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Hormonal therapy for sexual function in menopausal women

Nastri CO, Lara LA, Ferriani RA, Rosa-e-Silva AJS, Figueiredo JBP, Martins WP
Published Online: 
5 June 2013

We aimed to assess the effect of hormonal therapy (HT), specifically estrogens alone, estrogens in combination with progestogens, synthetic steroids, and SERMs, on sexual function in perimenopausal and postmenopausal women. The time around and after the last menstrual period (menopause) is associated with many symptoms, including a decline of sexual function. HT is a generic term that refers to any type of hormone therapy used during menopause for alleviation of menopause-related symptoms. We carried out an electronic search of medical literature databases, searching for randomised controlled trials (RCTs) comparing hormone therapy (HT) to either no treatment or a placebo treatment. No other type of study was included. The last search was performed in December 2012.

Twenty-seven studies were included; they were conducted in more than 30 countries. Sexual function was assessed in 8802 women in the treatment groups and in 7591 women in the control groups. A single study was responsible for the inclusion of 8462 women, 51.2% of the total number. We grouped the studies by participant characteristics with regard to menopausal symptoms. The symptomatic or early menopausal group was from nine studies in which women were perimenopausal (one study), up to 36 months postmenopause (one study), up to five years postmenopause (one study), experiencing vasomotor or other menopausal symptoms (five studies), or experiencing hot flushes and sexual dysfunction (one study). The unselected postmenopausal women group came from 18 studies. The group included women regardless of menopausal symptoms and allowed inclusion of women with more than five years since their final menstrual period. No studies were restricted to women with sexual dysfunction and only five studies evaluated sexual function as a primary outcome. Eighteen studies were deemed at high risk of bias, and the other nine studies were at unclear risk of bias. Twenty studies received commercial funding.

Findings for sexual function (measured by overall score) were as follows:

In the comparison of estrogens alone versus control, for symptomatic or early postmenopausal women the observed effect was compatible with a small to moderate benefit for sexual function in the HT group (high-quality evidence). For unselected postmenopausal women the observed effect was compatible with no effect to a small benefit, provided by low-quality evidence.

In the comparison of estrogens combined with progestogens versus control, for symptomatic or early postmenopausal women, the observed effect was compatible with a small to moderate benefit for sexual function in the HT group (moderate-quality evidence). For  unselected postmenopausal women, the observed effect was compatible with no effect to a small benefit (moderate-quality evidence).

In the comparison of tibolone versus control, for symptomatic or early postmenopausal women the observed effect was compatible with no effect to a small benefit for sexual function in the HT group (low-quality evidence). For unselected postmenopausal women, the observed effect was compatible with no effect to a moderate benefit (low-quality evidence).

In the comparison of SERMs (raloxifene and bazedoxifene) versus control, for symptomatic or early postmenopausal women the observed effect was compatible with no effect to a moderate benefit for sexual function in the HT group (low-quality evidence). For unselected postmenopausal women, the observed effect was compatible with a small harm to small benefit (low-quality evidence).

Comparing bazedoxifene combined with estrogens to control, for symptomatic or early postmenopausal women the observed effect was compatible with no effect to a small benefit, with moderate-quality evidence. No study was included in the subgroup of unselected postmenopausal women.

The included studies did not allow a comprehensive assessment of harms from these therapies; other systematic reviews must be taken into account to understand the possible harms of HT.

We concluded that HT treatment with estrogens alone or in combination with progestogens is associated with a small to moderate improvement in sexual function when used specifically in women with menopausal symptoms or who were in early postmenopause (within five years after onset of menopause), but not when used for any postmenopausal woman. Evidence regarding other HTs (tibolone, raloxifene, and bazedoxifene) is of low quality. The current evidence does not suggest an important effect of tibolone, raloxifene and bazedoxifene, alone or combined with estrogens, on sexual function.

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