***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : The aim of the study was to examine the efficacy of an unguided , self-help cognitive behavior therapy ( SH-CBT ) booklet on hot flush and night sweat ( HFNS ) problem rating , delivered in a work setting . Methods : Women aged 45 to 60 years , having 10 or more problematic HFNS a week , were recruited to a multicenter r and omized controlled trial , via the occupational health/human re sources departments of eight organizations . Participants were 1:1 r and omized to SH-CBT or no treatment waitlist control ( NTWC ) . The primary outcome was HFNS problem rating ; secondary outcomes included HFNS frequency , work and social adjustment , sleep , mood , beliefs and behaviors , and work-related variables ( absence , performance , turnover intention , and work impairment due to presenteeism ) . Intention-to-treat analysis was used , and between-group differences estimated using linear mixed models . Results : A total of 124 women were r and omly allocated to SH-CBT ( n = 60 ) and NTWC ( n = 64 ) . 104 ( 84 % ) were assessed for primary outcome at 6 weeks and 102 ( 82 % ) at 20 weeks . SH-CBT significantly reduced HFNS problem rating at 6 weeks ( SH-CBT vs NTWC adjusted mean difference , −1.49 ; 95 % CI , −2.11 to −0.86 ; P < 0.001 ) and at 20 weeks ( −1.09 ; 95 % CI , −1.87 to −0.31 ; P < 0.01 ) . SH-CBT also significantly reduced HFNS frequency , improved work and social adjustment ; sleep , menopause beliefs , HFNS beliefs/behaviors at 6 and 20 weeks ; improved wellbeing and somatic symptoms and reduced work impairment due to menopause-related presenteeism at 20 weeks , compared with the NTWC . There was no difference between groups in other work-related outcomes . Conclusions : A brief , unguided SH-CBT booklet is a potentially effective management option for working women experiencing problematic HFNS Background : During peri- and postmenopause there is a high prevalence of psychological symptoms such as emotional instability , depressive moods , anxiety , sleep disorders , and sexual dysfunction . Aetiologically relevant factors for discomfort are decline of sex hormones and psychosocial factors such as lifestyle , attitude towards menopause , pre-menopausal mental health and sociocultural factors . In contrast to the relevance of psychosocial factors , there are few studies on psychological interventions . The present study evaluates an open trial of cognitive-behavioural group intervention consisting of psychoeducation , group discussion and coping skills training for women suffering from climacteric symptoms . Methods : Thirty women were enrolled in this first trial . St and ardised ( MRS , HADS-D , Partnership Question naire , McCoy Female Sexuality Question naire ) and especially developed ( ‘ Attitudes Towards the Menopause ’ ) instruments were administered 3 times , twice before ( T1 and T2 ) and once after the group intervention ( T3 ) . General linear model repeated measures were used to analyse changes in question naire measures . Results : Taking the average of the two pre-intervention scores , significant improvements were observed in anxiety ( p < 0.01 ) , depression ( p < 0.02 ) , partnership relations ( p < 0.02 ) , overall score of sexuality ( p < 0.02 ) , hot flashes ( p < 0.01 ) and cardiac complaints ( p < 0.01 ) from pre- to post-intervention . No changes were found for sexual satisfaction and stressfulness of menopausal symptoms . Conclusions : This pilot study points at a possible effectiveness of cognitive-behavioural interventions for the treatment of climacteric syndrome . Further studies will have to use r and omised trials , comparing different treatments ( HRT , phyto-oestrogens , relaxation training , discussion groups ) for their effectiveness Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more CONTEXT Despite decades of accumulated observational evidence , the balance of risks and benefits for hormone use in healthy postmenopausal women remains uncertain . OBJECTIVE To assess the major health benefits and risks of the most commonly used combined hormone preparation in the United States . DESIGN Estrogen plus progestin component of the Women 's Health Initiative , a r and omized controlled primary prevention trial ( planned duration , 8.5 years ) in which 16608 postmenopausal women aged 50 - 79 years with an intact uterus at baseline were recruited by 40 US clinical centers in 1993 - 1998 . INTERVENTIONS Participants received conjugated equine estrogens , 0.625 mg/d , plus medroxyprogesterone acetate , 2.5 mg/d , in 1 tablet ( n = 8506 ) or placebo ( n = 8102 ) . MAIN OUTCOMES MEASURES The primary outcome was coronary heart disease ( CHD ) ( nonfatal myocardial infa rct ion and CHD death ) , with invasive breast cancer as the primary adverse outcome . A global index summarizing the balance of risks and benefits included the 2 primary outcomes plus stroke , pulmonary embolism ( PE ) , endometrial cancer , colorectal cancer , hip fracture , and death due to other causes . RESULTS On May 31 , 2002 , after a mean of 5.2 years of follow-up , the data and safety monitoring board recommended stopping the trial of estrogen plus progestin vs placebo because the test statistic for invasive breast cancer exceeded the stopping boundary for this adverse effect and the global index statistic supported risks exceeding benefits . This report includes data on the major clinical outcomes through April 30 , 2002 . Estimated hazard ratios ( HRs ) ( nominal 95 % confidence intervals [ CIs ] ) were as follows : CHD , 1.29 ( 1.02 - 1.63 ) with 286 cases ; breast cancer , 1.26 ( 1.00 - 1.59 ) with 290 cases ; stroke , 1.41 ( 1.07 - 1.85 ) with 212 cases ; PE , 2.13 ( 1.39 - 3.25 ) with 101 cases ; colorectal cancer , 0.63 ( 0.43 - 0.92 ) with 112 cases ; endometrial cancer , 0.83 ( 0.47 - 1.47 ) with 47 cases ; hip fracture , 0.66 ( 0.45 - 0.98 ) with 106 cases ; and death due to other causes , 0.92 ( 0.74 - 1.14 ) with 331 cases . Corresponding HRs ( nominal 95 % CIs ) for composite outcomes were 1.22 ( 1.09 - 1.36 ) for total cardiovascular disease ( arterial and venous disease ) , 1.03 ( 0.90 - 1.17 ) for total cancer , 0.76 ( 0.69 - 0.85 ) for combined fractures , 0.98 ( 0.82 - 1.18 ) for total mortality , and 1.15 ( 1.03 - 1.28 ) for the global index . Absolute excess risks per 10 000 person-years attributable to estrogen plus progestin were 7 more CHD events , 8 more strokes , 8 more PEs , and 8 more invasive breast cancers , while absolute risk reductions per 10 000 person-years were 6 fewer colorectal cancers and 5 fewer hip fractures . The absolute excess risk of events included in the global index was 19 per 10 000 person-years . CONCLUSIONS Overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 5.2-year follow-up among healthy postmenopausal US women .  All-cause mortality was not affected during the trial . The risk-benefit profile found in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases , and the results indicate that this regimen should not be initiated or continued for primary prevention of CHD Menopause is associated with a considerable variety of physical , psychological and social symptoms that can be treated using cognitive-behavioral techniques . In the present study , 21 women took part in an eight-week group intervention consisting of weekly two-hour sessions to address their slight symptoms related to the climacteric stage of life . The intervention included : psycho education on menopause , relaxation techniques , nutrition and fitness exercises , Kegel exercises , and problem-solving techniques . A control group was included that did not receive treatment and consisted of 28 women . The results revealed a significant reduction in most symptoms ( including depression and anxiety ) after intervention as compared to the baseline period . No changes appeared in the control group . The relevance of this work lies in the potential element of prevention this therapeutic package could offer to relieve various symptoms , slight and incipient , during the perimenopausal stage IMPORTANCE Effective , practical , nonpharmacologic therapies are needed to treat menopause-related insomnia symptoms in primary and women 's specialty care setting s. OBJECTIVE To evaluate the efficacy of telephone-based cognitive behavioral therapy for insomnia ( CBT-I ) vs menopause education control ( MEC ) . DESIGN , SETTING , AND PARTICIPANTS A single-site , r and omized clinical trial was conducted from September 1 , 2013 , to August 31 , 2015 , in western Washington State among 106 perimenopausal or postmenopausal women aged 40 to 65 years with moderate insomnia symptoms ( Insomnia Severity Index [ ISI ] score , ≥12 ) and 2 or more daily hot flashes . Blinded assessment s were conducted at baseline , 8 , and 24 weeks postr and omization . An intent-to-treat analysis was conducted . INTERVENTIONS Six CBT-I or MEC telephone sessions in 8 weeks . Participants su bmi tted weekly electronic sleep diaries and received group-specific written educational material s. The CBT-I sessions included sleep restriction , stimulus control , sleep hygiene education , cognitive restructuring , and behavioral homework ; MEC sessions provided information about menopause and women 's health . MAIN OUTCOMES AND MEASURES Primary outcome was scores on the ISI ( score range , 0 - 28 ; scores ≥15 indicate moderate to severe insomnia ) . Secondary outcome was scores on the Pittsburgh Sleep Quality Index ( score range , 0 - 21 ; higher scores indicate worse sleep quality ) . Additional outcomes included sleep and hot flash diary variables and hot flash interference . RESULTS At 8 weeks , ISI scores had decreased 9.9 points among 53 women receiving CBT-I ( mean [ SD ] age , 55.0 [ 3.5 ] years ) and 4.7 points among 53 women receiving MEC ( age , 54.7 [ 4.7 ] years ) , a mean between-group difference of 5.2 points ( 95 % CI , -6.1 to -3.3 ; P < .001 ) . Pittsburgh Sleep Quality Index scores decreased 4.0 points in women receiving CBT-I and 1.4 points in women receiving MEC , a mean between-group difference of 2.7 points ( 95 % CI , -3.9 to -1.5 ; P < .001 ) . Significant group differences were sustained at 24 weeks . At 8 and 24 weeks , 33 of 47 women ( 70 % ) and 37 of 44 ( 84 % ) in the CBT-I group , respectively , had ISI scores in the no-insomnia range compared with 10 of 41 ( 24 % ) and 16 of 37 ( 43 % ) in the MEC group , respectively . The CBT-I group also had greater improvements in diary-reported sleep latency , wake time , and sleep efficiency . There were no between-group differences in frequency of daily hot flashes , but hot flash interference was significantly decreased at 8 weeks for the CBT-I group ( -15.7 ; 95 % CI , -20.4 to -11.0 ) compared with the MEC group ( -7.1 ; 95 % CI , -14.6 to 0.4 ) ( P = .03 ) , differences that were maintained at 24 weeks for the CBT-I group ( -22.8 ; 95 % CI , -28.6 to -16.9 ) and MEC group ( -11.6 ; 95 % CI , -19.4 to -3.8 ) ( P = .003 ) . CONCLUSIONS AND RELEVANCE Telephone-based CBT-I improved sleep in perimenopausal and postmenopausal women with insomnia and hot flashes . Results support further development and testing of central ized CBT-I programs for treating menopausal insomnia . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01936441 In the present study , we tested the effectiveness of a cognitive-behavioral group treatment ( CBGT ) for  hot flashes in menopausal women . Treatment was administered over 8 , 90 min weekly sessions and consisted of education , relaxation training and 
    Output:
    
Generally , the face-to-face method played a key positive effect on symptom improvement , and the group CBT approach was more effective on psychological symptoms .
Discussion Although the indirect method is more cost-effective , it has less impact than the face-to-face method , and , it is better to utilize face-to-face approaches to achieve a better result , if possible .