TL;DR
Get workout gear delivered free with Prime
- Fast, free delivery on millions of items
- Prime Video, Amazon Music and more included
- Member-only deals all year
A new American College of Physicians guideline recommends menopausal hormone therapy as first-line pharmacologic treatment for hot flashes and night sweats. It sets out different hormone regimens based on whether a patient has a uterus and lists several nonhormonal medicines as alternatives, while noting that evidence is limited for some groups often excluded from trials.
The American College of Physicians (ACP) recommends menopausal hormone therapy as the first-line medication treatment for women with hot flashes and night sweats, called vasomotor symptoms. The new clinical guideline specifies estrogen plus progestogen for patients with a uterus and estrogen alone for those without one, while placing several nonhormonal medicines in later treatment tiers.
The ACP’s recommendations, published in the Annals of Internal Medicine, classify both hormone regimens as strong recommendations based on high-certainty evidence. For patients who cannot use first-line therapy or do not tolerate it, the guideline identifies the serotonin-norepinephrine reuptake inhibitors (SNRIs) desvenlafaxine and venlafaxine as second-line options, supported by moderate-certainty evidence.
Third-line options include the selective serotonin reuptake inhibitors escitalopram and paroxetine, as well as gabapentin; those recommendations are based on low-certainty evidence. The neurokinin receptor antagonists fezolinetant and elinzanetant are also listed as third-line treatments, with moderate-certainty evidence. These categories describe the guideline’s recommended sequence for pharmacologic treatment, not a requirement that every patient follow the same path.
The recommendations draw on a systematic review and meta-analysis by Susan Diem, MD, MPH, of the VA Health Care System in Minneapolis, and colleagues. The researchers included 90 trials reported in 102 publications, with treatment lasting at least eight weeks and a median duration of 12 weeks. The ACP also recommends clinicians proactively discuss menopause and provide education about treatment choices.
How the Guideline Ranks Treatment Options
The guidance gives clinicians and patients a clearer medication sequence for symptoms that can interfere with daily life. Hot flashes and night sweats affect most women during the menopause transition, according to the report, and the review found the greatest reductions in symptom frequency with estrogen therapy, oxybutynin, and neurokinin receptor antagonists. The guideline’s first-line position for hormone therapy reflects its evidence assessment of symptom treatment; it does not mean that hormones are appropriate for every patient.
The recommendation also makes treatment choice and discussion of individual circumstances central to care. A patient’s medical history, whether she has a uterus, treatment tolerance, and preferences may affect which option is suitable. The ACP’s ordering can inform those discussions, but the guideline does not remove the need to weigh potential benefits and harms for each person.
The change comes after years in which concerns about hormone therapy’s risks contributed to reduced use. The report says evidence and regulatory messaging have evolved, but it does not claim that all risks have disappeared. The guidance may prompt renewed conversations between patients and clinicians about treatment rather than leaving symptoms unaddressed because of broad assumptions about hormone therapy.
As an affiliate, we earn on qualifying purchases.
Evidence Behind the New Recommendations
Menopausal hormone therapy has long been recognized as effective for vasomotor symptoms. Use fell after the Women’s Health Initiative findings raised concerns about cardiovascular disease and breast cancer and led to boxed warnings. The source report says the U.S. Food and Drug Administration recently removed warnings about cardiovascular disease and breast cancer, while reanalyses of the WHI data have suggested more favorable outcomes for women closer to menopause.
In 2022, the Menopause Society said the benefit-risk balance is favorable for treating vasomotor symptoms in women younger than 60 who are within 10 years of menopause onset and have no contraindications. The ACP guideline now places hormone therapy first in its treatment recommendations, while distinguishing regimens according to whether a patient has a uterus.
The evidence review has limits. Trial participants were generally healthy, postmenopausal white women ages 49 to 57, and only eight studies involved perimenopausal women. Many trials excluded people with a history of breast cancer, endometrial disease, cardiovascular disease, stroke, or venous thromboembolism. Compounded estrogens were not evaluated, and the review could not establish how results differ by age, race, ethnicity, or menopausal status.
“The guideline recommends menopausal hormone therapy as first-line treatment for women with menopausal vasomotor symptoms.”
— Amir Qaseem, MD, PhD, MHA, and fellow ACP guideline authors
As an affiliate, we earn on qualifying purchases.
Who the Trial Evidence Leaves Out
The review offers limited evidence for patients with conditions that commonly led to trial exclusion, including a history of breast cancer, cardiovascular disease, stroke, or blood clots. The editorialists said those groups need research specific to their clinical circumstances rather than assumptions based on healthier trial participants. The guideline’s first-line recommendation should not be read as resolving whether hormone therapy is appropriate for an individual with a contraindication.
Researchers also could not determine reliably how treatment results vary by age, race, ethnicity, or menopausal status. Only eight included studies focused on perimenopausal women, and compounded estrogen products were not studied. The available evidence therefore does not answer every question about which treatments work best for every group or how results compare across all formulations and patient circumstances.
The supplied report does not detail the full text of the ACP’s safety guidance or provide individual prescribing advice. It also does not establish that one route of hormone administration is superior: the review found efficacy did not vary by route. Treatment decisions still depend on a patient’s history, risks, and preferences.
As an affiliate, we earn on qualifying purchases.
Research and Clinical Discussions Ahead
The ACP’s guideline calls for more evidence on treatments for patients who cannot take hormone therapy and on newer nonhormonal medicines. Further studies are also needed to clarify benefits and harms in populations underrepresented or excluded in existing trials, and to assess how findings vary by demographic group and menopausal stage.
For now, clinicians can use the treatment tiers to structure discussions about vasomotor symptoms, including whether hormone therapy is suitable or whether a nonhormonal option is a better fit. The guideline also encourages clinicians to raise menopause proactively and provide education. The source report does not identify a scheduled follow-up guideline or a specific date for new evidence; the next developments will depend on additional research and how the recommendations are applied in care.
serotonin-norepinephrine reuptake inhibitors for menopause
As an affiliate, we earn on qualifying purchases.
As an affiliate, we earn on qualifying purchases.
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 calls for estrogen plus progestogen for patients with a uterus and estrogen alone for those without one.
Which nonhormonal medicines are listed as alternatives?
Desvenlafaxine or venlafaxine are second-line options for patients who cannot use or do not tolerate first-line treatment. Third-line options include escitalopram, paroxetine, gabapentin, and the neurokinin receptor antagonists fezolinetant and elinzanetant.
Does the guideline mean hormone therapy is right for everyone?
No. The recommendation does not establish that hormone therapy is suitable for every patient. The evidence review excluded many people with relevant medical histories, and treatment choices still depend on individual circumstances and clinical judgment.
How strong is the evidence behind the first-line recommendation?
The ACP classifies the recommendations for estrogen plus progestogen and estrogen alone as strong recommendations based on high-certainty evidence. Evidence certainty differs for the listed nonhormonal options.
What evidence gaps did the review identify?
The review included few studies of perimenopausal women and could not determine reliably how results differ by age, race, ethnicity, or menopausal status. More research is needed for people with conditions that excluded them from many trials and for newer nonhormonal treatments.
Source: rss
Fall Picks
fall essentials
As an affiliate, we earn on qualifying purchases.
