Clinician Article
Nonestrogen Therapies for Treatment of Genitourinary Syndrome of Menopause: A Systematic Review.
PMID: 37543737
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GynecologyRelevance - 6/7
Newsworthiness - 5/7
Abstract
OBJECTIVE: To systematically review the literature and provide clinical practice guidelines regarding various nonestrogen therapies for treatment of genitourinary syndrome of menopause (GSM).
DATA SOURCES: MEDLINE, EMBASE, ClinicalTrials.gov , and Cochrane databases were searched from inception to July 2021. We included comparative and noncomparative studies. Interventions and comparators were limited to seven products that are commercially available and currently in use (vaginal dehydroepiandrosterone [DHEA], ospemifene, laser or energy-based therapies, polycarbophil-based vaginal moisturizer, Tibolone, vaginal hyaluronic acid, testosterone). Topical estrogen, placebo, other nonestrogen products, as well as no treatment were considered as comparators.
METHODS OF STUDY SELECTION: We double-screened 9,131 abstracts and identified 136 studies that met our criteria. Studies were assessed for quality and strength of evidence by the systematic review group.
TABULATION, INTEGRATION, AND RESULTS: Information regarding the participants, details on the intervention and comparator and outcomes were extracted from the eligible studies. Alternative therapies were similar or superior to estrogen or placebo with minimal increase in adverse events. Dose response was noted with vaginal DHEA and testosterone. Vaginal DHEA, ospemifene, erbium and fractional carbon dioxide (CO 2 ) laser, polycarbophil-based vaginal moisturizer, tibolone, hyaluronic acid, and testosterone all improved subjective and objective signs of atrophy. Vaginal DHEA, ospemifene, tibolone, fractional CO 2 laser, polycarbophil-based vaginal moisturizer, and testosterone improved sexual function.
CONCLUSION: Most nonestrogen therapies are effective treatments for the various symptoms of GSM. There are insufficient data to compare nonestrogen options to each other.
Clinical Comments
Gynecology
Although the authors did a tremendous task, I would have preferred that they had limited the inclusion criteria to randomized clinical trials, given that for several of the comparisons they had an acceptable number of studies. The inclusion of observational studies undermines the confidence of the results. I would have liked sensitivity analyses taking into account the quality of the studies to know the stability of the results. “Microablative fractional CO2 laser was evaluated in 41 single-group studies,” but only “six of them are randomized controlled trials (RCTs)” and “Erbium laser was studied in two RCTs comparing the laser to estrogen and in three single-group studies”. Under these conditions, I consider that assigning, "We recommend" and assigning the A classification given to some of the recommendations of this therapy could be generous.
Gynecology
It is good to have evidence to support the usefulness of non-estrogen alternatives that broadens the treatment choices for genito-urinary symptoms of menopause.
Gynecology
The efforts toward systematically reviewing the available evidence of non-estrogenic therapies for treating GSM is well-represented in this review. The conclusions were properly noted and are certainly of interest to clinicians.
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