At the risk of being a one-note Johnny, I am very concerned when lifestyle advice to menopausal women from normally credible, reputable sources is unsupported by evidence, at best, or is basically old-wives’ tales, at worst. If other health information were based on such equivocal and weak evidence, it would not be considered acceptable.

The Globe and Mail recently published a lifestyle article on hormone therapy for hot flashes, which I read with interest. It mentioned that HealthLink BC, a patient health information site run by the government of British Columbia, was recommending lifestyle advice that my own literature review indicates is unsupported. By contrast, its advice on medical therapy is generally referenced and based on evidence.

This is what HealthLinkBC says:

• Avoid using tobacco or drinking a lot of alcohol. They tend to make hot flashes worse.

The evidence on both of these is equivocal (see my previous post). There is some limited evidence from well-designed observational studies that never smoking and quitting smoking are associated with fewer hot flashes. The evidence on alcohol is mixed, with some studies showing alcohol decreases hot flashes.

• Manage stress. Stress can make hot flashes worse.

Well, there is evidence showing that being happy and contented actually increases hot flashes and stress decreases them. There is little good evidence about effects of stress.

• Exercise regularly, and eat a healthy diet.

As I indicated in my earlier post, the evidence on exercise is mixed and shows only modest changes. There is evidence that obesity (but not healthy weight) is associated with hot flashes, so losing weight is advisable as a way to decrease hot flashes only if you are obese.

• Try rhythmic breathing exercises. This is called paced respiration. It can help you meditate and relax, and it may reduce your hot flashes.

OK, the first randomized controlled trial on this recently reported. There was a modest (less than 20%) decrease in hot flashes in the group that used this paced respiration method in which you slow your resting breathing rate (kind of conflicts with the exercise advice). But (get this) the control group, which listened to music instead, had a 44% decrease in hot flashes. Keeping in mind that placebo effect is huge in hot flashes, we should all be listening to music rather than breathing slowly.

• Drink cold liquids rather than hot ones.

Hot liquids (and anything hot) can bring on a hot flash, but there is no evidence that they increase the overall frequency or severity of hot flashes.

• Eat smaller, more frequent meals. Digesting a lot of food can make you feel hotter.

No evidence. Also, while the immediate trigger of a hot flash may be warm ambient temperature and other heat sources, the problem is not that women affected are overly hot. Menopausal women in Canada have hot flashes in minus 20 degree Celsius weather. Hot flashes do not feel like being hot from ambient temperature or exercise, and body temperature before a hot flash is normal and then actually rises measurably during the hot flash.

• Stay cool
• Keep your area cool. Use a fan.
• Dress in layers. Then you can remove clothes as needed.
• Wear natural fabrics, such as cotton and silk.
• Sleep with fewer blankets.

Staying cool does help prevent the immediate onset of hot flashes and helps women recover from them quickly when they occur. However, from personal experience, I’m not sure it reduces the overall frequency.

• Use relaxation techniques, such as breathing exercises , yoga, or biofeedback.

No evidence.

From HealthLinkBC’s medical therapy section:

• Black cohosh may reduce or prevent hot flashes, depression, and anxiety.

There is a reference for the paragraph containing this statement to a Health Canada page on traditional herbal use of black cohosh, which includes menopausal symptoms. There is no reference to the medical literature, which has plenty on black cohosh. There have been some small randomized controlled trials (around 300 patients) showing benefit of black cohosh in hot flashes and published in a respected, peer-reviewed journal (Obstetrics and Gynecology). However, a Cochrane systematic review pooling data from 16 randomized controlled trials involving more than 2000 women with menopausal symptoms found “insufficient evidence to support the use of black cohosh for menopausal symptoms.” However, since some studies found some benefit, the review called for more research on this traditional herbal remedy.

I find a lot of information for patients tries to get around the fact that the evidence is poor by using words like “may” or “might.” As in, “black cohost may reduce or prevent hot flashes.” Or it may not. I suspect many patient-readers looking for something to try are not going to pick up on the subtle distinction of a remedy that may or will provide some benefit. And this is concerning, as many herbal remedies are not risk-free. Black cohosh has been linked with liver-damage events in people who have taken it, although a meta-analysis of black cohosh studies found no evidence of liver problems. Black cohosh may or may not have risky side effects.

But why not just be upfront with readers about the state of the research evidence on various lifestyle advice and herbal remedies? And why tell women something is going to help when it isn’t? I also find that a lot of patient advice is good, general health advice. But it’s like health authorities are trying to trick readers into following advice by selling it as something that’s going to help with a particular problem.

There are lots of good reasons to eat properly, quit smoking and limit alcohol. Like heart disease, cancer and diabetes. Don’t tell women healthy living will help their hot flashes when it won’t.