Articles
Stellate ganglion blockade provides multiple weeks relief from
menopausal hot flashes: Case Report Series
Running Title: Sympathetic blockade relieves hot flashes
Authors: Eugene Lipov, MD(1), Sergei Lipov, MD(2), and Jamie T. Stark, PhD(3)
1. Advanced Pain Centers, S.C.
519 N. Cass Ave.
Westmont, IL 60559
Phone: (877) 964-7246
Fax: (877) 742-8495
elipovmd@aol.com
2. Internamed
1975 Lin Lor Lane
Elgin, IL 60123
Phone: (847) 608-7542
Fax: (847) 608-9812
3. Athletic and Therapeutic Institute
1630 W Beach
Chicago, IL 60622
Phone: (217) 390-2002
Fax: (815) 577-9938
jamie.stark@atipt.com
*Corresponding Author, Address for reprint requests
Abstract
Objective: To investigate whether standard C6 stellate ganglion blockade
might provide relief from hot flashes associated with menopause.
Design: Six women were referred for severe menopausal hot flashes and
elected undergo standard stellate ganglion block (0.375% marcaine, 5cc) to evaluate a
novel intervention for hot flash relief. Hot flashes were assessed by self-reporting pre
and post stellate ganglion block.
Results: Initial stellate ganglion block was successful in all six subjects as
evidenced by a positive Horner’s syndrome and anhydrosis. Successful stellate
ganglion block resulted in complete alleviation of hot flashes for times ranging from
2-5 weeks. Patients returned for follow-up stellate ganglion block after mild hot
flashes returned. A second stellate ganglion block produced additional asymptomatic
periods of relief ranging from 4-18 weeks. In each case repeated block provided hot
flash relief equal to or greater than that of the initial block. Two patients who
submitted for a third stellate ganglion block reported 15 and 48 weeks relief.
Conclusion: Successful stellate ganglion block appear to be related to relief
of hot flashes. Repeat stellate ganglion block results in efficacious multiple week
relief of severe hot flashes associated with menopause.
Key Words: Menopause – Hot Flashes – Stellate Ganglion Block.
Introduction
Hot flashes are the most common symptom associated with menopause and
have been reported to occur in 68-82% of naturally menopausal women(1). Surgical
menopause is associated with an increased incidence and severity of hot flashes
compared to natural menopause(2). As reviewed by Freedman1 surgical menopause
results in hot flash incidence as high as 90%. Hot flashes have been reported in 21%,
30%, and 36% of women during premenopause, menopause, and postmenopause
respectively(2). Importantly, these results were reported in women not taking hormone
therapy, for whom symptoms are likely to be minimal. Independent of etiology, in
symptomatic women, hot flashes have been reported to occur daily in as many as
87% and over 1/3 of these women reported more than 10 hot flashes per day(3). Hot
flashes have been reported to occur as early as 2 years prior to menopause and
upwards of 50% of women experience hot flashes for up to 5 years. In addition, a
small subset of women experience hot flashes for the duration of their life (reviewed
in 4). Hot flashes are the most common reason women seek hormone therapy(5).
Although hormone therapy results in an 80-90% reduction in the occurrence of hot
flashes in symptomatic women, complications with hormone therapy include
headache, nausea, water retention, premenstrual irritability, and withdrawal vaginal
bleeding, all of which affect quality of life(6). In fact, withdrawal bleeding is the most
common reason women discontinue hormone therapy(7). Additionally, the fear of
cancer has been reported to cause apprehension towards beginning hormone therapy,
as well as has been listed as a major reason for discontinuing hormone therapy(8). Also
of note, hormone therapy use has decreased since the Women’s Health Initiative
(WHI) reported conflicting results regarding the efficacy of hormone therapy(9). These
factors have led women to seek out alternative, non-hormone based therapies for hot
flash relief.
Recent reviews of non-hormonal treatments for hot flashes concluded that
phytoestrogens and black cohosh are both ineffective in providing symptomatic relief
and potentially dangerous(4, 6, 10, 11). Other methods (including lifestyle intervention and
vitamin E therapy) are only marginally more effective at relieving hot flashes than
placebo. The most promising non-hormonal therapy, selective serotonin reuptake
inhibitors (SSRIs), have been reported to reduce hot flash scores (reviewed in 11),
however, SSRIs appear to be much less effective than hormone therapy. The above
factors highlight the need for novel, non-hormone based therapies for hot flash relief.
Hot flashes are marked by sweating in the face, head, neck, and chest and
generally last 1-5 min. Symptomatically, hot flashes present similar to hyperhidrosis,
a condition for which sympathectomy has been successfully used as treatment(12).
Because hot flashes typically occur during a discrete time frame surrounding the
menopausal period, sympathetic block may provide a non-hormonal alternative for
hot flash relief during the symptomatic period, without removal of any sympathetic
ganglia. Thus we hypothesized that a sympathetic block at the level of the stellate
ganglion would provide relief from severe hot flash associated with menopause.
Methods
Participants
Six menopausal women (ages 48-58 yrs) with severe hot flashes were
included in this case study. Women were referred by their gynecologist for
evaluation of stellate ganglion block as an intervention for hot flash relief.
Participation in the study group was elective and all women provided written consent.
Women who were currently sick, on hormone therapy, had a blood clotting disorder,
or had an American Society of Anesthesiologists (ASA) physical status score of P3 or
higher were excluded from the study (P1= no disease, P2=mild (one systemic
disease), P3=moderate (more than 1 systemic disease), P4=severe disease, P5=life
threatening disease).
Procedures
Patients underwent a standard stellate ganglion block performed on the
anteriolateral aspect of the C6 vertebra on the right side. Current indications for
stellate ganglion block include complex regional pain syndrome 1 or 2 of the upper
extremities, atypical facial pain, and complex regional pain syndrome 1 or 2 of the
chest. The use of stellate ganglion blocks in the current study may be considered by
some to be ‘off-label’ usage of this approved technique, however, no information
clarifying this issue could be located on the FDA website. Therefore, the authors
contend that stellate ganglion blocks should only be performed by board certified
anesthesiologists with visualization via fluoroscopy.
Briefly, following local analgesia (lidocaine 2%), 2cc of Iohexol (180mg/mL,
Omnipaque) was injected to visualize the ganglion and confirm needle placement via
radiography. 5cc of 0.375% marcaine was then injected into the stellate ganglion to
produce a sympathetic block. Efficacy of the stellate ganglion block was confirmed
by the presence of Horner’s syndrome and anhydrosis (absence of facial sweat).
Horner’s syndrome consists of enophthalmos (sinking of the eyeball into its cavity),
ptosis (droopy upper eyelid), swelling of the lower eyelid, miosis (abnormal
contraction of the pupil), and heterochromia (difference in eye color). All these signs
signify block of the sympathetic nervous system as it supplies the eye on the effected
side of the head. Stellate ganglion block carries the risk of infection, bleeding,
seizures, spinal cord trauma, however all can be effectively minimized with the use of
contrast dye and fluoroscopic guidance.
Analysis of Self-Reporting
Information regarding frequency and severity of hot flashes before and
following stellate ganglion block was obtained via consultation with the
anesthesiologist (Dr. E. Lipov). Patient’s symptoms were self-monitored and patients
resubmitted for additional stellate ganglion block when hot flashes elevated past a
level considered ‘mild’. Mild hot flashes were defined by the patient. Moderate to
severe hot flashes were defined as 7-10 hot flashes per day that caused interruption of
daily activities. All women in this study experienced more than 10 hot flashes per
day. Four of six women reported two or more hot flashes during the night that
interrupted sleep. Patients were called prior to submission of the manuscript to
confirm current relief status. The data contained in this manuscript are the result of
an extended case study in 6 individuals and should be interpreted as such.
Results
Stellate Ganglion Block
Patient information and the results of stellate ganglion block are presented in
Table 1. Initial stellate ganglion block (SGB1) was successful in all six patients as
evidenced by a positive Horner’s syndrome and anhydrosis. Repeat stellate ganglion
block (SGB2) was successful in five of six patients. Patient 2 displayed a delayed
Horner’s syndrome and lack of anhydrosis following SGB2, indicating the lack of a
successful stellate ganglion block, and thus serving as an internal control. Patient 2
submitted for an additional stellate ganglion block (SGB3). SGB3 produced a
positive Horner’s and anhydrosis indicating a successful stellate ganglion block.
Relief of Hot Flash Symptoms
The effects of stellate ganglion block on relief of hot flashes are summarized
in Table 2. Relief effects were present on the day of block. Patients experiencing
interrupted sleep all reported cessation of these problems beginning on day 1 of
treatment. For all patients, SGB1 resulted in asymptomatic periods of 2-5 weeks,
followed by a period of intermittent relief. Patients resubmitted for follow-up stellate
ganglion block (SGB2) at their discretion (i.e. when subjective hot flash symptoms
elevated past ‘mild’). Successful SGB2 resulted in asymptomatic periods of 4-18
weeks, all of which were equal to or greater than the period of relief following SGB1.
Patient 2, in whom SGB2 was unsuccessful, did not experience any relief of hot flash
symptoms following the procedure. A third block (SGB3) was successful in Patient 2
and has provided 15 weeks of symptomatic relief to date. Thus, Patient 2 provided an
internal control for this study demonstrating that successful stellate ganglion block is
requisite for hot flash relief. Patient 5 also underwent SGB3 and reported 48 weeks
of asymptomatic relief. We do not believe that stellate ganglion block ‘cured’ this
patient’s hot flashes, but assume that the extended relief period overlapped with the
natural time course of hot flash cessation in this patient.
Discussion
The present case study demonstrates that stellate ganglion block produces
significant relief of severe hot flashes associated with menopause. The data
contained in this manuscript represent an extended case study with 6 individuals.
Although the patient population is small and homogeneous, these results provide a
basis for investigation of stellate ganglion block as a non-hormonal treatment strategy
for women who suffer from severe menopausal hot flashes. As a stellate ganglion
block may be considered by some to be ‘invasive’, the authors suggest that this
intervention strategy be reserved for women in whom hormone therapy is
contraindicated.
Hot flashes are the most common symptom associated with menopause
occurring in 68-82% of naturally menopausal women1 and upwards of 90% of
surgically menopausal women(1). For women averse to hormone therapy (or in women
whom hormone therapy is contraindicated) there are few options. The overwhelming
evidence suggests that herbal remedies do not provide relief above that of placebo
and lifestyle interventions are only moderately more effective than placebo (reviewed
in 4, 6, 10, 11). Although SSRIs have proven to be moderately effective (reviewed in 11),
women with severe hot flashes need viable alternatives that provide adequate
symptomatic relief.
Given the marked similarity in symptomatic presentation of hyperhidrosis and
hot flashes and the effectiveness of sypathectomy for relief of hyperhidrosis, we
investigated the possibility that stellate ganglion block would provide relief from hot
flashes for significant durations of time. Our results demonstrate effective relief from
severe hot flashes in menopausal women. Stellate ganglion block produced an
asymptomatic period ranging from 2-5 weeks followed by a period of ‘mild’
symptoms lasting and additional 1-4 weeks. Additionally, repeated stellate ganglion
block produced equal or greater periods of relief. To our knowledge, no previous
reports exist investigating stellate ganglion block for relief of menopausal hot flashes.
One case study describes the use of stellate ganglion block to relieve similar
symptoms in a male. Hendy and colleagues(13) reported a case of a 77-year-old male
presenting with severe episodes of flushing and sweating following testicular infarct.
In this case study stellate ganglion block reduced the frequency and severity of these
events.
The actual mechanism responsible for hot flashes remains elusive, although
significant progress has been made. According to Freedman(1, 14, 15) Hot flashes likely
result from a narrowing of the thermoneutral zone, which increases the susceptibility
of the heat dissipation response to small fluctuation in core temperature (Tc). The
thermoneutral zone is the area where Tc fluctuates between the shivering threshold
and sweat threshold. Hot flashes are preceded by a rise in Tc that begins
approximately 17 min prior to that actual hot flash. During and following the hot
flash, at which point Tc crosses the sweat threshold, sweat rates increase. Following
the heat dissipation response Tc falls below the sweat threshold and re-enters the
thermoneutral zone. Often, Tc falls below the shivering threshold causing reflex
shivering and further illustrating the reduced size of the thermoneutral zone. Hot
flash frequency varies according to a circadian oscillation with a nadir in the morning
hours and a peak in the late afternoon.
Current evidence suggests that norepinephrine plays a central role in the
etiology of hot flashes. Freedman(15) demonstrated an increase in plasma 3-methoxy-4-
hydroxyphenylglycol (the main metabolite of central norepinephrine) levels following
hot flashes. Estrogen, the most potent anti-hot flash agent, has been shown to
increase hypothalamic norepinephrine(16). Drummond(17) reported relief of facial
temperature elevations and sweating in 9 patients with reflex sympathetic dystrophy
following stellate ganglion block, indicating the passage of sympathetic vasodilator
fibers through the stellate ganglion. Ikeda et al(18) reported the relief of climacteric
psychosis following stellate ganglion block with a concomitant decrease in plasma
norepinephrine. In the current study, stellate ganglion block ameliorated hot flashes
in menopausal women. Taken together these data suggest that the stellate ganglion
may be involved in the mechanisms controlling hot flashes.
Conclusion
Current evidence suggests that the most effective intervention for relief of hot
flashes associated with menopause is hormone therapy, however, hormone therapy is
associated with adverse side effects and has come under scrutiny following the results
of the WHI study. Given the lack of efficacy associated with ‘herbal’ remedies and
the limited results utilizing non-hormone drug therapies (e.g. SSRIs), the current
study presents a novel non-hormone based intervention for severe hot flash relief.
Our results demonstrate significant immediate relief of hot flashes following stellate
ganglion block. In addition, multiple week relief of severe menopausal hot flashes
was accomplished following repeat stellate ganglion block.
These results suggest additional research to evaluate the efficacy of this
treatment strategy. Ideally, a randomized controlled trial including placebo injections
and extensive symptom reporting to produce Level 1 evidence should be conducted to
accept or refute the results of this multiple case study. At this point we cannot
recommend the adoption of this methodology in practice until further studies have
been conducted. Stellate ganglion block does carry associated risk, however these
can be effectively avoided by the use of C-arm Fluoroscopy by board certified
anesthesiologists.
Acknowledgments
Manuscript preparation was supported by the Athletic and Therapeutic
Institute.
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