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Comments for: Surveillance proposal consultation document 2019 surveillance of Menopause: diagnosis and management(NICE NG23)

Below is the response from the British Acupuncture to NICE NG23.

No, we do not agree with the proposal not to update the guideline.

Your (2015-2019) evidence review found ‘improvements in sleep quality, vasomotor symptoms, and oestrogen levels, but no effect on luteinising hormone or follicle stimulating hormone levels’ from the four non-sham trials. The impact statement says of acupuncture that the new evidence is ‘showing little clinically important effect of this treatment’, but we think this pertains only to the two sham controlled trials, not the four others.

Looking at the most recent published systematic review (Befus et al 2018), in fact an umbrella review and meta-analysis, there is the same distinction apparent between the sham and non-sham trials. For the latter the SMDs for vasomotor symptoms are -.49 and -.66 (for frequency and severity) and 0.93 for health related QoL. The effect sizes were smaller, or not even statistically significant, with the sham trials.

On the basis that clinical significance should be measured from comparisons of the intervention against real world alternative possibilities, such as no treatment or usual care, then acupuncture is indeed clinically significant. It is less effective than hormone treatment, but the offer of acupuncture in that context would be on the basis of avoiding the possible side effects of HRT for those people for whom that is an issue.

The problem with sham comparator acupuncture trials is the strong possibility of confounding physiological effects from the sham intervention, hence it is unwise to attach much  weight to those results.

The authors of the above review concluded that the evidence did favour use of acupuncture for menopause-related vasomotor symptoms. We maintain that there is sufficient evidence to consider acupuncture as a possible intervention for menopause-related symptoms; hence the guideline should be updated.

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