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Kingsberg SA, Schulze-Rath R, Mulligan C, Moeller C, Caetano C, Bitzer J. Global view of vasomotor symptoms and sleep disturbance in menopause: a systematic review. Climacteric 2023; 26:537-549. [PMID: 37751852 DOI: 10.1080/13697137.2023.2256658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/03/2023] [Indexed: 09/28/2023]
Abstract
Studies have shown racial/ethnic differences in the prevalence of vasomotor symptoms (VMS), sleep disturbance and VMS treatment in menopause. To assess the reproducibility of these differences, we systematically reviewed observational studies, published in 2000-2021, reporting the prevalence/incidence of VMS, sleep disturbance or treatment use in menopausal women stratified by race/ethnicity. We screened 3799 records from PubMed and Embase and included 27 papers (19 studies). No incidence data were found. Prevalence data varied widely, but some common patterns emerged. In all five studies comparing VMS between Black women and White, Hispanic and/or East Asian women, the prevalence was highest in Black women and lowest in East Asian women. The prevalence of sleep disturbance overall was compared among Black, White and East Asian women in two study populations, and was highest in White women in both papers. Sleep disturbance was more common than VMS in East Asian women. In all four studies comparing hormone therapy use between White women and Black and/or East Asian women, treatment use was more common in White women. These results highlight the need for individualized counseling and treatment, outreach to under-served minorities, and standardized definitions and outcome measures for VMS and sleep disturbance for future studies.
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Affiliation(s)
- S A Kingsberg
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - R Schulze-Rath
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - C Mulligan
- Evidence Synthesis, Beacon Medical Communications, Brighton, UK
| | - C Moeller
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - C Caetano
- Pharmaceuticals, Medical Affairs Women's Healthcare, Bayer AG, Basel, Switzerland
| | - J Bitzer
- Department of Obstetrics and Gynecology, University Hospital, University of Basel, Basel, Switzerland
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2
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Ruth KS, Beaumont RN, Locke JM, Tyrrell J, Crandall CJ, Hawkes G, Frayling TM, Prague JK, Patel KA, Wood AR, Weedon MN, Murray A. Insights into the genetics of menopausal vasomotor symptoms: genome-wide analyses of routinely-collected primary care health records. BMC Med Genomics 2023; 16:231. [PMID: 37784116 PMCID: PMC10546673 DOI: 10.1186/s12920-023-01658-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 09/08/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Vasomotor symptoms (VMS) can often significantly impact women's quality of life at menopause. In vivo studies have shown that increased neurokinin B (NKB) / neurokinin 3 receptor (NK3R) signalling contributes to VMS, with previous genetic studies implicating the TACR3 gene locus that encodes NK3R. Large-scale genomic analyses offer the possibility of biological insights but few such studies have collected data on VMS, while proxy phenotypes such as hormone replacement therapy (HRT) use are likely to be affected by changes in clinical practice. We investigated the genetic basis of VMS by analysing routinely-collected health records. METHODS We performed a GWAS of VMS derived from linked primary-care records and cross-sectional self-reported HRT use in up to 153,152 women from UK Biobank, a population-based cohort. In a subset of this cohort (n = 39,356), we analysed exome-sequencing data to test the association with VMS of rare deleterious genetic variants. Finally, we used Mendelian randomisation analysis to investigate the reasons for HRT use over time. RESULTS Our GWAS of health-records derived VMS identified a genetic signal near TACR3 associated with a lower risk of VMS (OR=0.76 (95% CI 0.72,0.80) per A allele, P=3.7x10-27), which was consistent with previous studies, validating this approach. Conditional analyses demonstrated independence of genetic signals for puberty timing and VMS at the TACR3 locus, including a rare variant predicted to reduce functional NK3R levels that was associated with later menarche (P = 5 × 10-9) but showed no association with VMS (P = 0.6). Younger menopause age was causally-associated with greater HRT use before 2002 but not after. CONCLUSIONS We provide support for TACR3 in the genetic basis of VMS but unexpectedly find that rare genomic variants predicted to lower NK3R levels did not modify VMS, despite the proven efficacy of NK3R antagonists. Using genomics we demonstrate changes in genetic associations with HRT use over time, arising from a change in clinical practice since the early 2000s, which is likely to reflect a switch from preventing post-menopausal complications in women with earlier menopause to primarily treating VMS. Our study demonstrates that integrating routinely-collected primary care health records and genomic data offers great potential for exploring the genetic basis of symptoms.
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Affiliation(s)
- Katherine S Ruth
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK.
| | - Robin N Beaumont
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Jonathan M Locke
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Jessica Tyrrell
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Carolyn J Crandall
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA, 90024, USA
| | - Gareth Hawkes
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Timothy M Frayling
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Julia K Prague
- Exeter Centre of Excellence for Diabetes Research, University of Exeter, Exeter, EX2 5DW, UK
- Macleod Diabetes and Endocrinology Centre, Royal Devon and Exeter National Health Service Foundation Trust, Exeter, EX2 5DW, UK
| | - Kashyap A Patel
- Exeter Centre of Excellence for Diabetes Research, University of Exeter, Exeter, EX2 5DW, UK
- Macleod Diabetes and Endocrinology Centre, Royal Devon and Exeter National Health Service Foundation Trust, Exeter, EX2 5DW, UK
| | - Andrew R Wood
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Michael N Weedon
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Anna Murray
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
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Huang DR, Goodship A, Webber I, Alaa A, Sasco ER, Hayhoe B, El-Osta A. Experience and severity of menopause symptoms and effects on health-seeking behaviours: a cross-sectional online survey of community dwelling adults in the United Kingdom. BMC Womens Health 2023; 23:373. [PMID: 37452317 PMCID: PMC10347781 DOI: 10.1186/s12905-023-02506-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/24/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Almost all women will experience menopause, and the symptoms can have a severely detrimental impact on their quality of life. However, there is limited research exploring health-seeking behaviours and alternative service design or consultation formats. Group consultations have been successfully deployed in perinatal and diabetic care, improving accessibility and outcomes. This cross-sectional online survey was conducted to explore women's personal experiences of menopause, including perspectives on group consultations. METHODS An online survey investigated the experiences of individuals at all stages of menopause and their receptiveness towards group consultations for menopause. Respondents were categorised by menopause stage according to the STRAW + 10 staging system. Associations between menopause stage, acceptability of group consultations and participant demographics were assessed using logistic regression. RESULTS Respondents experienced an average of 10.7 menopausal symptoms, but only 47% of respondents felt they had the knowledge and tools to manage their symptoms. Advice on menopause was sought from a healthcare professional (HCP) by 61% of respondents, the largest trigger for this being severity of symptoms and the main barrier for this was the perception that menopause wasn't a valid enough reason to seek help. Of the respondents seeking advice from HCPs, 32% were prescribed transdermal HRT, 29% received oral HRT, 19% were offered antidepressants, 18% received local oestrogen and 6% were prescribed testosterone. Over three quarters (77%) of respondents indicated that they would join a group consultation for menopause and would be comfortable sharing their experiences with others (75%). Logistic regression indicated premenopausal respondents were 2.84 times more likely than postmenopausal women to be interested in a group consultation where they can meet or learn from others' experiences. CONCLUSIONS This study highlighted a strong willingness of women aged 35-70 to participate in group consultations for menopause, with motivation being strongest amongst premenopausal women. Low awareness of self-management and lifestyle interventions to manage the symptoms of menopause highlight the need for greater outreach, research and interventions to build knowledge and confidence in the general population at scale. Future studies should focus on investigating the effectiveness and economic impact of menopause group consultations and the lived experience of individuals participating in group consultations.
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Affiliation(s)
- David Roy Huang
- Self-Care Academic Research Unit (SCARU), Department of Primary Care & Public Health, Imperial College, London, W6 8RF UK
| | - Abigail Goodship
- Self-Care Academic Research Unit (SCARU), Department of Primary Care & Public Health, Imperial College, London, W6 8RF UK
| | - Iman Webber
- Self-Care Academic Research Unit (SCARU), Department of Primary Care & Public Health, Imperial College, London, W6 8RF UK
| | - Aos Alaa
- Self-Care Academic Research Unit (SCARU), Department of Primary Care & Public Health, Imperial College, London, W6 8RF UK
| | - Eva Riboli Sasco
- Self-Care Academic Research Unit (SCARU), Department of Primary Care & Public Health, Imperial College, London, W6 8RF UK
| | - Benedict Hayhoe
- Self-Care Academic Research Unit (SCARU), Department of Primary Care & Public Health, Imperial College, London, W6 8RF UK
| | - Austen El-Osta
- Self-Care Academic Research Unit (SCARU), Department of Primary Care & Public Health, Imperial College, London, W6 8RF UK
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Hassan F, Saleem A, Samuel SS, Sarfraz Z, Sarfraz A, Sarfraz M, Kc M. Neurokinin 1/3 receptor antagonists for menopausal women: A current systematic review and insights into the investigational non-hormonal therapy. Medicine (Baltimore) 2023; 102:e33978. [PMID: 37335635 DOI: 10.1097/md.0000000000033978] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Over 75% of menopausal women experience vasomotor symptoms (VMS), such as night sweats and hot flashes. Despite the prevalence of these symptoms, there is limited data on non-hormonal therapies to alleviate them. METHODS PubMed, Cochrane, Scopus, Ovid, Web of Science, and ClinicalTrials.Gov were searched for relevant studies. The search was performed using the following keywords, which were customized to suit the specific databases/registers: menopause, women, neurokinin 3, and/or Fezolinetant. The search was conducted until December 20, 2022. This systematic review was conducted in compliance with the PRISMA Statement 2020 guidelines. RESULTS A total of 326 records were found, with 10 studies (enrolling 1993 women) selected for inclusion. The women received 40-mg doses of NK1/3 receptor antagonists twice daily, with follow-ups at 1 to 3 weeks. Moderately strong evidence was found suggesting that NK1/3 receptor antagonists can help limit the frequency and severity of hot flashes in menopausal women. CONCLUSION While the results should be interpreted with caution until further clinical trials validate the efficacy and safety of NK1/3 receptor antagonists among menopausal women, these findings suggest that they are promising targets for future pharmacological and clinical studies in addressing vasomotor symptoms.
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Affiliation(s)
| | - Anam Saleem
- Punjab Medical College, Faisalabad, Pakistan
| | | | | | | | | | - Manish Kc
- KIST Medical College, Lalitpur, Nepal
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Lobo RA, Gompel A. Management of menopause: a view towards prevention. Lancet Diabetes Endocrinol 2022; 10:457-470. [PMID: 35526556 DOI: 10.1016/s2213-8587(21)00269-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/18/2021] [Accepted: 09/23/2021] [Indexed: 12/14/2022]
Abstract
Women spend approximately one-third of their lives with menopause, which occurs around 50 years of age. It is now appreciated that several important metabolic and cardiovascular disease risks emerge during the menopausal transition. Many important conditions occur 10-15 years after menopause, including weight gain and obesity, metabolic syndrome, diabetes, osteoporosis, arthritis, cardiovascular disease, dementia, and cancer; therefore, the occurrence of menopause heralds an important opportunity to institute preventative strategies. These strategies will lead to improved quality of life and decreased mortality. Various strategies are presented for treating symptoms of menopause and diseases that are asymptomatic. Among several strategies is the use of hormone therapy, which has efficacy for symptoms and osteoporosis, and can improve metabolic and cardiovascular health. When instituted early, which is key, in younger postmenopausal women (under 60 years) oestrogen has been found to consistently decrease mortality with a favourable risk-benefit profile in low-risk women. Prospective data show that long-term therapy might not be required for this benefit.
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Affiliation(s)
- Roger A Lobo
- Division of Reproductive Endocrinology, Columbia University, New York, NY, USA.
| | - Anne Gompel
- Pr Emérite de l'Université de Paris, Unité de Gynécologie Médicale, Reproductive Medicine Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
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Anderson RC, Hanyroup S, Song YB, Mohamed-Moosa Z, van den Bout I, Schwulst AC, Kaiser UB, Millar RP, Newton CL. Functional Rescue of Inactivating Mutations of the Human Neurokinin 3 Receptor Using Pharmacological Chaperones. Int J Mol Sci 2022; 23:ijms23094587. [PMID: 35562976 PMCID: PMC9100388 DOI: 10.3390/ijms23094587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 12/04/2022] Open
Abstract
G protein-coupled receptors (GPCRs) facilitate the majority of signal transductions across cell membranes in humans, with numerous diseases attributed to inactivating GPCR mutations. Many of these mutations result in misfolding during nascent receptor synthesis in the endoplasmic reticulum (ER), resulting in intracellular retention and degradation. Pharmacological chaperones (PCs) are cell-permeant small molecules that can interact with misfolded receptors in the ER and stabilise/rescue their folding to promote ER exit and trafficking to the cell membrane. The neurokinin 3 receptor (NK3R) plays a pivotal role in the hypothalamic–pituitary–gonadal reproductive axis. We sought to determine whether NK3R missense mutations result in a loss of cell surface receptor expression and, if so, whether a cell-permeant small molecule NK3R antagonist could be repurposed as a PC to restore function to these mutants. Quantitation of cell surface expression levels of seven mutant NK3Rs identified in hypogonadal patients indicated that five had severely impaired cell surface expression. A small molecule NK3R antagonist, M8, increased cell surface expression in four of these five and resulted in post-translational receptor processing in a manner analogous to the wild type. Importantly, there was a significant improvement in receptor activation in response to neurokinin B (NKB) for all four receptors following their rescue with M8. This demonstrates that M8 may have potential for therapeutic development in the treatment of hypogonadal patients harbouring NK3R mutations. The repurposing of existing small molecule GPCR modulators as PCs represents a novel and therapeutically viable option for the treatment of disorders attributed to mutations in GPCRs that cause intracellular retention.
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Affiliation(s)
- Ross C. Anderson
- Centre for Neuroendocrinology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa; (S.H.); (Z.M.-M.); (I.v.d.B.); (A.C.S.); (R.P.M.); (C.L.N.)
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa
- Correspondence:
| | - Sharika Hanyroup
- Centre for Neuroendocrinology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa; (S.H.); (Z.M.-M.); (I.v.d.B.); (A.C.S.); (R.P.M.); (C.L.N.)
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa
| | - Yong Bhum Song
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (Y.B.S.); (U.B.K.)
- Division of Research Center, Scripps Korea Antibody Institute, Chuncheon 24341, Korea
| | - Zulfiah Mohamed-Moosa
- Centre for Neuroendocrinology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa; (S.H.); (Z.M.-M.); (I.v.d.B.); (A.C.S.); (R.P.M.); (C.L.N.)
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa
- Department of Anatomy and Physiology, Faculty of Veterinary Sciences, University of Pretoria, Private Bag X04, Pretoria 0110, South Africa
| | - Iman van den Bout
- Centre for Neuroendocrinology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa; (S.H.); (Z.M.-M.); (I.v.d.B.); (A.C.S.); (R.P.M.); (C.L.N.)
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa
| | - Alexis C. Schwulst
- Centre for Neuroendocrinology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa; (S.H.); (Z.M.-M.); (I.v.d.B.); (A.C.S.); (R.P.M.); (C.L.N.)
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa
| | - Ursula B. Kaiser
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (Y.B.S.); (U.B.K.)
| | - Robert P. Millar
- Centre for Neuroendocrinology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa; (S.H.); (Z.M.-M.); (I.v.d.B.); (A.C.S.); (R.P.M.); (C.L.N.)
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa
- Department of Integrative Biomedical Sciences, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
- Deanery of Biomedical Sciences, University of Edinburgh, Edinburgh EH8 9JZ, UK
- School of Medicine, Medical and Biological Sciences Building, University of St Andrews, St Andrews KY16 9TF, UK
| | - Claire L. Newton
- Centre for Neuroendocrinology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa; (S.H.); (Z.M.-M.); (I.v.d.B.); (A.C.S.); (R.P.M.); (C.L.N.)
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Private Bag X323, Pretoria 0031, South Africa
- Deanery of Biomedical Sciences, University of Edinburgh, Edinburgh EH8 9JZ, UK
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Gilmore KL, Mansour D. A case vignette describing management of menopausal symptoms and migraine in the perimenopause. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:72-77. [PMID: 34732402 DOI: 10.1136/bmjsrh-2020-200977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/12/2021] [Indexed: 06/13/2023]
Affiliation(s)
| | - Diana Mansour
- Newcastle Hospitals NHS Foundation Trust, Newcroft House, Newcroft Centre, Newcastle, UK
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Menown SJ, Tello JA. Neurokinin 3 Receptor Antagonists Compared With Serotonin Norepinephrine Reuptake Inhibitors for Non-Hormonal Treatment of Menopausal Hot Flushes: A Systematic Qualitative Review. Adv Ther 2021; 38:5025-5045. [PMID: 34514552 PMCID: PMC8478773 DOI: 10.1007/s12325-021-01900-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022]
Abstract
Introduction Hot flushes/flashes (HFs) or other vasomotor symptoms affect between 45 and 97% of women during menopause. Hormone replacement therapy (HRT) is effective at alleviating menopausal symptoms, but some women cannot or prefer not to take HRT. Since current non-hormonal options have suboptimal efficacy/tolerability, there is a pressing need for an effective, well-tolerated alternative. The neurokinin 3 receptor (NK3R) has recently been implicated in the generation of menopausal HFs and represents a novel therapeutic target to ameliorate HF symptoms. This review aims to assess if NK3R antagonists (NK3Ras) are more effective than Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)—currently a common choice for non-hormonal treatment of menopausal HFs. Methods Studies were identified after systematically searching Ovid MEDLINE and EMBASE databases based on PRISMA guidelines. Trial quality and bias were assessed. Key efficacy outcomes (HF frequency, HF severity and number of night-time awakenings/night-sweats) and selected safety outcomes were extracted and analysed. Results Seven SNRI and four NK3Ra placebo-controlled randomised trials (plus four follow-up reports) were included in this review. NK3Ra administration resulted in a larger reduction from baseline in HF frequency, HF severity and night-sweats compared to SNRIs. Five of seven SNRI trials showed a reduction in HF frequency that was statistically significant (by 48–67% from baseline at weeks 8 or 12) whereas all NK3Ra trials showed a statistically significant reduction in HF frequency (by 62–93% from baseline at weeks 2, 4 or 12). While SNRI trials reported poor tolerability, particularly nausea, NK3Ra trials reported good tolerability overall, although two trials reported elevation in transaminases. Conclusion NK3Ras trials show encouraging efficacy and tolerability/safety. Completion of phase 3 NK3Ra trials are required to confirm efficacy and uphold safety/tolerability data but phase 2 results suggest that NK3Ras are more effective than SNRIs for non-hormonal treatment of menopausal HFs.
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Affiliation(s)
- Sara J. Menown
- School of Medicine, University of St Andrews, Medical and Biological Sciences Building, North Haugh, St Andrews, KY16 9TF UK
- Present Address: School of Medicine, Dentistry and Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, Scotland
| | - Javier A. Tello
- School of Medicine, University of St Andrews, Medical and Biological Sciences Building, North Haugh, St Andrews, KY16 9TF UK
- Biomedical Research Complex, University of St Andrews, North Haugh, St Andrews, KY16 9TZ UK
- Centre for Biophotonics, University of St Andrews, North Haugh, St Andrews, KY16 9SS UK
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