New Guideline Recommends Hormone Therapy First For Menopausal Symptoms

TL;DR

Prime Big Deal Days · Oct 6–7Offer from Amazon

Get health and wellness essentials delivered free — and shop member deals

• Fast, free delivery on millions of items
• Access to Prime Big Deal Days deals on October 6–7
• Prime Video, Amazon Music and more included

Start your free Prime trial →Free trial for eligible customers · Cancel anytime

As an affiliate, we earn on qualifying purchases.Hide

The American College of Physicians recommends menopausal hormone therapy as the first treatment for menopausal hot flashes and night sweats, with estrogen plus progestogen for women with a uterus and estrogen alone for those without one. The guideline places selected SNRIs second and several other medicines third, but notes that evidence is limited for people excluded from many trials.

The American College of Physicians (ACP) recommends menopausal hormone therapy as the first-line medication treatment for hot flashes and night sweats, known as vasomotor symptoms. The guideline specifies estrogen combined with progestogen for women with a uterus and estrogen alone for women without one, while ranking several nonhormonal medicines as alternatives or later options.

The guideline authors, led by Amir Qaseem, MD, PhD, MHA, describe both hormone therapy recommendations as strong and based on high-certainty evidence. For people who cannot use hormone therapy or do not tolerate it, the guideline lists the serotonin-norepinephrine reuptake inhibitors (SNRIs) desvenlafaxine and venlafaxine as second-line treatments, based on moderate-certainty evidence.

Third-line options include the selective serotonin reuptake inhibitors escitalopram and paroxetine and gabapentin, supported by low-certainty evidence, as well as the neurokinin receptor antagonists fezolinetant and elinzanetant, supported by moderate-certainty evidence. These rankings concern pharmacologic treatment of vasomotor symptoms; the guideline does not say that every patient should receive hormone therapy or that nonhormonal medicines are unsuitable.

The recommendations draw on a systematic review and meta-analysis by Susan Diem, MD, MPH, and colleagues, also published in the Annals of Internal Medicine. The review included 90 trials reported in 102 publications. It found the largest reductions in symptom frequency with estrogens, with or without progestogens, oxybutynin, and NK-receptor antagonists. The guideline authors also called for more research on oxybutynin because its evidence came from a small body of studies.

How the Treatment Ranking Changes Choices

The ACP guidance gives clinicians and patients a clearer evidence-based order of medication options for symptoms that can disrupt sleep and daily life. Hormone therapy has long been recognized as effective for vasomotor symptoms, but concerns about potential harms have shaped its use. By placing it first while naming specific alternatives, the guideline offers a framework for discussing treatment rather than treating all available medicines as interchangeable.

The recommendation is not a personal prescription. The choice of treatment depends on an individual’s health circumstances, including whether hormone therapy is appropriate, and the guideline’s evidence has limits. Its authors say more research is needed for people who have contraindications to hormone therapy and for newer nonhormonal treatments. Patients should discuss treatment choices and risks with a qualified clinician.

Evidence Behind the New Guidance

Concern about findings from the Women’s Health Initiative (WHI) contributed to boxed warnings and a decline in hormone therapy use over the past two decades. The source report says the U.S. Food and Drug Administration recently removed warnings related to cardiovascular disease and breast cancer, and that reanalyses of WHI data have been completed. The ACP guideline separately assesses trial evidence for medicines used to treat vasomotor symptoms.

The review covered trials lasting at least eight weeks, with a median duration of 12 weeks. Most participants were healthy, postmenopausal white women aged 49 to 57 who experienced several symptoms a day; only eight studies focused on perimenopausal women. Many trials excluded people with a history of breast or endometrial cancer, cardiovascular disease, stroke, or venous thromboembolism, limiting how readily results can be applied to those groups.

A 2022 Menopause Society position statement had said the risk-benefit balance of hormone therapy was favorable for treating symptoms in women under 60 who were within 10 years of menopause onset and had no contraindications. In an editorial accompanying the new publications, Stephanie Faubion and Regina Castaneda argued that concerns, misconceptions, and barriers to care have contributed to undertreatment. They welcomed the guideline’s call for clinicians to raise menopause and treatment proactively.

““Our results are consistent with previous systematic reviews reporting that estrogens, with and without progestogens, are highly effective for VMS.””

— Susan Diem and colleagues

Who the Trial Evidence Missed

The evidence base does not fully represent people with medical conditions that often led to exclusion from trials, including a history of breast cancer, cardiovascular disease, stroke, or blood clots. The source report says there was insufficient evidence to establish how results vary by age, race, ethnicity, or menopausal status, and only eight included studies examined perimenopausal participants.

It is also unclear from the reported evidence how all newer nonhormonal medicines compare across different patient groups and clinical circumstances. Compounded estrogens were not evaluated. The guideline authors and editorialists call for research focused on populations that need evidence specific to their circumstances rather than conclusions drawn from healthier trial participants.

Research and Clinical Discussions Ahead

The immediate next step is for clinicians and patients to use the recommendations as a framework for discussing symptom treatment, suitability, and alternatives. The ACP guideline encourages clinicians to initiate conversations about menopause and provide education, according to the accompanying editorial.

Further studies are needed on people who were commonly excluded from trials, on differences across demographic and menopausal groups, and on newer nonhormonal agents. Until that evidence is available, the guideline’s treatment ranking should be understood alongside its stated evidence limitations and an individual patient’s clinical circumstances.

Key Questions

What does the ACP recommend first for menopausal hot flashes and night sweats?

The ACP recommends menopausal hormone therapy as first-line pharmacologic treatment for vasomotor symptoms. The guideline specifies estrogen plus progestogen for women with a uterus and estrogen alone for women without one.

Which nonhormonal medicines does the guideline list?

It lists desvenlafaxine or venlafaxine as second-line options for people who cannot use or do not tolerate first-line therapy. Third-line options include escitalopram, paroxetine, gabapentin, fezolinetant, and elinzanetant, with different levels of evidence supporting them.

Does the guideline mean hormone therapy is right for everyone?

No. The recommendation establishes a treatment ranking, not a universal prescription. Whether hormone therapy is appropriate depends on a person’s health circumstances; patients should discuss choices with a qualified clinician.

What are the main limitations of the evidence?

Many trials enrolled healthy, postmenopausal white women and excluded people with certain health histories. The review had only eight studies of perimenopausal women and could not determine how results vary by age, race, ethnicity, or menopausal status.

Source: rss