Bromhidrosis treatment modalities: A literature review.

BACKGROUND: Treatment options for Bromhidrosis include botulinum toxin therapy, microwave-based therapy, laser therapy, and surgical intervention. Limited studies compare their efficacies. OBJECTIVE: The purpose of this literature review is to compare the efficacy and safety of these treatments for bromhidrosis. METHODS: A PubMed search included terms bromhidrosis and bromhidrosis AND treatment. RESULTS: A total of 25 articles were reviewed. Botulinum toxin therapy shows consistent benefit but requires repeated therapies. Microwave therapies have shown promising results but require larger cohort sizes with bromhidrosis. Similarly, laser therapy has shown promise with biopsy-proven results, but long-lasting effects remain unknown. Surgery has the best long-term prognosis, but the ideal surgical method remains unknown. LIMITATIONS: Each study varied in their treatment interval and method of assessing bromhidrosis, making direct comparisons difficult. CONCLUSIONS: Managing bromhidrosis requires shared decision making with the patient. Mild-to-moderate symptoms may be treated initially with botulinum toxin therapy. In cases that are refractory, laser therapy should be considered, as it is better studied than microwave therapy currently. Lastly, if the condition is severe and refractory to other options, surgery can be considered, although the ideal method remains unknown.

Women's views about physical activity as a treatment for vasomotor menopausal symptoms: a qualitative study.

BACKGROUND: Women commonly seek medical advice about menopausal symptoms. Although menopausal hormone therapy is the most effective treatment, many women prefer non-pharmacological treatments, such as physical activity. The effectiveness of physical activity has been inconclusive when assessed by randomised controlled trials, and it remains unclear how women feel about it as a possible treatment approach. The aim of the study was to explore symptomatic menopausal women's views and experiences of physical activity as a treatment for vasomotor and other menopausal symptoms. METHODS: An in-depth qualitative study was embedded within a randomised controlled trial that assessed the effectiveness of physical activity as a treatment for vasomotor menopausal symptoms in previously inactive vasomotor symptomatic women. Participants were randomised to one of two physical activity interventions or a usual care group. Both physical activity interventions involved two one-to-one consultations, plus either supporting materials or access to physical activity support groups, over 6 months. Semi-structured interviews were conducted with 17 purposively selected participants from all three trial groups after they had completed trial follow-up. Interviews were audio recorded, transcribed verbatim, and analysed by constant comparison. RESULTS: All participants talked positively about physical activity as a treatment for their menopausal symptoms, with most reporting participation had improved their hot flushes and night sweats. They reported that they had experienced improved sleep, physical health and psychological well-being. Those who received the physical activity plus social-support intervention reported their ability to cope with their menopausal symptoms had improved. Many participants commented that they would prefer doctors to discuss physical activity as a possible treatment for their hot flushes and night sweats, before offering medication. CONCLUSIONS: Based on the views and experiences of the women who participated in this study, healthcare professionals should continue discussing physical activity as a potential first treatment option with menopausal women. Furthermore, healthcare professionals should ensure they prepare, support, and encourage these women both physically and emotionally. TRIAL REGISTRATION: ISRCTN ISRCTN06495625 Registered 10/11/2010.

Axillary Osmidrosis: Past, Present, and Future.

Axillary osmidrosis is characterized by offensive odor resulting from bacterial decomposition of apocrine secretions in the axillae, and individuals with axillary osmidrosis suffer detrimental effects to their psychosocial functioning. We searched the literature in January 2019 for all English-language publications discussing axillary osmidrosis to identify previous reports, present trends, and emerging treatments. Studies were listed chronologically by the country of the first author's institution. Publications were also classified regarding the study type (literature review), pathophysiology, and treatments. We identified 133 publications on axillary osmidrosis, and of these, 120 were from East-Asian countries. Before 1990, there were only 9 publications, but after 2000, publications increased in number. One hundred of 133 reports discussed treatment, namely, 39 reports on suction curettage, 28 reports on open surgery, and 8 reports on subdermal laser. Other studies focused on the pathophysiology of axillary osmidrosis. This literature review revealed unique trends in the identified studies. Because control of axillary odor is a universal subject, the etiology and pathophysiology of axillary osmidrosis have been studied throughout the world and are clearly described. However, almost all studies of surgical treatments have been performed in East-Asian countries. After the year 2000, various surgical and nonsurgical treatments, namely, laser therapy and suction curettage, have been attempted. Emerging treatments for axillary osmidrosis include ethanol injections, microwave therapy, and microneedle radiofrequency technologies; however, further studies of these treatments are needed.

The Treatment of Axillary Odor: A Network Meta-Analysis.

BACKGROUND Axillary osmidrosis (AO) is common in plastic surgery. But there is no perfect way to treat AO. We systematically compared the efficacy of 10 AO treatments with network meta-analysis in order to provide reference for the clinical treatment of axillary odor. MATERIAL AND METHODS Chinese and English databases were searched by computer. Some relevant studies were collected for network meta-analysis. RESULTS We identified 56 studies, including a total of 8618 patients for meta-analysis. The network meta-analysis showed that 21 out of 45 pairs of 10 AO treatments had no statistical significance. In statistical comparison, subcutaneous curettage and swelling suction subcutaneous pruning were better than a single treatment. In addition, the effects of both laser and electric ion therapy were inferior to those of other treatments. The order of therapeutic effects predicted by surface under the cumulative ranking (SUCRA), curve was swelling aspiration+subcutaneous pruning >subcutaneous pruning >subcutaneous curettage+subcutaneous pruning >spindle excision >botulinum toxin A injection >swelling aspiration >subcutaneous curettage >YAG laser therapy >CO2 laser therapy >electric ion therapy. CONCLUSIONS In operative treatment of AO, swelling aspiration+subcutaneous pruning is the best operative treatment, and botulinum toxin A injection is the best in non-operative treatment. Overall, the effect of surgical treatment was more significant than that of non-surgical treatment.

Fractional microneedling radiofrequency treatment for axillary osmidrosis: A minimally invasive procedure.

BACKGROUND: Axillary osmidrosis is a distressing condition that can reduce quality of life and lead to personal and social problems. Fractional microneedling radiofrequency (FMR) treatment is a new minimally invasive procedure. OBJECTIVE: We sought to assess retrospectively the efficacy and safety of FMR treatment for axillary osmidrosis compared with subcutaneous surgery in a Chinese population. METHODS: In total, 48 and 42 patients receiving FMR treatment and subcutaneous surgery, respectively, were recruited. The treatments were assessed in terms of efficacy, complications, and malodor recurrence. Patient satisfaction and the Dermatology Life Quality Index (DLQI) were also evaluated. RESULTS: In total, 93.75% of patients in the FMR group and all patients in the surgery group showed good-to-excellent improvement in osmidrosis (P > 0.05). The patients' satisfaction in the FMR group was significantly higher than that in the surgery group at 1 month after treatment, but there were no differences between the two groups at the 3rd and 6th months (P > 0.05). The DLQI score was significantly decreased after both treatments. Two patients in the surgery group experienced hemorrhage complications, and no patients in the FMR group showed severe adverse effects. There was no significant difference in the malodor recurrence rate between the groups. CONCLUSIONS: Fractional microneedling radiofrequency treatment offers a safe and effective method for treating axillary osmidrosis with minimal recovery time and no strict postoperative immobilization.

Hematidrosis (bloody sweat): a review of the recent literature (1996-2016).

Hematidrosis is an eccrine sweat disorder characterized by one or more episodes of spontaneous, bloody sweating from non-traumatized skin. The author carried out a systematic review of all cases of hematidrosis reported in PubMed over the past 20 years. A total of 25 cases were reviewed; 21 were women (84%), the median age was 13 years (range 9-72), and the majority (62%) were from Asia, mainly India. Hematidrosis was located on the face-including the forehead (40%), eyes (40%), and ears (36%)-in 96% of the cases and on the umbilicus in 24% and the palms in 20%. Prodromal symptoms were reported by almost 30% of the patients. Possible triggering factors were identified in 56% of the cases; most of these (86%) were stress factors within families (conflicts or abuse) or at school. In two cases, platelet dysfunction and epilepsy were suspected as culprits. Nine patients had a psychiatric diagnosis associated with hematidrosis. The outcome was favorable in most of the cases with medical treatment (e.g., beta-blocker, anxiolytics) and psychological support. The number of cases has increased in recent years. Hematidrosis appears to be a somatization disorder that mainly affects children from developing countries. Its physiopathology remains largely unknown. It deserves better recognition because it is usually a temporary condition when managed properly.

Tratamento cirúrgico da bromidrose / Surgical treatment of bromhidrosis

INTRODUÇÃO:A bromidrose ou osmidrose é um problema que leva inúmeros pacientes a procurar tratamento médico especializado. A remoção das glândulas sudoríparas da região axilar por meio de exérese e lipoaspiração complementar é um procedimento de pequeno porte, tecnicamente simples e com poucas complicações. O objetivo deste trabalho é mostrar a aplicação da cirurgia neste problema, suas complicações e o grau de satisfação dos pacientes. MÉTODO: Trinta e dois pacientes foram submetidos à lipoaspiração e retirada dos tecidos da axila, sob anestesia local e sedação. Acompanhou-se por no mínimo 6 meses estes pacientes no pós-operatório, avaliando a evolução e possíveis complicações e aplicou-se o questionário CSQ-8 para o grau de satisfação no sexto mês. RESULTADOS: Após 6 meses de acompanhamento, poucas foram as complicações e as respostas ao questionário demonstraram alto grau de satisfação. CONCLUSÃO: Além de ser facilmente exequível, o procedimento se mostrou seguro e com poucas complicações.

INTRODUCTION: Bromhidrosis or osmidrosis causes many patients to seek specialized medical treatment. Removal of the sweat glands from the axillary region through excision and complementary liposuction is a minor, technically simple procedure, with few complications. The objective of this study is to review the role of surgery in bromhidrosis, complications of treatment, and the degree of patient satisfaction. METHOD: Thirty-two patients underwent liposuction and removal of axillary tissue under local anesthesia and sedation. The patients were followed up for at least 6 months postoperatively, to evaluate the outcome and possible complications. The Client Satisfaction Questionnaire was completed after 6 months. RESULTS: After 6 months of follow-up, there were few complications and the questionnaire revealed a high degree of satisfaction. CONCLUSION: In addition to being easily performed, the procedure was safe, with few complications.

Tratamiento con microondas en la hiperhidrosis y bromhidrosis axilar / Microwave Treatment for Axillary Hyperhidrosis and Bromhidrosis

La hiperhidrosis axilar (HA) y la bromhidrosis son un motivo de consulta frecuente en dermatología. Hoy en día el tratamiento más indicado es la inyección de toxina botulínica, una opción muy eficaz pero con el inconveniente de su temporalidad, y en el caso de la bromhidrosis su nula eficacia. Por otra parte, la indicación de la simpatectomía cada vez se recomienda menos por la alta incidencia de hiperhidrosis compensatoria. En este artículo se expone el tratamiento de la HA y la bromhidrosis con un dispositivo novedoso de microondas, capaz de reemplazar las glándulas ecrinas y apocrinas por fibrosis, consiguiendo unos resultados posiblemente permanentes. El procedimiento debe realizarse preferiblemente con anestesia local tumescente. Los efectos secundarios son temporales, principalmente inflamación local. Su eficacia clínica y seguridad sitúan a esta técnica, avalada por estudios recientes publicados, como una alternativa de primera elección tanto para la HA como para la bromhidrosis (AU)

Axillary hyperhidrosis (AH) and bromhidrosis are common causes of consultation in dermatology. Currently, the most widely prescribed treatment for AH is botulinum toxin, a very effective but temporary option; it is totally ineffective in bromhidrosis. Sympathectomy is an increasingly infrequent choice of treatment due to the high incidence of compensatory hyperhidrosis. We describe the treatment of AH and bromhidrosis with a novel microwave device that can fibrose eccrine and apocrine glands, achieving possibly permanent results. The procedure should preferably be performed under tumescent anesthesia. Side effects, principally local inflammation, are transient. Clinical effectiveness and safety, supported by recently published studies, position this technique as a first-choice option both for hyperhidrosis and for bromhidrosis (AU)

Pseudochromhidrosis: report and review of literature.

Chromhidrosis is a rare condition where colored sweat comes from the apocrine or eccrine glands. Pseudochromhidrosis is an uncommon condition where colored sweat is related to specific dye-producing bacteria, drugs, dyes, or chemical agents. This article provides a literature review of the various etiology, investigation, treatment, and prognosis. We propose an investigative algorithm to assist dermatologists, pediatric dermatologists, and general practitioners to diagnose this uncommon condition. The treatment options rely on the primary etiology such as removing dyes and chemical agents first and then treating the chromogenic bacteria. Topical and oral erythromycin seems to be the most effective treatment both in unidentified and identified chromogenic bacteria cases. Results and prognosis were excellent and without recurrence.

Osmidrosis Treatment Approaches: A Systematic Review and Meta-Analysis.

BACKGROUND: There are many treatment modalities associated with osmidrosis. The purpose of this study was to identify and compare effective osmidrosis treatments. METHODS: A systematic literature review and meta-analysis were performed using MEDLINE, EMBASE, and Cochrane databases. The osmidrosis treatment modalities were extracted as predictor variables, and recurrence and complications were extracted as outcome variables. Subgroup analysis was performed with regard to combined curettage, and fixed and random effect models were applied. RESULTS: Forty studies published prior to February 2016 were identified. The group that received surgery had the lowest incidence of recurrence as 3.0%, followed by the liposuction and laser groups (5.5%, 8.2%, respectively). The liposuction group had the lowest incidence of complications (hematoma, 1.6%; necrosis, 1.5%), followed by the surgery (hematoma, 1.9%; necrosis, 2.1%) and laser groups (hematoma, 3.1%; necrosis, 4.5%). When combining curettage, the recurrence rate was lower in the surgery (P = 0.06) and liposuction groups (P < 0.01). CONCLUSIONS: Surgery treatment has been demonstrated as the most effective result for treating osmidrosis. Liposuction has been identified as the most effective treatment, with the lowest number of associated complications. Combining the curettage method was an effective option for lowering recurrence rate in surgery and liposuction treatments. Finally, laser treatment was not significantly associated with benefits.

Diagnosis of Human Axillary Osmidrosis by Genotyping of the Human ABCC11 Gene: Clinical Practice and Basic Scientific Evidence.

The importance of personalized medicine and healthcare is becoming increasingly recognized. Genetic polymorphisms associated with potential risks of various human genetic diseases as well as drug-induced adverse reactions have recently been well studied, and their underlying molecular mechanisms are being uncovered by functional genomics as well as genome-wide association studies. Knowledge of certain genetic polymorphisms is clinically important for our understanding of interindividual differences in drug response and/or disease risk. As such evidence accumulates, new clinical applications and practices are needed. In this context, the development of new technologies for simple, fast, accurate, and cost-effective genotyping is imperative. Here, we describe a simple isothermal genotyping method capable of detecting single nucleotide polymorphisms (SNPs) in the human ATP-binding cassette (ABC) transporter ABCC11 gene and its application to the clinical diagnosis of axillary osmidrosis. We have recently reported that axillary osmidrosis is linked with one SNP 538G>A in the ABCC11 gene. Our molecular biological and biochemical studies have revealed that this SNP greatly affects the protein expression level and the function of ABCC11. In this review, we highlight the clinical relevance and importance of this diagnostic strategy in axillary osmidrosis therapy.

Blue-colored sweating: four infants with apocrine chromhidrosis.

Apocrine chromhidrosis is a very rare, idiopathic disorder of the sweat glands characterized by the secretion of colored sweat. Because hormonal induction increases sweating, the symptoms of apocrine chromhidrosis usually begin after puberty. Although treatment may not be necessary in some cases, capsaicin cream and 20% aluminum chloride hexahydrate solution have been successfully used to treat patients requiring intervention. Here we report four cases with apocrine chromhidrosis. To the best of our knowledge, our patients are the youngest cases reported in the literature.

Exercise for vasomotor menopausal symptoms.

BACKGROUND: Evidence suggests that many perimenopausal and early postmenopausal women will experience menopausal symptoms; hot flushes are the most common. Symptoms caused by fluctuating levels of oestrogen may be alleviated by hormone therapy (HT), but a marked global decline in its use has resulted from concerns about the risks and benefits of HT. Consequently, many women are seeking alternatives. As large numbers of women are choosing not to take HT, it is increasingly important to identify evidence-based lifestyle modifications that have the potential to reduce vasomotor menopausal symptoms. OBJECTIVES: To examine the effectiveness of any type of exercise intervention in the management of vasomotor symptoms in symptomatic perimenopausal and postmenopausal women. SEARCH METHODS: Searches of the following electronic bibliographic databases were performed to identify randomised controlled trials (RCTs): Cochrane Menstrual Disorders and Subfertility Group Specialised Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Wiley Internet interface), MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), the Science Citation Index and the Social Science Citation Index (Web of Science), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ovid) and SPORTDiscus. Searches include findings up to 3 March 2014. SELECTION CRITERIA: RCTs in which any type of exercise intervention was compared with no treatment/control or other treatments in the management of menopausal vasomotor symptoms in symptomatic perimenopausal/postmenopausal women. DATA COLLECTION AND ANALYSIS: Five studies were deemed eligible for inclusion. Two review authors independently selected the studies, and three review authors independently extracted the data. The primary review outcome was vasomotor symptoms, defined as hot flushes and/or night sweats. We combined data to calculate standardised mean differences (SMDs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I(2) statistic. We assessed the overall quality of the evidence for main comparisons using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods. MAIN RESULTS: We included five RCTs (733 women) comparing exercise with no active treatment, exercise with yoga and exercise with HT. The evidence was of low quality: Limitations in study design were noted, along with inconsistency and imprecision. In the comparison of exercise versus no active treatment (three studies, n = 454 women), no evidence was found of a difference between groups in frequency or intensity of vasomotor symptoms (SMD -0.10, 95% CI -0.33 to 0.13, three RCTs, 454 women, I(2) = 30%, low-quality evidence). Nor was any evidence found of a difference between groups in the frequency or intensity of vasomotor symptoms when exercise was compared with yoga (SMD -0.03, 95% CI -0.45 to 0.38, two studies, n = 279 women, I(2) = 61%, low-quality evidence). It was not possible to include one of the trials in the meta-analyses; this trial compared three groups: exercise plus soy milk, soy milk only and control; results favoured exercise relative to the comparators, but study numbers were small. One trial compared exercise with HT, and the HT group reported significantly fewer flushes in 24 hours than the exercise group (mean difference 5.8, 95% CI 3.17 to 8.43, 14 participants). None of the trials found evidence of a difference between groups with respect to adverse effects, but data were very scanty. AUTHORS' CONCLUSIONS: Evidence was insufficient to show whether exercise is an effective treatment for vasomotor menopausal symptoms. One small study suggested that HT is more effective than exercise. Evidence was insufficient to show the relative effectiveness of exercise when compared with HT or yoga.

Estudo de pacientes com hiperidrose, tratados com toxina botulínica: análise retrospectiva de 10 anos / Study of patients with hyperhidrosis treated with botulinum toxin: a 10-year retrospective analysis

INTRODUÇÃO: A hiperidrose caracteriza-se por sudorese excessiva, isolada ou associada, da testa, das mãos, dos pés e das axilas. Atinge cerca de 1 por cento da população. O objetivo deste estudo foi observar os efeitos da toxina botulínica nos pacientes com hiperidrose, demonstrando a técnica, as áreas de incidência e a duração dos resultados obtidos. MÉTODO: Foi realizada análise retrospectiva de 39 pacientes com hiperidrose primária tratados no período de julho de 2000 a julho de 2010, acompanhados durante 12 meses. Desses pacientes, 36 por cento eram do sexo masculino e 64 por cento, do sexo feminino. A idade variou de 16 anos a 41 anos. No total, foram tratadas 135 áreas. Realizou-se tratamento com injeções intradérmicas de toxina botulínica. A dose total aplicada variou entre 37,5 U e 150 U, com dose média de 75 U para cada região tratada. RESULTADOS: O efeito terapêutico foi observado a partir do terceiro dia, com redução de 50 por cento dos sintomas na primeira semana do tratamento e de até 94 por cento do quadro de hiperidrose após a segunda semana de tratamento. A redução dos sintomas durou, em média, 7 meses. Nenhum caso de hiperidrose compensatória foi observado. A mortalidade foi nula. CONCLUSÕES: O tratamento da hiperidrose primária com toxina botulínica tipo A, embora temporário, é uma opção de tratamento eficaz, segura, pouco invasiva e com alto grau de satisfação, permitindo aos doentes o retorno às atividades profissionais no mesmo dia. Os efeitos colaterais e as complicações são temporários, pouco frequentes e regridem sem deixar sequelas.

BACKGROUND: Hyperhidrosis is characterized by excessive sweating of the forehead, hands, feet, and armpits, either alone or in combination. It affects about 1 percent of the population. This study aimed to observe the effects of botulinum toxin in patients with hyperhidrosis and demonstrates the application technique of botulinum toxin, the areas of incidence of the disease, and the duration of the results. METHODS: A retrospective analysis of 39 patients with primary hyperhidrosis treated between July 2000 and July 2010 and followed up for 12 months was carried out. Of these patients, 36 percent were male and 64 percent were female. Patient ages ranged from 16 to 41 years. A total of 135 areas were treated. Treatment consisted of intradermal injections of botulinum toxin. The total dose applied ranged from 37.5 U to 150 U, with an average dose of 75 U for each treated area. RESULTS: The therapeutic effect of botulinum toxin was observed from the third day after treatment, with a 50 percent reduction in symptoms within the first week of treatment and up to 94 percent reduction in the number of hyperhidrosis events after the second week. The reduction of symptoms lasted, on average, for 7 months. No cases of compensatory hyperhidrosis or mortality were observed. CONCLUSIONS: The treatment of primary hyperhidrosis with type A botulinum toxin, although temporary, is an effective, safe, and minimally invasive treatment option. It has a high degree of satisfaction and allows patients to return to their professional activities on the same day. Side effects and complications are temporary, infrequent, and regress without sequelae.

Exercise for vasomotor menopausal symptoms.

BACKGROUND: Evidence suggests that many perimenopausal and early postmenopausal women will experience menopause symptoms, hot flushes being the most common. Symptoms caused by fluctuating levels of oestrogen may be alleviated by HRT but there has been a marked global decline in its use due to concerns about the risks and benefits of HRT; consequently many women are now seeking alternatives. As large numbers of women are choosing not to take HRT, it is increasingly important to identify evidence based lifestyle modification interventions that have potential to reduce vasomotor menopausal symptoms. OBJECTIVES: To examine the effectiveness of any type of exercise intervention in the management of vasomotor menopausal symptoms (hot flushes and night sweats) in perimenopausal and postmenopausal women. SEARCH STRATEGY: Searches of the following electronic bibliographic databases were performed to identify randomised controlled trials (RCTs): Cochrane Menstrual Disorders and Subfertility Group Specialised trials register; Cochrane Library (CENTRAL) (Wiley Internet interface), MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), Science Citation Index and Social Science Citation Index (Web of Science), CINAHL (Ovid) and SPORT Discus. Searches included dates up until 16-24 March 2010. SELECTION CRITERIA: RCTs in which any type of exercise intervention were compared no treatment/control or other treatments in the management of menopausal vasomotor symptoms in symptomatic perimenopausal/postmenopausal women. DATA COLLECTION AND ANALYSIS: Six studies were deemed eligible for inclusion. Three authors independently extracted data from eligible studies. Three meta-analyses according to comparator the group were performed. MAIN RESULTS: In the comparison of exercise versus no treatment/control (three studies), the non-significant effect size Standardised Mean Difference (SMD) for vasomotor symptoms was -0.14 (95% CI: -0.54 to 0.26); SMD was -0.04, -0.25, -0.38. For the analysis of exercise versus HRT (three studies), the non-significant SMD was 0.49 (95% CI: -0.27 to 1.26); SMD across studies was 0.13, 0.19 and 1.52, with all studies favouring HRT. In the comparison of exercise versus yoga (two studies), the non-significant SMD was -0.09 (95%CI:-0.64 to 0.45); SMD was -0.37 and 0.19. All comparisons were based on small samples. One small study reported data that could not be included in the meta-analysis; in this study hot flush scores were significantly lower in the exercise plus soy milk group (83%) than soy milk only group (72%). AUTHORS' CONCLUSIONS: The existing studies provided insufficient evidence to determine the effectiveness of exercise as a treatment for vasomotor menopausal symptoms, or whether exercise is more effective than HRT or yoga.