2019 surveillance of menopause (NICE guideline NG23)

Managing urogenital atrophy

We identified new evidence on ospemifene, which is licensed in the UK for treating urogenital atrophy in women who are not candidates for vaginal oestrogen. At the time of guideline development, ospemifene had received a UK marketing authorisation but information on its cost was not available for consideration in the related evidence review. The situation has changed because the treatment is now available (costing £39.50 for 28 tablets) and new evidence indicates that it may improve sexual function, vaginal dryness, and dyspareunia. However, the new evidence did not report on adverse events associated with ospemifene. It was not possible to tell from the abstracts whether the effects were clinically meaningful, or durable.

We also identified new evidence for prasterone use for up to 3 months. Prasterone has recently been licensed in the UK (costing £15.94 for 28 pessaries) for treating vulvar and vaginal atrophy in postmenopausal women having moderate to severe symptoms. Further evidence on the effects with prasterone treatment longer than 3 months and longer-term safety data is needed before considering an update of the guideline to evaluate the role of prasterone for treating vaginal symptoms of the menopause.

The cost of prasterone is comparable with available intravaginal oestrogen pessaries, and although ospemifene is more expensive, its use is restricted to a smaller group of women for whom intravaginal oestrogen is not suitable. Therefore, we do not expect these treatments to have a substantial impact on NHS resources. Additionally, we are not aware of any new safety issues relating to other currently recommended treatments for vaginal symptoms of menopause. For these reasons, we decided that an update was not necessary at this time.

New evidence for other treatments for short-term menopausal symptoms was identified: including drug treatments, psychological treatments, and alternative medicine and complementary therapies. However, the evidence for these treatments did not indicate a need to update the guideline because each intervention was usually assessed in a single small trial, which was deemed insufficient to change existing recommendations.

Long-term benefits and risks of hormone replacement therapy

We identified new evidence on the long-term risks and benefits of hormone replacement therapy. This included areas covered by the guideline such as cardiovascular outcomes, cancer outcomes, osteoporosis and dementia. The findings were generally consistent with the guideline. New evidence did not suggest that an update of the guideline is needed to consider additional risks or benefits of hormone replacement therapy.

For further details and a summary of all evidence identified in surveillance, see summary of evidence from surveillance.