#353 – Turn Down the Heat! Can non-hormonal drugs improve vasomotor symptoms in menopause?
CLINICAL QUESTION
Do non-hormonal medications improve menopausal vasomotor symptoms?
BOTTOM LINE
After 12 weeks, approximately 50-75% of women with menopausal vasomotor symptoms experience ≥50% decrease in hot flashes with selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) or gabapentin versus 35-60% on placebo. Placebo reduces the number of hot flashes by about 40-50%, with an additional 10-20% reduction from SSRIs, SNRIs, and gabapentin.
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EVIDENCE
- All results statistically different unless indicated.
- SSRIs (six meta-analyses, 4-11 RCTs, 547-2069 patients);1-6 SNRIs (five meta-analyses, 2-7 RCTs, 301-3685 patients);2-3,5,7-8 gabapentin (five meta-analyses, 2-9 RCTs, 901-3519 patients);2,3,9-11 clonidine (one meta-analysis, 4 RCTs, 30-198 patients).3 When outcomes not available, largest RCTs for each drug class retrieved.
- Hot flashes (daily):
- SSRIs,1 gabapentin,3 desvenlafaxine:12-13 Baseline 9-11;
- Mean difference: 1-2 fewer hot flashes over placebo at 4-12 weeks.
- Example: 3-4 hot flashes (desvenlafaxine) versus 5-6 (placebo).12
- Oxybutynin (148 patients):14 Four fewer hot flashes over placebo.
- Clonidine:3 One fewer hot flash over placebo.
- No difference when breast cancer patients excluded.
- SSRIs,1 gabapentin,3 desvenlafaxine:12-13 Baseline 9-11;
- Proportion with ≥50% reduction in number of hot flashes. Examples at 12 weeks, (unless noted):
- Gabapentin15 (600 patients): 73% versus 60% (placebo), number needed to treat (NNT)=8.
- Desvenlafaxine12 (567 patients): 68-75% versus 48% (placebo), NNT=4-5.
- SSRIs:
- Paroxetine16 (614 patients) or escitalopram17 (205 patients): 48-55% versus 36% (placebo), NNT=6-9 over 8-12 weeks.
- Fluoxetine, citalopram (150 patients):18 No difference versus placebo.
- Global assessment: “Much/Very much improved” over 12 weeks:
- Gabapentin:15 58% versus 44% (placebo), NNT=8.
- Oxybutynin:14 73% versus 26% (placebo), NNT=2.
- Quality of life: Versus placebo:
- Citalopram, fluoxetine, or sertraline:18-19 No difference.
- Escitalopram:20 Not clinically different.
- Hot flashes (daily):
- Limitations: Event rates not reported;2-8,10-11 standard mean differences used (difficult to interpret clinically);1,2,8,10-11 breast cancer patients included;2,3,6,9-11 RCTs industry funded.13-16,18-19
CONTEXT
- Guidelines:
- First-line: Hormone therapy; second-line: SSRIs, SNRIs, or gabapentin.21
- Hormone therapy:
- Versus placebo: ~18 fewer hot flashes/week (mostly estradiol 1-2mg).22
- Versus gabapentin: 1 fewer hot flash/day with hormone therapy.10
- Versus venlafaxine: RCT underpowered to compare agents for efficacy outcomes.23
- Patient satisfaction: 70% versus 51% venlafaxine.
- Dosing (daily):21 Paroxetine 10-25mg, desvenlafaxine 100-150mg, gabapentin 900-2400mg.
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Interesting but not conclusive results.
None
HRT should be gold standard , we should stop to have concern about HRT with bioidentical drugs
Excellent study material
i do use venlafaxine in my practice with good results
Alternatives to HRT are always welcome
Given a 50% respone rate to placebo therapy, it seems reasonable to start with such therapy for those
patients who inclined to more natural products as first ;ine therapy.
Interesting to see how HRT is still prominent but there is still such hesitation to taking it
These are all goo options .they can all be used and should be given to our patients as options after a discussion with them