Clinician Article
Vasomotor symptoms resulting from natural menopause: a systematic review and network meta-analysis of treatment effects from the National Institute for Health and Care Excellence guideline on menopause.
PMID: 28276200
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Family Medicine (FM)/General Practice (GP)Relevance - 6/7
Newsworthiness - 6/7 -
General Internal Medicine-Primary Care(US)Relevance - 6/7
Newsworthiness - 6/7 -
GynecologyRelevance - 6/7
Newsworthiness - 5/7
Abstract
BACKGROUND: Vasomotor symptoms (VMSs) are the hallmarks of menopause, occurring in approximately 75% of postmenopausal women in the UK, and are severe in 25%.
OBJECTIVES: To identify which treatments are most clinically effective for the relief of VMSs for women in natural menopause without hysterectomy.
SEARCH STRATEGY: English publications in MEDLINE, Embase, and The Cochrane Library up to 13 January 2015 were searched.
SELECTION CRITERIA: Randomised controlled trials (RCTs) of treatments for women with a uterus for the outcomes of frequency of VMSs (up to 26 weeks), vaginal bleeding, and discontinuation.
DATA COLLECTION AND ANALYSIS: Bayesian network meta-analysis (NMA) using mean ratios (MRs) and odd ratios (ORs).
MAIN RESULTS: Across the three networks, 47 RCTs of 16 treatment classes (n = 8326 women) were included. When compared with placebo, transdermal estradiol and progestogen (O+P) had the highest probability of being the most effective treatment for VMS relief (69.8%; MR 0.23; 95% credible interval, 95% CrI 0.09-0.57), whereas oral O+P was ranked lower than transdermal O+P, although oral and transdermal O+P were no different for this outcome (MR 2.23; 95% CrI 0.7-7.1). Isoflavones and black cohosh were more effective than placebo, although not significantly better than O+P. Not only were selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) found to be ineffective in relieving VMSs, but they also had significantly higher odds of discontinuation than placebo. Limited data were available for bleeding, therefore no conclusions could be made.
CONCLUSION: For women who have not undergone hysterectomy, transdermal O+P was the most effective treatment for VMS relief.
TWEETABLE ABSTRACT: Which treatment best relieves menopause flushes? Results from the #NICE guideline network meta-analysis.
Clinical Comments
Family Medicine (FM)/General Practice (GP)
This network analysis certainly helps me set out the benefits (less so the harms) for patients of different options for menopause vasomotor symptoms -- very helpful.
General Internal Medicine-Primary Care(US)
Transdermal estrogen + progesterone was found to be most effective for vasomotor symptoms after menopause, but black cohosh was close behind, which was news to me. The authors did not adequately explain why black cohosh was entirely discounted in their conclusions, other than "safety concerns." If this is the reason, why was it included in the study?
General Internal Medicine-Primary Care(US)
Interestingly, oral estradiol and progestogen has a lower OR point estimate (0.51 versus 0.23 for non-oral) with a confidence interval including 1. Isoflavones and black cohosh are more effective than placebo. Although the two are "non-inferior" to transdermal estradiol and progestogen, I would only consider either of these agents if the patient`s medical history or personal preferences suggested not prescribing the estradiol/progestogen. Neither selective serotonin reuptake inhibitors nor serotonin-norepinephrine reuptake inhibitors seem to be effective to relieve these symptoms. On the harm side, the estradiol/progestogen appear to increase the risk of vaginal bleeding (OR 2.76 [CI 0.68-12.06]). This article provides additional information to help clinicians counsel patients experiencing menopausal symptoms about risks and benefits of different treatment options.
General Internal Medicine-Primary Care(US)
This statistical tour de force systematic review (SR) addresses an important subject in the lives of menopausal women: the hot flashes that can substantially detract from quality-of-life during these years. The SR shows convincingly that transdermal estradiol plus progestin is by far most likely to provide relief compared with all the other treatments that have been studied in RCTs, assuming there are no contraindications to perimenopausal hormonal therapy such as a history of breast cancer, CAD, stroke or VTE, or a moderate-to-high risk for these conditions.
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