Non-pharmacologic Interventions to Alleviate Hot Flash Symptoms Among Breast Cancer Survivors - A Systematic Review
Keywords:
Behavioral therapy, Breast cancer survivors, Homeopathy, Hot flashes, Hypnosis, Non-pharmacologic approach, Relaxation techniques, Systematic review, YogaAbstract
Hot flash symptoms (also known as hot flush symptoms) are a major health issue for breast cancer survivors. Treatments for hot flash symptoms can be both pharmacologic and non-pharmacologic approaches. Although pharmacological interventions can reduce hot flash symptoms in the general population, selecting medications to treat hot flashes for breast cancer survivors is of concern if they can interact with tamoxifen use in these patients. Therefore,
it is essential to update the scientific evidence regarding the effectiveness of non-pharmacologic approaches on reducing hot flash symptoms for breast cancer survivors. The purpose of this systematic review was to investigate the scientific evidence on the effectiveness of non-pharmacologic approaches on alleviating hot flash symptoms among this group. A comprehensive literature search was conducted electronically using ScienceDirect, Scopus, PubMed, CINAHL, and Cochrane library. Published papers in English focused on non-pharmacologic approaches and hot flash symptoms in breast cancer survivors were selected. The search reviewed studies from January 2000-December 2020. The literature review was undertaken in February 2021. The definition of non-pharmacological interventions or complementary health approaches based on the National Center for Complementary and Integrative Health was used as a systematic framework for this review. Sixteen studies were included for analysis. The findings showed that acupuncture was considered a possibly effective method for alleviating hot flash symptoms in breast cancer survivors, whereas effectiveness of other non-pharmacologic approaches, including behavioral therapy, yoga, hypnosis, homeopathy, and relaxation techniques, could not be determined because of the small number of included trials.
In conclusion, the evidence showed insufficient data to support effectiveness of non-pharmacologic approaches in reducing hot flashes for breast cancer survivors. More rigorous studies are warranted to examine these interventions. Nurses need to discuss the pro and cons of these interventions with breast cancer survivors who want to use these alternative approaches for their health.
References
1. Chang HY, Jotwani AC, Lai YH, Jensen MP, Syrjala KL, Fann JR, et al. Hot flashes in breast cancer survivors: frequency, severity and impact. Breast. 2016;27:116–21. doi: 10.1016/j.breast.2016.02.013.
2. Hoda D, Perez DG, Loprinzi CL. Hot flashes in breast cancer survivors. Breast. 2003;9(5):431-38. doi:10. 1046/j. 1524-4741.2003.09526.x.
3. Morrow PK, Mattair DN, Hortobagyi GN. Hot flashes: a review of pathophysiology and treatment modalities. Oncologist. 2011;16(11):1658–64. doi:10.1634/theoncologist. 2011-0174.
4. Kligman L, Younus LJ. Management of hot flashes in women with breast cancer. Curr Oncol. 2010;17(1):81–6. doi:10.3747/co.v17i1.473.
5. Boekhout AH, Beijnen JH, Schellens JH. Symptoms and treatment in cancer therapy-induced early menopause. Oncologist. 2006;11(6):641–54. doi: 10.1634/theoncologist.11-6-641.
6. Carpenter JS. State of the science: hot flashes and cancer. Part 1: definition, scope, impact, physiology, and measurement. Oncol Nurs Forum. 2005;32 (5):959–68. doi: 10.1188/ 05.ONF.959-968.
7. Johns C, Seav SM, Dominick SA, Gorman JR, Li H, Natarajan L, et al. Informing hot flash treatment decisions for breast cancer survivors: a systematic review of randomized trials comparing active interventions. Breast Cancer Res Treat. 2016:156(3):415–26. doi:10.1007/s10549-016-3765-4.
8. North American Menopause Society. Treatment of menopause-associated vasomotor symptoms: position statement of The North American Menopause Society. 0000108177.85442.71.
9. Garcia MK, Graham-Getty L, Haddad R, Li Y, McQuade J, Lee RT, et al. Systematic review of acupuncture to control hot flashes in cancer patients. Cancer. 2015;121(22):3948–58. doi: 10.1002/cncr.29630.
10. Chen YP, Liu T, Peng YY, Wang YP, Chen H, Fan YF, et al. Acupuncture for hot flashes in women with breast cancer: a systematic review. J Cancer Res Ther. 2016;12(2):535–42. doi: 10.1097/01.GME.0000108177.85442.71.
11. Carlos L Lopes-Júnior, Cruz LA, Leopoldo VC, Campos FR, Almeida AM, Silveira RC. Effectiveness of traditional Chinese acupuncture versus sham acupuncture: a systematic review. Rev Lat Am Enfermagem. 2016;24(15) (2016) e2762. doi: 10.1590/1518-8345.0647.2762.
12. Chien TJ, Hsu CH, Liu CY, Fang CJ. Effect of acupuncture on hot flush and menopause symptoms in breast cancera systematic review and meta-analysis. PloS One. 2017; 12(8):e0180918. doi: 10.1371/journal.pone.0180918.
13. Salehi A, Marzban M, Zadeh AR. Acupuncture for treating hot flashes in breast cancer patients: an updated meta-analysis. Support Care Cancer. 2016;24(12):4895–99. doi:10.1007/s00520-016-3345-5.
14. Wang XP, Zhang DJ, Wei XD, Wang JP, Zhang DZ. Acupuncture for the relief of hot f flashes in breast cancer patients: a systematic review and meta-analysis of randomized controlled trials and observational studies. J Cancer Res Ther. 2018;14(Suppl.):S600–8. doi: 10.4103/0973-1482.183174.
15. Rada G, Capurro D, Pantoja T, Corbalán J, Moreno G, Letelier LM, Vera C. Non-hormonal interventions for hot flushes in women with a history of breast cancer. Cochrane Database Syst Rev. 2010;8(9):CD004923. doi: 10.1002/ 14651858.CD004923.pub2.
16. Kaplan M, Mahon S. Hot flash management: update of the evidence for patients with cancer. Clin J Oncol Nurs 2014; 18(Suppl.):59–67. doi: 10.1188/14.CJON.S3.59-67.
17. Ninot G. Defining the concept of non-pharmacological intervention (NPI) [Internet]. 2019 [cited 2021 Feb 2]. Available from: http://blogensante.fr/en/2013/09/16/definir-la-notion-dintervention-non-medicamenteuse/
18. National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: what’s in a name? [Internet]. 2018 [cited 2021 Feb 2]. Available from: https://www.nccih.nih.gov/health/complementaryalternative-
or-integrative-health-whats-in-a-name
19. Maki, PM. Subjective versus objective measurement of hot flushes: implications for menopause research. Maturitas. 2019; 120(2):90-1. doi.: 0.1016/j.maturitas.2018.07.004.
20. Goldstein KM, Coeytaux RR, Williams Jr JW, Shepherd-Banigan M, Goode AP, McDuffie JR, et al. Nonpharmacologic treatments for menopause-associated vasomotor symptoms [Internet]. 2016 [cited 2021 Feb 2]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK447618/pdf/Bookshelf_NBK447618.pdf
21. Sievert LL. Subjective and objective measures of hot flashes. Am J Hum Biol. 2013;25(5):573-80. doi: 10. 1002/ajhb.22415.
22. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. BMJ. 2009; 21;339:b2535. doi: 10.1136/bmj.b2535.
23. Higgins JPT, Altman DG, Sterne JAC. Assessing risk of bias in included studies. In: Higgins JPT, Green S. editors. Cochrane handbook for systematic reviews of interventions [Internet] 2011 [cited 2021 Feb 2]. Available from: www.cochrane‐handbook.org
24. Jadad AR, Moore RA, Carroll D et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin Trials. 1996: 17(1): 1–12. doi: 10.1016/0197-2456(95)00134-4.
25. Ahn E, Kang H. Introduction to systematic review and meta-analysis. Korean J Anesthesiol. 2018;71(2):103-12. doi.: 10.4097/kjae.2018.71.2.103.
26. Deng G, Vickers A, Yeung S, D’Andrea GM, Xiao H, Heerdt AS, et al. Randomized, controlled trial of acupuncture for the treatment of hot flashes in breast cancer patients. J Clin Oncol. 2007;25(35): 5584–90. doi: 10.1200/JCO. 2007.12.0774.
27. Frisk J, Carlhäll S, Källström AC, Lindh-Astrand L, Malmström A, Hammar M. Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicenter trial. Climacteric. 2008; 11(2):166-74. doi:10.1080/13697130801958709.
28. Hervik J, Mjåland O. Acupuncture for the treatment of hot flashes in breast cancer patients, a randomized, controlled trial. Breast Cancer Res Treat. 2009;116(2):311–6. doi: 10.1007/s10549-008-0210-3.
29. Liljegren A, Gunnarsson P, Landgren BM. Reducing vasomotor symptoms with acupuncture in breast cancer patients treated with adjuvant tamoxifen: a randomized controlled trial. Breast Cancer Res Treat. 2012;135(3): 791-8. doi: 10.1007/s10549-010-1283-3.
30. Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, et al. Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial. J Clin Oncol. 2010;28(4):634-40. doi:10.1200/JCO.2009.23.5150.
31. Frisk J, Källström AC, Wall N, Fredrikson M, Hammar M. Acupuncture improves health-related quality-of-life (HRQoL) and sleep in women with breast cancer and hot flushes. Support Care Cancer. 2012;20(4):715-24. doi:10.1007/s00520-011-1134-8.
32. Bokmand S, Flyger H. Acupuncture relieves menopausal discomfort in breast cancer patients: a prospective, double blinded, randomized study. Breast. 2013;22(3): 320-3. doi: 10.1016/j.breast.2012.07.015.
33. Bao T, Cai L, Snyder C, Betts K, Tarpinian K, Gould J, et al. Patient-reported outcomes in women with breast cancer enrolled in a dual-center, double-blind, randomized controlled trial assessing the effect of acupuncture in reducing aromatase inhibitor-induced musculoskeletal symptoms. Cancer. 2014120(3):381-9. doi:10.1002/cncr.28352.
34. Mao JJ, Bowman MA, Xie SX, Bruner D, DeMichele A, Farrar JT. Electroacupuncture versus Gabapentin for hot flashes among breast cancer survivors: a randomized placebo-controlled trial. J Clin Oncol. 2015;33(31): 3615-20. doi:10.1200/JCO.2015.60.9412.
35. Lesi G, Razzini G, Musti MA, Stivanello E, Petrucci C, Benedetti B, et al. Reducing vasomotor symptoms with acupuncture in breast cancer patients treated with adjuvant tamoxifen: a randomized controlled trial. Breast Cancer Res Treat. 2012;
135(3):791–8. doi.: 10.1007/s10549-010-1283-3.
36. Jacobs J, Herman P, Heron K, Olsen S, Vaughters L. Homeopathy for menopausal symptoms in breast cancer survivors: a preliminary randomized controlled trial. J Altern Complement Med. 2005;11(1):21-7. doi: 10.1089/acm.2005.11.21.
37. Ganz PA, Greendale GA, Petersen L, Zibecchi L, Kahn B, Belin TR. Managing menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Natl Cancer Inst. 2000;92(13):1054-64. doi:10.1093/jnci/92.13.1054.
38. Mann E, Smith MJ, Hellier J, Balabanovic JA, Hamed H, Grunfeld EA, et al. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial. Lancet Oncol. 2012;13(3):309-18. doi: 10.1016/S1470-2045(11)70364-3.
39. Fenlon DR, Corner JL, Haviland JS. A randomized controlled trial of relaxation training to reduce hot flashes in women with primary breast cancer. J Pain Symptom Manage. 2008;35(4):397–405. doi.: 10.1016/j.jpainsymman.2007.05.014.
40. Elkins G, Marcus J, Stearns V, Perfect M, Rajab MH, Ruud C, et al. Randomized trial of a hypnosis intervention for treatment of hot flashes among breast cancer survivors. J Clin Oncol. 2008;26(31):5022-6. doi: 10.1200/JCO.2008.16.6389.
41. Carson JW, Carson KM, Porter LS, Keefe FJ, Seewaldt VL. Yoga of awareness program for menopausal symptoms in breast cancer survivors: results from a randomized trial. Support Care Cancer. 2009;17(10):1301–9. doi: 10. 1007/s00520-009-0587-5.
42. World Health Organization. WHO global report on traditional and complementary medicine 2019 [Internet]. 2019 [cited 2021 Feb 2]. Available from: https://www.who.int/traditional-complementary-integrative-medicine/WhoGlobalReportOnTraditionalAnd Complementary Medicine2019.pdf
43. Innes KE, Selfe TK, Vishnu A. Mind-body therapies for menopausal symptoms: a systematic review. Maturitas 2010;66(2):135-49. doi: 10.1016/j.maturitas.2010. 01.016.
44. Misra S. Randomized double blind placebo control studies, the “Gold Standard” in intervention based studies. Indian J Sex Transm Dis AIDS. 2012;33(2): 131–4. doi: 10. 4103/0253-7184.102130.
2. Hoda D, Perez DG, Loprinzi CL. Hot flashes in breast cancer survivors. Breast. 2003;9(5):431-38. doi:10. 1046/j. 1524-4741.2003.09526.x.
3. Morrow PK, Mattair DN, Hortobagyi GN. Hot flashes: a review of pathophysiology and treatment modalities. Oncologist. 2011;16(11):1658–64. doi:10.1634/theoncologist. 2011-0174.
4. Kligman L, Younus LJ. Management of hot flashes in women with breast cancer. Curr Oncol. 2010;17(1):81–6. doi:10.3747/co.v17i1.473.
5. Boekhout AH, Beijnen JH, Schellens JH. Symptoms and treatment in cancer therapy-induced early menopause. Oncologist. 2006;11(6):641–54. doi: 10.1634/theoncologist.11-6-641.
6. Carpenter JS. State of the science: hot flashes and cancer. Part 1: definition, scope, impact, physiology, and measurement. Oncol Nurs Forum. 2005;32 (5):959–68. doi: 10.1188/ 05.ONF.959-968.
7. Johns C, Seav SM, Dominick SA, Gorman JR, Li H, Natarajan L, et al. Informing hot flash treatment decisions for breast cancer survivors: a systematic review of randomized trials comparing active interventions. Breast Cancer Res Treat. 2016:156(3):415–26. doi:10.1007/s10549-016-3765-4.
8. North American Menopause Society. Treatment of menopause-associated vasomotor symptoms: position statement of The North American Menopause Society. 0000108177.85442.71.
9. Garcia MK, Graham-Getty L, Haddad R, Li Y, McQuade J, Lee RT, et al. Systematic review of acupuncture to control hot flashes in cancer patients. Cancer. 2015;121(22):3948–58. doi: 10.1002/cncr.29630.
10. Chen YP, Liu T, Peng YY, Wang YP, Chen H, Fan YF, et al. Acupuncture for hot flashes in women with breast cancer: a systematic review. J Cancer Res Ther. 2016;12(2):535–42. doi: 10.1097/01.GME.0000108177.85442.71.
11. Carlos L Lopes-Júnior, Cruz LA, Leopoldo VC, Campos FR, Almeida AM, Silveira RC. Effectiveness of traditional Chinese acupuncture versus sham acupuncture: a systematic review. Rev Lat Am Enfermagem. 2016;24(15) (2016) e2762. doi: 10.1590/1518-8345.0647.2762.
12. Chien TJ, Hsu CH, Liu CY, Fang CJ. Effect of acupuncture on hot flush and menopause symptoms in breast cancera systematic review and meta-analysis. PloS One. 2017; 12(8):e0180918. doi: 10.1371/journal.pone.0180918.
13. Salehi A, Marzban M, Zadeh AR. Acupuncture for treating hot flashes in breast cancer patients: an updated meta-analysis. Support Care Cancer. 2016;24(12):4895–99. doi:10.1007/s00520-016-3345-5.
14. Wang XP, Zhang DJ, Wei XD, Wang JP, Zhang DZ. Acupuncture for the relief of hot f flashes in breast cancer patients: a systematic review and meta-analysis of randomized controlled trials and observational studies. J Cancer Res Ther. 2018;14(Suppl.):S600–8. doi: 10.4103/0973-1482.183174.
15. Rada G, Capurro D, Pantoja T, Corbalán J, Moreno G, Letelier LM, Vera C. Non-hormonal interventions for hot flushes in women with a history of breast cancer. Cochrane Database Syst Rev. 2010;8(9):CD004923. doi: 10.1002/ 14651858.CD004923.pub2.
16. Kaplan M, Mahon S. Hot flash management: update of the evidence for patients with cancer. Clin J Oncol Nurs 2014; 18(Suppl.):59–67. doi: 10.1188/14.CJON.S3.59-67.
17. Ninot G. Defining the concept of non-pharmacological intervention (NPI) [Internet]. 2019 [cited 2021 Feb 2]. Available from: http://blogensante.fr/en/2013/09/16/definir-la-notion-dintervention-non-medicamenteuse/
18. National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: what’s in a name? [Internet]. 2018 [cited 2021 Feb 2]. Available from: https://www.nccih.nih.gov/health/complementaryalternative-
or-integrative-health-whats-in-a-name
19. Maki, PM. Subjective versus objective measurement of hot flushes: implications for menopause research. Maturitas. 2019; 120(2):90-1. doi.: 0.1016/j.maturitas.2018.07.004.
20. Goldstein KM, Coeytaux RR, Williams Jr JW, Shepherd-Banigan M, Goode AP, McDuffie JR, et al. Nonpharmacologic treatments for menopause-associated vasomotor symptoms [Internet]. 2016 [cited 2021 Feb 2]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK447618/pdf/Bookshelf_NBK447618.pdf
21. Sievert LL. Subjective and objective measures of hot flashes. Am J Hum Biol. 2013;25(5):573-80. doi: 10. 1002/ajhb.22415.
22. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. BMJ. 2009; 21;339:b2535. doi: 10.1136/bmj.b2535.
23. Higgins JPT, Altman DG, Sterne JAC. Assessing risk of bias in included studies. In: Higgins JPT, Green S. editors. Cochrane handbook for systematic reviews of interventions [Internet] 2011 [cited 2021 Feb 2]. Available from: www.cochrane‐handbook.org
24. Jadad AR, Moore RA, Carroll D et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin Trials. 1996: 17(1): 1–12. doi: 10.1016/0197-2456(95)00134-4.
25. Ahn E, Kang H. Introduction to systematic review and meta-analysis. Korean J Anesthesiol. 2018;71(2):103-12. doi.: 10.4097/kjae.2018.71.2.103.
26. Deng G, Vickers A, Yeung S, D’Andrea GM, Xiao H, Heerdt AS, et al. Randomized, controlled trial of acupuncture for the treatment of hot flashes in breast cancer patients. J Clin Oncol. 2007;25(35): 5584–90. doi: 10.1200/JCO. 2007.12.0774.
27. Frisk J, Carlhäll S, Källström AC, Lindh-Astrand L, Malmström A, Hammar M. Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicenter trial. Climacteric. 2008; 11(2):166-74. doi:10.1080/13697130801958709.
28. Hervik J, Mjåland O. Acupuncture for the treatment of hot flashes in breast cancer patients, a randomized, controlled trial. Breast Cancer Res Treat. 2009;116(2):311–6. doi: 10.1007/s10549-008-0210-3.
29. Liljegren A, Gunnarsson P, Landgren BM. Reducing vasomotor symptoms with acupuncture in breast cancer patients treated with adjuvant tamoxifen: a randomized controlled trial. Breast Cancer Res Treat. 2012;135(3): 791-8. doi: 10.1007/s10549-010-1283-3.
30. Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, et al. Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial. J Clin Oncol. 2010;28(4):634-40. doi:10.1200/JCO.2009.23.5150.
31. Frisk J, Källström AC, Wall N, Fredrikson M, Hammar M. Acupuncture improves health-related quality-of-life (HRQoL) and sleep in women with breast cancer and hot flushes. Support Care Cancer. 2012;20(4):715-24. doi:10.1007/s00520-011-1134-8.
32. Bokmand S, Flyger H. Acupuncture relieves menopausal discomfort in breast cancer patients: a prospective, double blinded, randomized study. Breast. 2013;22(3): 320-3. doi: 10.1016/j.breast.2012.07.015.
33. Bao T, Cai L, Snyder C, Betts K, Tarpinian K, Gould J, et al. Patient-reported outcomes in women with breast cancer enrolled in a dual-center, double-blind, randomized controlled trial assessing the effect of acupuncture in reducing aromatase inhibitor-induced musculoskeletal symptoms. Cancer. 2014120(3):381-9. doi:10.1002/cncr.28352.
34. Mao JJ, Bowman MA, Xie SX, Bruner D, DeMichele A, Farrar JT. Electroacupuncture versus Gabapentin for hot flashes among breast cancer survivors: a randomized placebo-controlled trial. J Clin Oncol. 2015;33(31): 3615-20. doi:10.1200/JCO.2015.60.9412.
35. Lesi G, Razzini G, Musti MA, Stivanello E, Petrucci C, Benedetti B, et al. Reducing vasomotor symptoms with acupuncture in breast cancer patients treated with adjuvant tamoxifen: a randomized controlled trial. Breast Cancer Res Treat. 2012;
135(3):791–8. doi.: 10.1007/s10549-010-1283-3.
36. Jacobs J, Herman P, Heron K, Olsen S, Vaughters L. Homeopathy for menopausal symptoms in breast cancer survivors: a preliminary randomized controlled trial. J Altern Complement Med. 2005;11(1):21-7. doi: 10.1089/acm.2005.11.21.
37. Ganz PA, Greendale GA, Petersen L, Zibecchi L, Kahn B, Belin TR. Managing menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Natl Cancer Inst. 2000;92(13):1054-64. doi:10.1093/jnci/92.13.1054.
38. Mann E, Smith MJ, Hellier J, Balabanovic JA, Hamed H, Grunfeld EA, et al. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial. Lancet Oncol. 2012;13(3):309-18. doi: 10.1016/S1470-2045(11)70364-3.
39. Fenlon DR, Corner JL, Haviland JS. A randomized controlled trial of relaxation training to reduce hot flashes in women with primary breast cancer. J Pain Symptom Manage. 2008;35(4):397–405. doi.: 10.1016/j.jpainsymman.2007.05.014.
40. Elkins G, Marcus J, Stearns V, Perfect M, Rajab MH, Ruud C, et al. Randomized trial of a hypnosis intervention for treatment of hot flashes among breast cancer survivors. J Clin Oncol. 2008;26(31):5022-6. doi: 10.1200/JCO.2008.16.6389.
41. Carson JW, Carson KM, Porter LS, Keefe FJ, Seewaldt VL. Yoga of awareness program for menopausal symptoms in breast cancer survivors: results from a randomized trial. Support Care Cancer. 2009;17(10):1301–9. doi: 10. 1007/s00520-009-0587-5.
42. World Health Organization. WHO global report on traditional and complementary medicine 2019 [Internet]. 2019 [cited 2021 Feb 2]. Available from: https://www.who.int/traditional-complementary-integrative-medicine/WhoGlobalReportOnTraditionalAnd Complementary Medicine2019.pdf
43. Innes KE, Selfe TK, Vishnu A. Mind-body therapies for menopausal symptoms: a systematic review. Maturitas 2010;66(2):135-49. doi: 10.1016/j.maturitas.2010. 01.016.
44. Misra S. Randomized double blind placebo control studies, the “Gold Standard” in intervention based studies. Indian J Sex Transm Dis AIDS. 2012;33(2): 131–4. doi: 10. 4103/0253-7184.102130.
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2021-09-03
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Wanchai A, Armer JM. Non-pharmacologic Interventions to Alleviate Hot Flash Symptoms Among Breast Cancer Survivors - A Systematic Review. PRIJNR [Internet]. 2021 Sep. 3 [cited 2024 Dec. 22];25(4):567-86. Available from: https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/253359
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