Menopausal Symptoms: Comparative Effectiveness of Therapies

Clinical Practice Brief: Menopausal Symptoms—Comparative Effectiveness of Therapies

Introduction

The Agency for Quality Healthcare Research and Quality (AHRQ) published a report from 2015 comparing effectiveness of therapies for menopausal symptoms. This report was created by reviewing 283 systematic reviews, cohort studies and case-control studies found through a comprehensive literature review. Limitations of the review include difference in scales found in the studies and potential population differences from the various studies. Another limitation is that not all treatment options were explored in the studies (i.e., St John’s Wort for depression, etc.). Prescribers need to be aware of side effects and contraindications for all products discussed as these are not discussed in this review (Grant et al., 2015).

Summary

Vasomotor Symptoms such as Hot Flashes, Night Sweats, and Flushes

Estrogens, isoflavones, Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine Reuptake Inhibitors (SSRI/SNRI), gabapentin, ginseng and black cohosh were tested against placebo. No therapy was tested against another.

  • Estrogen in any method of use was effective in relieving vasomotor symptoms (High Evidence Strength).
  • SSRI/SNRI is not as effective at vasomotor symptom relief as estrogens but is superior to the other modalities tested and does not have the adverse effects of estrogens (High Evidence Strength).
  • Few differences were seen in symptom relief with gabapentin, isoflavones and black cohosh (Low to Moderate Evidence Strength).
  • Ginseng’s effect was unclear on vasomotor symptoms (Low Evidence Strength).

Quality of Life

Estrogens, isoflavones, SSRI/SNRIs, ginseng and black cohosh were tested against placebo. No therapy was tested against another. Estrogen in any method of use was effective in relieving vasomotor symptoms (High Evidence Strength)

  • Estrogens in any form and SSRI/SNRI had positive effect on quality of life (High Evidence Strength).
  • Isoflavones, ginseng and black cohosh had no significant effect on quality of life (Low to Moderate Evidence Strength).

Psychological Symptoms Such as Depression, Anxiety and Global Well-Being

SSRI/SNRI, estrogen, gabapentin and isoflavones were tested against placebo. No therapy was tested against another. Estrogen in any method of use was effective in relieving vasomotor symptoms (High Evidence Strength)

  • SSRI/SNRI and estrogens were effective against depression and alteration of global psychological function (High Evidence Strength). Vasomotor symptoms can cause in increased risk for psychological symptoms, which is why estrogen may be effective.
  • Gabapentin and isoflavones had low or insufficient evidence strength when treating depression or global psychological symptoms though isoflavone may help with anxiety symptoms (Moderate Evidence Strength).

Sexual Function Such as Dyspareunia, Sexual Activity and Sexual Interest

Estrogens, isoflavones, SSRI/SNRIs, ginseng and black cohosh were tested against placebo. No therapy was tested against another. Estrogen in any method of use was effective in relieving vasomotor symptoms (High Evidence Strength).

  • Vaginal estrogens improved pain associated with sexual intercourse (High Evidence Strength).
  • All estrogen products improved interest in sexual activity (Moderate Evidence Strength).
  • Sexual activity frequency improved with the use of testosterone (Moderate Evidence Strength).
  • Overall, all estrogens had a positive global effect on sexual function (Moderate Evidence Strength).

Urogenital Atrophy and Vaginal Dryness

Vaginal estrogens, nonvaginal estrogens, isoflavones and Ospemifene were tested against placebo. No therapy was tested against another.

  • Vaginal estrogen showed a greater effect than nonvaginal estrogens.
  • Vaginal estrogen, nonvaginal estrogen and Ospemifene were each effective against placebo (High Evidence Strength).
  • Isoflavones were effective but had a low evidence strength.

Sleep

Eszopiclone, estrogen, SSRI, Gabapentin, Isoflavones and Ginseng were tested against placebo. No therapy was tested against another.

  • Eszopiclone was effective in treating sleep-related symptoms better than placebo. The effect was three times higher than other treatment options against placebo (Evidence Strength not measured).
  • Sleep disorders associated with vasomotor symptoms were relieved with estrogen allowing for improved sleep (High Evidence Strength).
  • Other treatment options had low or insufficient evidence strength and effects were attributed to improvement in vasomotor symptoms.

References

Grant, M.D., Marbella, A., Wang, A.T., Pines, E., Hoag, J., Bonnell, C. Aronson, N. (2015). Menopausal symptoms: Comparative effectiveness of therapies.

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases: Measles. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015.

This "Practice Brief" was developed by the Practice Committee of the American Association of Nurse Practitioners.

Robin Arends, DNP, CNP, FNP-BC, FAANP
Brian Buchner, DNP, RN, ACNP, FAANP
Oralea Pittman, DNP, FNP-BC, FAANP
Phyllis Everett, MSN, RN, AOCN, APNG, NP-C
Allen Prettyman, PhD, FNP-BC, FAANP
George Peraza-Smith, DNP, GNP-BC, CNE, FAANP
Kenneth Wysocki, PhD, FNP-C, FAANP