TREATMENT OF HOT FLUSHES IN BREAST CANCER PATIENTS BY ACUPUNCTURE WITH DIET AND OTHER COMPLEMENTARY THERAPIES. 

Most women treated surgically for early breast cancer they undergo treatment with chemotherapy and/or Tamoxifen and/or ovarian ablation may have vasomotor symptoms that usually continue for years. Hot flushes are brought out from the thermo-regulatory centre, possibly attributable to decrease in hypothalamic opioid activity produced by low oestrogen concentrations.

Acupuncture therapy stimulates hypothalamic opioid activity and relieves hot flushes. Twenty-two breast cancer women with vasomotor symptoms following chemotherapy and Tamoxifen, received acupuncture treatment sessions of 20-30 minutes twice weekly for 3-8 weeks treatment with a detoxifying healthy diet programme and changes in life style. All patients were followed up 3-5 weeks after the last acupuncture session and showed a reduction in the number of hot flushes (average 80% after the completion of treatment course).

This study concludes that acupuncture, associated with a dietary programme and healthy life style may be an alternative treatment of choice in breast cancer survivor women suffering from hot flushes following chemotherapy and/or Tamoxifen and deserves further clinical appraisal.

Introduction:

Although traditional Chinese acupuncture therapy has aroused great interest in western medicine for its analgesic property in the treatment of pain (1, 2), it has also been used to treat some non-painful conditions, including vasomotor symptoms. Hot flushes exemplify a considerable clinical problem for some patients on adjuvant or palliative treatment for breast cancer and are labeled by the medical professions as one of the vasomotor symptoms, due to changes in circulation (cutaneous vasodilatation), body temperature, and heart rate (3).

The exact mechanisms causing these symptoms are unknown, but the decline in level of oestrogen concentrations has been suggested (4). Since some of the oestrogen is normally present in fatty tissues, it is more likely that obese patients may develop hot flushes than thin ones. A typical attack of hot flushes is characterised by the a sudden rushing sensation of warmth or even intense heat that spreads over various parts of the body, especially the chest, face, and head which may severely impair quality of life.

Profuse sweating and a feeling of suffocation usually accompany these hot flushes which are followed by a chill. Low levels of oestrogen are associated with hot flushes, but not necessarily causally. Accordingly with an abrupt loss of ovarian oestrogen due to Tamoxifen, (5) ovarian ablation or chemotherapy, patients experienced the worst hot flushes. Tamoxifen is a drug used for breast cancer with a mechanism for blocking the effect of oestrogen hormone on cells. This type of drug has unique characteristics as summarised in Table 1.

- For adjuvant therapy of breast cancer, patients are prescribed Tamoxifen for a period

   not less than 5 years. Others may receive the drug for as long as their cancer

   continues to be controlled as palliation.

- Tamoxifen is more effective in women whose tumours are oestrogen receptor   

   (ER) positive.

- Tamoxifen. may interact with other drugs such as warfarin.

- Tamoxifen is contraindicated in pregnancy.

- Tamoxifen causes a slight increase in risk of endometrial cancer and thrombosis. –

- Tamoxifen protects against osteoporosis in post-menopausal women and reduces a

   woman's risk of heart disease.

- Although Tamoxifen has rare serious side effects, there are other side effects such

   as: temporary nausea, bone pain or swelling, weight gain, allergic reactions - this

   may include skin rashes and temporary thinning of the hair. 

Table 1. Characteristics of Tamoxifen.

Recent research work on breast cancer patients investigated prevalence, severity and management of hot flushes (5). This study significantly contributes to the patho-physiology of hot flushes in women with breast cancer and concludes that hot flushes are more common in women with a high school education and those who were younger at diagnosis and more severe in women with a higher body mass index as well as those receiving Tamoxifen. Despite this, however, clinical research on management of hot flushes following the treatment of breast carcinoma is scarce. Hot flushes in breast cancer patients tend to be worse than in healthy postmenopausal women (Table 2).

 FACTS ON HOT FLUSHES IN BREAST CANCER PATIENTS (5)

-  Postmenopausal hot flushes are more severe in women who have been treated for

   breast cancer compared with healthy women (5).

- Breast cancer patients have hot flushes attacks twice as often as healthy  

   postmenopausal women (5) and for longer periods of time after menopause (4).

- In breast cancer patients, 54% were still having hot flushes more than 10 years

   after menopause, compared with 4% to 35% of healthy postmenopausal women (5).

- Women with a history of breast cancer have few options for managing hot flushes.

   Hormone replacement therapy alleviates the symptoms but most doctors feel that

   hormone treatment is risky for women who have had breast cancer (6).

Table 2. Some facts on hot flushes in breast cancer patients.

The main aim of this paper is to propose an approach to therapeutic guidance in acupuncture practice in which western diagnosis of hot flushes, coupled with the application of both acupuncture and dietetic principles, offers a practical solution for breast cancer pateints undergoing chemotherapy and Tamoxifen treatment.

HOT FLUSHES: ETIOLOGY AND PATHOPHYSIOLOGY

According to Western medicine, hot flush is a disorder of unknown etiology with signs and symptoms treated by symptomatic methods. Breast cancer treatment by ovarian ablation, cytotoxic drugs and Tamoxifen can impact the onset of menopause and precipitate vasomotor symptoms (5, 7, 8) suggesting that the latter might induce or increase hot flushes and night sweats. However, medical research scientists have developed several theories to explain the mechanism of hot flushes production in menopausal women and among them are: the hypothalamic disorder of thermoregulatory centre (9), Prostaglandin stimulation of gonadotrophins through hypothalamus (10, 11), and the low level of oestrogen (12).

For the past two decades it has been thought that the lack of oestrogen is the principle cause of hot flushes, because when oestrogen level falls, it influences the sympathetic nervous system, leading to dilatation of blood vessels and as a result flushing and sweating occur. If we assume that hot flushes are principally caused by lowered oestrogen levels as such, why does not everybody have them, and why do those who do have them, not have them consistently?  This is still a research mystery. Catecholamines and opiates are also thought to influence the heat regulatory mechanism in hypothalamus. There are also some other factors might trigger the attack of hot flushes, summarised in Table 3.

-Socio-economic factors in association with a decline of oestrogen production are

  related to the occurrence of hot flushes (13).

- Lack of fitness and exercises: walking, jogging, jumping rope, dancing, tennis etc.

   are usually the missing ingredients in most breast cancer patients. Therefore,

   patient physical inactivity is a life style risk factor for developing hot flushes (14).

-Unhealthy diet: there is an intimate link between diet and hot flushes

  development, not only in breast cancer patients, but also in women approaching

   menopause (15). It was found that certain type of foods may precipitate the hot flushes  

  attack, because they contain chemical substances such as histamine (in cheese and

   red wine), betaphenylethylamine (in chocolate), tyramine (in pickled herrings,

   cheese and marmite) and nitrite (in bacon, salami and hot dogs).

- Hot flushes are significantly associated with cigarette smoking (16, 17). One study

   showed that smoking changed the breakdown of oestrogen in the liver and  

   subsequently lowered one form of estrogen in the blood (18). While another         

   investigation illustrated a relationship between increased caffeine intake and      

   decreased free oestrogen (15).

- Other factors that may be linked to hot flushes such as: hot drinks, spicy foods and

   alcohol (13, 19, 15), over‑exertion (exhaustion, over‑work and failure to relax

   physically and/or mentally) are the triggering factors of hot flushes attack. In

   addition, natural changes in the environment, such as the weather (very hot or very 

   cold) may initiate an attack of hot flushes.

Table 3. Factors contributing in the onset of hot flushes.

deterioration in the yin of the Liver, weakness in the “blood” of the heart and an

exhaustion of the “Water” of the kidney. The deficiency of Water is countered by an excess of fire which endangers the control of the yin of the Liver and unleashes its yang. Hot flushes are associated with other symptoms such as depression, palpitation, insomnia and tiredness which are related to the dysfunction of the heart, liver, spleen and kidney organs. There are two pathological mechanisms in these manifestations:

     a. The combined effects of deficiency in the kidney, hyperactivity in the liver

         and flare-up of the heart fire, will lead to palpitation, insomnia, nocturnal

         emission and dizziness. In addition, there are signs of red tongue proper and

        a wiry, small, rapid, weak pulse.

b.  The imbalance between the spleen and liver is manifested by emotional depression, irritability, loss of temper and an oppressive feeling in the chest.

Hot flush is an attack of acute warm or hot sensation that may or may not be coupled with a sudden reddening of the head, neck and chest, followed by profuse sweating. Without warning, hot flushes can occur at any time, day or night, and after these symptoms have resolved a feeling of cold and chill or shiver may be experienced. They last mostly from a few seconds to a few minutes but, in rare cases, can extend to a half-hour or about an hour (20). A few patients have some unusual symptoms associated with hot flush which may be felt as pressure in the head, anxiety, a tingling sensation, or nausea. Physical examination of women with hot flushes is second only to the history in gaining information about the patient’s complaints, their possible genesis and treatment. The medical acupuncturist needs to know of other medical conditions, which may give similar clinical picture to hot flushes, as there are other conditions that can produce vasomotor symptoms (Table 4).

Differential diagnosis of hot flushes (21)

-  systemic diseases,

-  carcinoid syndrome,

-  systemic mast cell disease,

-  phaeochromocytoma,

-  medullary carcinoma of the thyroid,

-  pancreatic islet-cell tumours,

-  renal cell carcinoma,

-  neurological flushing,

-  emotional flushing,

-  high fever,

-  medications (e.g. diabinese and niacin),

-    -   spinal cord injury,

-    -   flushing reaction related to alcohol abuse and drugs,

-   flushing associated with food additives and eating.

Table 4. Hot flushes in other diseases.

It has been reported that mild hot flushes occur in 40% of healthy women aged 39 or more with normal menstrual cycle (22). On the other hand, the same study reported 85% of menopausal women experience hot flushes and 30% describe them as severe. In other studies, hot flushes occur in 50-70% of climacteric women associated with palpitation, dizziness, tachycardia or sweating (23, 24). The prevalence of hot flushes appears to differ by race: the incidence is higher among western women than in women from the developing countries (25, 26, 27). These studies suggest that, in Japan, Hong Kong, Pakistan and Mexico, 10 percent or less of menopausal women experience hot flushes. The low incidence in Japan has been linked to high soybean consumption, which stimulates oestrogen production.

TREATMENT OF HOT FLUSHES:

For more than 35 years hormone replacement therapy (HRT) has been used to treat hot flushes. However, little attention has been paid to the treatment of hot flushes in breast cancer patients who are prescribed HRT only with caution and not usually as first-line medication. Previous studies have shown that oestrogen is the treatment of choice in hot flushes as compared to that of  non-hormonal drugs such as Clonidine, sedatives, tranquillisers, beta-blockers,  veralipride, vitamin E and evening primrose oil (28, 29, 30, 31). The latter showed contradictory results with lack of scientific evidence to support using primrose oil in controlling hot flushes (31).

Complementary treatments tend to strengthen and support the endocrine system as they work in conjunction with a healthy diet and adequate exercise. Whatever the mechanisms of most complementary medicine are, the diversity of its effect may be due to its different physiological properties: some produce stimulating effects, while others are sedative in action. In the Western scientific view, such theory is hard to prove, since a controlled trial would involve monitoring the health of thousands of users and non-users of complementary medicines over several decades. Despite the lack of scientific evidence (32), complementary therapies are now accepted by public (33) because they think that such treatment may alleviate the severity of hot flushes. The main complementary therapies are:

1.  Aromatherapy: utilizes distilled essential plant oils (actual aroma of the plant) such as lavender, camomile, camphor, eucalyptus and cedarwood in the application of bath and massage techniques to improve the health and balance of the body and mind. Looking at the patient’s emotional, psychological and physical aspect, each oil has a specific therapeutic function e.g. improves poor circulation, reduces water retention and inflammation and alleviates hot flushes (34). However, aromatherapy is mainly used as a natural aid alongside other main complementary or Western treatments.

2.  Homeopathy: requires a detailed consultation for an effective homeopathic remedy with prescription of sanguinaraand glonoinum for hot flushes and cauophylum for the associated mental symptoms. Other homeopathic remedies are used for hot flushes and their associated symptoms such as: Lachesis , Pulsatilla , Valeriana and Sepia (35).

3.  Herbal medicine: Although herbs are generally undertaken singly or as a compound  in a capsule or extract form, prescription of  precise doses for herbal remedies is not easy since each patient responds differently and like conventional drugs to cause side effects (36). Daily Drinking of few cups of sage tea  (using one tablespoon of sage per cup of water infused it for twenty minutes) may help to alleviate vasomotor symptoms. There are a few herbs used for treatment of hot flushes:

a. Dong Quai has a sedative and analgesic property and is used by the Chinese as a strengthening treatment for liver and to promote blood circulation. It does not eliminate hot flushes but it does seem to diminish their severity. 

b. Ginseng, like ginseng tea, is an oestrogen-like plant derivative and seems to              accelerate metabolism and help boost energy reserves but does not particularly                 affect hot flushes.

c. Black Cohosh (Cinicifuga racemosa) relieves the typical physical symptoms of hot flushes, night sweats and emotional stress. Black Cohosh seems to work better if it is taken at night but too high a dose will cause nausea and vomiting.

         d. Other herbs commonly used to alleviate hot flushes include vitex agnus

         castii, blue cohosh, wild yam root, liquorice root, false unicorn root, Red Clover

         (Trifolium pratense) and sarsaparilla.

    4. Vitamin E:  Research findings in the 40s and early 50s indicated that vitamin E  

        (alpha-tocopherol) in doses between 20 and 100mg for a period of one week to

several months might alleviate hot flushes in menopausal women (37, 38). In 1998, Barton and colleagues showed that a dose from 400 to 800 IUs daily with vitamin C was sufficient to control hot flushes in cancer survivor patients (30). However, previous research studies in humans have shown that only about 25% of the fat-soluble oil form of vitamin E is absorbed after oral dose (39). It is known that, to double the plasma concentration of vitamin E, the normal oral dose must be increased by as much as ten-fold (40). Therefore, a high oral dose of normal fat soluble vitamin E, when used to produce higher tissue levels frequently results in gastrointestinal symptoms such as nausea, flatulence or diarrhoea and is still no guarantee of achieving adequate plasma levels. Furthermore, vitamin E should not be prescribed for patients with diabetes, hypertension and heart diseases (rheumatic heart diseases and heart failure).

ACUPUNCTURE MANAGEMENT

Acupuncture management includes a combination of acupuncture, dietary suggestions, and lifestyle recommendations:

Western medicine typically offers hormonal and non-hormonal therapies for hot flushes but many patients simply cannot or do not wish to take these chemicals. Traditional Chinese acupuncture, one of the most holistic medical systems available today, offers these patients great help, taking into account the whole pattern of each patient’s physical and mental-emotional symptoms (41).

Many aspects of acupuncture mechanisms in painful conditions are now understood in the light of recent scientific researches. However, the acupuncture effects on hot flushes may have 3 objective explanations:

(1) The sedative effect has been shown in previous research work to decrease delta and theta wave activity on the electro-encephalogram (42, 43). This effect is utilised for acupuncture treatment of associated symptoms in hot flushes such as insomnia and anxiety.

(2) The homeostatic or regulatory effect (44) to maintain the state of balance in the body internal environment is achieved by regulating the activity of sympathetic and parasympathetic autonomic nervous system as well as the endocrine system (45).

(3) The psychological effect in calming and tranquillising the patient is by its mechanism on the mid-brain reticular formation in increasing the content of several neurotransmitters and hormones, such as endorphin, serotonin and dopamine, in brain tissue following acupuncture (46). This should not be confused with hypnosis or autosuggestion because the latter are very different from acupuncture in many respects (47). However, a good acupuncturist can implement the physiological effect with appropriate psychological reinforcement (44).

According to acupuncture theories, needling of the selected specific points will try to increase water and combat fire through compensating deficiency and controlling excesses in order to restore the yin/yang balance. Therefore, acupuncture treatment nourishes the yin, clears heat and quiets the spirit by treating the kidney and heart yin depletion and strengthens liver blood with extinguishing liver wind. In certain cases when the deficient liver yin reaches a certain degree of severity, the disorders Rising Liver Fire or Hyper Liver Yang Ascending occur, including the following signs and symptoms: ill-temper, restlessness, headache, vertigo and hot flushes. The acupuncture points used for treatment of hot flushes are classified into 3 groups (Table 5. and Fig. 1).

SPECIFIC ACUPOINTS (48,  48a, 48b)

Anatomical location

Therapeutic effect(s)

BL.62. (Shenmai)

0.5 cun inferior to the tip of lateral malleolus.

The specific therapeutic effects are subjective (sensation of “Deqi” and its radiation) and objective (analgesia and tranquillisation).

LIV.14 (Qimen)

Vertically below the nipple, in the 6th intercostals space.

KI.3 (Taixi)

Midway between the tip of the medial malleolus and the medial border of the tendo-Achilles.

H.7 (Shenmen)

At the transverse wrist crease, on the radial side of the tendon of the flexor carpi ulnaris.

TE.6 (Zhigou)

On the back of the forearm between ulna and radius, 3 cun proximal to the wrist crease.

GENERAL HOMEOSTATIC

POINTS

The regulation of body temperature is geared to delicately balanced homeostatic mechanisms, mediated either through the nervous system or by chemical transmitters.

Generally, homeostasis is maintained by the balanced activity of the autonomic nervous system and also by the endocrine system.

SP.6 (Sanyinjiao0

3 cun above the tip of medial malleolus on the medial border of the tibia.

LI.11 (Quchi)

At the lateral end of the transverse elbow crease when the elbow is semiflexed.

ST.36 (Zusanli

One fingerbreadth lateral to the inferior border of the tibial tuberosity, 3 cun below the knee joint.

SEDATIVE POINTS

The acupuncture sedative effect has shown a decrease in delta and theta brain wave activity on electro-encephalogram.

DU.20 (Baihui)

On the vertex of the skull, 5 cun behind the anterior hairline, on the midline

LI.4 (Hegu)

At the highest point of the muscles on the back of the hand when the forefinger and the thumb are abducted

Table 5. The types, anatomical locations and therapeutic effects of acupuncture points used in treatment of hot flushes.

B. Diet, detoxification, life style and other preventive measures:

"Everyone has a doctor in him or her; we just have to help it in its work. The natural healing force within each one of us is the greatest force in getting well. Our food should be our medicine. Our medicine should be our food. But to eat when you are sick, is to feed your sickness."—Hippo crates, MD., 460-370 BC, Father of Western Medicine.

1. Diet (healthy diet, minerals and vitamins):

Surprisingly, diet does not feature heavily along side Western medicine, which nevertheless underlines the importance of a healthy and balanced diet in preventing hot flushes. Although diet can play a major role in maintaining a healthy endocrine system, I would never advocate, in my personal clinical experience, that healthy diet alone is sufficient in treating hot flushes unless coupled with acupuncture.  Diet planning on the basis of food properties can, however, be useful to achieve its optimal therapeutic effect on hot flushes (19). The quality of diet, once it has improved the patient’s condition, should be maintained throughout life. In Chinese Medicine unhealthy diet, including habitual liquor consumption and voracious eating of fatty and sweet foods may create heat, phlegm and dampness. Ancient Chinese Medicine recommends that a well-balanced diet can be nutritionally adequate; heavily based on complex carbohydrates (starches) with very little amount of simple carbohydrates (sugars) and differs significantly in its low fat content (49). Therefore, there is a need for a framework of healthy dietetic knowledge within which the acupuncturists can advise patients suffered from hot flushes.

There are 2 ways in which patient’s diet can trigger hot flushes:

1. Excess foods have a toxic effect resulting in production of more hot flushes. In the short term, the harmful effect of such food items (as described below) may be very small but the cumulative action of vasomotor symptom development will be apparent when taken regularly over a long period.

2. Deficiency of vitamins may be produced by eating refined foods such as white flour, white sugar and canned or frozen foods, from which much of the nutritional quality (including minerals) has been removed or lost. Regular intake of these foods may result in a bad circulation and a general lack of resistance leading to hot flushes.

Although no direct relationship between the intake of these foods and the onset of hot flushes has yet been proved, their effect in lowering general health and resistance is quiet definite. Physiologically, the normal healthy body is able to neutralize and eliminate any harmful substances derived from the ingested food and usually vasomotor symptoms may not become apparent until the mechanism of eliminative functions has been disturbed.

Healthy diet:

With the exception of skimmed milk, cottage cheese and low fat yoghurt, full fat milk, semi-skimmed milk and milk products such as butter, full and half-fat cheese as well as pudding, custards and blancmanges should be avoided. An alternative, soya milk can be used as a low-fat milk substitute.

Patients with hot flushes should consider eating white meat (chicken, turkey, and fish) with little red meat (Beef, Pork and lamb) in order to reduce the level of arachidonic acid, which might trigger an attack of hot flushes. Fish is preferable to other types of white meat as it provides a higher content of vitamins A and D and is more readily digested. Therefore, the source of protein should be mainly from beans and legumes and their by-products. Plant compounds of Phytoestrogens which are classified as two main categories: isoflavones and lignans, have oestrogenic properties (50).

Western physiology indicated that the liver is the centre of metabolism responsible for the breakdown and elimination of all food impurities. Once liver function is disturbed the level of toxins in the blood rises and consequently triggers hot flushes symptoms. Because of a high content of saturated fatty acids in animal fat and the greater difficulty to metabolise it by the liver (compare to vegetable oils which are rich in the type of unsaturated fatty-acids necessary to maintain the health) patients with hot flushes should use vegetable oils, such as corn or sunflower oil. According to Traditional Chinese Medicine, too much oily food will lead to accumulation of heat and Dampness in the body and manifest itself as a hot clinical pattern (1). Certain types of food and drinks, which might trigger hot flushes, are summarised in Table 6.

Food and drink to avoid in hot flushes

1. Refined white sugar, brown sugar and sugar substitutes

2. Foods containing sugar (cakes, biscuits, chocolates, and puddings).

3. Cheese and dairy products.

4. Red meat (pork, beef and lamb).

5. White bread.

6. Fatty food (pastry, fried food and pies), including oily dressing.

7. Some type of fruit (banana, grapes, melon and water melon).

9. Tea, coffee gluten, yeast,  caffeinateed beverages.

10.Processed foods, peanuts and vinegar.

Table 6. Some types of food and drink triggering hot flushes in menopausal women.

Less restriction is applied to starchy foods encouraging the patients to eat wholemeal bread, unsugared cereal, boiled and baked potatoes, beans, peas and lentils. More vegetables such as leaf and salads as well as fruit are recommended to provide soluble fibres.

Correcting dietary errors and adopting a nutritional regime, which maintain a high level of health are based on a healthy diet recommended by leading dieticians, nutritionists and other medical researchers (51, 63) (Table 7).

THE HEALTHY DIET FOR HOT FLUSHES (63)

1.      An increase in consumption of fruits, vegetables (with exception of certain fruits,

      see Table 5) and whole grains.

2.      Eating plant-based diet, which is low in saturated fat and cholesterol, more than

      meat-based diet.

3.  White meats such as fish and chicken should be preferred over red meat.

4.  Decreasing intake of refined foods.

5.  Decreasing intake of alcohol with a limit of 14 units per week.

6.  Diet should contain: brown rice, millet, amaranth, quinoa, buckwheat and potatoes,

     yeast-free bread, Organic fresh vegetables, frozen or freshly juiced, Fresh or       

     frozen organic fruits (not canned).

Table 7. Some recommendations on a healthy diet for patients with hot flushes.

Minerals and vitamins:

Based on experimental observations, recommendation is made for consumption of more vegetable and fruit that provide some antioxidant nutrients, e.g. beta-carotene, vitamin C and vitamin E (52). It has been found in animal experimental studies that vitamin B6 affects neurotransmitter metabolism and its interaction with oestrogen-receptors restores irregularity (53). Calcium, zinc and magnesium are well known in their positive effect on human female hormonal balance (54). Niacin is essential in the synthesis of oestrogen (55).

2. Detoxification Programme (fasting):

Normal health is maintained by balancing the assimilation of nutrients and elimination of impurities. Once this balance is disturbed by the presence of hereditary weakness, or any other factors such as chemotherapy or cytotoxic drugs, various signs and symptoms can develop, including hot flushes. Accumulation of toxins can weaken vital organs, and obstruct the body's natural cleansing processes. Impaired immunity, sluggish brain function, hypersensitivity responses, digestive disturbances, bizarre drug reactions and lethargy are just some possible effects of such a build up which can lead to chronic health problems. Consequently, these toxins may be stored in the body and irritate or inflame the cells and tissues; and can lead to triggering hot flushes. Functions such as filtering, transforming and discharging toxins are associated with the liver. Physiologically, liver is usually the main organ of detoxification deactivating two types of toxins: endogenous toxins developed from our biochemical and cellular activities generated through normal everyday functions and mainly caused by physical and mental stress. The exogenous toxins are derived from air pollutions, alcohol, foods and chemical substances, including drugs through our breathing, ingesting, or through physical contact (56). In addition, acupuncture may help the imbalanced liver (liver Qi congestion), which is primarily caused by an excess of toxins (57).

Hot flushes in breast cancer patients on endocrine therapy are usually accompanied by at least 3 or more liver imbalance signs and symptoms such as: tiredness, weakness, easy fatigability, persistent headaches, lack of concentration and thick white or yellow coated tongue.

The basic principle of detoxification is that the body needs help to cleanse itself by a process of neutralisation and excretion of potentially harmful chemicals, such as caffeine, acetaminophen, sodium benzoate, tannin and nicotine. These toxins are supposedly built up in the body because of unhealthy diet, chemical medicine (i.e. Tamoxifen) and the effect of environmental pollution. Although ancient Greek, Chinese and Indians have healing philosophies using various method of physical cleansing, there is also a spiritual element in that process with an example of fasting, which is advocated in the Bible and the Koran (58). Early Chinese natural philosophy employed methods and techniques known as “wei-sing” (the protection of life) as part of preventive medicine, including fasting (59, 60). Detoxification programme consists of essential elements of fasting recommended mainly in Germany and France, and based on a variety of choices.

Pathophysiology, Side effects and contra-indications of fasting:

When internal toxin levels reach a threshold during an acute or chronic disease, an instinctive action of fasting, either “water fasting” or “Juice fasting” is indicated. The effect of fasting starts in a slow depletion of carbohydrate stores (mostly glycogen) within 12-24 hours. As the fasting continues for 3-4 weeks, the body fat metabolism and autolysis of protein begins. During that period, an increase in the levels of plasma growth hormone and adrenocoticotropin hormones and a decrease in the insulin level are noticed

As with any therapy, fasting may have some side effects such as headaches, weight loss, nutritional deficiencies, Weakness, muscle cramps and postural hypotension with dizziness (60). The development of these is increased with lengthy fasting (more than four days per week) and rarely serious side effects occur with fasting for three days or less per week (61).

Certain contraindications (62) in using detoxification method are summarised in Table 8.

-   Severely underweight patients (particularly in malnutrition).

-  Eating disorders (e.g. anorexia).

-  Metabolic diseases (e.g. diabetes mellitus).

-  Self-applied fasting without proper medical supervision, particularly in long       

    fasting (for more than 3 days per week).

-  Mental diseases (such as the hypochondriac patient with deep emotional                 

   disorder).

       - Pre- and post-operative conditions

       - Low immunity

 - Heart diseases (Congestive heart failure and Cardiac arrhythmia)

 - Digestive disorders such as ulcerative colitis, gastric and peptic ulcers.

- Severe bronchial asthma

- Others (such as terminal illness and Epilepsy)

Table 8. Contraindications of fasting in some conditions associated with hot flushes.

Through 14 years acupuncture experience, I have evolved a scientifically based method of fasting for elimination of impurities or “toxins”.  Fasting is known as a great natural healing therapy and a useful personal tool for many medical problems including hot flushes. It is a useful way to detoxify, but sometimes creates some difficulties particularly when the patient works and has a family to look after. A healthy diet (with inclusion and exclusion) is usually advised prior to fasting in order to achieve a better-tolerated detoxification. On non-fasting days, the patient should maintain a healthy diet to ensure good nutrition and also to help the cleansing process (Table 6, Table 7).

Fasting not only acts as an essential part of transformational medicine but also promotes relaxation by energizing the body, mind and emotions. There are some early transient fasting symptoms such as: headache (particularly during the first day or even the second) weakness, irritability, insomnia or bad dreams and dizziness. During the first week of two-day fasting, the body excretes the toxin and the general energy level declines with exaggeration of existing sign and symptoms. However, in the second week of fasting the patient usually feels better and more alive.

If the patient’s diet consists of red meat, dairy products, refined sugars and canned food the transition period for fasting must be few days longer than without in order to reduce the habit of intense cravings created by those type of foods.  Assurance of the patient is necessary that body will regain its efficiency afterwards by allowing better digestion and absorption of nutrients. 

The process of fasting is not only useful for occasional detoxification, but also assists the generation and regulation of body oestrogen. Through the following steps the detoxification can be achieved within 3- 4 weeks by fasting for any 2 days per week:

1.  No food or drink to take in that fasting day from 7 am to 7 p.m. except consuming:

     - a variety of raw, fresh, organic type of fruit (preferably apple with the skin)     

       or a fresh organic raw vegetables (preferably carrot). Fruits and vegetables are

       easily assimilated and require minimum digestion and metabolism, while they  

       supply many nutrients and stimulate the body to clear its waste- products.

- water (with no limit).

2. The fast should end after 7 p.m. by consuming:

     - one hand-size, medium thickness steak of chicken or turkey or fish      

       (Grilled or steamed) with good amount of green vegetable and 1-2 brown

        toasts.

- water (with no limit), camomile tea or herbal tea (2-3 cups).

During the period of detoxification the patient should continue with household duties or light office work but without extra physical exertion.

3. Life style (14, 63)

EXERCISES:

Physical activity can increase the concentration of endogenous oestrogen which contributes in the reduction of hot flushes (14) and can decrease the quantity of circulating follicular stimulating hormone  (FSH) and Luetinizing hormone  (LH) with an increase in the level of endorphin during the attack of hot flush. Recent research work on hot flushes indicated that physical exercise on a regular basis affects neurotransmitters, which regulate the central thermoregulation (64). In Sweden, Hammar and colleagues  (65) found that 50% of the physically active postmenopausal women have moderate-to-severe hot flashes. However, the study did not look at the physical activity level of the control group.

Therefore, all forms of regular exercises, daily or at least three or four times weekly, such as a 30-45  minutes (in 3 equal phases of 10-15 minutes) of brisk walking, might help to prevent or lessen hot flushes. However, patients who are planning an exercise programme should have a thorough check with their general medical practitioners.

RELAXATION

As emotional and mental stresses may trigger and increase the frequency of hot flushes, relaxation is a useful tool in increasing the emotional strength and in turn relieving and reducing the number of hot flush attacks (66, 67). Therefore, patients have several choices of methods used in relaxation and these are: Acupressure, the Alexander technique, Body Massage, Reflexology, Shiatsue and Yoga.

4. Other preventive measures:

Other useful suggestions given to patients with hot flushes are summarised in Table 9.

- avoid alcohol, hot drinks and drinking six glasses of purified water a day.

- avoid hot showers and baths and putting a clip-on fan in the vanity area to use

   while applying makeup or using the hairdryer.

- dress in layers of breathable cotton and using all-cotton sheets to avoid chafing.

- wear thin cotton or silk night-wear, sleeping with a fan overhead if possible, as          

   well as one by the bedside (clip-on fans work well) and placing a thermos of cool

   water by the bedside.

- Eliminate caffeine, especially afternoon caffeinated tea or coffee.

- Consider an increase of vitamin B complex, Vitamin C, calcium/magnesium and

   potassium intake which are depleted through excessive perspiration.

- Eat a healthy diet with early meal in the evening and avoid spicy foods, excess

   fat, refined sugar and foods high in additives and/or preservatives.

- Exercise (early in the day) and use a relaxation tape before bedtime.

- No cigarette smoking.

- Purify environments from the source of any toxic materials by removing: stored or

   leaking chemicals, dyes, paints, solvents, glues, acids, insecticides and cleaning  

   agents.

Table 9. Basic ways to avoid hot flushes

CLINICAL STUDY

This study involved twenty two cancer patients aged from 38 – 59 years range. All

had been diagnosed and referred by their consultant clinical oncologist for

acupuncture treatment of hot flushes. With exception of one patient, None of the rest

had previously received any form of acupuncture therapy. All patients had tried

various types of conventional therapy but either had temporary response or failed to

achieve any improvement in their hot flushes. The most significant problem for these

patients was the severity of hot flushes which disturbed their social activities and

sleeping pattern. The number and frequency of hot flushes episodes (day and night)

were recorded daily on the patient’s diary card. For each patient we noted the changes

in daytime and night time hot flushes between the first and last visit for acupuncture

treatment and the 3-5 week follow up  visit.

Acupuncture treatments were conducted at points selected according to

standardised acupuncture formulae, traditionally used for treatment of hot flushes.

The acupuncture needles were 3cm, 30 gauge solid disposable stainless steel needles.

The level to which the insertion of needles varied with the thickness of skin and

subcutaneous fatty tissues at the site of the acupuncture points. The therapeutic

effect was found to be at its best when the patient had a feeling of a needle sensation

of heaviness or numbness propagating along a variable distance from that site as

described in classical acupuncture literature (68) and previous research work (69, 70).

Generally, after 4-6 sessions of treatment (each session lasted for 20-30 minutes), a good result was usually obtained. However, the outcome was considered to be ineffective when there was no change in patient's clinical picture after receiving 8 sessions of treatment. The effective acupuncture points used in treatment of hot flushes were discussed earlier. The course of acupuncture therapy consists of 6-14 sessions based on two treatment sessions per week.

The assessment and Curative criteria:

During the whole study, patient’s hot flushes were recorded for number, intensity and timing. The patients were asked to write that down in a diary through out and at the end of the study period. The result was subjectively analysed and assessed before and at the end of the study period. The responses of patients to acupuncture and diet was determined by the followings:

1. NONE (Disappearance of hot flushes): patient's subjective signs and symptoms have disappeared completely following the treatment with no recurrence on the 3-5 weeks follow up visit.

2. MILD (Very Few hot flushes): patient's  subjective signs and symptoms have improved remarkably, but very few mild hot flushes attacks, each lasts for few seconds, may continue.

3. MODERATE (Moderate hot flushes): patient’s subjective sings and symptoms are largely alleviated, but the patient may still have frequent attacks of hot flushes, each lasts for 1-4 minutes.

4. NO CHANGE: patient’s subjective signs and symptoms remain unchanged and each hot flush may last longer than 4 minutes.

Discussion

Although there is no clearly defined treatment modality for breast cancer patients experiencing hot flashes in which oestrogen replacement is used with caution (6), alternatives are now available. Acupuncture is known to stimulate neuropeptide synthesis which control body functions such as cardiovascular physiology and hormonal secretions (71).  Wyon and colleagues (41) have carried out a scientific clinical research on twenty-four healthy women with natural menopause, suffering from hot flushes. These women were randomly assigned to two groups, one group received treatment with electro-acupuncture (EA), the other with superficial needle position (SNP) acupuncture. The results showed that the frequency of flushes decreased significantly by more than 50 per cent in both groups, and remained decreased in the EA group, whereas in the SNP group it increased slightly again over the three months after treatment.

Diet also plays an important role in preventing hot flushes, particularly when it is combined with acupuncture treatment.  Many types of foods, such as Soy containing considerable amounts of