UPDATE ON TREATMENT OF MENSTRUAL DISORDERS
Martha Hickey and Cynthia M Farquhar
Disturbances of Menstrual Bleeding, are a major social and medical problem for women, their families and the health services, and a common reason for women to consult their general practitioners or gynecologists. In the United Kingdom, each year one in 20 women consults their GPs about heavy menstrual bleeding.
Heavy bleeding is the most common menstrual complaint. In most cases, this has no identifiable pelvic or systemic cause and is termed dysfunctional uterine bleeding. Irregular dysfunctional uterine bleeding is generally associated with anovulation. Historically, many women with heavy menstrual bleeding were advised to undergo hysterectomy, which was the only way of ensuring a "cure". However, a range of new and effective interventions can now be offered for dysfunctional uterine bleeding and other common causes of menstrual disorder, such as fibroids and endometriosis. These interventions may reduce bleeding and pain to acceptable levels and will induce amenorrhea in some women.
We present case studies comparing the "traditional" approaches to common menstrual disorders with more recent developments.
Case 1 - Dysfunctional Uterine Bleeding
Presentation: A 39-year-old overweight woman presented with regular heavy menstrual bleeding. She had had three caesarean sections and a laparoscopic sterilization. An ultrasound examination revealed a normal-sized uterus and irregular, thickened endometrium. The ovaries appeared normal.
Management: Traditional management might have included a trial of medical therapy, such as luteal-phase progestin. If this failed or was not acceptable to the patient, the next step was often an abdominal hysterectomy, as few other effective treatments were available. Current management would include hysteroscopy or saline infusion sonography to rule out sub-mucous fibroids or large polyps, which may contribute to heavy bleeding. Subsequent treatment options include insertion of a levonorgestrel-releasing intrauterine system or endometrial ablation.
In this case, outpatient hysteroscopy revealed a normal uterine cavity and, after earlier counseling about likely disturbances in menstrual bleeding patterns, a levonorgestrel-releasing intrauterine system (20 μg/24 h) was inserted.
Intrauterine Progestin Therapy
Oral luteal-phase progestin may help regulate bleeding patterns in irregular bleeding secondary to anovulatory cycles but are ineffective in regular dysfunctional uterine bleeding and may actually increase menstrual bleeding. Longer regimens (Days 5–25 of the menstrual cycle) have been found to have similar effectiveness to the levonorgestrel intrauterine system in dysfunctional uterine bleeding when compared in a randomised controlled trial, but their acceptability is poor, with only 30% of patients reporting that they would have the treatment again.
Intrauterine administration of progestin, as in the levonorgestrel-releasing intrauterine system, results in higher endometrial concentrations of progestin compared with oral administration, but relatively little systemic absorption. The Mirena system (Schering) releases 20 μg of levonorgestrel/24 h and, in women with ovulatory dysfunctional uterine bleeding, has been shown to produce an 86% reduction in objectively measured menstrual blood loss at 3 months and a 97% reduction at 12 months, with amenorrhea in 50% of women at 12 months. This effect continues over a 5-year period. In addition, limited data from small case series suggest that this system may also be an excellent treatment for endometrial hyperplasia of most grades, and may thus be helpful in anovulatory dysfunctional uterine bleeding.
A disadvantage of intrauterine progestin therapy is erratic vaginal bleeding or spotting, particularly during the early months of use, and women need to be warned that these disruptions may occur but are likely to improve and do not represent treatment failure. Mirena also offers highly effective contraception and rapid reversibility.
Continuation rates for Mirena vary, partly depending on the indication (treatment of heavy bleeding or contraception). A study of 250 women who used Mirena for contraception found 66% continuation at 2 years, with most removals in the first 6 months because of irregular bleeding. When Mirena is used to treat menorrhagia, continuation rates may be up to 80% at 1 year. In a randomised trial in which women awaiting hysterectomy received either Mirena or no treatment, 68% elected to continue with Mirena at 1 year, while 20% elected to undergo hysterectomy. Cost–benefit analysis showed that Mirena was three times cheaper than hysterectomy. Endometrial biopsy or hysteroscopy is not required routinely before Mirena insertion and should be carried out only if there are other clinical indications.
Endometrial Ablation
Endometrial ablation is a minimally invasive therapy for dysfunctional uterine bleeding that preserves the uterus and is suitable for women who have completed childbearing. Many techniques have been developed. The first generation techniques (laser, transcervical resection of the endometrium and rollerball) require visualisation of the uterus with a hysteroscope and, although safe, require skilled surgeons.
New techniques have been introduced recently with the aim of providing simpler, quicker, safer and more effective procedures that can be used in outpatient settings. These include cryoablation, hydrothermal ablation (through irrigation with hot saline solution), heated balloon systems, diode laser hyperthermy, microwave ablation, thermal radiofrequency ablation, and photodynamic therapy (intrauterine light delivery).
Most women are satisfied with the reduction in bleeding after endometrial ablation, but an estimated 20% require further surgery, and 10% eventually undergo hysterectomy. Factors associated with negative outcomes include increasing uterine size, young age, fibroids, adenomyosis and failure to thin the endometrium with agents such as gonadotropin-releasing hormone (GnRH) agonists before the procedure.
Counselling should include the fact that amenorrhoea cannot be guaranteed and that this surgery is not contraceptive, but that subsequent pregnancy may be dangerous for both mother and fetus.
It is also important to recognize that many of these techniques are still under development and investigation, and that "blind" therapies have the potential to cause unrecognized uterine damage. Overall, evidence suggests that success rates and complication profiles of most of the newer ablation techniques compare favorably with first generation methods. However, very few randomized controlled trials have assessed their efficacy, safety and acceptability.
Case 2 - Menorrhagia and fibroids
Presentation: A 45-year-old nulliparous woman presented with increasingly heavy menstrual bleeding and pain associated with the passage of clots. A trial of medical therapy with a non-steroidal anti-inflammatory drug had failed. Transvaginal ultrasound revealed a fibroid uterus with one 3 cm intramural fibroid, one 2 cm subserous fibroid, and a distorted endometrial cavity suggesting a sub-mucous fibroid.
Management: Traditional management would probably have included an early resort to major abdominal surgery, such as abdominal hysterectomy or myomectomy. A newer approach is clear identification of the position of the fibroids in relation to the endometrial cavity, followed by removal of the sub-mucous fibroids using hysteroscopic techniques with possible endometrial resection.
In this case, saline infusion sonohysterography confirmed the presence of a sub-mucous fibroid. This was resected hysteroscopically under general anesthesia, leading to a substantial reduction in menstrual bleeding and a reduction in dysmenorrhoea.
Saline Infusion Sonohysterography
In this technique, saline is instilled transcervically into the uterine cavity to distend the uterus and increase contrast, and the cavity is visualized using ultrasound. Saline infusion sonohysterography is more accurate than transvaginal ultrasound alone in diagnosing submucous fibroids and endometrial polyps in women with abnormal uterine bleeding,12 and can be performed in the outpatient clinic. An alternative form of imaging is diagnostic hysteroscopy, but this is invasive and often performed under general anaesthesia. Use of saline infusion sonohysterography has been shown to reduce the need for diagnostic hysteroscopy.13
Hysteroscopic Resection of Fibroids
Sub-mucous fibroids seem to be more commonly associated with menorrhagia than other uterine myomas, and their removal appears to substantially improve menstrual symptoms. However, hysteroscopic resection of submucous fibroids is unlikely to influence subsequent fibroid growth or symptoms associated with remaining myomas.
Conventional hysteroscopic resection of submucous fibroids requires general anaesthesia. Future prospects include outpatient removal of fibroids with devices such as the operating bipolar microhysteroscope. This device vaporizes lesions through diathermy; it can operate in a saline environment, and its small size means it can be used without cervical dilatation, thereby allowing intervention to be combined with diagnostic hysteroscopy.
Endometrial Ablation
Microwave endometrial ablation has also been shown to be effective for the management of heavy menstrual bleeding associated with both sub-mucous and intramural fibroids, providing they are less than 5 cm in diameter. Hydrothermal endometrial ablation may also be effective in the presence of fibroids.
Embolisation
Embolisation of symptomatic uterine fibroids is an alternative to surgical myomectomy. It has been widely used in the last 5–10 years and is well accepted by patients and apparently successful in reducing fibroid size and ameliorating symptoms in some. Embolisation may avert the need for hysterectomy for some women with symptomatic uterine fibroids. However, the relative benefits of embolisation and myomectomy have not yet been tested in a prospective randomised study, and embolisation has been associated with serious side effects, such as infection, bowel obstruction and loss of ovarian function. There is also concern about the integrity of areas embolised during any subsequent pregnancies.
Fertility
There is potential for newer techniques to preserve or restore fertility, but their place has not yet been established. A trial is underway in the United Kingdom comparing the relative effects of embolisation and myomectomy on fertility, but results will not be available for several years.
Medical Therapies for Menorrhagia
Aside from intrauterine progestin therapy there have been few new medical therapies for dysfunctional uterine bleeding. Intrauterine progestin therapy can be used for heavy menstrual bleeding associated with uterine fibroids, but there is some evidence that expulsion rates may be increased in the presence of sub-mucous fibroids. However, the success of medical therapy can be optimized by accurate clinical selection of patients and use of the most effective methods.
Tranexamic acid is an antifibrinolytic agent which significantly reduces heavy menstrual bleeding, by an average of 110 mL per cycle, and is more effective than mefenamic acid and ethamsylate for objectively measured menorrhagia. However, there has been a reluctance to prescribe tranexamic acid because of possible side effects, such as increased risk of thrombogenic disease (deep venous thrombosis). Long-term studies in Sweden failed to demonstrate any increase in thrombosis in women using tranexamic acid above that in the general population.
Prostaglandin synthetase inhibitors, such as mefenamic acid, taken during menstruation may decrease bleeding by an average of 124 mL per cycle and have the added advantage of relieving dysmenorrhoea.
Case 3 - Endometriosis
Presentation: A 26-year-old woman presented with a history of dysmenorrhoea since menarche and perimenstrual pain on passing bowel motions. She had never been pregnant and had been sexually active for 2 years without using contraception. She had recently been prescribed the oral contraceptive pill, with only a minor reduction in symptoms.
Management: In the past, this patient might have been diagnosed with primary "spasmodic" dysmenorrhoea and not further investigated. The presence of bowel symptoms may have led to a diagnosis of irritable bowel syndrome. It should be recognised that these symptoms may represent endometriosis, even in a young woman. A new approach would include transvaginal ultrasound examination to rule out ovarian abnormality followed by laparoscopic surgery or medical therapy, depending on the reason for treatment (infertility or pain) and the severity of symptoms.
In this case, ultrasound examination revealed bilateral ovarian masses suggestive of endometriomas. This was confirmed at laparoscopy, which demonstrated extensive endometriosis (score, III–IV on the American Fertility Society scale) with obliteration of the pouch of Douglas. Laparoscopic removal of endometriomas and excision of deep endometriosis was performed, leading to a reduction in dysmenorrhoea and bowel symptoms, which was maintained at 6 months. However, future recurrence is likely.
Improvements in Diagnosis
Traditional gynecological teaching held that endometriosis was a condition of late reproductive life. It is increasingly acknowledged that endometriosis is also common in teenagers and younger women, and that this diagnosis must be considered in premenopausal women with persistent dysmenorrhoea, dyspareunia and bowel symptoms. In addition, some women with endometriosis present with symptoms that are atypical or non-cyclical. In women with dysmenorrhoea, the incidence of endometriosis ranges from 40% to 60%, and in women with subfertility it ranges from 20% to 30%. Diagnosis in this group is often delayed, resulting in prolonged and poorly controlled symptoms.
Conservative laparoscopic Surgery
A traditional surgical approach is laparoscopic removal of superficial endometriosis by techniques such as diathermy or laser ablation. More recently, complete removal of all visible endometriosis, including deep endometriosis and nodules, has been advocated, with stripping of the peritoneum if necessary. Both approaches are conservative in that they preserve the uterus and ovaries.
There is increasing evidence from randomised controlled trials that conservative laparoscopic surgery for endometriosis, especially when it is complete, increases fecundity and reduces disease-related symptoms, such as dysmenorrhoea and dyspareunia. However, there is a substantial risk of some symptoms persisting and of recurrence or exacerbation within 6 months.
The combination of laparoscopic laser ablation and adhesiolysis has been demonstrated in a case series to be beneficial for pelvic pain associated with minimal, mild and moderate endometriosis over a 1-year follow-up period.
Medical Therapy
Traditional medical therapy for endometriosis has included danazol, oral progestins and GnRH analogues. These drugs do not enhance fertility but may be helpful in some patients to relieve symptoms and prevent their recurrence, either alone or in combination with surgery. However, there is little good evidence to support use of medical therapy, with few randomised placebo-controlled trials, and many questions remain unanswered. It is unclear how long treatment should continue and what the long-term effects are, and this information is likely to be difficult to obtain. Although ovarian suppression with GnRH analogues relieves symptoms of endometriosis, it is necessary to "add back" hormone replacement therapy to prevent bone demineralisation if they are given for more than 6 months. No clear differences have been shown between the above drugs except in adverse events.
There is preliminary evidence from case series that the levonorgestrel-releasing intrauterine system may reduce the size of rectovaginal endometriotic deposits and alleviate pain, and that it may be a suitable therapy for symptomatic endometriosis and adenomyosis. While this system will not help women desiring pregnancy, it offers an exciting possibility for the future medical treatment of endometriosis.
Future Developments
Possible future developments in management of menstrual disorders include improved understanding of the mechanisms of menstrual disturbance and the factors that control the establishment and progression of endometriosis. In the latter condition, specific therapies directed at molecular targets regulating the growth of ectopic endometrium are a possibility. Similarly, improved understanding of the molecular and genetic factors controlling fibroid growth may lead to targeted therapies to prevent or limit their proliferation.
In addition, new roles for established therapies, such as the levonorgestrel-releasing intrauterine system, are still being explored, including the treatment of symptomatic endometriosis and endometrial hyperplasia. The management of one of the most common complaints in women's health, menstrual disorders, is likely to continue to improve over the coming years.
ADHD A RESULT OF DELAYED BARIN DEVELOPMENT
Scientists in the United States have discovered that youngsters with attention deficit hyperactivity disorder (ADHD) have a delay in the development of some parts of their brains.
They are suggesting that some regions of the brain reach maturity as much as three years later in children with ADHD even though there remains a normal a pattern of development.
The scientists at the National Institutes of Health (NIH) compared the brain scans of 446 children ranging from pre-school to young adults.
Of the group 223 had been diagnosed with ADHD.
Magnetic resonance imaging (MRI) scans of the brain were carried out twice at around three-year intervals.
The researchers found that the delay in ADHD was most prominent in regions at the front of the brain outer mantle (cortex), which is important for the ability to control thinking, attention and planning.
Other than this both groups showed a similar back-to-front wave of brain maturation with different areas peaking in thickness at different times.
The imaging study revealed that in youngsters with ADHD, the brain matures in a normal pattern but is delayed on average three years in some regions.
Dr. Philip Shaw who led the research says that finding a normal pattern of cortex maturation, even though it is delayed, in children with ADHD should reassure parents and may also explain why many youngsters eventually appear to grow out of the disorder.
Dr. Shaw and colleagues at the National Institute of Mental Health (NIMH) Child Psychiatry Branch were able to detect the thickening and thinning of thousands of cortex sites by using a new image analysis technique which picks up the focal and regional changes where the delay is most marked.
Previous brain imaging studies have failed to detect the developmental delay because they focused on the large lobes of the brain.
Of the 223 with ADHD, half of 40,000 cortex sites attained peak thickness at an average age of 10.5, compared to age 7.5 in those without the disorder.
The scans focused on the age when cortex thickening during childhood thins prior to puberty and unused neural connections are then pruned to provide optimal efficiency during the teenage years.
In both groups the sensory processing and motor control areas at the back and top of the brain peaked in thickness earlier in childhood, while the frontal cortex areas responsible for higher-order executive control functions peaked later, during the teen years.
These frontal areas support the ability to suppress inappropriate actions and thoughts, focus attention, remember things from moment to moment, work for reward, and control movement, all functions which are often disturbed in people with ADHD.
Circuitry in the frontal and temporal areas at the side of the brain that integrate information from the sensory areas with the higher-order functions showed the greatest maturational delay in those with ADHD and one of the last areas to mature, the middle of the prefrontal cortex, was delayed by five years in those with the disorder.
The motor cortex emerged as the only area that matured faster than normal in the youngsters with ADHD, in contrast to the late-maturing frontal cortex areas that direct it.
This mismatch says the scientists might explain the restlessness and fidgety symptoms common among those with the disorder.
They also say that the delayed pattern of maturation observed in ADHD is the opposite of that seen in other developmental brain disorders like autism, in which the volume of brain structures peak at a much earlier-than-normal age.
The findings support the theory that ADHD results from a delay in cortex maturation and in future the researchers hope to find genetic explanations for the delay and ways of boosting processes of recovery from the disorder.
Dr. Shaw says however that brain imaging is still not ready for use as a diagnostic tool in ADHD and the diagnosis of ADHD remains clinical, based on taking a history from the child, the family and teachers.
The research is published in the current online edition of the Proceedings of the National Academy of Sciences. Be the first to rate this post.
MALE INFERTILITY
Efficacy of varicocelectomy in management of male infertility
Prof Ashok Agarwal
Cleveland Clinic and Case Western University
Dr Fnu Deepinder
Saint Joseph Hospital
Last updated on 16 October 2008
Varicocele is present in approximately 40% of men presenting with infertility. Although varicocele repair is widely used in the management of male factor infertility, the effectiveness of varicocelectomy has been intensely debated, and there is still no consensus on the topic. The recent development of assisted reproductive techniques (ART) has lead to intracytoplasmic sperm injection (ICSI) being increasingly used for all causes of male infertility including the varicocele. However, these techniques deprive patients from the satisfaction of natural conception in addition to not being cost effective.
Existing literature is conflicting, and very few sufficiently large and adequately controlled prospective trials are available evaluating the efficacy of varicocelectomy in improving pregnancy outcomes. Two published meta-analyses evaluating prospective randomized trials came to the conclusion that varicocele repairs do not improve sub-fertility, and hence recommended against varicocele repair for unexplained infertility (Kamishke and Nieschlag, 2001; Evers et al., 2008). However, these meta-analyses have been critiqued because of methodological flaws; and consequently have not resolved the issues surrounding varicocelectomy and sub-fertility (Ficarra et al., 2006). Two recently very well conducted meta-analyses utilizing a new approach have assessed the effect of varicocelectomy on pregnancy outcomes and semen parameters (Agarwal et al., 2007; Marmar et al., 2007). In these analyses, surgical varicocelectomy in selected patients demonstrated a beneficial effect on fertility status. In infertile men with palpable lesions and at least one abnormal semen parameter, it improves the odds of spontaneous pregnancy in their female partners. Similarly, varicocelectomy significantly improves semen parameters in infertile men with palpable varicocele and abnormal semen parameters. It is important to keep in mind that the couples who fail to achieve a natural pregnancy after varicocele repair may achieve better results with assisted reproductive techniques because of the increase in semen quality.
The exact mechanism by which varicocelectomy improves fertility in affected men remains unknown. Oxidative stress and DNA damage to sperm which are well documented components of varicocele pathophysiology have however shown improvement after varicocele repair. In an important research trial, elevated levels of thiobarbituric acid reactive substances which are markers of oxidative stress in seminal and peripheral plasma of varicocele patients returned to normal one month post-varicocelectomy. In this study, other markers of oxidative stress were also decreased and the total anti-oxidant capacity was increased six months after varicocelectomy (Hurtado de Catalfo et al., 2007). Confirming the increased anti-oxidant capacity after varicocele repair, a more recent study also found a significant decrease in the levels of 8-hydroxy-2-deoxy-guanosine (8-OHdG), another marker of oxidative stress in all post-varicocele repair patients. In this study, investigators also demonstrated a significant decline in the incidence of 4977 bp deletion in mitochondrial DNA, a marker of oxidant mediated DNA damage after varicocele repair (Chen et al., 2008). High pre-operative 4-hydroxy-2-noneenal (4-HNE) modified protein levels in the testis have shown to predict a response to varicocele repair (Shiraishi and Naito, 2006).
In clinical practice, the main treatment options for infertile males with varicoceles have been varicocelectomy and assisted reproductive techniques; however, there are economic and pregnancy outcome advantages for varicocelectomy versus IVF, and this should be reported to patients at the time of counseling. The Best Practice Policy committee of the American Urological Association (AUA) and the American Society for Reproductive Medicine (ASRM) in their most recent guidelines have recommended varicocele repair for infertile men with clinically palpable varicocele and at least one or more abnormal semen parameters with female partner having either normal or potentially treatable fertility (ASRM, 2006).
YOGA FOR FIBROMYALGIA
Yoga that includes gentle stretches and meditation may help alleviate the symptoms of fibromyalgia, a small study finds.
Twenty-five women diagnosed with fibromyalgia, a chronic pain syndrome, were enrolled in a two-hour yoga class that met once a week for eight weeks. Another group of 28 women diagnosed with the condition were put on a waiting list and told to continue their normal routine for dealing with fibromyalgia.
After eight weeks, the yoga group reported improvements in both physical and psychological aspects of fibromyalgia, including decreased pain, fatigue, tenderness, anxiety and better sleep and mood.
"The women were somewhat apprehensive when we started, but once they got into the rhythm of it they found it to be very helpful," said lead study author James Carson, a clinical psychologist and pain specialist at Oregon Health & Science University in Portland. "They came back after the first week reporting less pain, better sleep and feeling encouraged for the first time in years. That type of change continued to build over the course of the program."
At the end of the study, about 4.5 percent in the yoga group reported being "very much better," 9.1 percent said they were "much better," 77 percent were "a little better" while 4.5 percent reported no change. In comparison, no one in the the control group reported that they were "very much better" or "much better," 19.2 percent reported being "a little better," and 38.5 percent reported "no change."
Average pain scores dropped from a 5 to a 4 on a 10-point scale, although there was no improvement in the overall "tender point" score.
The study was limited by its small sample, absence of follow-up and over-reliance on self-reported data, the researchers noted.
The study, published online Oct. 14, is in the November print issue of the journal Pain.
No cure exists for fibromyalgia, which is characterized by multiple tender points, fatigue, insomnia, anxiety, depression, and memory and concentration problems. Some 11 to 15 million Americans have the debilitating condition, about 80 to 90 percent of them women, according to background information in the article.
Fibromyalgia can be very difficult to treat, with many patients reporting little relief from medications, said Dr. Bruce Solitar, a clinical associate professor of medicine in the division or rheumatology at NYU Langone Medical Center in New York City.
Yoga is probably worth trying, Solitar said. But he noted that patients in the study were in a yoga class specially tailored to their needs and said the class at a local yoga studio might be too intense.
The yoga sessions evaluated in the study included 40 minutes of gentle stretching and poses, 25 minutes of meditation, 10 minutes of breathing techniques, a 20-minute lesson on applying yoga principals to daily life and coping with fibromyalgia and 25 minutes of group discussion. Participants were also encouraged to practice at home with a DVD on most days.
Though it's unknown how much of the positive effect shown in the study is the "placebo" effect of doing something that feels empowering vs. something special about the yoga and meditation itself, that may be beside the point if people feel better, Solitar said.
"Many patients report that not much helps them, so anything that's positive is a very good thing," Solitar said.
In the study, women practiced Yoga of Awareness, a type of yoga developed by Carson, a yoga and meditation instructor, and his wife, study co-author Kimberly Carson. Carson taught the class. (Carson reported no financial considerations that would cause a conflict of interest.)
Yoga of Awareness draws from the Kripalu school of yoga, Carson said, which emphasizes the "inner dimensions" of yoga, such as accepting pain and being willing to learn from pain and stressful circumstances, being mentally "present in the moment" and learning to distinguish between actual events and the mind's tendency to "catastrophize" pain -- that is, thinking it's the worst pain ever when really it's manageable, he said.
Previous research showed Yoga of Awareness improved pain, fatigue, sleep and mood in women with breast cancer, Carson said.
It's unknown what aspects of Yoga of Awareness are the most beneficial, but Carson said he believes the exercise, meditation and the social aspects all contribute.
"It's the combination that has a synergistic effect," Carson said. "Our mind and body are very connected, but we are often not aware of that fact.
Techniques like yoga really reinforce that connection and make us much more conscious of the fact that our thoughts and our feelings are affecting our body, and our body is affecting how we think and feel."
If you have fibromyalgia and are looking for a yoga class, Carson recommended seeking out a class advertised as "gentle" and making sure the instructor knows you have physical challenges so that poses can be modified.
Since many yoga classes don't incorporate much meditation, Carson also recommends seeking out a meditation class, which teaches breathing exercises to reduce stress and cope with pain.
A study published in August in the New England Journal of Medicine found tai chi may also help give fibromyalgia sufferers some relief. Like yoga, tai chi is a mind-body exercise that emphasizes slow, gentle movements to build strength and flexibility, as well as deep breathing and relaxation, to move qi, or vital energy, throughout the body.
More information
The U.S. National Center for Complementary and Alternative Medicine has more on yoga.
SOURCES: James Carson, Ph.D., clinical psychologist, assistant professor, department of anesthesiology, Oregon Health & Science University, Portland, Or.; Bruce Solitar, M.D., clinical associate professor of medicine, division of rheumatology, NYU Langone Medical Center, New York, N.Y.; Pain, November 2010
