“The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2023 nonhormone therapy position statement of The North American Menopause Society

A profile of safety and efficacy of fezolinetant for the treatment of menopausal vasomotor symptoms

INTRODUCTION

Fezolinetant is a first-in-class non-hormonal pharmacological treatment recently approved for moderate-to-severe vasomotor symptoms (VMS) associated with menopause. Its mechanism of action selectively targets the pathophysiology of VMS at hypothalamic level, antagonizing binding of neurokinin B, overexpressed in estrogen deprived menopausal women, to the neurokinin 3 receptor (NK3R) in the thermoregulatory center.

AREAS COVERED

Fezolinetant reduced VMS frequency and severity in phase 3 randomized placebo-controlled trials in healthy menopausal women (SKYLIGHT 1 and 2) and in women unsuitable for menopause hormone therapy (MHT) (DAYLIGHT). The effect on VMS positively translated into improvements in menopause-specific quality of life, as well as sleep disturbances and impairment. Safety data were reassuring across studies, especially 52-weeks safety trials (SKYLIGHT 4 and MOONLIGHT 3).

EXPERT OPINION

Fezolinetant represents a highly anticipated innovation, offering the possibility to bridge the therapeutic gap for many women who cannot or do not wish to use MHT. While the potential application of fezolinetant in some clinical settings will add substantial value to the management of VMS, some research gaps need to be addressed in order to provide meaningful insight into the benefit-risk profile that ultimately will improve counseling and prescription tailoring in symptomatic menopausal women.

Cooling the flames: Navigating menopausal vasomotor symptoms with nonhormone medications

PURPOSE

While the gold standard for vasomotor symptoms remains hormone therapy, prescription menopause therapies are significantly underutilized. Nonhormone therapies represent an alternative treatment modality that may improve access to care for patients who cannot or choose not to take hormones. This review aims to update pharmacists on the evidence behind new-to-market fezolinetant and all other nonhormone prescription treatment options for menopausal vasomotor symptoms.

SUMMARY

Prescription nonhormone therapy options for vasomotor symptoms include selective serotonin reuptake inhibitors, including Food and Drug Administration-approved low-dose paroxetine, serotonin-norepinephrine reuptake inhibitors, gabapentin, pregabalin, oxybutynin, and fezolinetant. Evidence supporting the use of these options is summarized in this review. All have an important place in treatment for those unable to take the gold standard of hormone therapy; however, most offer only mild to moderate improvement in symptoms. Fezolinetant has been shown to result in a significant reduction in vasomotor symptom frequency when compared to other nonhormone therapies and was not different when compared to hormone therapies. However, additional studies and efforts to address the affordability of fezolinetant and head-to-head comparisons with other agents are needed.

CONCLUSION

Vasomotor symptoms of menopause can severely impact the health and well-being of individuals. However, treatment of these symptoms is underutilized due to real and perceived drawbacks of therapy. Pharmacists are ideally suited to bridge this gap, but first it is important for pharmacists to be knowledgeable about and comfortable with the evidence supporting all treatment options.

Updates in nonhormonal therapy for perimenopausal and menopausal symptoms

PURPOSE OF REVIEW

Perimenopausal and menopausal symptoms are common and may significantly impact quality of life. Menopausal hormone therapy is the most effective treatment but may not be appropriate in all cases. Nonhormonal alternatives range from lifestyle changes and dietary supplements to medical interventions and prescription therapies. This review will summarize the newest advancements in nonhormonal therapies for bothersome perimenopausal and menopausal symptoms.

RECENT FINDINGS

The Menopause Society recently updated their recommendations and guidelines for nonhormonal therapies. Previous recommendations, such as clonidine and pregabalin, are no longer recommended. A new class of medication, neurokinin B antagonists, are now available to target vasomotor symptoms and show promise in addressing sleep and mood issues.

SUMMARY

Well tolerated, effective nonhormonal therapies are available to address perimenopausal and menopausal symptoms for those patients who are not candidates for or chose not to use menopausal hormone therapy.

A review of menopause in transgender and gender diverse individuals

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of the specific challenges, health considerations, and healthcare needs of transgender and gender diverse (TGD) people navigating menopause, highlighting the intersection of gender identity, hormone treatment, and age-related changes.

RECENT FINDINGS

Research on menopause in TGD individuals is lacking, without guidelines to support clinical management. This is the first review of its type to summarize the described impact of the menopausal transition on TGD individuals, the potential long-term risks associated with both gender-affirming hormone therapy and the intersectionality with aging, and how these risks may impact hormone management and overall comprehensive care.

SUMMARY

By drawing on the shared principles of cisgender menopausal hormone therapy and gender-affirming hormone therapy, providers are well positioned to apply their expertise to support the TGD population during menopause. We recommend using shared decision-making, culturally competent care, and a strong understanding of the biological, personal, and social experiences of TGD people that do not necessarily conform to stereotypically ciswoman experiences.

Mental Well-being in Menopause

The hormonal changes that accompany the transition to menopause are disruptive to most women, and for some, mental health maybe adversely affected. Depressive symptoms and major depression are the best-studied conditions in association with menopause, but anxiety, executive function, and comorbid pre-existing psychiatric conditions all influence the symptomatology that women will experience during this phase of their lives. The epidemiology, diagnosis, and evidence-based treatment guidelines for perimenopausal patients are discussed.

Safety of Fezolinetant for Treatment of Moderate to Severe Vasomotor Symptoms Due to Menopause: Pooled Analysis of Three Randomized Phase 3 Studies

INTRODUCTION

This study evaluated the safety and tolerability of fezolinetant in women with vasomotor symptoms (VMS) due to menopause in a pooled analysis of data from three 52-week phase 3 studies (SKYLIGHT 1, 2, and 4).

METHODS

SKYLIGHT 1 and 2 were double-blind, placebo-controlled studies where women (≥ 40 to ≤ 65 years), with moderate to severe VMS (minimum average ≥ 7 hot flashes/day) were randomized to once-daily placebo, fezolinetant 30 mg or 45 mg. After 12 weeks, those on placebo were re-randomized to fezolinetant 30 mg or 45 mg, while those on fezolinetant continued on their assigned dose for 40 weeks. SKYLIGHT 4 was a placebo-controlled, double-blind, 52-week safety study. Safety was assessed by frequency of treatment-emergent adverse events (TEAEs) and endometrial events. TEAEs of special interest included liver test elevations and endometrial hyperplasia or cancer or disordered proliferative endometrium.

RESULTS

Totals of 952 participants receiving placebo, 1100 receiving fezolinetant 45 mg, and 1103 receiving fezolinetant 30 mg took ≥ 1 dose of study medication. TEAEs occurred in 55.3%, 62.9%, and 65.4%, respectively; exposure-adjusted results were consistent with these results. Most frequent TEAEs in fezolinetant-treated participants included upper respiratory tract infection (7.7-8.3%), headache (6.8-8.2%), coronavirus disease 2019 (5.8-6.1%), back pain (3.1-3.7%), arthralgia (2.9-3.2%), diarrhea (2.3-3.2%), urinary tract infection (2.9-3.4%), and insomnia (2.0-3.0%). The incidence of drug-related serious TEAEs and associated treatment withdrawals was low. Elevations in liver transaminases occurred in 1.5-2.3% of fezolinetant-treated participants, were typically asymptomatic and transient, resolved on treatment or discontinuation, with no evidence of severe drug-induced liver injury (Hy's law). Endometrial safety results were well within US Food and Drug Administration criteria. Analysis of benign and non-benign neoplasm controlled for exposure demonstrated no increased risk versus placebo.

CONCLUSION

Pooled data confirm the safety and tolerability of fezolinetant over 52 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers, NCT04003155, NCT04003142, and NCT04003389. Graphical abstract available for this article.

The association between metabolic dysfunction-associated steatotic liver disease diagnosis and vasomotor symptoms in midlife women

OBJECTIVE

Metabolic dysfunction-associated steatotic liver disease (MASLD) and vasomotor symptoms (VMS) are associated with increased cardiovascular disease risk. Although visceral adiposity has been linked to MASLD and VMS independently, this study aimed to evaluate associations between the two in midlife women.

METHODS

A cross-sectional study of women aged 45-60 years receiving primary care at one of four sites was conducted from March 1 through June 30, 2021. MASLD diagnosis was obtained utilizing the International Classification of Diseases , Ninth Revision and Tenth Revision codes. VMS burden was evaluated with the Menopause Rating Scale and categorized as severe/very severe versus none/mild/moderate. Logistic regression models were used to assess the association between VMS and diagnosed MASLD both univariately and after individually adjusting for several risk factors.

RESULTS

A total of 4,599 women were included in the final analysis, 304 (7%) of whom had an MASLD diagnosis. On univariate analysis, women with an MASLD diagnosis were more likely to have severe/very severe VMS (odds ratio [OR], 1.50; 95% CI, 1.08-2.08; P = 0.015). However, the association between MASLD diagnosis and severe/very severe VMS was no longer statistically significant after individually adjusting for body mass index (adjusted OR, 1.36; 95% CI, 0.97-1.92) and hypertension (adjusted OR, 1.38; 95% CI, 0.99-1.93).

CONCLUSIONS

The relationship between MASLD and VMS appears to be best explained by other variables including BMI and hypertension. Although they do not appear to be directly linked, given the prevalence of bothersome VMS in midlife women, addressing VMS may enable greater adherence to lifestyle modifications as part of MASLD management.

Effects of a therapeutic lifestyle modification intervention on health-related quality of life and sexual functioning and cardiometabolic health in perimenopausal Chinese women: a randomized controlled trial

OBJECTIVE

This study aimed to evaluate the effects of a therapeutic lifestyle modification (TLM) intervention on health-related quality of life, sexual functioning and cardiometabolic health in perimenopausal Chinese women.

METHOD

The study was a randomized controlled trial (registration number: ChiCTR2300070648). Ninety-four perimenopausal women aged between 40 and 55 years were randomly assigned in a 1:1 ratio to receive the TLM intervention or usual care for 12 weeks. Menopause-specific Quality of Life (MENQOL), Female Sexual Function Index (FSFI), pelvic floor muscle strength (PFMS) and composite cardiometabolic indicators were evaluated at baseline and post intervention.

RESULTS

After 12 weeks, linear mixed-effects models showed that the TLM intervention led to a statistically significant improvement in MENQOL (-0.60, 95% confidence interval [CI] - 0.80 to -0.41), FSFI (3.82, 95% CI 2.03 to 5.61), resting heart rate (-5.44, 95% CI -10.40 to -0.48), waist circumference(-3.14, 95% CI -4.15 to -2.13) and body fat percentage (-4.25, 95% CI -6.92 to -1.58) compared to the control group. There were also statistically significant differences between the intervention (TLM) group and the control group in the proportions of PFMS (p = 0.006).

CONCLUSION

The TLM intervention effectively improved menopause-specific quality of life in midlife women, supported by enhancements in female sexual functioning and cardiometabolic health status.

Clinical Hypnosis and Cognitive Behavioral Therapy for Hot Flashes: A Scoping Review

Background

Hot flashes can be a prevalent issue for postmenopausal women, but traditional treatments such as hormone therapy can have adverse side effects. Recommended psychotherapies for managing hot flashes include cognitive behavioral therapy (CBT) and clinical hypnosis, but an in-depth review comparing the efficacy of both treatments is warranted.

Objectives

The aim of the present scoping review was to assess the clinical significance and efficacy of symptom reduction of CBT and clinical hypnosis as treatments of hot flashes.

Eligibility Criteria

Peer-reviewed primary studies were included in this review if they were published in English, used CBT or clinical hypnosis as their intervention, included hot flash outcomes, and sampled women aged 18 years or older.

Sources of Evidence

A search was conducted on PubMed, Web of Science, and PsycINFO over December 2023 and January 2024.

Charting Methods

Extracted information included eligible studies' authors, year of publication, country, title, design, participant population, intervention type, control group, primary and secondary outcomes, and key findings.

Results

Of the 1847 studies identified by the literature search, 23 studies were included in this scoping review. While CBT was found to benefit bother and daily interference related to hot flashes, only studies investigating clinical hypnosis found significant reductions in the frequency and severity of hot flashes.

Conclusions

Clinical hypnosis was found to outperform CBT by a large effect in treatment for hot flashes based on the current state of the literature. While both modalities treat psychological distress, only clinical hypnosis demonstrates the ability to reduce the severity and frequency of hot flashes, thus showing clinical significance. Limitations and future directions for research into CBT and clinical hypnosis for hot flashes are discussed.

Effect of Soy Isoflavones on Measures of Estrogenicity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Despite recommendations to increase plant food consumption for public and planetary health and the role that soy foods can play in plant-predominant diets, controversies around the effects of soy foods, especially soy isoflavones, are a barrier to their intake. Given their cardioprotective effects and ability to alleviate menopausal symptoms, addressing these concerns is particularly relevant to women. This systematic review and meta-analysis of randomized controlled trials aimed to determine the effect of soy isoflavones on measures of estrogenicity in postmenopausal women. MEDLINE, Embase, and Cochrane Library were searched through August 2024 for randomized trials ≥3-mo investigating soy isoflavones compared with non-isoflavone controls in postmenopausal women. Outcomes included endometrial thickness (ET), vaginal maturation index (VMI), follicle-stimulating hormone (FSH), and estradiol. Independent authors extracted data and assessed risk of bias. Grading of Recommendations, Assessment, Development and Evaluation was used to assess certainty of evidence. We included 40 trials (52 trial comparisons, n = 3285) assessing the effect of a median reported dose of 75 mg/d of soy isoflavones in substitution for non-isoflavone controls over a median of 24 wk. Soy isoflavones had no statistically significant effect on any measure of estrogenicity; ET [mean difference, -0.22 mm (95% confidence interval, -0.45, 0.01 mm), PMD = 0.059], VMI [2.31 (-2.14, 6.75), PMD = 0.310], FSH [-0.02 IU/L (-2.39, 2.35 IU/L), PMD = 0.987], and estradiol [1.61 pmol/L (-1.17, 4.38 pmol/L), PMD = 0.256]. The certainty of evidence was high to moderate for all outcomes. Current evidence suggests that soy isoflavones do not exhibit estrogenic effects compared with non-isoflavone controls on 4 measures of estrogenicity in postmenopausal women. This synthesis supports that soy isoflavones likely act as selective estrogen receptor modulators, differing clinically from the hormone estrogen. Addressing public health concerns may promote soy foods as high-quality plant protein sources with low environmental impact and cost, particularly benefiting postmenopausal women and aligning with sustainable dietary patterns and guidelines. This study was registered in PROSPERO as CRD42023439239.

Pharmacokinetic evaluation of fezolinetant for the treatment of vasomotor symptoms caused by menopause

INTRODUCTION

Vasomotor symptoms (VMS) affect the majority of menopausal women, with possible negative impact on several domains of quality of life (QoL). Although menopausal hormone therapy (MHT) represents an effective treatment, the risk-benefit profile is not favorable for every woman. Non-hormonal options are limited in number and efficacy.

AREAS COVERED

Fezolinetant is a novel oral non-hormonal drug recently approved for the treatment of moderate-severe VMS. It acts as an antagonist of neurokinin 3 receptor (NK3R), the main target of neurokinin B (a tachykinin over-expressed by kisspeptin/neurokinin B/dynorphin [KNDy] neurons after menopausal hypoestrogenism), involved in the modulation of the thermoregulatory hypothalamic center. Here, we report pharmacodynamics and pharmacokinetic properties of fezolinetant as well as its efficacy and safety data from available clinical trials.

EXPERT OPINION

Fezolinetant has shown efficacy in reducing the frequency and severity of VMS with a positive impact on sleep- and health-related QoL and acceptable safety and tolerability profile. Given the limited availability of effective non-hormonal options for VMS, fezolinetant could potentially represent a game-changer for care of menopausal women, especially when relative or absolute contraindications to MHT use are present. Further studies to gain more information about the safety profile and potential extra-VMS benefits or disadvantages are warranted in real-life clinical practice.

Prevalence and impact of vasomotor symptoms due to menopause among women in Canada: A subgroup analysis from an international cross-sectional survey of Women with Vasomotor Symptoms Associated with Menopause (WARM Study)

OBJECTIVE

The aim of the study was to assess the prevalence of postmenopausal vasomotor symptoms (VMS) and the impact of VMS and related treatment patterns among perimenopausal and postmenopausal Canadian women.

METHODS

A subgroup analysis of data from a cross-sectional online survey of women aged 40-65 years conducted November 4, 2021, through January 17, 2022, evaluated the prevalence of moderate/severe VMS among postmenopausal Canadian women. The analysis also assessed survey responses from perimenopausal and postmenopausal Canadian women with moderate/severe VMS who completed the Menopause-Specific Quality of Life questionnaire, Work Productivity and Activity Impairment questionnaire, and the Patient-Reported Outcomes Measurement Information System Sleep Disturbances-Short Form 8b and answered questions about treatment patterns and attitudes toward treatments.

RESULTS

Of 2,456 Canadian postmenopausal women, 360 (14.7%; primary analysis) reported moderate/severe VMS in the previous month. Perimenopausal and postmenopausal women with moderate/severe VMS (n = 400; secondary analysis) reported negative impact on overall quality of life (mean total Menopause-Specific Quality of Life questionnaire score: 4.3/8). VMS impaired overall work and daily activities by 30.2% and 35.7%, respectively. Overall mean (SD) Patient-Reported Outcomes Measurement Information System Sleep Disturbance-Short Form 8b score (scale 8-40) was 28.5 (6.9), confirming sleep disturbances in this population. The majority of women (88% of the total cohort) sought advice, but about half were never treated. Most women had positive or neutral attitudes toward menopause.

CONCLUSIONS

In a survey conducted in Canada, moderate/severe VMS were reported by 14.7% of postmenopausal women and were associated with impairment in quality of life, work productivity, daily activities, and sleep in perimenopausal and postmenopausal women.

Searching for an oasis from the vasomotor symptoms of menopause: Could elinzanetant be the answer?

In the OASIS 1 and 2 trials, elinzanetant, a selective neurokinin-1,3 receptor antagonist, was compared to placebo in women aged 40-65 with moderate to severe menopausal vasomotor symptoms (VMSs) at multiple sites over 26 weeks. Elinzanetant significantly reduced VMS frequency and severity and improved sleep disturbance and menopause-related quality of life compared to placebo with few adverse side effects.1.

A prospective, multicenter, randomized, double-blind placebo-controlled trial on purified and specific Cytoplasmic pollen extract for hot flashes in breast cancer survivors

OBJECTIVE

evaluate the efficacy and tolerability of PureCyTonin against hot flashes (HF) in breast cancer survivors (BCS).

METHODS

a prospective, multicenter, randomized, double-blind placebo-controlled trial was conducted in Italy.

INTERVENTIONS

administration of PureCyTonin or placebo, for 3 months. Effectiveness was investigated through the compilation of a daily diary for HF and of validated questionnaires (Menopause Rating Scale (MRS), Pittsburgh Sleep Quality Index (PSQI), Visual Analogical Scales (VAS) for HF, sweating, irritability, fatigue, sleep, quality of life), carried out before starting the treatment (T0), after 1 month (T1) and after 3 months (T2). Any side effects and HF diary were recorded at each visit.

RESULTS

19 women were randomized to receive PureCyTonin and 20 to placebo. At T2 compared to T0, in the PureCyTonin group, we found a reduction in the number of HF (p = 0.02) measured by daily diary. An improvement in the subjective perception of women regarding HF intensity (p = 0.04), sweat nuisance (p = 0.02), irritability (p = 0.03) and fatigue (p = 0.04) was observed through VAS scale measurement at T2 compared to T0.The total MRS score was significantly better in the PureCyTonin group at T1 (p = 0.03) compared to T0.

CONCLUSIONS

PureCyTonin significantly reduces HF number after 3 months of therapy in BCS and it is well-tolerated.

The need for biopsychosocial menopause care: a narrative review

IMPORTANCE AND OBJECTIVE

Menopause is a reproductive transition affecting half the world's population. Stigma and limited availability of evidence-based treatments that support biopsychosocial well-being mean that this life stage is often associated with challenging symptoms and reduced quality of life (QoL). The aim of this review was to examine the extent literature on psychological and mind-body interventions to manage perimenopausal and postmenopausal symptoms, and apply an interdisciplinary clinical, research, and cultural knowledge framework to guide recommendations for improving QoL and healthy aging in this population. We also aimed to understand the ideal delivery mode for such interventions.

METHODS

Using Scopus, Medline, and PubMed, a review of systematic reviews, guidelines, and randomized controlled trials was undertaken to examine the use of psychological and mind-body interventions to improve menopause-related QoL and symptoms, including hot flushes, depression, anxiety, fatigue, pain, and sleep; conclusions were based on an analysis of this available evidence and linked to clinical and cultural considerations.

DISCUSSION AND CONCLUSION

Empirical support exists for a number of psychological and mind-body approaches to support QoL and symptoms during the menopause transition. The literature also identifies the need for menopause care that is culturally responsive.An online multimodal model of menopause care is thus recommended, incorporating evidence-based treatments (eg, cognitive behavioral therapy, yoga, hypnosis) and treatment techniques (eg, mindfulness, and education including nutrition support), as well as First Nations wisdom. We also recommend financial well-being approaches to support people undergoing menopause. Integrated, multimodal approaches should be available online to remove time, location, and healthcare access barriers, and be designed with diverse consumers to ensure equity for those underserved due to region, LGBTIQ+ assigned female at birth status, and for multicultural and First Nations people.

Addressing menopause symptoms in the primary care setting: opportunity to bridge care delivery gaps

OBJECTIVE

Menopause symptoms affect quality of life and financial well-being but are often unaddressed in primary care clinics. Therefore, we evaluated the extent of menopause symptom documentation in electronic health records (EHRs) by primary health care professionals.

METHODS

We retrospectively reviewed adult women who reported moderate or higher vasomotor symptoms on a Mayo Clinic survey conducted from March 1, 2021, through June 30, 2021. We then assessed adequacy of menopause symptom documentation in the EHRs of these women who had primary care visits during the survey period. We reviewed the percentage of documented vasomotor symptoms from May 1, 2019, through May 1, 2021.

RESULTS

In the Mayo Clinic Health System-Northwest Wisconsin Region, 229 women self-reported moderate or higher vasomotor symptoms in the Mayo Clinic survey. Although only 23% of these women had vasomotor symptoms listed in the EHR clinical problem lists, 60% of these women had vasomotor symptoms documented in their clinic notes from the primary care visit. Approximately 6% of women reported hormone therapy use for management of menopause symptoms, and nearly 15% reported use of nonhormone prescription therapies for vasomotor symptoms.

CONCLUSIONS

A greater proportion of women in our study had EHR documentation of bothersome menopause symptoms than those reported in other studies, but vasomotor symptoms remain generally untreated. We need better methods for identifying midlife women with bothersome menopause symptoms in primary care clinics so that appropriate treatment options, including hormone therapy, can be discussed and offered.

British Gynaecological Cancer Society and British Menopause Society guidelines: Management of menopausal symptoms following treatment of gynaecological cancer

These guidelines have been developed jointly by the British Gynaecological Cancer Society and British Menopause Society to provide information for all healthcare professionals managing women treated for gynaecological cancer. Menopausal symptoms can have a significant impact on quality of life for women. Cancer therapies, including surgery, pelvic radiotherapy, chemotherapy and endocrine therapy, can all affect ovarian function. The benefits and risks of using hormone replacement therapy are considered by cancer type with guidance on the type of HRT and optimal time of commencement after cancer treatment. Vaginal estrogens can be very effective for improving urogenital symptoms and are safe for the majority of women, including those for whom systemic HRT is contraindicated with rare exceptions. Alternative options to HRT are reviewed including pharmacological and non-pharmacological approaches.

Physician-patient alignment on menopause-associated symptom burden: real-world evidence from the USA and Europe

OBJECTIVE

This study aimed to evaluate physician-patient alignment on menopausal symptom burden and impact for women experiencing natural vasomotor symptoms (nVMS) or VMS induced by endocrine therapy for breast cancer (iVMS).

METHODS

For this real-world, cross-sectional survey, physicians from the USA and five European countries provided data for consulting patients experiencing nVMS/iVMS; patients optionally self-reported their experiences. Alignment between physician and patient responses was assessed using weighted Cohen's κ analysis.

RESULTS

Physicians and patients completed 1029 pairs of surveys (846 nVMS; 183 iVMS). In 28.1% of cases for nVMS and 29.6% for iVMS, patients reported more severe vasomotor symptoms (VMS) than physicians; alignment of responses was slight (nVMS, κ = 0.1364, p ≤ 0.0001; iVMS, κ = 0.1014, p = 0.039). For the non-VMS symptoms surveyed, 18.5-34.9% of patients with nVMS and iVMS reported symptoms without a corresponding physician report; sleep disturbances, cognitive difficulties and mood changes were among the symptoms most under-reported by physicians. Alignment regarding the impact of nVMS and iVMS on sleep, mood and overall quality of life was moderate.

CONCLUSIONS

Only slight to moderate physician-patient alignment was found across all areas surveyed. These findings suggest that physicians often underestimate the severity of VMS and the presence of other menopausal symptoms, highlighting a need to improve physician-patient communication.

Efficacy and safety of fezolinetant for moderate-severe vasomotor symptoms associated with menopause in individuals unsuitable for hormone therapy: phase 3b randomised controlled trial

OBJECTIVES

To assess the efficacy and safety of the non-hormonal, neurokinin 3 receptor antagonist, fezolinetant, to treat moderate-severe vasomotor symptoms associated with menopause in individuals unsuitable for hormone therapy.

DESIGN

Phase 3b randomised controlled trial.

SETTING

16 countries.

PARTICIPANTS

453 individuals aged 40-65 years with moderate-severe vasomotor symptoms associated with menopause who were considered unsuitable candidates for hormone therapy (contraindicated, caution (based on medical history), stoppers (previous discontinuation of hormone therapy), or averse (informed choice not to use hormone therapy)) were randomised to receive fezolinetant (n=227) or placebo (n=226).

INTERVENTION

Fezolinetant 45 mg or placebo once daily for 24 weeks.

MAIN OUTCOME MEASURES

The primary endpoint was mean change in daily frequency of moderate-severe vasomotor symptoms from baseline to week 24. Secondary endpoints were mean change in symptom severity, sleep disturbance using the Patient-Reported Outcome Measurement Information System Sleep Disturbance Short Form (PROMIS SD-SF) 8b total score, and safety.

RESULTS

370 (81.7%) participants completed the study (fezolinetant=195, placebo group=175). The safety and full analysis sets comprised 452 participants who received at least one dose of study drug. Mean age was 54.5 (standard deviation 4.7) years and most of the participants (435 (96.7%) were white and categorised as either hormone therapy averse (168 (37.2%)) or caution (165 (36.5%)). At week 24, fezolinetant significantly reduced the frequency (least squares mean difference -1.93, 95% confidence interval (CI) -2.64 to -1.22; P<0.001) and severity of vasomotor symptoms (-0.39, -0.57 to -0.21; P<0.001). At week 24, the fezolinetant group had a greater reduction in sleep disturbance (PROMIS SD-SF 8b total score) compared with placebo (-2.5, -3.9 to -1.1; P<0.001). Improvements over placebo were observed as early as week 1. Both groups showed similar incidences of treatment emergent adverse events (TEAEs, 147 (65.0%) in the fezolinetant group, 138 (61.1%) in the placebo group) and serious TEAEs (10 (4.4%) and 8 (3.5%), respectively). The most common TEAEs in the fezolinetant group were covid-19 (30 (13.3%)), headache (20 (8.8%)), and fatigue (13 (5.8%)).

CONCLUSIONS

Fezolinetant was efficacious and well tolerated over a six month period for treating moderate-severe vasomotor symptoms in individuals considered unsuitable for hormone therapy. These results highlight the utility of fezolinetant as an effective treatment option for those who have contraindications to or choose not to use hormone therapy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05033886; EudraCT 2021-001685-38.

Non-hormonal pharmacological interventions for managing vasomotor symptoms-how can we help: 2024 landscape

BACKGROUND

Vasomotor symptoms (VMS) affect 70% of menopausal women and are considered as hallmark symptoms of the menopausal transition experienced by over three quarters of women and severely by 25% of women. Estrogen withdrawal alone is not fully responsible for the onset of the menopausal vasomotor symptoms and the mechanism of altered thermoregulation appears to be centrally mediated with alterations in hypothalamic neurotransmitters playing a key part. The loss of thermoregulatory control coexists with the altered Kisspeptin- Neurokinin B-Dynorphin-expressing (KNDy) neurons of the arcuate nucleus signaling triggered by menopause.

OBJECTIVE

Aim of the review was to explore evidence-based non-hormonal pharmacological interventions for treating vasomotor symptoms.

METHODS

Comprehensive overview of relevant literature.

CONCLUSIONS

In the population where, hormonal options are contraindicated or not preferred by the patient, it is essential to explore evidence-based non-hormonal pharmacological interventions for treating vasomotor symptoms. The 2024 landscape of available treatments has expanded yet again, arming the providers with an even wider range of possibilities to help their patients. Fezolinetant, is the first NK3R antagonist developed for the purpose of treating hot flashes in menopausal women. NK3R antagonists provide a safe and effective treatment option for managing menopausal women with VMS.

Survey of patient experience and management of vasomotor symptoms due to menopause from the PatientsLikeMe community

OBJECTIVE

This study aimed to describe menopause and treatment experiences of women with vasomotor symptoms due to menopause in the United States.

METHODS

A cross-sectional survey was administered to women 40-65 years of age recruited from PatientsLikeMe, a dedicated online platform for patients.

RESULTS

A total of 196 women (mean age 55.7 years; 81.2% White) completed the survey and were included in the analyses. The majority (87.2%) reported experiencing bothersome symptoms; 54.3% (100/184) had daytime hot flashes, and 59.2% (109/184) had nighttime sweats and hot flashes, up to 5 times per day on average. Mean postmenopause duration was 10.8 years. Although most (68.5%, 126/184) reported having vasomotor symptoms for less than 5 years, some (14.1%, 26/184) had symptoms for more than a decade. Only 35.2% (69/196) were treated for their symptoms; the most frequently reported prescription treatment was hormone therapy (58%; 40/69), which was administered for less than 3 years in most cases (67.5%, 27/40). Although women were generally satisfied with their interactions with healthcare providers, 23.0% reported inadequate support. Sleep, personal relationships, and physical, emotional, and mental well-being were the most affected by vasomotor symptoms. Healthcare professionals with training in women's health were the most valued resource for dealing with the symptoms associated with menopause.

CONCLUSIONS

Not all women with symptoms were treated. In those whose concerns were addressed by providers, a reluctance to pursue treatment was still observed. A need persists to ensure that this population has the resources and support needed to effectively manage symptoms.

Prevalence and impact of vasomotor symptoms associated with menopause among women in Brazil: Subgroup analysis from an international cross-sectional survey

OBJECTIVE

This study assessed the prevalence and impact of moderate and/or severe vasomotor symptoms and related treatment patterns in midlife women in Brazil.

STUDY DESIGN

Brazilian women aged 40 to 65 years completed an online survey. The prevalence of moderate to severe vasomotor symptoms was assessed in postmenopausal women who completed a series of questionnaires to elicit responses regarding their treatment patterns and attitudes to treatments.

MAIN OUTCOME MEASURES

Perimenopausal and postmenopausal women with moderate to severe vasomotor symptoms completed three standardized questionnaires (Menopause-Specific Quality of Life questionnaire, Work Productivity and Activity Impairment questionnaire, and the Patient-Reported Outcomes Measurement Information System Sleep Disturbances Short Form 8b) and answered open-ended questions.

RESULTS

Of 1244 postmenopausal women who accessed the survey, 36.2 % had experienced moderate to severe vasomotor symptoms in the previous month. Moderate to severe vasomotor symptoms among 501 perimenopausal and postmenopausal women negatively affected overall quality of life (mean total score on the Menopause-Specific Quality of Life questionnaire was 3.6/8). On the Work Productivity and Activity Impairment questionnaire, women's scores for impairments in overall work and daily activities due to vasomotor symptoms were 50.3 % and 60.0 %, respectively. Overall mean (standard deviation) score on the Patient-Reported Outcomes Measurement Information System Sleep Disturbances Short Form 8b was 25.5 (5.8) on a scale of 8 to 40. Most women sought medical advice (65.5 %), but over half were not receiving treatment. Those who received treatment reported moderately favorable attitudes to hormone and nonhormone prescription medicines, but safety concerns remained.

CONCLUSION

Brazilian women experienced a relatively high prevalence and burden of moderate to severe vasomotor symptoms.

Real-world evaluation of treatment utilization by women experiencing vasomotor symptoms associated with menopause in the United States and Europe: Findings from the REALISE study

OBJECTIVES

Despite the profound impact of menopausal symptoms on women, treatment utilization is low, and many seek alternative therapies. The REALISE study aimed to evaluate the treatment landscape - that is, pharmacological treatment, lifestyle changes (LC), and use of over-the-counter (OTC) products - for women from six high-income countries experiencing vasomotor symptoms (VMS) and receiving healthcare.

STUDY DESIGN

Analysis of a secondary dataset, the Adelphi Real World Disease Specific Programme™, a large, cross-sectional, point-in-time survey conducted in the United States and five European countries (February-October 2020). Physicians provided demographic, clinical, and treatment data; women were stratified by VMS severity (mild; moderate-severe) and presence of concomitant sleep/mood symptoms. Women completed forms on VMS severity, concomitant symptoms, LC, and OTC product use. Two subgroups were identified: VMS-only and VMS + sleep/mood.

MAIN OUTCOME MEASURES

Prescription treatment, LC, and OTC product utilization.

RESULTS

Physicians (n = 233) provided data on 1767 women; 825 (46.7 %) completed a self-completion form. Physicians rated 60 % of women with moderate-severe VMS, of whom 709 (66.8 %) were currently prescribed pharmacological treatment; 27.1 % had never been prescribed. Hormone therapy was most frequently prescribed in the moderate-severe group (overall, 49.8 %; VMS-only, 57.4 %; VMS + sleep/mood, 47.3 %), followed by serotonergic antidepressants (15.7 %; 9.7 %; 17.6 %, respectively). Most women (78.3 %) with moderate-severe VMS adopted LC, and 57.6 % used at least one OTC product for VMS relief.

CONCLUSIONS

Nearly a third of women with moderate-severe VMS had never received treatment despite access to healthcare. This, combined with the prevalent use of LC/OTC products, suggests an unmet need for new treatment options to manage VMS and concomitant sleep/mood symptoms.

Menopause and MHT in 2024: addressing the key controversies - an International Menopause Society White Paper

The vision of the International Menopause Society (IMS) is that all women across the world will have easy and equitable access to evidence-based knowledge and health care, empowering them to make fully informed midlife health choices. The aim of this White Paper is to provide a well-balanced educational narrative of the menopause and menopause hormone therapy (MHT) from IMS experts, leading into World Menopause Day 2024. This is achieved by exploring the anthropology and history of menopause, the principles and controversies of prescribing MHT, and by placing this into regulatory and menopause society contexts. The White Paper also lays the groundwork for the forthcoming updated IMS recommendations on menopause and will act as a blueprint for the future ethical management of menopause from practical and aspirational perspectives. An important section of the paper is 'The 5Ws of prescribing MHT': WHO is MHT for; WHAT types and doses of MHT; WHEN should MHT be started and stopped; WHY is MHT important; WHERE can MHT be accessed? A key points summary of this information is provided for healthcare professionals and the public. The summary provides 'easy to access' advice regarding several recent controversial MHT prescribing issues in the healthcare and media spotlights.

Beyond breast cancer: An exploration of the experiences of middle-aged female breast cancer survivors in Australia

OBJECTIVES

Middle-aged women (i.e., aged 40-65 years) who live with, through and beyond breast cancer (survivors) are an under-researched population, particularly within an Australian context. The unmet needs reported within this population include fatigue, psychological distress, body image concerns, early-onset menopause, and a lack of information on these issues. This study explores how the experiences of breast cancer survivorship impact the lives of Australian middle-aged women.

STUDY DESIGN

Qualitative analysis of written comments in an open text field of a survey completed by 644 women reporting breast cancer in the middle-aged cohort of the Australian Longitudinal Study of Women's Health gathered between 1996 and 2013. Data was collected from any participants who reported breast cancer in any survey. Researchers conducted a thematic analysis using consensus coding on data and identified key themes.

MAIN OUTCOME MEASURES

Any data where participants described their experiences of breast cancer survivorship.

RESULTS

This cohort reported a unique experience of breast cancer survivorship due to their age group. Analysis developed the following themes: the middle-aged context of breast cancer; care and support, body changes, overcoming fears and maintaining balance; and finding a 'new normal'.

CONCLUSIONS

Breast cancer survivorship is a diverse experience. For many it involves chronic limitations and challenges. Investigation and application of survivorship care plans in Australia could benefit breast cancer survivors by including multidisciplinary health professionals in their care. Unmet needs and psychological distress were described by participants rather than biomedical concerns. Further recommendations include development of online support groups providing access to rehabilitation professionals, especially for otherwise isolated rural women.

Comprehensive Management of Menopausal Symptoms

Menopause is an inevitable physiologic process that typically occurs in women between the ages of 45 and 56 years old. It involves the permanent cessation of ovarian function and is recognized to have occurred when there has been no menstrual cycle for 12 consecutive months without another cause. Vasomotor symptoms, such as hot flushes and night sweats, and genitourinary syndrome of menopause, which includes symptoms of vaginal dryness, dyspareunia, and urinary incontinence, are common symptoms of menopause. Symptoms range from mild to severe, and for those interested in treating their symptoms, there are hormonal and nonhormonal options available. Choosing appropriate therapies is based on each individual's health history and personal preferences. Because menopause can affect mental, physical, and emotional health, it is critical for nurses to recognize the changes that occur in menopause so that they can make appropriate inquiries to elicit symptom information. Nurses play an important role in counseling and supporting individuals through the menopause transition with evidence-based guidance.

Treatment utilization and non-drug interventions for vasomotor symptoms in breast cancer survivors taking endocrine therapy: Real-world findings from the United States and Europe

OBJECTIVES

Vasomotor symptoms induced by endocrine therapy are common in breast cancer survivors and a risk factor for therapy discontinuation and lower quality of life. The REALISE study evaluated the real-world treatment landscape in breast cancer survivors with vasomotor symptoms taking endocrine therapy, including pharmaceuticals, lifestyle changes, and over-the-counter products.

STUDY DESIGN

Secondary analysis of the Adelphi Vasomotor Disease Specific Programme™, a large cross-sectional point-in-time survey and chart review conducted in the US and five European countries (February-October 2020). Oncologists provided demographic, clinical, and treatment data for adult breast cancer survivors with induced vasomotor symptoms taking endocrine therapy (tamoxifen or aromatase inhibitors); patients voluntarily completed self-report surveys on their symptom severity, concomitant sleep and/or mood symptoms, lifestyle changes, and use of over-the-counter products.

MAIN OUTCOME MEASURES

Patient characteristics; vasomotor symptom severity; use of pharmaceuticals, lifestyle changes, and over-the-counter products (from pre-defined lists); lines of treatment.

RESULTS

Overall, 77 oncologists reported data for 618 breast cancer survivors, of whom 183 (29.6 %) completed self-report forms. Physicians classified 420 (68.0 %) women as experiencing moderate-severe vasomotor symptoms, of whom 66.9 % were receiving treatment. In total, 15.2 % of all breast cancer survivors were prescribed systemic hormone therapy. Venlafaxine (24.7 %), citalopram (16.5 %), and paroxetine (13.6 %) were the most commonly prescribed nonhormonal medications. Lifestyle changes (77.8 %) and over-the-counter products (61.6 %) were common, especially in patients with concomitant sleep and/or mood symptoms.

CONCLUSIONS

Despite contraindications, a relatively large proportion of treatment-seeking breast cancer survivors with vasomotor symptoms were prescribed systemic hormone therapy. This, combined with high patient-reported use of lifestyle changes and over-the-counter products, suggests a need for symptomatic relief and demand for new nonhormonal alternatives with established safety profiles in this population.

Treatment satisfaction, unmet needs, and new treatment expectations for vasomotor symptoms due to menopause: women's and physicians' opinions

OBJECTIVE

To assess treatment satisfaction, unmet treatment needs, and new vasomotor symptom (VMS) treatment expectations among women with moderate to severe VMS and physicians treating women with VMS.

METHODS

This noninterventional, nonrandomized survey included qualitative interviews and quantitative surveys of women and physicians in the US. Participating women had moderate to severe VMS in the past year and received ≥1 hormone therapy (HT), non-HT, or over-the-counter (OTC) treatment for VMS in the past 3 months. Participating physicians were obstetrician-gynecologists (OB-GYNs) and primary care physicians (PCPs) who treated ≥15 women with VMS in the past 3 months. Two online survey questionnaires were developed using insights from literature, qualitative interviews, and clinical experts. Menopause Symptoms Treatment Satisfaction Questionnaire (MS-TSQ) measured treatment satisfaction. Results were summarized descriptively.

RESULTS

Questionnaires were completed by 401 women with VMS and 207 physicians treating VMS. Among women, mean total MS-TSQ score ranges were 62.8-67.3 for HT, 59.8-69.7 for non-HT, and 58.0-64.9 for OTC treatments. Among physicians, mean total MS-TSQ scores were considerably higher for HT than for non-HT and OTC treatments (HT: 73.4-75.6; non-HT: 55.6-62.1; OTC: 49.2-54.7). Women reported "lack of effectiveness" (41.2%), and physicians reported "long-term safety concerns" (56.5%) as main features that do not meet their current treatment expectations. The majority of women and physicians would consider trying a new non-HT treatment for VMS (75.8 and 75.9%, respectively).

CONCLUSIONS

Treatment satisfaction and new treatment expectations were similar but with some differences between women and physicians; the need for additional treatments for VMS was identified.

Retrospective text and qualitative analyses of patient experience and management of vasomotor symptoms due to menopause: voices from the PatientsLikeMe community

OBJECTIVE

Vasomotor symptoms (VMS) due to menopause cause substantial burden and distress. Some women join online communities to share experiences and treatment outcomes through peer-to-peer interactions. This study describes women's experiences with VMS and symptom management on the PatientsLikeMe online support group.

METHODS

Mixed-methods research included women aged 40 to 65 years in the PatientsLikeMe community who were recruited using convenience sampling. Text from online posts by members was analyzed retrospectively using natural language processing. Relevant data, including numbers and percentages of women and frequencies of mentions, were summarized descriptively. Qualitative semistructured interviews were conducted; data, notes, and recordings were transcribed and deidentified and thematic analyses were performed.

RESULTS

Demographic information was available from 1,614 accounts included in retrospective text analyses. Women had a mean age of 56.7 years; most were White (87.8%) and not Hispanic/Latino (90.2%). Hot flashes and night sweats were most commonly mentioned symptoms (n = 146). Of 16 women who were interviewed, 14 met the inclusion criteria, and their responses were included in the analysis. VMS impacted life quality in terms of physical (43%) and mental well-being (36%), social activities (21%), and productivity (14%). Symptom management included temperature regulation (43%), lifestyle changes (36%), over-the-counter Estroven (29%), hormone therapy (21%), and contraceptives (21%). Half of the women were surprised by symptom intensity and duration; many felt unheard by their healthcare providers.

CONCLUSIONS

VMS have a substantial negative impact on multiple aspects of women's life. Management strategies for these symptoms vary widely, and many women feel unprepared for navigating the complex challenges of menopause.

Female Reproductive Endocrine Disorders

This article is a summary of normal menstrual bleeding and how to recognize abnormalities based on patient's symptoms as well as identify possible causes in order to direct treatment. This article discusses abnormal uterine bleeding including the definition, etiology, evaluation, and treatment. It also discusses primary ovarian insufficiency, transgender medicine, and menopause.

Menopause and the workplace: consensus recommendations from The Menopause Society

ABSTRACT

Menopause is a natural life transition experienced by half the world's population. Women aged 50 years and older are the fastest growing demographic group in many countries, making essential contributions to the workforce. Although menopause is a universal and natural life transition, the symptom experience is highly variable among women. Some women may experience few or no symptoms, whereas others may be bothered by moderate to severe symptoms for a decade or longer, which can adversely affect quality of life, relationships, job satisfaction, and career advancement. Indeed, menopause symptoms, including vasomotor and genitourinary symptoms, as well as sleep and mood disturbances are associated with multiple adverse work outcomes. Studies to date have demonstrated that these adverse work outcomes related to menopause symptoms include a compromised ability to work, reduced work productivity, absenteeism, and even loss of employment or an early exit from the workforce. Further, the relationship between menopause symptoms and work may be bidirectional, with certain aspects of the work environment being linked with a greater menopause symptom burden, such as insufficient restroom facilities, unpredictable or long work hours, the inability to take breaks, and confined or crowded workspaces. Thus, workplace solutions may need to be tailored based on women's individual needs, the work environment, and the type of work.The Menopause Society, in conjunction with an expert panel of medical and legal experts and women's health advocates, has developed a set of consensus recommendations that challenges employers to create a menopause-supportive workplace for their employees. These recommendations include, among other things, suggestions for employers to review policies and healthcare plans and benefits and to consider flexibility and accommodations that may be needed for some women with menopause symptoms. Guidance for women with menopause symptoms that affect them at work in terms of understanding their resources and empowering them to be self-advocates are also provided, as well as recommendations for what occupational health professionals should know and do for women with bothersome menopause symptoms in the workplace.

The effect of mindfulness-based stress reduction program applied to postmenopausal women on insomnia and quality of life

This study aimed to determine the effect of the mindfulness-based stress reduction program applied to postmenopausal women on insomnia and quality of life. A quasi-experimental pretest-posttest control group design was used. The sample of the study consisted of a total of 151 postmenopausal women, including 73 in the experimental group and 78 in the control group. In the study, the mindfulness-based stress reduction program (MBSR) was applied to the women in the experimental group for eight weeks, and then the women repeated the program individually for another eight weeks. The second measurement data were collected eight weeks after the collection of the first measurement data, and the third measurement data were collected 16 weeks later. The mean score obtained from the second measurement application of the Women's Health Initiative Insomnia Rating Scale (WHIIRS) was lower in the experimental group than in the control group (p < .05). In addition, the mean scores from the second and third measurement applications of the Menopause-Specific Quality of Life Questionnaire (MENQOL) were lower in the experimental group than in the control group (p < .05). The MBSR program reduced postmenopausal women's insomnia and improved their quality of life. This program can be used safely to treat insomnia and improve the quality of life of postmenopausal women. NCT05202054 (date: 21.01.2022).

Cardiovascular and physiological risk factors in women at mid-life and beyond

Cardiovascular disease (CVD) is the leading cause of death in women. After menopause, sex-specific and gender-specific factors may play an important role in increasing CVD risk, with changes in sex hormones, body fat distribution, lipid and metabolic profile, and structural and functional vascular modifications. Premature and early-onset menopause are detrimental to cardiovascular health due to the early cessation of the protective effect of endogenous estrogen. An independent association of menopause with an increased risk of CVD has been documented in early menopause (<45 years). Sex-related differences are relevant in pharmacokinetics and pharmacodynamics; different enzyme formations, drug compatibility, efficacy, and side effects vary for different sexes. Despite some progress in sex and gender research in CVD, disparities remain. Menopausal hormone therapy (MHT) is available at mid-life for symptoms of menopause and may impact cardiovascular risk. Taken early, MHT may reduce CVD morbimortality. However, this is balanced against the risk of increased thrombosis. This paper reviews physiologic changes that contribute to cardiovascular risk in postmenopausal women and discusses clinical implications. Specifically, it explores the atheroprotective effects of estrogen and MHT and the associations between menopause with lipid levels, hypertension, body composition, and diabetes for women at mid-life and beyond.

The effect of progressive muscle relaxation exercises on postmenopausal sleep quality and fatigue: a single-blind randomized controlled study

OBJECTIVE

This single-blind, randomized controlled study aimed to determine the effect of progressive muscle relaxation exercises on sleep quality and fatigue in the postmenopausal period. Progressive muscle relaxation aims to relax the muscles in the body and includes breathing techniques.

METHODS

This study was carried out between January 2022 and July 2022 with 63 postmenopausal women who applied to a district state hospital and had poor sleep quality. The women assigned to the experimental group (EG) (n = 31) applied progressive muscle relaxation exercises every day for 8 weeks. In contrast, the women in the control group (CG) (n = 32) continued their routine coping habits related to sleep problems and fatigue in the postmenopausal period. The EG and CG were reevaluated using the Piper Fatigue Scale and the Pittsburg Sleep Quality Index in the fourth and eighth weeks. The women applied progressive muscle relaxation exercises with a guide prepared by the researchers and the compact disc of the Turkish Psychologists Association. In the data analysis, the independent-samples t test, Fisher's exact test, and χ2 test were used to compare individual, obstetric, and medical characteristics between the groups. The difference between dependent groups at different times was evaluated by repeated-measures analysis of variance.

RESULTS

There was an improvement in fatigue symptoms in the progressive muscle relaxation exercises-performing EG at the end of 8 weeks compared with the CG, and fatigue symptoms increased in the CG (P < 0.001). There was a greater improvement in the sleep quality of the progressive muscle relaxation exercises-performing EG at the end of 8 weeks compared with the CG (P < 0.001).

CONCLUSIONS

In our study, it was determined that progressive muscle relaxation exercises had an improving effect on sleep quality and fatigue.

Endocrine consequences of breast cancer therapy and survivorship

Breast cancer survivorship is increasing, due to earlier diagnosis of the disease and more effective therapies. Long-term endocrine sequelae, including early menopause, bone health, fertility implications and menopausal symptoms, are important survivorship issues. Ovarian failure is common with chemotherapy and options for preserving fertility in young women include ovarian suppression during chemotherapy and oocyte or embryo cryopreservation before chemotherapy. Tamoxifen as adjunct therapy in premenopausal women leads to ovarian stimulation, sometimes ovulation and occasionally pregnancy with important teratogenic implications. Aromatase inhibitor therapy with or without gonadotrophin releasing hormone (GnRH) agonist leads to profound bone loss and anti-resorptive therapy is advised to prevent fracture. Tamoxifen acts to preserve bone in postmenopausal women but not premenopausal women. Pregnancy is not discouraged in young women with early breast cancer, even to the point of pausing adjunct therapy in order to conceive. However, menopausal hormone therapy is discouraged even years later. Non-hormonal therapy for menopausal symptoms in breast cancer survivors is available but, in some cases, estrogen-containing therapy may be worthy of consideration for quality of life in the informed patient.

Recommended measurement instruments for menopausal vasomotor symptoms: the COMMA (Core Outcomes in Menopause) consortium

OBJECTIVE

The aim of the study is to identify suitable definitions and patient-reported outcome measures (PROMs) to assess each of the six core outcomes previously identified through the COMMA (Core Outcomes in Menopause) global consensus process relating to vasomotor symptoms: frequency, severity, distress/bother/interference, impact on sleep, satisfaction with treatment, and side effects.

METHODS

A systematic review was conducted to identify relevant definitions for the outcome of side-effects and PROMs with acceptable measurement properties for the remaining five core outcomes. The consensus process, involving 36 participants from 16 countries, was conducted to review definitions and PROMs and make final recommendations for the measurement of each core outcome.

RESULTS

A total of 21,207 publications were screened from which 119 reporting on 40 PROMs were identified. Of these 40 PROMs, 36 either did not adequately map onto the core outcomes or lacked sufficient measurement properties. Therefore, only four PROMs corresponding to two of the six core outcomes were considered for recommendation. We recommend the Hot Flash Related Daily Interference Scale to measure the domain of distress, bother, or interference of vasomotor symptoms and to capture impact on sleep (one item in the Hot Flash Related Daily Interference Scale captures interference with sleep). Six definitions of "side effects" were identified and considered. We recommend that all trials report adverse events, which is a requirement of Good Clinical Practice.

CONCLUSIONS

We identified suitable definitions and PROMs for only three of the six core outcomes. No suitable PROMs were found for the remaining three outcomes (frequency and severity of vasomotor symptoms and satisfaction with treatment). Future studies should develop and validate PROMs for these outcomes.

Management of the Vasomotor Symptoms of Menopause: Twofers in Your Clinical Toolbox

The number of midlife women transitioning into menopause is substantial, with more than 1 million women in the United States entering menopause each year. Vasomotor symptoms (VMS), mood and sleep disturbances, and sexual problems are common during the menopause transition yet often go untreated. Menopausal hormone therapy is the most effective treatment of VMS, and the benefits typically outweigh the risks for women without contraindications who are younger than 60 years or within 10 years from menopause onset. For women who cannot or choose not to use hormone therapy, nonhormone prescription options exist to treat VMS. Many of these therapies have secondary benefits beyond VMS relief. For example, whereas paroxetine is Food and Drug Administration approved to treat VMS, it can also help with depressive and anxiety symptoms. The aim of this paper is to summarize prescription treatments of VMS and their secondary benefits for other common symptoms experienced by midlife women. The tools presented will help clinicians caring for midlife women provide individualized, comprehensive care with the goal of improving their quality of life during the menopause transition and beyond.

Menopause transition and cardiovascular disease risk

The risk of cardiovascular disease (CVD) notably increases in the fifth decade of a woman's life, coinciding with the onset of menopause and occurring 10 years later than the similar age-related increase in men. Menopause marks a significant transition in a woman's life and is accompanied by cardiometabolic changes, including a shift in body composition, increased blood pressure, disruptions in lipoproteins, and insulin resistance. There is increasing evidence that the menopause transition is a risk factor for CVD, independent of age-related changes, especially considering that the earlier the onset of menopause, the greater is the CVD risk. Further, menopause-related symptoms such as vasomotor symptoms, sleep disturbances, and mood changes may all have a direct impact on CVD risk. In this review, we summarize the current literature regarding CVD in midlife women, focusing on the cardiometabolic changes related to ovarian aging versus chronological aging, as well as those related to specific menopause characteristics, including age, type of menopause and the use of menopause hormone therapy.

A Contemporary View of Menopausal Hormone Therapy

Enthusiasm for the use of hormones to ameliorate symptoms of perimenopause and menopause has waxed and waned over the years. Both treatment for symptoms and training of women's health care practitioners in the management of menopause have sharply declined since publication of the Women's Health Initiative initial results in 2002. Findings from that trial, which treated a population of older, asymptomatic patients, have been extrapolated over the past 21 years to all estrogen products, all menopausal women, and all delivery mechanisms. Our patients deserve a more nuanced, individualized approach. Conjugated equine estrogens and medroxyprogesterone acetate are no longer the predominant medications or medications of choice available for management of menopausal symptoms. All hormones are not equivalent any more than all antiseizure medications or all antihypertensives are equivalent; they have different pharmacodynamics, duration of action, and affinity for receptors, among other things, all of which translate to different risks and benefits. Consideration of treatment with the right formulation, at the right dose and time, and for the right patient will allow us to recommend safe, effective, and appropriate treatment for people with menopausal symptoms.

Design of OASIS 1 and 2: phase 3 clinical trials assessing the efficacy and safety of elinzanetant for the treatment of vasomotor symptoms associated with menopause

OBJECTIVE

Elinzanetant is a selective neurokinin-1,3 receptor antagonist in development for the treatment of vasomotor symptoms (VMS) associated with menopause. The pivotal, double-blind, randomized, placebo-controlled phase 3 studies Overall Assessment of efficacy and Safety of elinzanetant In patients with vasomotor Symptoms (OASIS) 1 and 2 will assess the efficacy and safety of elinzanetant in women with VMS.

METHODS

The OASIS 1 and 2 pivotal studies are designed in accordance with regulatory guidance. Postmenopausal women with moderate/severe VMS are randomized to receive 120 mg elinzanetant or placebo once daily for 12 weeks, followed by a 14-week active treatment extension. Primary endpoints are the mean change in frequency and severity of moderate/severe VMS from baseline to weeks 4 and 12. Key secondary endpoints will assess the onset of action and effects on sleep disturbance and menopause-related quality of life. Primary and key secondary endpoints will be analyzed using a mixed model with repeated measures. Feedback from postmenopausal women with VMS was used during protocol development.

RESULTS

Women confirmed the relevance of endpoints that assess the impact of VMS, sleep disturbance, and mood changes, and the need for new nonhormone treatments. Educational materials around study design, conduct and expected assessments and procedures were developed based on questions and concerns raised by women.

CONCLUSIONS

The OASIS 1 and 2 pivotal phase 3 studies will enable assessment of the efficacy and safety of elinzanetant as a treatment for VMS, together with its effect on sleep disturbances, depressive symptoms, and menopause-related quality of life. Feedback from postmenopausal women with VMS was used to maximize patient centricity in the trials.

Fezolinetant: a novel nonhormonal therapy for vasomotor symptoms due to menopause

INTRODUCTION

During menopause, the majority of women experience vasomotor symptoms which may lead to several untoward effects and negatively impact quality of life. Fezolinetant, a novel agent directly targeting the underlying pathophysiology of menopause-associated vasomotor symptoms, offers an alternative to hormonal therapies for which many patients have a contraindication or unwillingness to take due to safety concerns.

AREAS COVERED

This review summarizes key pharmacologic, pharmacokinetic, and pharmacodynamic parameters of fezolinetant along with efficacy and safety data derived from clinical trials. A literature search of peer-reviewed publications evaluating the efficacy and safety of fezolinetant was conducted using PubMed and EMBASE databases. A review of registered trials in clinicaltrials.gov was evaluated to identify ongoing studies.

EXPERT OPINION

Placebo-controlled studies demonstrated that fezolinetant led to a statistically significant reduction in vasomotor symptom frequency and severity among patients with moderate-to-severe vasomotor symptoms. The most common adverse event is headache (5-10%) and no serious safety signals have been noted. Direct head-to-head comparison with hormonal therapies and nonhormonal therapies for vasomotor symptoms, assessment of sleep outcomes, and evaluation of efficacy and safety beyond 1 year are key areas where additional data are still needed.

Weight Gain in Midlife Women

PURPOSE OF REVIEW

To summarize the evidence and clinical implications of weight and body composition changes during midlife in women and provide an overview of weight gain prevention and management in this population.

RECENT FINDINGS

Aging-related changes such as decreased energy expenditure and physical activity are important culprits for weight gain in midlife women. The hormonal changes of menopause also influence body adiposity distribution and increase central adiposity. These body changes can have health consequences including the development of cardiometabolic diseases, osteoarthritis, cancer, worsening in cognition, mental health, and menopause symptoms. Midlife women experience changes related to aging, menopause, and lifestyle which favor weight gain. Clinical practice should focus on early counseling and anticipatory guidance on the importance of dietary changes and physical activity to attenuate this phenomenon. Future research should focus on the longitudinal relationship between weight trends in midlife and health consequences and mortality.

Fezolinetant for the treatment of vasomotor symptoms associated with menopause: a meta-analysis

This systematic review and meta-analysis investigated the efficacy and safety of fezolinetant for the treatment of moderate-to-severe vasomotor symptoms (VMS) associated with menopause. PubMed, Cochrane Library, Embase and Web of Science were searched for randomized controlled trials (RCTs) published from inception to June 2023, comparing fezolinetant to placebo in postmenopausal women suffering from moderate-to-severe VMS. The mean difference and risk ratio were calculated for continuous and binary outcomes, respectively. R software was used for the statistical analysis, and RoB-2 (Cochrane) to assess the risk of bias. We performed subgroup analysis based on different dosing regimens. Five RCTs comprising 3302 patients were included. Compared with placebo, at 12-week follow-up, fezolinetant significantly reduced the daily frequency of moderate-to-severe VMS (weighted mean difference [WMD] - 2.36; 95% confidence interval [CI] - 2.92, -1.81) and daily severity of moderate-to-severe VMS (WMD -0.22; 95% CI -0.31, -0.13). Also, fezolinetant significantly improved the quality of life (WMD -0.42; 95% CI -0.58, -0.26) and sleep disturbance (WMD -1.10; 95% CI -1.96, -0.24). There were no significant differences between groups in adverse events. These findings support the efficacy and safety of fezolinetant for the treatment of VMS related to menopause.

Efficacy and safety of fezolinetant for moderate to severe vasomotor symptoms associated with menopause among women in East Asia: a phase 3 randomized study (MOONLIGHT I)

OBJECTIVE

To evaluate the efficacy and safety of fezolinetant for moderate to severe vasomotor symptoms (VMS) associated with menopause in East Asian women.

METHODS

In this phase 3, randomized, double-blind study, postmenopausal women with moderate to severe VMS (minimum average frequency in the 10 days before randomization, ≥7/day or 50/week) received fezolinetant 30 mg/day or placebo (weeks 1-12), followed by an open-label extension phase with fezolinetant 30 mg/day (weeks 13-24). The co-primary endpoints were the mean changes in the daily frequency and severity of VMS at weeks 4 and 12.

RESULTS

Among 301 participants, the difference in the least squares mean change (95% confidence interval) from baseline in the daily frequency of moderate to severe VMS versus placebo was -0.65 (-1.41 to 0.12) at week 4 and -0.55 (-1.35 to 0.26) at week 12. The differences in the least squares mean change from baseline in the VMS severity score versus placebo were -0.06 (-0.14 to 0.03) and -0.13 (-0.27 to 0.01) at weeks 4 and 12, respectively. Serious adverse events occurred in 0.7% of participants receiving fezolinetant in weeks 1 to 12, compared with 1.3% of those receiving placebo.

CONCLUSIONS

Fezolinetant was generally safe but did not reduce the frequency or severity of VMS versus placebo in postmenopausal women in this study.ClinicalTrials.Gov Identifier: NCT04234204.