Case Report

Acupuncture for Hot Flashes in PostmenopausalHemodialysis-Dependent Women:

Two Case Reports

Kun Hyung Kim, OMD, MS,1 Seung Yeon Na, MD,2 Myeong Soo Lee, PhD,1 Se Hyun Kim, PhD,3

So Young Jung, BSc,1 and Sun Mi Choi, OMD, PhD1

Abstract

Objective: This study aimed to observe the effects of acupuncture for hot flashes in postmenopausal hemodi-alysis-dependent women.Methods: Two postmenopausal hemodialysis-dependent women were treated with individualized manualacupuncture for 1 and 3 months to reduce the occurrence of hot flashes and were observed through 7 and 11months, respectively, from baseline.Results: Hot flashes were significantly improved after acupuncture treatment in both of the patients, and theeffects persisted through the final observation period (hot flash scores decreased from 57 to 33 and 22 at 1 and 11months from baseline in patient 1, and from 14 to 6 and zero at 1 and 7 months from baseline in patient 2). Thebeneficial effects of acupuncture on quality of life were partially observed in these 2 patients. No acupuncture-related serious adverse events occurred during the study.Conclusions: Further controlled studies need to be conducted among larger samples to determine whetheracupuncture is an effective and safe treatment for hot flashes in postmenopausal hemodialysis-dependentwomen.

Introduction

Hot flashes are the most frequently reported vasomotorsymptom among menopausal women, affecting 50%–

90%, and they negatively influence various dimensions ofwomen’s lives.1–3 However, women’s health issues have beenneglected among hemodialysis patients,4 and little is knownabout the prevalence and impact of hot flashes in postmeno-pausal women with end-stage renal disease (ESRD).5 Littleinformation is available on the use of hormone therapy (HT)in hemodialysis patients, and those treatments may be con-troversial due to a very high risk of cardiovascular diseaseand altered pharmacokinetics of estrogen.6,7 Data about theeffects and safety of nonhormonal agents for hot flashes in thispopulation are very sparse.

We describe 2 postmenopausal hemodialysis-dependentwomen who received acupuncture as alternative treatmentfor hot flashes. These women experienced more than half tocomplete relief of hot flashes, their quality of life improved,and these effects persisted after the treatments were finished.The clinical course, practical implications, and possible

mechanisms of symptom relief associated with the acu-puncture treatment are considered.

Subjects

Both patients were referred to our research center fromone local artificial kidney center in June and September 2008for treatment of hot flashes. Written informed consent wasobtained from each patient for this study. Patient 1, a 48-year-old woman, started hemodialysis 16 years ago due toreflux nephropathy. She regularly underwent a 4-hour he-modialysis treatment 3 times per week and maintained anormal glucose level and blood pressure. She experiencedamenorrhea for 6 months without a history of hysterectomyor oophorectomy. After suffering from severe hot flashes for8 months, patient 1 tried local HT for 2 months but receivedno relief from hot flashes. Patient 2, a 55-year-old woman,started hemodialysis 17 years ago. Her renal disease wascomplicated due to comorbidities of type 2 diabetes andpoorly controlled hypertension. She underwent 3- or 4-hourhemodialysis treatments 4 times per week due to painful

1Acupuncture, Moxibustion & Meridian Research Center, Korea Institute of Oriental Medicine, Daejeon, South Korea.2Department of Internal Medicine, Eulji University Hospital, Daejeon, South Korea.3Graduate School of East–West Medical Science, Kyung Hee University, Yongin, Korea.

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intradialytic muscle cramps. Patient 2 experienced amenor-rhea for 15 months without history of hysterectomy or oo-phorectomy. Her hot flashes started 17 months ago. Shereported that her hot flashes were less severe at baseline thanthey had been in the beginning but were still intolerablewhen occurring during hemodialysis because they felt likesymptomatic intradialytic hypotension. She had experiencedlocal and systemic HT but received no relief from hot flashes.

Interventions and Outcomes

The intensity and the severity of hot flashes and quality oflife (QOL) were evaluated at baseline, during treatment, andfollow-up periods (Tables 1 and 2). Normal thyroid functionand postmenopausal status were confirmed at baseline. Pa-tients documented the frequency of hot flashes according toseverity, which ranged from 0 to 4 (0: none, 1: mild, 2:moderate, 3: severe, 4: very severe) in the modified daily logcreated by Sloan et al. for 1 week prior to each measurementtime.1 Hot flash scores were produced by the sum of multi-plied scores between the frequency and related severityscores to evaluate overall hot flash activities. The MenopauseRating Scale (MRS) and the Kidney Disease and Qualityof Life (KDQOL�-36) scale were employed to estimatemenopause-related and kidney disease-related QOL.

Both patients received individualized manual acupuncturetreatment with de qi response for 30–45 minutes 3 times perweek for 4 weeks as an initial treatment. One (1) practitioner(K.K.H.) with 5 years of clinical experience provided acu-puncture treatment just before hemodialysis. The most fre-

quently used acupoints were SP6, SP9, ST36, LV3, CV4, HT7,and LI4. The total number of acupoints ranged from 14 to 26per session. Needling at the arteriovenous fistula located armwas avoided to prevent undesirable side-effects. After 2months post-treatment, patient 1 requested extra acupuncturetreatments for her remaining vasomotor symptoms, so 20additional treatments were performed during the subsequent2 months. The total number of acupuncture sessions was 32for patient 1 and 12 for patient 2. No concomitant HT, non-hormonal agent, or nonpharmacologic interventions otherthan acupuncture for relieving hot flashes were reportedduring the entire observation periods.

Hot flash scores

After 12 sessions of initial treatment, the hot flash scoresdecreased from 57 to 33 in patient 1 and from 14 to 6 inpatient 2 (42.1% and 57.1% reduction from baseline, respec-tively). Hot flash scores for patient 1 were 24 at 3 monthsafter baseline, and 20 additional sessions of acupuncturetreatment were performed. However, the hot flash scores ofpatient 1 hardly changed despite additional acupuncturetreatments, and remained at 22 points through 11 monthsafter baseline. In patient 2, the hot flash scores were com-pletely resolved at 4 months after baseline, and these effectswere maintained until the 7-month follow-up visit.

Menopause-related QOL

Patient 1 showed marked decrease in the total and psy-chologic, somatic, and urogenital subscale scores of the MRS

Table 1. Outcome Measurements for Patient 1

Timelinea Baseline 1 month 3 months 5 months 8 months 11 months

Hot flash scoreb 57 33 24c 22c 22c 22c

MRSTotal score (max¼ 44) 41 7 32 20 15 10Psychologic (max¼ 16) 16 3 12 7 4 3Somatic (max¼ 16) 13 2 11 7 5 4Urogenital (max¼ 12) 12 2 9 6 6 3

KDQOLTM-36Symptom/problem list 56.25 89.58 33.33 72.73 66.67 83.33Effect of kidney disease 40.63 71.88 25.00 43.75 81.25 59.38Burden of kidney disease 0 25.00 6.25 25.00 25.00 31.25SF-12 physical composite 31.89 43.10 32.24 28.95 37.25 34.91SF-12 mental composite 24.09 44.32 39.15 50.45 40.76 55.25

Laboratory findingsFSH (mIU/mL) >200.0 186.14 188.91 >200.0 — —Estradiol (pg/mL) <10 <10 <10 <10 — —TSH (mIU/mL) 1.63 — 1.00 — — —Free T4 (ng/dL) 1.10 — 0.89 — — —Serum albumin (g/dL)d 4.2 4.4 4.3 3.9 — —iPTH (pg/mL) 132.3 102.8 120.1 98.97 — —Calcium (mg/dL) 9.7 9.8 10.1 9.6 — —Phosphorus (mg/dL) 4.4 3.4 2.3 3.0 — —Hemoglobin (g/dL) 13.3 12.5 13.1 11.2 — —Hematocrit (%) 41.7 38.3 39.1 33.8 — —

aTime point after baseline.bAverage daily hot flash scores per week.cMore than 50% reduction from baseline value.dSerum alumin levels were derived from routine medical records.MRS, menopause rating scale; KDQOLTM-36, kidney disease and quality of life questionnaire; iPTH, intact parathyroid hormone; FSH,

follicle-stimulating hormone; TSH, thyroid-stimulating hormone.

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at 1 month after baseline, but those scores increased at 3months after baseline. After 20 sessions of additional acu-puncture treatment (5 months after baseline), the total andthree subscale scores continuously decreased up to 11 monthsafter baseline. In patient 2, the total, somatic, and urogenitalsubscale scores were decreased at 1 month after baseline.However, the total and psychologic subscale score worsenedat 4 and 7 months after follow-up. Only the somatic subscalescore showed reduction at 4 and 7 months after baseline.

Kidney-disease-related QOL

Patient 1 reported increased scores of all five subscalesincluding symptom/problem list, effects of kidney disease,burden of kidney disease, SF-12 physical health composite,and SF-12 mental health composite at 1 month after baseline.Beneficial effects from acupuncture lasted through 11months after baseline in the symptom/problem list, effect ofkidney disease, burden of kidney disease, and SF-12 mentalhealth composite subscale. However, only partial benefitswere observed for patient 2 in the effect of kidney disease,SF-12 physical health composite, and mental health compos-ite subscales at 1 month after baseline. For patient 2, a long-term effect was only seen for the SF-12 physical healthcomposite subscale at the 7-month follow-up visit.

Adverse events

Slight and transient adverse events were reportedthroughout the entire study period. Mild and intermittent

local pain without functional discomfort at one needling site(HT 8) lasted for 1 month in patient 1. Minimal bleedinginduced by acupuncture, which stopped shortly thereafter,were the most commonly noted events. There were nocomplaints about those events, and the patients tolerated theacupuncture procedure well overall.

Discussion

The 2 postmenopausal dialysis-dependent women in thisstudy showed more than half and complete relief of hotflashes after 12 and 30 sessions of acupuncture treatmentover a period of 7 or 11 months, respectively. Partial oroverall improvement in QOL was observed in both patients,which is known to be strongly associated with decreasedmortality and hospitalization in dialysis patients.8 Duringthe study period, no additional interventions for hot flashesor related-vasomotor symptoms were reported. These pre-liminary results correspond to previous research that re-ported clinically relevant improvements of hot flashes inpatients with natural and surgical menopause, and breastand prostate cancer.9–12 Various factors, including the pa-tient’s expectations for and beliefs around acupuncture,patient–practitioner interactions, and natural spontaneousremission of hot flashes may be responsible for the observedeffects.13

In hemodialysis-dependent women, the risk of cardio-vascular death is at least 20-fold greater than in the generalpopulation, and a higher prevalence of breast and endome-trial cancer in women with ESRD has also been reported.5,6

Furthermore, the potential risk of arteriovenous fistula orgraft thrombosis resulting in dialysis access failure may beincreased by the use of hormone therapy.5,14 Currently, therisk/benefit ratio and optimal dose of hormone therapy formenopausal hot flashes in women with chronic kidney dis-ease (CKD)/ESRD remains unstudied.15 Little evidence forthe use of nonhormonal agents for relieving hot flashes isavailable due to altered pharmacokinetics in CKD/ESRDpatients.16 Untreated menopausal hot flashes may worsenthe symptom burden and QOL of menopausal women withdialysis. Given these concerns, alternative interventions suchas acupuncture in patients who are at high risk for side-effects associated with conventional hormone therapy, suchas women with CKD/ESRD, need to be further investigated,as suggested by the Agency of Healthcare Research andQuality.17

The mechanism of acupuncture in reducing hot flashesstill remains unknown. One possible explanation suggeststhat regulating the endogenous opioid level by acupunctureinfluences the action of calcitonin gene-related-peptide, apotent vasodilator that might be involved in sweating andflushing, thereby alleviating hot flashes. This hypothesis hasbeen tested in three clinical trials with inconsistent results inthe non-CKD population.9,12,18 No previous research existsfor the action of acupuncture for menopausal hot flashes inCKD/ESRD women.

Our case reports showed the favorable effects of acu-puncture for relieving hot flashes and improving QOL inpostmenopausal women undergoing hemodialysis for whomlittle evidence is available for HRT and other pharmacologicinterventions. Nevertheless, these results only constitute thelowest level of evidence. Future controlled trials are needed

Table 2. Outcome Measurements for Patient 2

Timelinea Baseline1

month4

months7

months

Hot flash scoreb 14 6c 0c 0c

MRSTotal score (max¼ 44) 16 9 20 19Psychologic (max¼ 16) 2 2 9 7Somatic (max¼ 16) 6 2 3 3Urogenital (max¼ 12) 8 5 8 9

KDQOLTM-36Symptom/problem list 72.92 65.91 60.42 75.00Effect of kidney disease 46.88 62.50 43.75 46.88Burden of kidney disease 25.00 31.25 25.00 31.25SF-12 physical composite 39.20 52.81 43.05 48.44SF-12 mental composite 47.01 54.67 50.59 46.23

Laboratory findingsFSH (mIU/mL) 130.10 120.61 — —Estradiol (pg/mL) <10 <10 — —TSH (mIU/mL) 1.58 — — —Free T4 (ng/dL) 1.30 — — —Serum albumin (g/dL)d 4.5 4.5 4.4 —iPTH (pg/mL) 51.26 — — —Calcium (mg/dL) 9.6 8.9 — —Phosphorus (mg/dL) 9.7 5.5 — —Hemoglobin (g/dL) 10.7 11.6 — —Hematocrit (%) 33.8 36.3 — —

aTime point after baseline.bAverage daily hot flash scores per week.cMore than 50% reduction from baseline value.dSerum albumin levels were derived from routine medical records.MRS, menopause rating scale; KDQOLTM-36, kidney disease and

quality of life questionnaire; iPTH, intact parathyroid hormone; FSH,follicle-stimulating hormone; TSH, thyroid-stimulating hormone.

ACUPUNCTURE FOR HOT FLASHES IN WOMEN ON DIALYSIS 917

to determine the effectiveness and the safety of acupuncturefor menopausal hot flashes in CKD/ESRD women.

Acknowledgments

This study was supported by the Development of Acu-puncture, Moxibustion, and Meridian Standard HealthTechnology Project (K10010) of the Korea Institute of Or-iental Medicine. We would like to acknowledge the 2 womenwho participated in this preliminary report.

Disclosure Statement

No competing financial interests exist.

References

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5. Mattix H, Singh AK. Estrogen replacement therapy: Im-plications for postmenopausal women with end-stage renaldisease. Curr Opin Nephrol Hypertens 2000;9:207–214.

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11. Deng G, Vickers A, Yeung S, Cassileth B. Randomized,controlled trial of acupuncture for the treatment of hot fla-shes in breast cancer patients. J Clin Oncol 2007;25:5584–5590.

12. Frisk J, Spetz AC, Hjertberg H, et al. Two modes of acu-puncture as a treatment for hot flushes in men with prostatecancer: A prospective multicenter study with long-termfollow-up. Eur Urol 2009;55:156–163.

13. Paterson C, Dieppe P. Characteristic and incidental (placebo)effects in complex interventions such as acupuncture. BMJ2005;330:1202–1205.

14. Daly E, Vessey MP, Hawkins MM, et al. Risk of venousthromboembolism in users of hormone replacement therapy.Lancet 1996;348:977–980.

15. National Kidney Foundation. K/DOQI Clinical PracticeGuidelines for Cardiovascular Disease in Dialysis Patients.Am J Kidney Dis 2005;45(suppl 3):S1–S153.

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17. Nelson H, Haney E, Humphrey L, et al. Management ofmenopause-related symptoms. Evidence Report/TechnologyAssessment No. 120. (Prepared by the Oregon Evidence-based Practice Center, under Contact No. 290-02-0024.)AHRQ Publication No. 05-E016-2. Rockville, MD: Agency forHealthcare Research and Quality, March 2005.

18. Wyon Y, Lindgren R, Lundeberg T, Hammer M. Effects ofacupuncture on climacteric vasomotor symptoms, quality oflife, and urinary excretion of neuropeptides among post-menopausal women. Menopause 1995;2:3–12.

Address correspondence to:Sun Mi Choi, OMD, PhD

Acupuncture, Moxibustion & Meridian Research CenterKorea Institute of Oriental Medicine

Daejeon, 305-811South Korea

E-mail: smchoi@kiom.re.kr

918 KIM ET AL.