Menopause is a Whole-Person Developmental Transition: An Overview of Menopause Information and Acupuncture Therapy Approaches to Symptom Management

Abstract

This proceeding summarizes a symposium on multidisciplinary menopause management held on April 13, 2024, as part of the American Academy of Medical Acupuncture’s 2024 conference. The workshop featured a presentation that integrated conventional medical perspectives and acupuncture therapy approaches to managing menopause symptoms. Topics included the stages of the menopausal transition, vasomotor symptoms, genitourinary syndrome of menopause, bone and cardiovascular health, and psychological well-being. The presentation also provided traditional Chinese medicine theories, pattern recognition in patient presentation, and evidence from clinical trials on acupuncture efficacy. In this study, we highlight the major points of the presentation.

INTRODUCTION

In April 2024, the American Academy of Medical Acupuncture (AAMA) annual symposium was held at the Radisson Blu Hotel Mall of America in Minneapolis, MN, with the theme “Embracing the Diversity of Acupuncture: Connecting People and Paradigms.” Several invited talks were presented, including the talk reviewed here: Menopause: There’s so much more to it than hot flashes and the Kidneys. The symposium included an overview of multidisciplinary approaches to managing menopause, including vasomotor symptoms and genitourinary syndrome of menopause, bone health (including osteoporosis, muscular strength, and mobility), and sexual and psychological health during menopause. In this report, we highlight the major points of the presentation.

BACKGROUND

It has been said that “menopause is having a moment.”^1,2 From President Biden’s Executive Order³ calling on Congress to make an investment of $12B in new funding for women’s health research and launching the White House Initiative of Women’s Health to many celebrities such as Oprah providing a Menopause Class⁴ and Drew Barrymore talking about menopause,⁵ we can see that menopause is active in public discourse. This activity is merited, as physicians^6,7 and advanced practice providers⁸ are undertrained in menopause medicine and many women who seek menopause care do not receive it.⁹ It is a serious situation when neither providers nor patients have a clear picture of what this important life transition is, as well as what evidence-based conventional and integrative therapeutics are safe and indicated for symptom management and disease prevention. It is also important to note that women are seeking integrative health and medicine interventions: Roughly half of women seek integrative health care for vasomotor symptom management^10,11 and acupuncture compared to usual care demonstrates moderate effect sizes in the treatment of vasomotor symptoms.¹² Thus, this talk was designed to provide an overview of the menopause transition stages and basics of conventional and scientific knowledge, followed by acupuncture therapy management of menopause symptoms.

PRESENTATION SUMMARIES

Conventional Care—Overview of Menopause

First off, it is important to note that the menopausal transition is a whole-person developmental transition. It is much more than solely the cessation of menses. Menopause is staged according to STRAW-10+ guidelines¹³ and the basics of the guidelines are presented here. Perimenopause refers to the stage in the menopause transition characterized by irregular menstrual cycles (early perimenopause) or 2–12 months of no menstrual bleeding (late perimenopause). During perimenopause ovarian function is declining but still present, and estrogen, progesterone, and androgens (testosterone) levels are fluctuating. Perimenopause typically occurs in women's 40 s, but for some, it may occur as early as in their 30 s. Perimenopausal symptoms and irregular menstrual bleeding may last anywhere between 4 and 10 years. Testing estrogen levels during perimenopause is unlikely to be helpful because of how variable estrogens are during this time—estrogen is not declining linearly. Last, it is important to keep in mind that symptoms might not be related to perimenopause. Other possible causes of a woman’s symptoms in their 30 s or 40 s could be thyroid disorder, diagnosed anxiety/depression, diabetes/insulin resistance or metabolic syndrome, high cholesterol, high prolactin levels, and underlying sleep disorder, among other conditions. Postmenopause begins after amenorrhea of 12 consecutive months and lasts for the rest of a woman’s life. Early post menopause is characterized by bothersome symptoms for many and 10–16% of postmenopausal women experience vasomotor symptoms into their 70 s.¹⁴

The menopausal transition may affect one or multiple systems of the body, ranging from pulmonary to digestive (see Table 1). Thus, it is important for clinicians to bear in mind that women may experience much more than hot flashes and night sweats. Other relevant and frequently reported symptoms include mood swings, lower sex drive, fatigue, anxiety, depression, lack of focus, poor concentration, incontinence, itchy or crawly skin, achy joints and muscles, headaches, digestive issues, allergies, weight gain, facial hair growth, changed body odor, burning of tongue/roof of the mouth, and more.¹⁵ An identified symptom cluster of menopause includes vasomotor symptoms (VMS, hot flashes, night sweats, sense of anxiety, and/or palpitations), pain (onset or worsening), sleep problems, mood (anxiety and/or depression), and cognitive problems.^16–18 With respect to VMS, duration varies by ethnicity, as reported by the Study of Women Across the Nation (SWAN): Japanese women experienced VMS an average of 4.8 years, White women 6.5 years, Hispanic women 8.9 years, and African American women 10.1 years.¹⁹

Table 1.

All Systems May Be Affected

Endocrine	Decline in estrogen and progesterone, increase in follicle-stimulating hormone and luteinizing hormone
Skeletal	Declining estrogens contribute to accelerated bone loss (osteopenia)
Muscular	Declining estrogens contribute to accelerated muscle loss (sarcopenia)
Nervous	Hormonal flux can lead to mood swings, sleep disturbances, memory issues
Cardiovascular	Changes in lipid profiles, blood pressure, increased cardiovascular risks
Integumentary	Helps regulate body temperature with the sympathetic nervous system, and is involved in vasomotor events
Lymphatic	Swollen lymph nodes are reported by some women
Respiratory	Fluctuating hormones can exacerbate preexisting asthma, allergies
Digestive	Fluctuating hormones can lead to bloating, indigestion, changes in bowel habits
Urinary	Fluctuating hormones can lead to increased urinary frequency, urgency, incontinence
Reproductive	Cessation of menses

VMS are important to manage to increase comfort in women but also because VMS may have negative health consequences. These consequences are far-ranging, from cardiometabolic to bone and cognitive diseases. VMS are associated with increased risk of hypertension, insulin resistance, and worsening lipid profiles.^20–22 A combined history of migraine and persistent VMS is associated with an increased risk for cardiovascular disease (CVD) and stroke, according to a recent analysis of women in the Coronary Artery Risk Development in Young Adults (CARDIA) study.²³ This is the first study to examine the joint influences of migraine and hot flashes/night sweats (vasomotor symptoms) independent of traditional heart disease risk factors and estrogen use. In fact, VMS may represent a novel female-specific CVD risk factor²⁴ as the American Heart Association indicates that menopause is a period of accelerated CVD risk.²⁵ VMS are also associated with decreased bone mineral density and increased risk of fractures.^26,27 Recent studies also demonstrate associations between VMS and Alzheimer’s disease (AD).²⁸ VMS during sleep, known as night sweats, are associated with lower levels of beta-amyloid 42/20 which is a component of the known biology of AD. Low beta-amyloid 42/40 ratios are associated with a clinical diagnosis of AD, although this does not mean a patient definitely has the disease.

Acupuncture Therapy—Theory and Research Overview

Theory

Chinese medicine theory related to menopause dates back to the Inner Canon of the Yellow Emperor which has been a fundamental doctrinal source for Chinese medicine for more than 2,000 years.²⁹ This book comprises two texts—each of 81 chapters or treatises in a question-and-answer format between the mythical Yellow Emperor and six of his equally legendary ministers. The Suwen (素問), also known as Basic Questions, covers the theoretical foundation of Chinese medicine and its diagnostic methods while the Lingshu (靈樞; Spiritual Pivot), discusses acupuncture therapy in detail. Within the Basic Questions, women’s aging is described in 7-year cycles. For example, at age 14, Qi and Blood fill the meridians, and menses or Tian Gui (天癸, heavenly fluid) begin. Girls in the 1920s experienced puberty at an average age of 14, however, girls these days start puberty between 8 and 13 years of age.³⁰ At age 49 menstruation ceases. This age is close to the modern average of menopause in the United States, at 51 years.¹⁵ Of clinical relevance to acupuncture therapy provision is that while menstruation has ceased, the Tian Gui is not completely absent. What remains of Tian Gui is directed toward the Heart. Blockage in the movement of Tian Gui to the Heart may result in palpitations, anxiety, or fatigue.³¹ Thus, facilitating the smooth flow of Tian Gui is an important task for acupuncture therapy to reduce these common symptoms during the menopausal transition and early postmenopause. This age is also said to be marked by the decline of Spleen function & Kidney Jing (Essence). The decline of Spleen function—described as digestion more broadly—is essential to consider when treating midlife women. Without the middle Jiao properly digesting food that supports the manufacture of Qi and Blood, then not only will women experience digestive symptoms, but the center will not fulfill its role of balancing the upper and lower Jiaos. This may lead to the disruption of the Kidney and Heart being harmonized, a pattern commonly seen among midlife women.

Also, of importance to the provision of correct acupuncture therapy for menopausal symptoms is clarity regarding physiological Heat and pathological Heat in the body. There are two sources of physiological Heat in the body: Sovereign Fire, which is Heart Fire in the chest, and Ministerial Fire which is at the Ming Men, situated between the Kidneys.³² Chaotic Ministerial Fire can flare up and irritate the chest, causing VMS. Acupuncture therapy would anchor or root the Ministerial Fire and reduce its flaring-up nature. Pathogenic Heat and Fire include external Heat that can invade the body and internal Heat can include pathogenic Heat harassing the Heart and Blood Heat. External Heat, in the form of Wind Heat, would be met with the Wei (Defensive) Qi, which governs the opening and closing of pores. People typically experience fever and chills, but fever (higher than normal core temperature) is physiologically distinct from vasomotor symptoms (increased sensitivity to external heat and cold, thus the temperature at which we chill or sweat changes, and thus a hot flash is due to the narrowing of this thermoregulatory zone).³³

Research

Quite a lot of research has been conducted on acupuncture therapy for VMS. In fact, a recent search in PubMed for acupuncture AND vasomotor delivers some 162 results, and this reduces to 82 records when adding menopause to the search, dating 1994–present. A brief overview of major randomized controlled trials (RCTs) includes three major trials: 1.

2009 ACUFLASH³⁴ study randomized 267 postmenopausal women (Norway) to receive 10 weekly acupuncture treatment sessions + education (individualized) or education alone (control). The primary outcomes include greater hot flash frequency reduction (p < 0.001) and greater hot flash intensity reduction (p < 0.001) in the acupuncture group compared to the control. A secondary data analysis revealed that the most commonly used acupoints (regardless of syndrome diagnosed) were SP6 (Sanyinjiao), HT6 (Yinxi), KI6 (Zhaohai), KI7 (Fushou), CV4 (Guanyuan), LU7 (Lieque), LI4 (Hegu), LV3 (Taichong), ST36 (Zusanli), KI3 (Taixi).³⁵

2016 AIM³⁶ study (USA) randomized 209 peri- or postmenopausal women to receive 6 months of acupuncture (individualized) or waitlist control. Among those who received acupuncture, VMS decreased by 36.7% and increased by 6.0% in the control group (p < 0.001). At 12 months, the reduction from baseline in the acupuncture group was 29.4% when compared to controls (p < 0.001).

2019 ACOM³⁷ study (Denmark) 70 women with moderate/severe VMS were randomized to either acupuncture therapy for 5 weekly sessions or wait list control. Acupuncture protocol was associated with significantly reduced hot flushes (p < 0.001), and day and night sweats (p = 0.0056) compared to the wait list control group. The protocol consisted of CV3 (Zhongji), CV4 (Guanyuan), LR8 (Ququan), SP6 (Sanyinjiao), and SP9 (Yinlingquan).

The most recent meta-analysis of acupuncture for VMS included an umbrella systematic review which included three systematic reviews and four RCTs.¹² Acupuncture compared to usual care reduces VMS frequency with a moderate effect size (standardized mean differences [SMD] −0.66, 95% CI, −1.06 to −0.26, I2 = 61.7%, 5 trials) and VMS severity (SMD −0.49, 95% CI −0.85 to −0.13, I² = 18.1%, 4 trials). Acupuncture compared to sham acupuncture SMDs were smaller or not statistically significant.

Acupuncture Therapy—Pattern Recognition Overview

One may apply general pattern recognition to peri and postmenopausal cases when determining the correct course of treatment. Given that the transition is a whole-person phenomenon, assessment of symptoms and signs is a particularly good fit with acupuncture therapy. That being said, here are several helpful tables to consider, according to the time of day or night that the VMS occurs. This is one way to organize one’s thinking, and of course, consider the whole clinical picture and adjust accordingly.

Morning VMS

One may consider deficiency in the center, with Spleen and Stomach being dysregulated (Table 2). Typically, women will present with digestive symptoms and associated pale complexion, weakness, and fatigue that is commonly seen with Spleen Qi deficiency. The Spleen/Stomach times are 7–11 am and thus correspond timing-wise for VMS. Of note is spontaneous sweating (sweating for no reason), common when the Spleen is deficient, and Qi is unable to hold the pores in check and thus sweat pours out. See Table 2 for acupoints to consider for acupuncture therapy.

Table 2.

Morning Vasomotor Symptoms

Spleen/stomach Qi deficiency	Acupuncture points to consider
Clinical manifestations, pulse, tongue
Temperature: Hot flashes worse in the morning, spontaneous sweating	BL20 (Pishu)
Other: Fatigue, weak limbs, pale complexion	BL21 (Weishu)
Tongue: Pale	CV6 (Qihai) and CV12 (Zhongwan)
Pulse: Weak or fine	ST36 (Zusanli)
	CV14 (Juque)

Afternoon VMS

When considering afternoon VMS, the most common presentations are Yang Ming excess or Blood Stasis (also an excess condition). The main differentiating factors are whether there are corresponding classical Yang Ming symptoms such as constipation, red tongue with a yellow, dry coat, and/or a deep, forceful pulse. Blood Stasis commonly presents with clotty, dark red menstrual fluid which may be accompanied by pain, a choppy pulse, mental restlessness and possibly high blood pressure, insomnia, and/or musculoskeletal pain. See Table 3 for acupoints to consider for acupuncture therapy.

Table 3.

Afternoon Vasomotor Symptoms

Clinical manifestations, pulse, tongue	Acupuncture
Yang Ming excess
Temperature: Constant heat but hot flashes more severe in the afternoon (3–5 pm), hands and feet sweating	ST44 (Neiting)
Temperature: Agitated, irritable	LI4 (Hegu)
Gastrointestinal (GI): History of constipation, dry stools, difficult bowel movements. Abdominal distension, pain	LI11 (Quchi)
Other: Stagnation in the GI; may co-occur with Spleen Qi deficiency	LI6 (Pianli)
Tongue: Dry, yellow coat. Red body	ST36 (Zusanli)
Pulse: Deep, forceful	BL25 (Dachangshu)
	GV14 (Dazhui)
	PC5 (Jianshi)
Blood stasis
Temperature: Hot flashes worse in the afternoon	BL17 (Geshu)
Temperature: Mentally restless, irritable	CV3 (Zhongji)
Temperature: Abdominal pain, dry mouth	SP6 (Sanyinjiao), SP8 (Diji), and SP10 (Xuehai)
Gynecological history: Irregular periods, dark and clotty menstrual fluid	LI4 (Hegu)
Other: Insomnia, high blood pressure, musculoskeletal pain	LIV3 (Taichong)
Tongue: Purplish, bluish, possibly stasis dots	GV20 (Baihui)
Pulse: Choppy, rough	HT7 (Shenmen)

Evening and night VMS

Several key distinctions can be made between patterns of evening or night VMS. Overall, this is a time when Kidney and/or Heart may reveal dysregulation. Specifically, when Heart Yin and Blood are deficient, there is insufficient substance to hold and calm the Heart Shen (Spirit), manifesting as possible palpitations, insomnia, and 5-palm heat (hands, feet, center of the chest). When Kidney Yin is deficient, dry mouth, depression, anxiety, pale urine, dizziness, vertigo, poor hearing, achy bones, and/or poor memory may be seen. Lastly, when Kidney and Heart are disharmonized, both Kidney signs like achy back, dizziness, and tinnitus, as well as Heart signs (palpitations, poor memory) will be seen. This is a pattern of Tian Gui not flowing smoothly from the Kidneys to the Heart, and regulating this pathway between organs is essential for a patient to realize the full potential of the menopausal transition: nourishment of the Heart by Tian Gui. See Table 4 for acupoints to consider for acupuncture therapy.

Table 4.

Evening or Night Vasomotor Symptoms

Clinical manifestations, pulse, tongue	Acupuncture points to consider
Heart Yin and blood deficiency
Temperature: Intermittent waves of low-grade heat, 5 palm heat, night sweats	LU10 (Yuji)	CV6 (Qihai), CV14 (Juque)
Chest: Heart vexation, palpitations	SP6 (Sanyinjiao)	GV14 (Dazhui)
Other: Insomnia. Symptoms are worse in afternoon → night	HT7 (Shenmen), HT8 (Shaofu)	BL15 (Xinshu)
	KD2 (Rangu), KD3 (Taixi)	BL17 (Geshu), BL20 (Pishu)
	KD6 (Zhaohai)	BL24 (Qihaishu)
	PC5 (Jianshi), PC6 (Neiguan)
	LV3 (Taichong)
Kidney Yin deficiency
Temperature: Night sweats, sensation of heat, dry mouth at night, hot flashes/flushes	LI4 (Hegu)	CV4 (Guanyuan)
Psychological: Depression, anxiety	SP6 (Sanyinjiao)	GV20 (Baihui)
Other: Pale urine. Dizziness or vertigo. Poor memory, hearing problems, low back pain, achy bones, fatigue	HT7 (Shenmen)	BL23 (Shenshu)
Tongue: Normal body, without coating; red in severe cases	KD3 (Taixi)
Pulse: Weak Kidney positions, floating empty	KD6 (Zhaohai)
	LV3 (Taichong)
Kidney and Heart not harmonized
Temperature: Hot flashes, night sweats, malar flush, evening heat	LI4 (Hegu)	GV20 (Baihui)
Chest: Palpitations	SP6 (Sanyinjiao)	GV14 (Dazhui)
Psychological: Mental restlessness, poor memory, anxiety	HT7 (Shenmen)	GV24 (Shenting)
Gastrointestinal: Dry stools	KD1 (Yongquan)	BL15 (Xinshu)
Pain: Backache	KD3 (Taixi)	BL23 (Shenshu)
Other: Insomnia, blurry vision, dizziness, tinnitus, dry mouth	PC7 (Daling)
Tongue: Red, without coating, redder tip	PC8 (Laogong)
Pulse: Rapid, fine, floating or deep (especially chi position)	LV3 (Taichong)

CLOSING

The symposium ended with a robust question-and-answer session that highlighted the complexities and nuances of menopausal transition symptoms and management. In conclusion, the Menopause: There’s so much more to it than hot flashes and the Kidneys symposium provided an overview of what menopause and the menopausal transition are, associated symptoms, and disease risks, as well as insights into acupuncture therapy, approaches to the management of menopause symptom presentations. This workshop provided a platform to educate the audience on menopause-related topics affecting the health of women.

Footnotes

ACKNOWLEDGMENTS

The author is grateful to the AAMA staff and board for their efficient organization and smooth conduct of the 2024 AAMA conference.

AUTHORS’ CONTRIBUTIONS

L.T.-S. conceived of, wrote, and edited the manuscript.

AUTHOR DISCLOSURE STATEMENT

The author has no conflict to declare.

FUNDING INFORMATION

No funding was received for this article.

References

Dominus

. Women Have Been Misled About Menopause. The New York Times, 2023.

Stevis-Gridneff

. The Daily. Menopause is Having a Moment, 2023.

Biden

. FACT SHEET: President Biden Issues Executive Order and Announces New Actions to Advance Women’s Health Research and Innovation. The White House. Available from: https://www.whitehouse.gov/briefing-room/statements-releases/2024/03/18/fact-sheet-president-biden-issues-executive-order-and-announces-new-actions-to-advance-womens-health-research-and-innovation/ [Last accessed: September 2, 2024].

Daily

. Menopause Curriculum. Available from: https://www.oprahdaily.com/menopause-class/ [Last accessed: August 20, 2024].

Show

TDB

. Take Care Everywhere - Menopause Edition with Gabrielle Union & Dr. Kameelah Phillips. August 5, 2024. Available from: https://www.thedrewbarrymoreshow.com/episode/august-5-2024-take-care-everywhere-menopause-edition-with-gabrielle-union-dr-kameelah [Last accessed: September 3, 2024].

Allen

, Laks

, Zahler-Miller

, et al. Needs assessment of menopause education in United States obstetrics and gynecology residency training programs. Menopause, 2023; 30(10):1002–1005; doi: 10.1097/GME.0000000000002234

Kling

, MacLaughlin

, Schnatz

, et al. Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: A Cross-Sectional Survey. Mayo Clin Proc, 2019; 94(2):242–253; doi: 10.1016/j.mayocp.2018.08.033

Manson

, Kaunitz

. Menopause management–getting clinical care back on track. N Engl J Med, 2016; 374(9):803–806; doi: 10.1056/NEJMp1514242

Bonafide. State of Menopause Survey. Available from: https://cdn.shopify.com/s/files/1/0011/8590/6751/files/Bonafide_State_of_Menopause.pdf?v=1624280664 [Last accessed: May 22, 2021].

10.

Johnson

, Roberts

, Elkins

. Complementary and alternative medicine for menopause. J Evid Based Integr Med, 2019; 24:2515690X19829380; doi: 10.1177/2515690X19829380

11.

NRC Health UoUM. An NRC Health Community Insights Study: University of Utah Menopause Program; 2024.

12.

Befus

, Coeytaux

, Goldstein

, et al. Management of menopause symptoms with acupuncture: An umbrella systematic review and meta-analysis. J Altern Complement Med, 2018; 24(4):314–323; doi: 10.1089/acm.2016.0408

13.

Harlow

, Gass

, Hall

, et al.; STRAW + 10 Collaborative Group. Executive summary of the stages of reproductive aging workshop + 10: Addressing the unfinished agenda of staging reproductive aging. J Clin Endocrinol Metab, 2012; 97(4):1159–1168; doi: 10.1210/jc.2011-3362

14.

Huang

, Grady

, Jacoby

, et al. Persistent hot flushes in older postmenopausal women. Arch Intern Med, 2008; 168(8):840–846; doi: 10.1001/archinte.168.8.840

15.

Aging NIo. What is menopause? National institute on aging. Available from: https://www.nia.nih.gov/health/menopause/what-menopause#symptoms [Last accessed: August 15, 2024].

16.

Harlow

, Karvonen-Gutierrez

, Elliott

, et al. It is not just menopause: Symptom clustering in the study of women’s health across the Nation. Womens Midlife Health, 2017; 3:3; doi: 10.1186/s40695-017-0021-y

17.

Cray

, Woods

, Mitchell

. Symptom clusters during the late menopausal transition stage: Observations from the Seattle Midlife Women’s Health Study. Menopause, 2010; 17(5):972–977; doi: 10.1097/gme.0b013e3181dd1f95

18.

Cray

, Woods

, Herting

, et al. Symptom clusters during the late reproductive stage through the early postmenopause: Observations from the Seattle Midlife Women’s Health Study. Menopause, 2012; 19(8):864–869; doi: 10.1097/gme.0b013e31824790a6

19.

Avis

, Crawford

, Greendale

, et al.; Study of Women’s Health Across the Nation. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med, 2015; 175(4):531–539; doi: 10.1001/jamainternmed.2014.8063

20.

Thurston

, El Khoudary

, Sutton-Tyrrell

, et al. Vasomotor symptoms and lipid profiles in women transitioning through menopause. Obstet Gynecol, 2012; 119(4):753–761; doi: 10.1097/AOG.0b013e31824a09ec

21.

Jackson

, El Khoudary

, Crawford

, et al. Hot flash frequency and blood pressure: Data from the study of women’s health across the nation. J Womens Health (Larchmt), 2016; 25(12):1204–1209; doi: 10.1089/jwh.2015.5670

22.

Thurston

, Chang

, Barinas-Mitchell

, et al. Menopausal hot flashes and carotid intima media thickness among midlife women. Stroke, 2016; 47(12):2910–2915; doi: 10.1161/STROKEAHA.116.014674

23.

Kim

, Schreiner

, Yin

, et al. Migraines, vasomotor symptoms, and cardiovascular disease in the coronary artery risk development in young adults study. Menopause, 2024; 31(3):202–208; doi: 10.1097/GME.0000000000002311

24.

Thurston

, Aslanidou Vlachos

, Derby

, et al. Menopausal vasomotor symptoms and risk of incident cardiovascular disease events in SWAN. J Am Heart Assoc, 2021; 10(3):e017416; doi: 10.1161/JAHA.120.017416

25.

El Khoudary

, Aggarwal

, Beckie

, et al.; American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention; and Council on Cardiovascular and Stroke Nursing. Menopause transition and cardiovascular disease risk: Implications for timing of early prevention: A scientific statement from the American heart association. Circulation, 2020; 142(25):e506–e532; doi: 10.1161/CIR.0000000000000912

26.

Gast

, Grobbee

, Pop

, et al. Vasomotor symptoms are associated with a lower bone mineral density. Menopause, 2009; 16(2):231–238; doi: 10.1097/gme.0b013e318185e25b

27.

Crandall

, Aragaki

, Cauley

, et al. Associations of menopausal vasomotor symptoms with fracture incidence. J Clin Endocrinol Metab, 2015; 100(2):524–534; doi: 10.1210/jc.2014-3062

28.

Thurston

, Wu

, Chang

, et al. Menopausal vasomotor symptoms and white matter hyperintensities in midlife women. Neurology, 2023; 100(2):e133–e141; doi: 10.1212/WNL.0000000000201401

29.

. The yellow emperor’s classic of medicine: A new translation of the neijing suwen with commentary. Shambhala, 1995:336.

30.

Baby

, Ilkowitz

, Cheema Brar

. Impacts of the COVID-19 pandemic on the diagnosis of idiopathic central precocious puberty in pediatric females in New York City. J Pediatr Endocrinol Metab, 2023; 36(6):517–522; doi: 10.1515/jpem-2022-0628

31.

Maciocia

. The Foundations of Chinese Medicine. Churchill Linvingstone; 1989.

32.

Rosenberg Ze. Afterglow: Ministerial Fire and Chinese Ecological Medicine. Singing Dragon; 2023.

33.

Freedman

, Krell

. Reduced thermoregulatory null zone in postmenopausal women with hot flashes. Am J Obstet Gynecol, 1999; 181(1):66–70.

34.

Borud

, Alraek

, White

, et al. The acupuncture on hot flushes among menopausal women (ACUFLASH) study, a randomized controlled trial. Menopause, 2009; 16(3):484–493; doi: 10.1097/gme.0b013e31818c02ad

35.

Borud

, Alræk

, White

, et al. The acupuncture treatment for postmenopausal hot flushes (Acuflash) study: Traditional Chinese medicine diagnoses and acupuncture points used, and their relation to the treatment response. Acupunct Med, 2009; 27(3):101–108; doi: 10.1136/aim.2009.000612

36.

Avis

, Coeytaux

, Isom

, et al. Acupuncture in Menopause (AIM) study: A Pragmatic, Randomized Controlled Trial. Menopause, 2016; 23(6):626–637; doi: 10.1097/GME.0000000000000597

37.

Lund

, Siersma

, Brodersen

, et al. Efficacy of a standardised acupuncture approach for women with bothersome menopausal symptoms: A Pragmatic Randomised Study in Primary Care (the ACOM study). BMJ Open, 2019; 9(1):e023637; doi: 10.1136/bmjopen-2018-023637