 20 thousand additional breast cancer
cases in 5 years of the study [14].
In
fairness it should be mentioned that in the 1970s, over 50 epidemiological
cohort studies (selective and non-randomized) by 52 thousand patients with
breast cancer and 108 thou women without breast cancer showed an increased
incidence, particularly noticeable in long-term (over 5 years) of HRT. The risk
was the same for different types of used estrogen (conjugated and derivatives 17b-estradiol).
Then, it was concluded that the addition of progestogen without such therapy
increases the risk of breast cancer by 30%. Actually it is because of this
since 1980 progestogens used in HRT as a cyclic and continuous operation.
Later, however, large-scale studies of combined HRT also found an increase in
the relative risk for long-term hormone replacement therapy in Europe and the
United States at HRT for more than 5 years in a population of 1.3-1.4 times
[15, 16].
In
general it can be added that the impact of excessive production of estrogen is
an established and proven in experimental and clinical and well-documented risk
factor for breast cancer. The increased incidence in recent years due to
increased reproductive life of women nearly doubled (from 15-20 years to 20-40
years) by a decline in the number of births (the so-called "estrogen
window"). Known and the fact that patients who have recovered from breast
cancer, two to five times higher risk of developing contralateral breast cancer,
breast cancer, and women who have had breast cancer at a young age - ten times
[4, 9, 17].
Endometrial cancer (ER). As already mentioned above the 70
studies was noted and a clear relationship between estrogen and hormone
replacement therapy increases the risk of ER. It increases with the duration of
estrogen, from less than 1.4 when receiving 1 to 9.5% of the frequency with a
duration of more than 10 years. After discontinuation of the risk was reduced
by the end of the second year to the general population figures, although still
remained higher for at least 10 years of age. Adding a progestin did not solve
the fundamental problem. So, taking progestin less than 10 days the incidence
of ER was 2.4%, and those taking more than 10 days - 1.1%. It is also known that
the combined HRT for 5 years, and further increases the risk of developing ER
twice [15, 18].
Ovarian cancer. More than 300 publications on HRT
and ovarian cancer were observed against the background of the increasing
incidence of HRT. Only nine studies referred to a slight increase in the risk
of long-term HRT. However, large-scale trials on 948 576 female patients in
postmenopazualnom period set significantly increased risk of developing ovarian
cancer. Moreover, this risk increased with increasing period of HRT (5 years
later it increased twice as compared with the control), but does not depend on
the particular drug used. In this case, there are clear differences in
histologic variants of ovarian cancer among female patients with and without
HRT. The authors evaluated the use of HRT in the UK for 15 years, 1.3 million
of additional ovarian cancer and 3.3 million additional deaths from cancer at
other sites [18, 19].
It
is now considered a proven safety of use of hormone replacement therapy for cancers of the cervix. There is
evidence of significant decrease risk of developing colorectal cancer (30-40%), and some others (hepatocellular,
cerebral) and the absence of hormone replacement therapy on the incidence of malignant melanoma, cancer of lung and kidney [2, 18,
20].
Alternative treatments for FCS. Alternative
methods regarding HRT medication used for contraindications to its carrying.
Their use can be divided into:
- Non-hormonal drugs (including drugs for symptomatic treatment)
- Herbal treatment
- Other (including nonmedicamental methods and optimization of lifestyle)
Non-hormonal drugs, normalizing the functional state of the CNS and ANS, reduce the
severity of clinical manifestations of the FCS, the psycho-emotional background
and optimizing the quality of life of patients. Although it should be noted
immediately that the effectiveness of this treatment is much less than the HRT.
With
the predominance of sympathetic reactions used drugs sympatholytic action - reserpine
and obzidan. In addition to the effect of catecholamines and serotonin, they
have directed psychotropic action. To reduce the severity and frequency of use
tidal clonidine - an alpha2-adrenoceptor agonist central action. Stugeron
reduces sympathic and has antihistaminic activity. With the predominance of
parasympathetic reactions of drugs are shown adrenergic and holinoliticheskogo
(tincture of belladonna, and Belloidum bellataminal) which inhibit the
vegetative and emotional excitability, as well as the I-generation
antihistamines (tavegil or suprastin).
In
the presence of psychotic symptoms commonly used selective serotonin reuptake
inhibitors: fluoxetine (Prozac, Prodep, Fontex, Seromex, Seronil, Sarafem),
paroxetine, citalopram, etc. Also appointed reuptake inhibitor of serotonin and
norepinephrine: venlafaxine (Efexor, Effexor), duloxetine (Cymbalta, Ariclaim, Xeristar,
Yentreve), milnacipran (Savella, Ixel, Dalcipran). Accession neuropathic
symptoms is an indication for the use of gabapentin (Neurontin) that 900 mg /
day reduces the intensity of hot flashes by about 50% [9, 20, 22].
Vitamins
B1, B6 and E help to normalize the changes homeostasis.
ATP (Triadenyl, Triphospaden, Triphosphaden, etc) improves the transmission of
nerve excitation of the vagus nerve on the heart, thereby reducing
sympathetic-adrenal effect of ANS on the myocardium. Operational and neurotropic
agents, e.g. tazepam relating to the number of minor tranquilizers. In the
presence of depressive symptoms and hypochondriacal syndrome using
tranquilizers and antipsychotic drugs. Preference is given to frenolon, as it
does not cause lethargy, drowsiness, weakness, and can be used in the daytime.
Also shown are the psychotropic stimulants - Piracetam, Cerebrolysin, Aminalon
and others [7, 17, 21].
The
disadvantage of this treatment is prescribing courses in between which can
renew the hot flashes. Also they do not have a positive impact on the typical
complications of menopause (osteoporosis, urogenital disorders, poor skin condition,
etc.).
The
group of herbal preparations are preparations containing phytoestrogens
incorporates three basic substances (isoflavones, lignans and coumestans).
Typically, the composition includes not only the active ingredient, but more
typical for plant material. The effectiveness of herbal remedies in relieving
symptoms of FCS is much lower than that of HRT. And they will in most cases be
used only for the treatment of hot flashes, without affecting - like hormonal
preparations - the state of the bone, cardiovascular system, mood, skin and
urogenital symptoms. At the same time, they do not have and most of the side
effects typical of HRT.
Pharmacoeconomics. The cost of treatment of the FCS
is separate and rather important discussion topic because to a certain extent
influence the choice of one or another of his schemes. In general, treatment of
symptoms and complications of FCS consists of direct and indirect costs. Direct
costs include the costs of medicines and periodic medical examinations (eg,
hormone replacement therapy is necessary before the two surveys are different
indentation in the year). And in indirect costs are credited to achieve a
certain lifestyle (extra food, spa treatments, etc.), periods of disability, as
well as the costs of treating complications (fractures in osteoporosis,
bleeding, etc.) and some others [10, 24].
Due
to the fact that HRT gives the lowest frequency of serious complications of the
FCS, it is the most cost-effective. And given the fact that about a third of
patients for various reasons, may promptly move on to another type of therapy,
it is important to prevent the side effects of this treatment. Conducted
pharmacoeconomic analyzes clearly show the economic benefits of HRT in women
with a uterus. Similarly found that virtually all treatments associated with
symptomatic medications and herbal remedies were more expensive than HRT. Thus,
with the use of HRT with conjugated drugs (used mostly in the U.S.), it ranges
from $ 35 - $ 85 a month, and the use of generics can be $ 13. When using
combination products the cost is $ 61 - $ 73, and in combination with a skin
cream, depending on the dose and its frequency of reception - $ 25-150 per
month (see Table 2). The cost of phototherapy varies significantly depending on
the drug and its mode of application - from 300 USD / month (Remens, Tribulus)
to 30-50 USD / month (Klimadinon, Klimaktoplan, Feminal). [25-27].
In
the presence of psychotic symptoms economically most recognized is the use of
selective serotonin reuptake inhibitors and norepinephrine reuptake inhibitors.
Systematic surveys economic treatment of depression showed significant benefits
compared with antidepressants (e.g., tricyclic antidepressants), due to their
greater effectiveness and a smaller number side effects [27, 28].
At
the same time, it should be remembered that a more specific definition of
economically viable strategies for different regions of the world is difficult
because of significant differences in the structure of health care in different
countries. Added to this is an extremely small and evidence base of
effectiveness of most alternative therapies.
A
few simple tips for preventing symptoms of FCS:
1.
Maximum replace coffee with green tea. About 2-3 cups of green tea help get rid
of toxins. Green tea contains vitamins and minerals that are so necessary to a
woman during menopause, has a diuretic effect.
2.
We must remember that spicy food and alcohol increase hot flashes. Try not to
eat them.
3.
When the tides in the body running out of vitanutrientov: vitamin C, B
vitamins, magnesium and potassium. This is useful for receiving vitamin-mineral
complexes (see Table. 3).
4.
Do not drink and do not eat very hot food - it provokes hot flashes.
5.
Do not overheat. Wear clothes that can be easily partially removed at the time
of hot flashes (coat, jacket). At night, takes cover in layers so you can
remove coverings one layer.
6.
Discard the hot bath, sauna.
7.
Try to keep the room in which you are, it is well ventilated and the air in it
was a little cool.
8.
Moderate exercise improves the state of health.
9.
Do not forget about acupuncture, it helps a lot.
10.
And one more thing: hot flashes in women who smoke are more frequent and
heavier. It is better to quit smoking.
11.
And most importantly, rest.
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