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The American College of Physicians recommends menopausal hormone therapy as first-line medication for vasomotor symptoms, with estrogen plus progestogen for women with a uterus and estrogen alone for those without one. The guideline ranks certain antidepressants, gabapentin and neurokinin receptor antagonists as alternatives, while noting that evidence is limited for groups often excluded from trials.
The American College of Physicians (ACP) recommends menopausal hormone therapy as the first-line medication for women experiencing hot flashes and night sweats, placing selected nonhormonal drugs in second- or third-line roles. The guideline specifies estrogen combined with progestogen for women with a uterus and estrogen alone for those without one, and says both recommendations are supported by high-certainty evidence.
The guidance, written by Amir Qaseem, MD, PhD, MHA, and colleagues, appears in the journal Annals of Internal Medicine. For patients who cannot use hormone therapy or do not tolerate it, the ACP names the serotonin-norepinephrine reuptake inhibitors desvenlafaxine and venlafaxine as second-line options. That recommendation is based on moderate-certainty evidence.
Third-line options include the selective serotonin reuptake inhibitors escitalopram and paroxetine, as well as gabapentin. The guideline rates the evidence for those drugs as low certainty. It also lists the neurokinin receptor antagonists fezolinetant and elinzanetant as third-line treatments, supported by moderate-certainty evidence. The recommendations concern medication treatment of vasomotor symptoms, not every aspect of menopause care.
The recommendations draw on a systematic review and meta-analysis by Susan Diem, MD, MPH, and colleagues, also published in the journal. Researchers included 90 trials reported across 102 publications. The trials generally lasted at least eight weeks, with a median duration of 12 weeks; participants were mostly healthy, postmenopausal white women ages 49 to 57. The review found symptom reductions with estrogen, with or without progestogen, and with neurokinin receptor antagonists, among other treatments.
How the Treatment Ranking Affects Care
The guideline gives clinicians and patients a clearer evidence-based ordering of medication options for disruptive hot flashes and night sweats. It puts hormone therapy first when it is appropriate, while identifying alternatives for people who cannot take it or do not tolerate it. That distinction matters because the recommendations are not a direction for every patient to use hormones; treatment decisions still depend on individual health circumstances and preferences.
Vasomotor symptoms affect many women during the menopause transition and can interfere with daily life. The ACP also encourages clinicians to start conversations about menopause and provide education, according to an accompanying editorial by Stephanie Faubion and Regina Castaneda of the Mayo Clinic. The editorialists said concerns about risks, misconceptions, access barriers and undertreatment have contributed to lower use of hormone therapy. The new ranking may inform those discussions, but it does not resolve individual questions about benefits and risks.
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Evidence Behind the New Guidance
Hormone therapy has long been used to treat vasomotor symptoms, but use declined after findings from the Women’s Health Initiative raised concerns about cardiovascular disease and breast cancer and led to boxed warnings. The source report says the FDA recently removed warnings about those risks and that re-analyses of the trial data have been completed. The ACP guideline adds a new treatment recommendation based on a review of randomized trials; it does not mean hormone therapy is suitable for everyone.
In 2022, the Menopause Society said the benefit-risk balance is favorable for treating symptoms for women under 60 and within 10 years of menopause onset who have no contraindications. The ACP review’s evidence base also has limits: only eight studies involved perimenopausal women, and many trials excluded people with prior breast or endometrial cancer, cardiovascular disease, stroke or venous thromboembolism. Compounded estrogens were not evaluated.
“Hormone therapy should be the first-line treatment for women with menopausal vasomotor symptoms.”
— Amir Qaseem and colleagues, ACP guideline authors
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Who the Existing Trials Leave Out
The strength of the recommendations does not erase gaps in the research. Trial participants were largely healthy, postmenopausal white women, and people with several medical histories that can affect hormone-treatment decisions were commonly excluded. The review could not establish how treatment effects differ by age, race, ethnicity or menopausal status, and evidence specific to people who cannot use hormone therapy remains an identified need.
The source report also notes that newer nonhormonal agents need more study. Although the review included several drug types, trial duration was generally short, and the findings do not settle how benefits and harms compare over longer periods or across underrepresented groups. The guideline’s treatment order should not be read as individualized medical advice; patients should discuss options with a qualified clinician.
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Further Research and Clinical Discussions
The immediate next step is for clinicians and patients to use the guideline’s treatment ranking in discussions of symptom relief, contraindications and preferences. The ACP calls for more evidence on nonhormonal treatments and on patients for whom hormone therapy is contraindicated. The editorialists likewise call for research involving groups excluded from existing trials, rather than relying on evidence drawn mainly from healthier populations.
The supplied report does not identify a scheduled update or a specific next publication date. Further studies will be needed to clarify how well the options work across different ages and populations, and to better characterize benefits and harms for people not represented in the trial evidence.
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Key Questions
What does the ACP recommend first for menopausal hot flashes?
The ACP recommends menopausal hormone therapy as first-line medication for vasomotor symptoms. Whether it is suitable depends on the patient’s circumstances and should be discussed with a clinician.
Which hormone regimen does the guideline describe?
It recommends estrogen plus progestogen for women with a uterus and estrogen alone for those without one. Both recommendations are rated strong and based on high-certainty evidence in the guideline.
What nonhormonal medications are listed as alternatives?
Desvenlafaxine or venlafaxine are listed as second-line options when hormone therapy is contraindicated or not tolerated. Third-line choices include escitalopram, paroxetine, gabapentin, fezolinetant and elinzanetant; the evidence ratings vary by drug.
Does the guideline settle treatment for every patient?
No. Many studies excluded people with conditions such as prior breast cancer or cardiovascular disease, and evidence remains limited for several populations. Patients should review their personal health history and treatment choices with a qualified clinician.
Source: rss
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