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Spring Evidence Updates

Exhausted mature woman entering

Menopause—Not Just Hormones

Non-hormonal treatments serve as useful second-line options for hot flashes, when patients have contraindications to or do not want hormonal therapy.


A 2023 Tools for Practice article Turn Down The Heat summarized non-hormonal medications for vasomotor symptoms in menopause.

The evidence summary confirms the medications listed in the 2022 Menopause module. Numbers needed to treat (NNT) to achieve ≥ 50% reductions in number of hot flashes at 12 weeks were:

  • Gabapentin: 8
  • Desvenlafaxine: 4 to 5
  • SSRIs: 6 to 9 at 8–12 weeks for paroxetine or escitalopram

Note: fluoxetine and citalopram did not differ from placebo.

Bottom line

At 12 weeks, SSRIs/SNRIs or gabapentin can improve menopausal vasomotor symptoms with relatively low numbers needed to treat. Put another way: on average, 15 more women out of 100 will see a ≥ 50% reduction in hot flashes after treatment with SSRIs/SNRIs or gabapentin (compared to placebo). 

Cognitive Behavioural Therapy

A BMJ news article reported that the upcoming NICE guideline on menopause diagnosis and management includes CBT as an adjunct or alternative option for hot flashes, night sweats, depressive symptoms, and sleep problems. 

The evidence showed that CBT mostly was beneficial in terms of helping cope with vasomotor symptoms. CBT was also beneficial for various measures of sleep difficulty associated with menopause. The final guidelines are expected to be published in May 2024.

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ADHD  Medications—Heart Matters

The 2023 module ADHD in Adults stated that further study was needed on the longer term cardiovascular effects of ADHD medication. A large, recent nested case-control study (n=278,027 individuals with ADHD in the cohort) from Sweden looked at the long term risk of CVD in people 6 to 65 years of age taking ADHD medication. Of the total cohort, 10,388 people had ADHD and CVD (the cases), and 51,672 people with ADHD and no CVD were selected as controls. No one had CVD at baseline, and the amount of cumulative exposure to medication was determined. 

Compared to patients with ADHD who were not taking medication, longer cumulative medication use was associated with an increased risk of CVD, especially hypertension and arterial disease. Overall, the study found that for each 1-year use of ADHD medications, there was a 4% increased risk of CVD. Similar patterns were seen in those age < 25 and those ≥ 25 years.

Bottom line

It would be important to regularly monitor cardiovascular risks, signs, and symptoms during ADHD treatment.

Middle-aged man sits on bed with head down and covers face with hands.

Erectile Dysfunction—Exercise Helps

A 2023 systematic review and meta-analysis (11 RCTs, n=1,147) reported that aerobic exercise improved erectile dysfunction (ED) by about 3 points on an ED scale. On this scale, the minimum clinically important difference is considered to be 2 points. The effect was greater in those with more severe ED (up to 5 points). Although some participants were taking a PDE5 inhibitor, this did not modify the treatment benefit.

Typical improvements on the same scale from an umbrella review are 2 points for testosterone therapy, 4 for shockwave therapy, and 4 to 8 for PDE5Is.

Bottom line

The 2020 module Men’s Health: Testosterone Deficiency and Erectile Dysfunction discussed lack of exercise as a risk factor for ED. Patients should be advised that aerobic exercise can help improve their ED.