• Elisheva R Danan, Catherine Sowerby, Kristen E Ullman, Kristine Ensrud, Mary L Forte, Nicholas Zerzan, Maylen Anthony, Caleb Kalinowski, Hamdi I Abdi, Jessica K Friedman, Adrienne Landsteiner, Nancy Greer, Rahel Nardos, Cynthia Fok, Philipp Dahm, Mary Butler, Timothy J Wilt, and Susan Diem.
• Center for Care Delivery & Outcomes Research, VA Health Care System, and Department of Medicine, University of Minnesota, Minneapolis, Minnesota (E.R.D., S.D.).
• Ann. Intern. Med. 2024 Oct 1; 177 (10): 140014141400-1414.

BackgroundPostmenopausal women commonly experience vulvovaginal, urinary, and sexual symptoms associated with genitourinary syndrome of menopause (GSM).PurposeTo evaluate effectiveness and harms of vaginal estrogen, nonestrogen hormone therapies, and vaginal moisturizers for treatment of GSM symptoms.Data SourcesMedline, Embase, and CINAHL through 11 December 2023.Study SelectionRandomized controlled trials (RCTs) of at least 8 weeks' duration enrolling postmenopausal women with at least 1 GSM symptom and reporting effectiveness or harms of hormonal interventions or vaginal moisturizers.Data ExtractionRisk of bias and data extraction were performed by one reviewer and verified by a second reviewer. Certainty of evidence (COE) was assessed by one reviewer and verified by consensus.Data SynthesisFrom 11 993 citations, 46 RCTs evaluating vaginal estrogen (k = 22), nonestrogen hormones (k = 16), vaginal moisturizers (k = 4), or multiple interventions (k = 4) were identified. Variation in populations, interventions, comparators, and outcomes precluded meta-analysis. Compared with placebo or no treatment, vaginal estrogen may improve vulvovaginal dryness, dyspareunia, most bothersome symptom, and treatment satisfaction. Compared with placebo, vaginal dehydroepiandrosterone (DHEA) may improve dryness, dyspareunia, and distress, bother, or interference from genitourinary symptoms; oral ospemifene may improve dryness, dyspareunia, and treatment satisfaction; and vaginal moisturizers may improve dryness (all low COE). Vaginal testosterone, systemic DHEA, vaginal oxytocin, and oral raloxifene or bazedoxifene may provide no benefit (low COE) or had uncertain effects (very low COE). Although studies did not report frequent serious harms, reporting was limited by short-duration studies that were insufficiently powered to evaluate infrequent serious harms.LimitationsMost studies were 12 weeks or less in duration and used heterogeneous GSM diagnostic criteria and outcome measures. Few studies enrolled women with a history of cancer.ConclusionVaginal estrogen, vaginal DHEA, oral ospemifene, and vaginal moisturizers may improve some GSM symptoms in the short term. Few long-term data exist on efficacy, comparative effectiveness, tolerability, and safety of GSM treatments.Primary Funding SourceAgency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42023400684).

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