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

BJOG. 2017 Sep;124(10):1514-1523. doi: 10.1111/1471-0528.14619. Epub 2017 May 11.


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.

Keywords: Hormonal treatment; menopause; network meta-analysis; uterus.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Administration, Cutaneous
  • Bayes Theorem
  • Cimicifuga
  • Estradiol / administration & dosage
  • Estrogens / administration & dosage
  • Female
  • Hot Flashes / therapy*
  • Humans
  • Isoflavones / therapeutic use
  • Menopause*
  • Middle Aged
  • Network Meta-Analysis
  • Odds Ratio
  • Phytotherapy / methods
  • Practice Guidelines as Topic*
  • Progestins / administration & dosage
  • Randomized Controlled Trials as Topic
  • Serotonin and Noradrenaline Reuptake Inhibitors / therapeutic use
  • Treatment Outcome
  • Vasomotor System*


  • Estrogens
  • Isoflavones
  • Progestins
  • Serotonin and Noradrenaline Reuptake Inhibitors
  • Estradiol