I

NTRODUCTION

CHAPTER-1
INTRODUCTION
“The changes,the highs and lows,
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 and the hormonal shifts,there is power in that.”
-Michele obama
The natural and permanent end of menstruation brought on by an oestrogen deficit that is
unrelated to a pathological disease is known as menopause.The Greek words pausis,
which means stop, and men, which means month, are the origin of the term menopause1
A twelve-month amnenorrhea signifies the end of a woman's reproductive and
childbearing years.For most women, this happens between the ages of 45 and 56.In the
US, the median age of natural menopause is 51 years old.The majority of women have
vasomotor symptoms during menopause, however other organ systems like the
urogenital, psychological, and cardiovascular can also be impacted2

The World Health Organization (WHO) defines natural menopause as the permanent
cessation of menstruation resulting from the loss of ovarian follicular activity or follicle
depletion. Natural menopause is recognized to have occurred after 12 consecutive
months of amenorrhea for which there is no other pathologic or physiologic cause.
Menopause occurs with the final menstrual period, which is known with certainty only in
retrospect a year or more after the event.Menopause is a normal condition involving the
permanent end of menstrual cycles due to cessation of the production of reproductive
hormones from the ovaries for at least 12 consecutive months .It is a diagnosis that is
made retrospectively.3
Menopause is described as either no menses for a year in the absence of preceding
chemotherapy or tamoxifen usage, or no menses following surgical removal of all
ovarian tissue, according to the NCCN Clinical Practice Guidelines in Oncology (NCCN
Guidelines) for Survivorship.4

Menopause is divided into three basic stages

Perimenopause, menopause, and postmenopause are the three main phases of the
menopause.
Premenopause: This term refers to the period of time before the perimenopause begins,
but it can also refer to the period of time before the last menstrual cycle.

• Perimenopause: The period of time following menopause in which endocrine

alterations and changes in the menstrual cycle take place, but amenorrhoea has not yet set
in for a full year

• Postmenopause: Commences at the end of the last menstrual cycle, but is not identified
until 12 months following the onset of amenorrhoea.5
A hot flush is an unexpectedly warm sensation on the skin that many women go through
during the menopause.One of the most common signs of the menopausal transition is
thought to be hot flashes.Hot flashes are typically described as brief episodes of extreme
heat in the face and upper arms that are frequently followed by skin flushing and
excessive perspiration. Anxiety and palpitations are common after hot flashes, and many
are accompanied by chills. Hot flashes are experienced by 60–80% of women going
through menopause at some point throughout the transition.6

9
Flush or hot flashes are by far the most typical menopausal symptom. Approximately
75% of women experience these abrupt, fleeting, recurring temperature spikes. Hot
flashes typically begin before to a woman's previous menstruation. Hot flashes last two
years or fewer for 80% of women. Fewer women than men have hot flashes for longer
than two years. There appears to be a direct correlation between these flashes and
declining oestrogen levels. The frequency and intensity of hot flashes differ from woman
to woman.The most common sign of perimenopause and menopause, which is the natural
period of time that ends when your ovaries stop producing eggs and your menstrual cycle
ceases, are hot flashes.Hot flashes are referred to by doctors as vasomotor symptoms
(VMS).A hot flash causes you to feel intensely heated.7
Diaphragmatic breathing, abdominal breathing, belly breathing, and timed respiration are
other terms for deep breathing. Your lower tummy rises and your lungs are completely
filled with air as you breathe deeply. One relaxing method that may help lower tension
and anxiety is deep breathing. These workouts might also aid in the management of long-
term medical issues.a method of relaxation where the practitioner concentrates on taking
deep, steady breaths. The diaphragm, the thin muscle that divides the chest from the
abdomen, and the abdominal muscles are used in deep breathing, which entails breathing
in slowly through the nose and out through the mouth. This lowers heart rate and blood
pressure, eases muscle tension, and increases the amount of oxygen in the circulation8
One technique to help you relax is deep breathing. Hot flashes may be less severe if
performed several times a day or before they start. Breathing techniques might also assist
in lowering the frequency of daily heat flashes.9
Rae Haining (2009) in her article insisted that hot flushes are most common symptom of
menopause affecting 85% of menopausal women. A hot flush is a sudden feeling of heat
in the upper part of body, face and neck as it becomes flushed. Hot flush is well known
as the classic menopausal symptom and affects 60-85% of menopausal women and why
it occurs is because 2 estrogen a female sex hormone is required to maintain a balanced
body temperature. When estrogen levels are suddenly reduced due to menopause, body is
unable to maintain a balanced body temperature. During a hot flash, endorphin levels
plummet. 5
Hot flushes are a vasomotor symptom that can vary greatly in intensity and length. For
most women, they happen seldom and don't cause much concern, but for 20% of them,
they can be extremely severe and significantly impair quality of life, work, and sleep.
The typical duration of a hot flash is between 30 and 10 minutes. Flashes, often known as
night sweats, can be extremely faint or intense and cause sleep disturbances at night.
There may be red spots on the arms, back, and chest. There may be shaking and profuse
perspiration. Hot flushes typically start in the face and chest, move to other areas of the
body, such the back of the neck, and cause the skin's surface to become heated across the
entire body.10
Debra Barton in (2002) found that deep breathing can reduce hot flushes by reducing
core body temperature which rises before hotflushes. So to keep body temperature down
she insisted to practice deep slow breathes twice a 3 day and she found that deep
breathing exercise reduce hotflushes about 40 percent. In article by Carol Krucoff of
Washington points out that the frequency of hot flushes can be reduced by about 50
percent through slow deep breathing. Astrid P (2007) recommends to practice the slow

10
deep breathing technique for 15 minutes, two times a day on a regular basis for atleast
one month.5

NEED FOR THE STUDY

Many women enter the menopause unprepared, not understanding what to anticipate,
when or how the process will unfold, or how long it will take. Because of this, a woman
who experiences a wide range of affects from her hot flashes may get confused and
nervous, thinking that something strange is happening to her.In the West, the average age
of the last menstrual cycle is 51 years old, while the most common age range for
menopause is between 45 and 55. The median age of natural menopause in developing
nations like the Philippines and India is 44 years old, which is significantly earlier than
average.Menopause women frequently suffer hot flushes, which are defined as an abrupt
sensation of warmth in the upper body that typically which is typically concentrated
around the face, neck, and chest. The majority of the community members, the
investigator discovered, were ignorant about the hot flashes symptoms associated with
menopause, and they relied on relaxation, lying down, and drinking water to avoid the
discomfort.5

Hormone replacement therapy was not well known to the majority of menopausal
women, and those who were did not want to spend money on treatment. Some women
going through menopause found taking medications challenging. Therefore, the
researcher aimed to raise awareness of hot flashes in menopausal women and to employ
medication-free therapy options. Deep breathing exercises were chosen as a risk-free
treatment option that could be utilised by people from various socioeconomic
backgrounds. The researcher aimed to evaluate the efficacy of the deep breathing
technique in women going through menopause in this manner.5.

STATEMENT OF THE PROBLEM

A study to assess the effectiveness of deep breathing exercise on hot flushes experience
of menopausal women in a selected area of jammu and Kashmir.

OBJECTIVES
• To assess the pretest and post test degree of hot flushes among menopausal
womens.
• To assess the effectiveness of deep breathing exercise on hotflushes among
menopausal women.
• To find the association between post test with the selected demographic variables.
HYPOTHESIS

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 H0- There is no significant difference in degree of hot flushes in experimental and
control group after intervention.
H1- There is significant difference in degree of hot flushes between experimental and
control group after intervention.

OPERATIONAL DEFINITIONS
Hot flushes experience
In this study it refers to feeling of a sudden brief flushing and sensation of heat caused by
dilation of skin capillaries usually associated with menopausal endocrine imbalance.
Deep breathing exercise
In this study it refers to breathing exercise in which a person counsciously takes slow
deep breath through the nose and exhale through the mouth.
Menopausal women
In this study it refers to normal condition involving the permanent end of menstrual
cycles due to the cessation of the production of reproductive hormones from the ovaries
for at least 12 consecutive months.

DELIMITATIONS
• Age above 45 years.
• Non working.
• The study size is limited to those who are willing to participate.

12
 REVIEW OF
LITERATURE

CHAPTER-2
REVIEW OF LITERATURE
13
 Review of literature is a key step in research process.Review of literature
refers to an extensive, exhaustive and systematic examination of publication
relevant to the research project (B.T. Basavathappa, 2001).The term review of
literature refers to the activities involved in identifying or searching for
information on a topic and developing an understanding on the state of
knowledge of the topic (Polit FD.and Beck TC, 2008).

Literature related to the topic is presented in this chapter as follows.

1. Literature about effect of deep breathing exercise on hotflushes

2.Literature about non-pharmacological management of hot flushes.

3.Literature about pharmacological management of hot flushes.

1.Effect of deep breathing exercise on hot flushes

Hammer M, Berg G (1990) investigated the frequency of moderate and severe
hot flushes in a group of women (n=142) of experimental group who took part in
organized physical exercise on a regular basis and investigated control group of women
aged52 and 54 years old in the city of Linkoping, in Sweden. Only women with natural
menopause and without a history of hormonal replacement treatment were statistically
compared in the study.

Freedman R.R.(1992) attempted to develop an effective behavioral treatment

formenopausal hotflushes and to determine the active behavioral components.Thirty
three women with frequent menopausal hotflushes were randomly assigned to receive
eight sessions of training in paced respiration and the hotflushes were objectively
measured and found that the subjectsundergoing paced respiration had significant
reduction in hotflush frequencyand respiratory rate. He concluded that paced respiration
training may be, a useful treatment alternative for the reduction of hotflushes.

David S (2004) designed a study to determine the effect of regular physical

exercise on the frequency of hotflushes.He investigated the frequency of moderate and
severe hot flushes in 79 postmenopausal women of experimental groupand compared
with control group of 866 postmenopausal women between fifty two and fifty four years
old to whom exercise were not taught. The study clearly demonstrated that regular
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physical exercise decreased the frequency and severity of hotflushes.The women in the
experimental group passed through a natural menopause without the use of hormone
replacement therapy,the physically active women who had no hot flushes
spendanaverageof3.5hoursperweekexercising,whilewomenwhoexercised less than this
amount were more likely to have hot flushes.

Cathryn Booth (2007) conducted a study to assess the feasibility and efficacy of ayoga
treatment for menopausal symptoms.She selected 12 peri and post menopausal women
experiencing menopausal hotflushes 4 times per day or 4 days per week. Pre and Post
treatment was assessed byWiklund Symptom Checklist which include frequency,
duration, severity of hotflushes,interference of hotflushes with daily life and subjective
sleep quality. Participants with hot flushes symptoms were asked to practice breathing
exercise at home every day and found significant difference from pretreatment to post-
treatment improvements were found in general wellbeing.

Mouloud AD (2008) conducted a study to evaluate effect of yoga on menopause

syndrome. A total of 47 postmenopausal women aging 45 - 63 years participated in a 12
weeks restorative yoga intervention. Menopausal symptoms were assessed before
intervention, at 4th week and 12th week. After intervention symptoms were observed
through 20 item checklist that embedded menopause symptom.Questions were scored
on a scale of 0-3, 0 (none), 1(mild), 2(moderate) or 3 (severe). If the total score was 15
or above, women were selected for yoga practice which include breathing technique.
Posture and relaxation process taught by certified yoga teacher and found significant
improvement from pretest to post test and concluded that yoga is powerful technique to
relieve hotflushes symptoms

Fenlon, (2008) conducted a study on effectiveness of relaxation therapy on hot flushes

among menopausal women.150 menopausal women were selected. The symptoms were
assessed out the end of the intervention program. The researcher concluded that number
of hot flushes was decreased by one month (median difference 7 hot flushes per week;
95% CI 4 to 7; P < 0.001) but the effect was not significant by three months (median
difference 5 hot flushes per week; 95% CI 0 to 10; P < 0.06). Severity of hot flushes
was also lowed by one month (median difference 0.54; 95% CI 0.11 to 1.01; P = 0.01)
but the difference became non-significant by y three months (median difference 0.56;

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0.02 to 1.18; P = 0.05).

Chattha .R.et.al. (2008) conducted a randomized controlled study in 14 centers of

yoga research in Bangalore to assess the effect of a regularlypracticed yoga on peri-
menopausal symptoms such as hotflushes, night sweats
andsleepdisturbance.Theyrandomized120peri-menopausal women between the ages of
40 and 55 years to experimental and control group.The women in the experimental
group practiced yoga postures (asana), breathing exercise and cyclic meditation for one
hour 5 days per week. The control group participated in supervised simple physical
exercises for the same amount of time per week and she found that women in the
experimental group experienced a greater reduction in hotflushes, night sweats and
sleep disturbances than the control group.

Mary.R.Tylor.R.N.(2008) conducted a study to assess the participants perspectives

on a yoga intervention for menopausal symptoms. A pilot study was conducted to assess
the effect of yoga practice among 11 menopausal women for 10 week, after doing
exercise women reported that they feel relaxed andphysically better. Many viewed that
yoga reduce stress and manage their menopausal symptoms.

Vincy bala et.al., (2010) conducted prospective study to assess the effectiveness
of deep breathing exercise on hot flushes experience of menopausal women in
Coimbatore. 30 menopausal women were randomly selected. She provided deep
breathing exercise to the experimental group for 15 minutes in twice a day for 4 weeks.
The symptoms were measured through menopausal rating scale. The researcher found
that, there was a significant difference between experimental and control group after the
intervention. (t-test=20.56, P>0.05). The researcher concluded that, deep breathing
exercise is effective in hot flushes symptoms among menopausal women.

2.Non-Pharmacologicalmanagementofhotflushes.
Myra SH (1995) conducted a study on the feasibility and effectiveness of offering
an alternative psychological treatment for women reportingmenopausal hot
flushes.Women reporting hot flushes at least once a week, were interviewed and asked
to choose between no treatment,HRT or psychological treatment,Cognitive Relaxation
Therapy (CRT), which includes relaxation, stress reduction and information about

16
coping with hot flushes.
The results stated that a large proportion of women choosed the
psychological treatment, because they wanted help, but did not want to have
HRT. Moreover, many of them wanted to learn skills to help them to control
their symptoms themselves.

Irvin.J.H (1996) designed a study to investigate the efficacy of elicitation of the

relaxation response for the treatment of menopausal hotflushes and psychological
symptoms.The volunteer sample consisted of 33 women between the ages of 44 and 66
years experiencing atleast five hotflushes per 24 hours and not using hormone
replacement therapy.The setting was an outpatient clinic in a tertiary care teaching
hospital.The interventions used to measure both the frequency and intensity of
hotflushes by Spiel bergerState-Trait Anxiety Inventory (STAI) and the Profile ofMood
Scale (POMS). The first 3weeks of baseline measurement of frequency and intensity of
hotflush symptoms and the pre intervention psychological scores were compared with
the final 3 weeks measurement of frequency and intensity and the post intervention
psychological scores for symptomatic improvement. The experimental group
demonstrated significant reduction in hotflush intensity; there were no significant
changes for the control group.

Gary E, Joel M, Vered S, Hasan R (2006) conducted a single arm, pilot study and
investigated the use of hypnosis to reduce hot flushes in 16 breast cancer survivors.Each
patient received 4 weekly sessions of hypnosis and instructed self-hypnosis.Patients
completed daily diaries of the frequency and severity of their hot flushes and also
completedpost treatment ratings of the degree to which hot flushes indicated a 59%
decrease in total daily hot flushes and a 70% decrease in the degree to which hot flushes
interfered with daily activities which include social activities, leisure
activities,sleep,mood, concentration, relations with others, sexuality, enjoyment of life
and overall quality of life.
This pilot study suggests that clinical hypnosis may be an effective non- hormonal
and non-pharmacological treatment for hot flushes.

Daley A (2006) designed a study to determine the use of complimentary and

alternative medicine including non-pharmacological intervention to alleviate
menopausal symptoms.Participants aged 46-55 year completed a postal questionnaire
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that contained items relating to demographics, lifestyle factors, weight, height, exercise
behavior, menopausal status, vasomotor symptoms, utilization and perceived
effectiveness of a range of complementary and alternative medicine.Among1 206
women who responded 563(47%)were symptomatic. Non-pharmacological
interventions for symptom management were diet or nutrition (44.3%), exercise
(41.5%), relaxation or stress management (27.4 %) and homeopathic or naturopathic
remedies (25.4%).The study concluded that
manymenopausalsymptomaticwomenareusingawiderangeofnon-pharmacological
intervention and reports these to be effective,particularly those who are white,
physically active and do not smoke.

Ruta N (2008) selected 102 postmenopausal women and recruited them

fortwostudiesinSweden.Inthefirststudy,womenwererandomizedtoreceive
eithertransdermalestrogenorplacebo.Inthesecondstudy,women were randomized to three
groups and received oral estrogen, acupuncture or applied relaxation for 12 weeks.
Menopausal symptoms were measured with daily logs.The results stated that the
number of hot flushes in a 24 hour period decreased significantly after 4th and 12th
week in all treatment groups. The researcher concluded that, acupuncture decreased the
number of hotflushesmore than placebo.
Laurie. K. (2008) conducted a study to evaluate the direct and indirect relationship
between stress, psychological distress, psychosocialfactors,menopause symptom
severity and physical health in middle aged women.One hundred and sixteen women
aged 45-55 years were recruited through women’shealth centers and community
organizations.They completed a short questionnaire asking about stress, psychological
distress, menopause symptoms andphysical health.This research concluded that women
with high emotional intelligence appear to hold more positive attitudes to menopause
and experience less severe stress, psychological distress and menopause symptoms and
better physical health.These result suggested that women who expect menopause to be a
negative experience, are highly stressed or distressed.

JuliaG(2008)designed study to assess the effectiveness of professional herbal

practice in the treatment of menopausal symptoms.She conducted the study in a primary
18
health care centre in UK.Participants were 45 women aged 46-59 experiencing self
defined menopausal symptoms and no menstrual bleeding for 3 months. Exclusion
criteria included use of hormone replacement therapy.Participants were block
randomized into a treatment group (n=30) offered treatment from one of three herbal
practitioners, and control group (n=30) offered treatment after waiting for 4
months.Change in menopausal symptoms was measured in both groups using the
validated Greene Climacteric scale.
The treatment group demonstrated a statistically and clinically significant

reduction in menopausal symptoms compared to control group. Cho.S.H.

(2009) attempted critically to assess whether acupuncture therapy reduces
vasomotor menopausal symptom and to evaluate the adverse effects of
acupuncture therapy on the basis of the results of randomized controlled
trials(RCTS).

Eleven studies, which included a total of 764 individual cases were systematically
reviewed.Six trials compared acupuncture treatment to sham or placebo acupuncture.
Only one study using a nonpenetrating placebo needle found a significant difference in
the severity outcomes of hotflushes between groups.Five studies reported a reduced
frequency of hotflushes within groups. An analysis of the outcomes of the trials that
compared acupuncture with hormone therapy, for reducing vasomotor symptoms
showed that acupuncture was superior.

Jue Z, Fan Q (2009), conducted a study to explore the effects of acupuncture and
auricular acupressure in relieving menopausal hot flushes of bilaterally ovariectomized
Chinese women. Women were randomized into an acupuncture and auricular
acupressure group (n = 21) and a hormone replacement therapy (HRT) group(Tibolone,
n = 25).Each patient was given a standard daily log and was asked to record the
frequency and severity of hot flushes and side effects of the treatment felt daily. The
serum levels of follicle stimulating hormone (FSH), LH and E 2 were detected before
and after the treatment.
After the treatment and the follow-up, both the severityand frequency of hot flushes
in the two groups were relieved significantly when compared with pre-treatment (P <
0.05).There was no significant difference in the severity of hot flushesbetween them
after treatment (P > 0.05), while after thefollow-up, the severity of hot flushes in the
19
HRT group wasalleviated more and the levels of FSH decreased significantly and the
levels of E2 increased significantly in both groups (P < 0.05), and they changed more in
the HRT group (P < 0.05). The researcher concluded that acupuncture and auricular
acupressure can be used as alternative treatments to relieve menopausal hot flushes, for
those bilaterally ovariectomized women who are unableor unwilling to receive HRT.

3.Pharmacological management of hot flushes.

Barton DL, Loprinzi CL (1998) developed and conducted a placebo

controlled randomized crossover trial, after1 week baseline period, patients

received 4 weeks of an identical appearing placebo or vice versa. Diaries were
used to measure potential toxicities of hot flushes during the baseline week and
the two subsequent 4 weeks treatment periods.
The 120 patients evaluated for toxicity failed; 105 patients who finished
the first treatment period showed a similar reduction in hot flush frequencies.A
crossoverranalysisshowedthatVitE.wasassociatedwithaminimaldecreasein
hotflushes.
Albertazzi, (2003) conducted a randomized, double-blind, placebo controlled
trial to assess the effect of daily dietary supplementation of soy protein isolate powder
on hot flashes in postmenopausal women by Menopause and Osteoporosis center, Italy.
Age in the treatment group (n=51) was 48-61 years, while in the control group (n=53) it
ranged from 45-62 years. The diets of the 104 women were supplemented with either 60
g soy powder (40 g isolated soy protein) or 60 g placebo (casein) daily for 12 weeks. By
the end of the 12th week, women taking the soy protein isolate had a 45-percent
reduction in daily hot flashes compared to a 30-percent reduction obtained with the
placebo group(P<001).
Brigitte LS, Deborah K, Brocaw (2004)conducted a study to review the literature
on clonidine, benlafaxine, selective serotonin reuptake inhibitors and gabapentin for the
treatment of hot flushes in women unable or unwilling to take hormonal
therapies.Several non hormonal alternatives have been evaluated in small controlled and
uncontrolled trials. The results stated that oral and transdermal formulations of

20
clonidine are moderately effective in reducing hot flushes.Venlafaxine, paroxitine and
gabapentien suggests greater reductions in hotflush frequency and severity
comparedwiththoseofcloridine.Flexetiveappearstodisplay modes of benefit, Compared
trials have been conducted. Most women studied in these trials had a history of breast
cancer and many were taking concurrent tamoxifn.A lot of these agents were fairly well
tolerated.

Clonidine,Venlafaxine,paroxetine,fluoxetineandgabapentinare non-
hormonal agents that have demonstrated efficacy in small controlled and
uncontrolled trials in reducing hotflushes and should be considered in patients
unwilling or unable to take hormonal therapies.

Evans ML (2005) designed a study to examine the efficacy of extended

release valafaxine for the treatment of postmenopausal hotflushes. Eighty
postmenopausal women with more than 14 hot flushes per week were
randomized to receive treatment with extended releases venlafaxine or placebo.
Participants received 37.5mg daily for 1 week followed by 75 mg daily for 11
weeks and through questionnaires she assessed hot flush score, quality of life
andsexualfunction.Participantsweretreatedfor12weeks.Ofthe80subjects who
enrolled in the study, 40 were in the treatement group and 40 in the control
group.
The result stated that subjective assessment at monthly visits of the effects
of hotflush symptoms on daily living were significantly improved in the
treatment group. The research concluded that extended release venlafaxine 75
mg per day, is an effective treatment for postmenopausal hot flushes.
Pandya, (2005) conducted a study to evaluate the effectiveness of the two different
doses of gabapentin. 347 post menopausal women were selected. The researcher
reported that after the intervention the frequency of hot flushes was reduced with the
900mg/day dose of gabapentin (mean change -2.1; 95% CI -2.95 to - 1.23). A lower
dose (300 mg/day) did not achieve a significant effect (mean change - 0.8; 95% CI -1.7
to 0.1). The same effects were observed on severity scores (low dose mean change -
1.79; 95% CI -4.38 to 0.80 and high dose mean change -4.88; 95% CI -7.23 to -2.53)
Thurston RC (2007) conducted the pilot study to check the feasibility and efficacy
of yoga treatment for menopausal symptoms. The subjects included 12 pre and post-
21
menopausal women who experienced at least 4 hot flushes per day, 4days per week. 10
weeks yoga program was provided. Pre and post test was assessed throw the wiklund
symptoms check list related to menopausal symptoms frequency, duration, and severity
of hot flushes measured by 24 hours ambulatory skin conductance monitoring and
subjective sleep quality checked by Pitts burgh sleep quality index. Yoga was practiced
15 min each day for 10 weeks. Eleven women completed the study and attended a mean
of 7.45(S.D.1.63) classes. Significant pre to post treatment improvement were found
related to menopausal symptoms, like hot flushes, sleep disturbances and quality.
Literature Related to Non Pharmacological Measures on Hot Flushes.

Anna Ratka.et.al.(2009) designed a study to find the association of various

dimensions of Hotflushes with systemic levels of gonadal steroids,the goal of this study
were to compare concentration of gonadal hormones between menopausal women with
hotflushes and those with no hotflushes and to characterize the association between
steroid levels and multiple dimensions of hotflushes.Menopausal women with
hotflushes and without hotflushes participated in 4 study sessions, one every 2
months.Concentration of gonadal hormones was measures at each bi-monthly sessions.
Steroid levels were correlated to duration, frequency,length of each episode,timing and
intensity of hotflushes.Data from 20 women with hotflushes and15women without
hotflushes with similar demographic profiles were analysed.The results from the present
study showed that systemic levels of estrone and progesterone were significantly lower
in women experiencing hotflushes than in asymptomatic women. There was single
association between levels of estradiol, estrone,
Progesteroneandandrostenedionebutnottestosteronewithduration,frequency, timing and
intensity of hotflushes.
The result stated that subjective assessment at monthly visits of the effects
of hotflush symptoms on daily living were significantly improved in the
treatment group. The research concluded that extended release venlafaxine 75
mg per day, is an effective treatment for postmenopausal hot flushes.
Pauliina Tuomikoski, et.al., (2009) conducted study to compare the vascular
responses to hormone therapy in women with and without hot flushes. She randomly
assigned 143 post-menopausal women (mean age 52±0.2, time since menopause
19.5±0.9months) with intolerable hot flushes (more than seven moderate/severe

22
episodes per day) or tolerable hot flushes (fewer than three mild episodes per day) to
receive 1 mg of transdermal estradiol gel, oral estradiol 2mg with and without daily
medroxyprogestrone acetate, or placebo for 6 months. The hot flushes were assessed by
pulse wave analysis and endothelial function testing. The researcher identified, the
women with tolerable hot flushes oral estradial caused a decreased of hot flushes 13.2%
(P=0.028) in first systolic peak after nitrglyceerin. In addition the time to the pulse-
wave velocity after nitroglycerin was decreased by 8.4% P=0.018. So researcher
concluded that estradiol was effective in tolerable hot flushes.
.
Avis, et.al., (2009) conducted randomized, single blind prospective study to
evaluate effectiveness of alternative treatments on menopausal symptoms in Brazil. 3
group pre and post test design was used in this study. Participants were 56 menopausal
women aged 44 to 55 years, experiencing four or more hot flushes per day. Participated
in this study subjects were randomized based on the intervention like usual care (19),
sham acupuncture (18) and standardized individual acupuncture based on traditional
Chinese medicine (19) for 8 weeks duration. All groups demonstrated a significant
decrease in mean frequency of hot flushes (P=0.01). The two acupuncture groups (sham
and traditional Chinese medicine) demonstrated a significantly greater decrease than the
usual care group (p <0.05). So the researcher found that acupuncture treatment have the
effect on hot flushes and menopausal symptoms.
Borud EK, Alraek T, White A, Grimsgaard S, et.al.,(2009) conducted the study to
compare the effectiveness of individualized acupuncture treatment plus selfcare versus
self-care alone on hot flushes and health related to quality of life in post menopausal
women. Totally 267 participants were post menopausal women experiencing, average
12.6 hot flushes per 24 hours. The acupuncture group received 10 individualized
acupuncture treatments for 12weeks and advice on self care, whereas the control group
received only advice on self care. Hot flushes were measured by the frequency, intensity
(1-10 scale) and hours of sleep per night and were registered in a diary. Hot flash
frequency decreased by 5.8 per 24 hours in the acupuncture group (n = 134) and 3.7 per
24 hours in the control group (n = 133), a difference of 2.1 (P < 0.001). Hot flash
intensity decreased by 3.2 units in the acupuncture group and 1.8 units in the control
group, a difference of 1.4 (P < 0.001). It showed significant reduction in hot flushes

23
symptoms in acupuncture group.
Elkins et.al., (2009) conducted prospective study, randomly assigned women to
complete five weekly hypnotic sessions or serve as the study control by American
society of medicine, UK. Totally 51 menopausal women were taken as study
participants. Hot flushes scores 68% decreased from baseline to end point (p<0.05)
change in the menopause symptoms like self reported anxiety, depression, interference
of hot flushes on daily activities and sleep for treated subjects compared with control
subjects.

METHODOLOGY

24
 CHAPTER-III

METHODOLOGY

This chapter deals with the description of the research methodology

adopted by the investigator to assess the effect of deep breathing exercise to
reduce hotflush experience of menopausal women. It includes research design,
population, sample size, inclusion and exclusion criteria for sample selection,
sampling technique, tool, data collection procedure and data analysis.

RESEARCH APPROACH

The present study aimed at evaluating the effect of deep breathing

exercise on hotflushes experience among menopausal women in a selected area.
Hence quantitative approach will be considered to be most appropriate to
accomplish the objectives of the study.

RESEARCH DESIGN
A non equivalent control group pretest-post test quasi-experimental design is
used.

Experimental group O1xxxxxxxxxxxxxxx O2

Control group O1-----------------------O2

O1 – Assessing degree of hot flushes before intervention for experimental and

control group

O2- Assessing degree of hot flushes after 15 days of intervention for

experimental and control group.

X –Deep breathing exercise

VARIABLES OF THE STUDY

Independent variable: Deep breathing exercise

Dependent variable: Hot flushes experience

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SETTING OF THE STUDY
The study will be conducted in a selected area of Jammu and Kashmir.

POPULATION
The population of this study includes all the menopausal women above 45 years
with menopausal symptoms and not taking any treatment.

SAMPLE
This study will include 30 menopausal women who will fulfill the inclusion
criteria for sample selection.

SAMPLING TECHNIQUE

The purposive sampling technique will be used. According to the

availability, the samples will be selected.

SAMPLING CRITERIA

Inclusion criteria:

 Menopausal womens
 Menopausal women with complaints of hotflushes symptom.
 Menopausal women willing to participate.

Exclusion criteria:

 Women who had undergone menopause due to Hysterectomy

 Other medical condition such as Diabetes mellitus, Hypertension

and cardiac disease.

 Womens who are taking medications.

DESCRIPTION OF THE TOOL

The tool is divided into two parts

Part 1:-Demographic data that is assessed with the help of questionnaire.

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 Part 2:-

Rating scale is used to assess the degree of hotflushes before and after
intervention. . It consists of 10 questions and 3 columns.(very frequent, frequent, and
rare)to rate the response to know the degree of symptom before and after intervention.

DATA COLLECTION PROCEDURE

The main study is conducted in selected area in jammu and kashmir.Permission was obtained
from the Panchayat president. 15 members in each area as experimental and control group.
The investigator selected the sample according to the complaints and inclusion criteria.
Data has been collected by interviewing the sample individually through questionnaire.
The investigator taught deep breathing exercise to experimental group and the control
groups were not taught exercise. The investigator visited the menopausal women, of
experimental group one by one, daily morning and evening and insisted them to do the
exercise. The duration for doing exercise was 15 minutes in the morning and evening. On
15th day and 30th day the investigator gave same questionnaire for the menopausal
women and observed the changes. Total data collection period was 30 days.

DATA ANALYSIS AND INTERPRETATION

The data analysis will be done by using descriptive statistics and inferential statistics.

Descriptive statistics

Frequency and percentage distribution will be used to analyse demographic

variables. Mean and standard deviation will be used to assess the significant difference of
symptoms in experimental and control group before and after intervention.

Inferential statistics.

Inferential Statistics ‘t’-test will be used to find the significant difference in

symptom and problem faced by menopausal women before and after intervention. Chi –
square test was used to check association between demographic variables and symptoms
of hotflushes.

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