COMMENTARY

A Dozen Treatments for Vasomotor Symptoms of Menopause: Which Works Best?

Peter Kovacs, MD, PhD

Disclosures

November 14, 2017

A Dozen Treatments for Vasomotor Symptoms of Menopause

At the time of natural or surgical menopause, the ovaries cease their cyclic activity, resulting in important hormonal changes. Estradiol and androgen levels decline, and progesterone is no longer produced in cyclic fashion. These changes lead to significant clinical effects. Some of these effects remain silent (skeletal, cardiovascular); while others, such as vasomotor effects, are associated with well-characterized symptoms. Vasomotor symptoms affect up to 75% of women entering menopause.

Various hormonal and nonhormonal treatments are available for the relief of vasomotor symptoms. In a new review and meta-analysis, Sarri and colleagues[1] evaluated the efficacy and adverse effects, as well as treatment discontinuation rates, of various treatments.

A total of 47 randomized controlled trials were considered for this meta-analysis, which assessed the efficacy of 12 different treatments when compared with placebo:

  • Acupuncture;

  • Sham acupuncture;

  • Transdermal estrogen (E) + progestogen (P);

  • Oral E+P;

  • Tibolone;

  • Raloxifene;

  • Selective serotonin reuptake inhibitors (SSRIs);

  • Serotonin-norepinephrine reuptake inhibitors (SNRIs);

  • Isoflavones;

  • Chinese herbal medicine;

  • Black cohosh; and

  • Multibotanicals.

What Worked Best?

For reduction of vasomotor symptoms, transdermal E+P was more effective than placebo (mean ratio [MR], 0.23; 95% confidence interval [CI], 0.09-0.57). Oral E+P was also shown to have good efficacy (MR, 0.52; 95% CI, 0.25-1.06). Isoflavones (MR, 0.62; 95% CI, 0.44-0.87) and black cohosh (MR, 0.40; 95% CI, 0.16-0.90) were also superior to placebo. The other treatments were not found to significantly differ from placebo.

Transdermal E+P was less likely than placebo to be discontinued (odds ratio [OR], 0.61; 95% CI, 0.37-0.99), as was the combination of oral E+ bazedoxefine. Owing to side effects, SSRIs and SNRIs were more likely than placebo to be discontinued.

Vaginal bleeding during treatment was assessed as an adverse event. Data, however, were insufficient to allow valid conclusions to be drawn. The investigators concluded that transdermal E+P reduces hot flush frequency most effectively, but data support oral E+P use as well. They also concluded that although isoflavones and black cohosh reduce vasomotor symptoms, there are concerns about their safety. Finally, they do not recommend SSRIs or SNRIs as first-line treatments for vasomotor symptoms associated with natural menopause.

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