Hot flushes: oestrogen still does most, and costs least

Design

Systematic review and meta-analysis of randomised trials

Population

90 trials in women with menopausal vasomotor symptoms

Primary outcome

Frequency and severity of vasomotor symptoms; quality of life; sleep; harms

Effect

Oestrogen reduced frequency and severity; NKRAs, SSRIs, SNRIs, gabapentin reduced frequency only

This systematic review, commissioned by the American College of Physicians to inform its guidance, pooled 90 randomised trials of at least eight weeks of drug treatment for menopausal vasomotor symptoms.

Against placebo, oestrogen with or without a progestogen, conjugated oestrogen with bazedoxifene, and oxybutynin reduced both how often and how severely hot flushes occurred. Neurokinin receptor antagonists such as fezolinetant, SNRIs, SSRIs, gabapentin and progestogens reduced frequency but not severity. Oestrogen's effect depended on dose, not route. Oestrogen was judged high economic value with high certainty; fezolinetant low value.

Certainty was low to moderate for most comparisons, trials were short, and observational data on long-term harms were excluded. So this review answers what works for symptoms, not the separate question of long-term risk, which still needs an individual conversation.

• For bothersome hot flushes without contraindications, oestrogen is the most effective option.
• Add a progestogen for women with a uterus to protect the endometrium.
• Where oestrogen is unsuitable, SSRIs, SNRIs, gabapentin or oxybutynin reduce how often flushes occur.
• Ask about sleep; several non-hormonal options improved it.
• Discuss long-term risks individually; this review did not assess them well.

Why it matters

Newer, costlier non-hormonal drugs did not outperform the oldest, cheapest option.

Don't overread it

The trials were short; this review cannot speak to long-term breast or cardiovascular risk.

The statistics, in plain English

Certainty of evidence is graded: high means further research is unlikely to change the estimate, low means it may well change. Most comparisons here were low to moderate. 'Reduced frequency but not severity' means fewer flushes, but those that occur may feel the same.

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