The American College of Physicians has issued a new clinical guideline recommending menopausal hormone therapy as the first-line treatment for vasomotor symptoms such as hot flashes and night sweats. Based on high-certainty evidence, the guideline strongly recommends estrogen combined with progestogen for women with a uterus and estrogen monotherapy for those without a uterus.
For women who cannot take or do not tolerate hormone therapy, the guideline lists the SNRIs desvenlafaxine and venlafaxine as second-line options. Third-line treatments include the SSRIs escitalopram and paroxetine, gabapentin, and the neurokinin receptor antagonists fezolinetant and elinzanetant. The recommendations draw on a systematic review and meta-analysis of 90 randomized trials, which found that hormone therapy's efficacy did not vary by route of administration and that higher doses produced more pronounced effects.
The guidance arrives after decades of declining hormone therapy use, which the guideline's accompanying editorial attributes to lingering misconceptions about risks and undertreatment of menopausal symptoms. Recent re-analyses of Women's Health Initiative data and the FDA's removal of boxed warnings on cardiovascular disease and breast cancer have shifted the risk-benefit picture, especially for women closer to menopause. The editorialists also note that more evidence is needed for populations excluded from the current trials, including women with contraindications to hormone therapy and those using newer nonhormonal agents.