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Internet-delivered therapies have a short history and promising results have been shown for several health problems, particularly for psychiatric conditions. This study was a first attempt to evaluate whether Internet-delivered applied relaxation for hot flushes in postmenopausal women may be useful. Due to a high drop-out rate the study was prematurely terminated after inclusion of approximately two thirds of calculated women. The Internet-delivered applied relaxation must probably be modified for such populations and settings before it can be used further. This article will discuss the benefits and pitfalls to learn in order to meet the challenges of future studies. Clinical trial registration number: NCT01245907., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: This work aimed to study the efficacy of group therapy with applied relaxation on vasomotor symptoms and health-related quality of life in postmenopausal women., Methods: In this open, randomized controlled trial, 60 healthy postmenopausal women with at least seven moderate to severe hot flashes per 24 hours were randomized to either group therapy with applied relaxation (n = 33) or untreated control group (n = 27) for 12 weeks. A follow-up visit was scheduled 3 months after the end of therapy or participation in the control group. Salivary cortisol was measured three times during a 6-month period. Hot flashes were recorded in self-registered diaries, and health-related quality of life was assessed with the Women's Health Questionnaire., Results: The number of hot flashes decreased by 5.0 per 24 hours in the applied relaxation group compared with 1.9 in the control group on the 12th week (P < 0.001) and still remained at the same level at the 3-month follow-up (P < 0.001). Health-related quality of life for vasomotor symptoms, sleep, and memory improved significantly on the 12th week measurement in the applied relaxation group compared with the control group. Salivary cortisol concentration was lowered markedly in the applied relaxation group on a single measurement but was otherwise mainly stable in both groups., Conclusions: Applied relaxation can be used to treat vasomotor symptoms in healthy postmenopausal women.

Objective: To assess if transdermal or oral estrogens, acupuncture and applied relaxation decrease the number of menopausal hot flushes/24 h and improve climacteric symptoms, as assessed by the Kupperman index, more than transdermal placebo treatment., Setting: An outpatient clinic at a Swedish university hospital., Methods: A total of 102 postmenopausal women were recruited to two studies performed in parallel. In Study I, the women were randomized between transdermal placebo or estrogen treatment and, in Study II, between oral estrogens, acupuncture or applied relaxation for 12 weeks. Climacteric symptoms were measured with daily logbooks on hot flushes. Women completed the assessment questionnaire for the Kupperman index at baseline and after 12 weeks., Results: The number of flushes/24 h decreased significantly after 4 and 12 weeks in all groups except the placebo group. Both at 4 and 12 weeks, acupuncture decreased the number of flushes more (p<0.05; p<0.01, respectively) than placebo. At 12 weeks, applied relaxation decreased the number of flushes more (p<0.05) than placebo. The Kupperman index score decreased in all groups except the placebo group. The decrease in score was significantly greater in all treatment groups than in the placebo group (p<0.01)., Conclusion: Acupuncture and applied relaxation both reduced the number of hot flushes significantly better than placebo and should be further evaluated as alternatives to hormone therapy in women with menopausal vasomotor complaints.

Objective: To evaluate the effect of applied relaxation and electro-acupuncture on vasomotor symptoms in women treated for breast cancer., Methods: Thirty-eight postmenopausal women with breast cancer and vasomotor symptoms were randomized to treatment with electro-acupuncture (n = 19) or applied relaxation (n = 19) during 12 weeks. The number of hot flushes was registered daily in a logbook before and during treatment and after 3 and 6 months of follow-up., Results: Thirty-one women completed 12 weeks of treatment and 6 months of follow-up. After 12 weeks of applied relaxation, the number of flushes/24 h had decreased from 9.2 (95% confidence interval (CI) 6.6-11.9) at baseline to 4.5 (95% CI 3.2-5.8) and to 3.9 (95% CI 1.8-6.0) at 6 months follow-up (n = 14). The flushes/24 h were reduced from 8.4 (95% CI 6.6-10.2) to 4.1 (95% CI 3.0-5.2) after 12 weeks of treatment with electro-acupuncture and to 3.5 (95% CI 1.7-5.3) after 6 months follow-up (n = 17). In both groups, the mean Kupperman Index score was significantly reduced after treatment and remained unchanged 6 months after end of treatment., Conclusion: We suggest that applied relaxation and electro-acupuncture should be further evaluated as possible treatments for vasomotor symptoms in postmenopausal women with breast cancer.

Objective: The aim was to evaluate and compare the effects of applied relaxation and oral estradiol treatment on hot flushes, mood and psychological wellbeing in postmenopausal women., Patients and Methods: In a prospective study, 30 postmenopausal women with vasomotor symptoms were randomized to applied relaxation or oral estradiol treatment during 12 weeks with 6 months follow-up. Number and severity of flushes were registered daily and Kupperman's Index and a general estimate of climacteric symptoms, Mood Scale and Symptom Check List were completed at baseline, 4, 8 and 12 weeks of treatment, and 3 and 6 months after therapy., Results: After 12 weeks of treatment, the number of flushes/24 h decreased significantly over time in both treatment groups. In the group receiving applied relaxation, the mean number of flushes/24 h decreased from 6.0 (95% CI 4.5-7.6) to 3.0 (95% CI 2.1-3.9) after 12 weeks of treatment. The mean number of flushes/24 h was 1.7 (95% CI 0.7-2.5) at 6 months follow-up; i.e. a 72% decrease. In the estrogen group, the mean number of flushes/24h decreased from 8.4 to 0.8; i.e a 90% decrease in the number of flushes after 12 weeks of treatment. The significant change in flushes reached after 12 weeks of treatment and remained to 6 months after end of treatment in both groups. Estrogen therapy reduced flushes significantly faster than applied relaxation. General climacteric symptoms according to the Visual Analogue Scale and the Kupperman's Index decreased significantly over time in both groups. General mood (Mood Scale) increased significantly in the estrogen group, but not in the group receiving applied relaxation. Psychological wellbeing according to Symptom Checklist, increased significantly from baseline to 12 weeks in both groups., Conclusions: We suggest that applied relaxation may be used as an alternative treatment of vasomotor symptoms for postmenopausal women but should be further evaluated.

Objective: To assess if regular physical exercise or oral oestradiol therapy decreased vasomotor symptoms and increased quality of life in previously sedentary postmenopausal women., Setting: A prospective, randomised trial at a University Hospital., Methods: 75 postmenopausal, sedentary women with vasomotor symptoms were randomised to: exercise three-times weekly over 12 weeks (15 women), oral oestradiol therapy for 12 weeks (15 women) and 45 women to three other treatment arms. Results from the exercise and oestradiol groups are presented here. The effects on vasomotor symptoms and wellbeing were assessed with logbooks and validated questionnaires., Results: Ten women fulfilled 12 weeks of exercise. The number of flushes was rather unchanged in five women and decreased to 28% (range 18-42%) of baseline in the other five women. Five of the ten women continued to exercise another 24 weeks, thus in all 36 weeks. The mean number of flushes decreased by about 50% in these five women (from 6.2/24 to 3.2 flushes/24 h at 36 weeks). In the same group a score made as the product of reduction in number and severity of flushes decreased by 92% at 12 weeks, 75% at 24 weeks and 72% at 36 weeks compared with baseline. In the estrogen group flushes decreased from 8.4 to 0.8 (P<0.001) after 12 weeks of therapy and remained at this level after 36 weeks. Well-being according to different measurements improved significantly in both groups, albeit more markedly in the estrogen group., Conclusions: Apart from many other health benefits regular physical exercise may decrease vasomotor symptoms and increase quality of life in postmenopausal women, but this has to be further evaluated scientifically. Exercise should be introduced gradually to ensure compliance.

Objective: To compare the effects of electro-acupuncture with oral estradiol and superficial needle insertion on hot flushes in postmenopausal women., Material and Methods: Forty-five postmenopausal women with vasomotor symptoms were randomized to electro-acupuncture, superficial needle insertion or oral estradiol treatment during 12 weeks, with 6 months' follow-up. The number and severity of flushes were registered daily and the Kupperman index and a general estimate of climacteric symptoms were completed before, during and after therapy., Results: In the electro-acupuncture group, the mean number of flushes/24 h decreased from 7.3 to 3.5 (ANOVA, p < 0.001). Eleven of the 15 women had at least a 50% decrease in number of flushes (with a mean decrease of 82%). Superficial needle insertion decreased the number of flushes/24 h from 8.1 to 3.8 (p < 0.001). In seven out of 13 women, the number of flushes decreased by at least 50% (mean decrease 83%). In the estrogen group, the number of flushes decreased from 8.4 to 0.8 (p < 0.001). The decrease in number of flushes persisted during the 24-week follow-up period in all treatment groups. The Kupperman index and the general climacteric symptom score decreased, and remained unchanged 24 weeks after treatment in all groups (p < 0.001). Electro-acupuncture decreased the number of flushes/24 h significantly over time, but not to the same extent as the estrogen treatment. No significant difference in effect was found between electro-acupuncture and the superficial needle insertion., Conclusion: We suggest that acupuncture is a viable alternative treatment of vasomotor symptoms in postmenopausal women and cannot recommend superficial needle insertion as an inactive control treatment.

Vasomotor symptoms with hot flushes and sweating are reported by about 75 percent of women around menopause. Hormone replacement therapy (HRT) is the treatment of choice but some women have medical contraindications or side effects. There is, therefore, a need of alternative therapies. Progestagens may decrease hot flushes, as will clonidin and selective serotonin reuptake inhibitors. Phytoestrogens, which exist in some dietary products and complementary and alternative medicines have estrogen-like effects and may decrease hot flushes, although there are contradictory scientific reports. Acupuncture, exercise and behavioral therapy may also decrease vasomotor symptoms. No alternative therapy is as effective as HRT.

Objective: The objective was to assess whether menopausal women with vasomotor symptoms had a lower stress-coping than menopausal women without symptoms and if stress-coping changed when vasomotor symptoms had been effectively treated with estrogens. The objective was also to assess whether menopausal women, effectively treated for vasomotor symptoms, had a higher neuroticism score than women without such symptoms., Methods: Two groups of physically and mentally healthy postmenopausal women were recruited from the outpatient clinic at the Department of Obstetrics and Gynaecology, University Hospital of Linköping, Sweden. Sixteen women with vasomotor symptoms (target group) were treated with oral 17 beta-estradiol, 2 mg/day during 3 months. A comparison group was formed comprising 17 women without vasomotor symptoms. The Kupperman Index was used to cover menopausal characteristics in all women at baseline as well as at the second visit after 3 months. Stress-coping was measured by means of the Stress Coping Inventory, which is an instrument developed to measure of the individual's appraisal of having adaptive resources for handling stressful situations. At the second visit all women were also asked to complete the Eysenck Personality Inventory., Results: Women in the target group had a significantly lower stress-coping than women in the comparison group at baseline as well as after 3 months. Stress-coping did not change after estrogen therapy, although the vasomotor symptoms had virtually disappeared. Women in the target group successfully treated for vasomotor symptoms, had a significantly higher neuroticism score compared to the comparison group., Conclusions: Differences in behaviour patterns and personality are probably two reasons why some women report or seek advice due to vasomotor symptoms and some women do not. Stress-coping in women with moderate to severe vasomotor symptoms is unaffected by estrogens.

Applied relaxation (AR) was tested in a series of six women with postmenopausal hot flushes. The AR program consisted of group instructions 1 hour per week over a 12 week duration. The number of flushes were registered from 1 month before to 6 months after training AR. Menopausal symptoms (Kupperman Index), psychological well-being (Symptom Checklist), and mood (MOOD Scale) were measured at various moments during the study. For the six patients the number of flushes decreased from the baseline period to 6 months follow-up with 59, 61, 62, 67, 89 and 100% respectively, in mean 73%. While the scores on the Kupperman Index and the Symptom Checklist followed the pattern of the flushes, a similar trend was not seen for the scores on the MOOD Scale.