Doctors Urge Hormone Therapy as First Choice for Hot Flashes in New Guideline

The American College of Physicians has issued a new clinical guideline that places hormonal therapy at the front of the treatment line for menopausal vasomotor symptoms, the hot flashes and night sweats that disrupt the daily lives of millions of women. Published in Annals of Internal Medicine, the guideline recommends estrogen combined with progestogen for women who still have a uterus, and estrogen alone for women who have had a hysterectomy, as the first-line pharmacologic treatment for perimenopausal and postmenopausal women seeking relief from these symptoms. The recommendation marks a clear statement from the largest medical specialty organization of internal medicine physicians in the United States about where the balance of benefits and harms lies for the most common complaint of the menopausal transition.

Vasomotor symptoms are not a minor inconvenience. According to the guideline, they are the most common symptoms associated with menopause, affecting up to 80 percent of women. They typically begin during perimenopause, the transitional phase before menstruation stops permanently, when declining and fluctuating levels of reproductive hormones destabilize the body’s temperature regulation. The result is the sudden, often intense sensation of heat known as a hot flash, frequently accompanied by sweating, flushing, and a racing heart, as well as night sweats that can drench sleepwear and interrupt rest. The guideline notes that these episodes can persist well into the postmenopausal years, and that their frequency and severity can disrupt daily activities and erode quality of life.

The physiological story behind vasomotor symptoms is rooted in estrogen. As ovarian function wanes, estrogen levels fall and fluctuate unpredictably, and this hormonal instability is thought to narrow the thermoneutral zone in the brain’s temperature-regulating machinery, making small shifts in core body temperature trigger full heat-dissipation responses. The consequences ripple outward: the guideline highlights that the same hormonal changes can contribute to sleep disturbance, weight fluctuations, anxiety, depression, and genitourinary symptoms, creating a cluster of complaints that often arrive together and compound one another. A woman whose nights are repeatedly broken by hot flashes may also face worsening mood and concentration problems the next day, which is why effective treatment of vasomotor symptoms can have benefits well beyond the episodes themselves.

In developing the recommendation, ACP drew on a related systematic review and meta-analysis, also published in Annals of Internal Medicine, that evaluated pharmacologic treatments for menopausal vasomotor symptoms. The college concluded that estrogen in combination with progestogen, and estrogen monotherapy for women without a uterus, had the most favorable profile of benefits compared with harms among the available options. The addition of progestogen for women with an intact uterus is a long-standing safety principle in hormone therapy, because unopposed estrogen can stimulate the uterine lining and increase the risk of endometrial problems; pairing it with progestogen protects the uterus while preserving estrogen’s effectiveness against hot flashes.

The guideline does not treat hormone therapy as the only option, and it lays out a clear sequence for women who cannot or do not wish to take estrogen. For patients who have contraindications to estrogen therapy or who do not tolerate it, ACP suggests serotonin-norepinephrine reuptake inhibitors, or SNRIs, as second-line treatment, specifically naming desvenlafaxine and venlafaxine. These medications, better known as antidepressants, have demonstrated the ability to reduce the frequency and severity of hot flashes through their effects on neurotransmitter signaling pathways that participate in temperature regulation.

If SNRIs are unsuitable or ineffective, the guideline moves to a third tier of options: a selective serotonin reuptake inhibitor, or SSRI, such as escitalopram or paroxetine; gabapentin, a medication originally developed for seizures and nerve pain that also dampens hot flashes; or a neurokinin receptor antagonist, abbreviated NKra, with elinzanetant and fezolinetant named as the agents in this class. The neurokinin receptor antagonists represent a distinctly newer approach, targeting the neuropeptide signaling pathway in the brain’s thermoregulatory circuitry that becomes overactive as estrogen declines. Their inclusion among third-line options reflects the recent arrival of these drugs as nonhormonal treatments designed specifically for vasomotor symptoms.

Beyond the specific drug rankings, ACP places strong emphasis on how treatment decisions should be made. The college advises clinicians to use an informed decision-making approach, discussing with each patient the benefits and harms of the available options, any contraindications, coexisting medical conditions, and the patient’s own values and preferences. Notably, the guideline also directs physicians to consider the financial burden of treatment and patients’ access to and availability of the various therapies, an acknowledgment that the best medication on paper is of little use if a patient cannot afford it or obtain it. This framing treats the choice of therapy as a collaborative process rather than a one-size-fits-all prescription.

ACP also draws attention to a quieter problem: many women never raise the topic at all. The college encourages physicians to ask their patients directly about their experience with menopausal vasomotor symptoms, because many women may not initiate these discussions on their own. Whether due to embarrassment, the cultural normalization of suffering through menopause, or the belief that nothing effective is available, women’s silence about hot flashes and night sweats can leave treatable symptoms unaddressed for years. By prompting clinicians to open the conversation, the guideline aims to close the gap between the large share of women affected and the smaller share who receive care.

The timing of the guideline reflects a broader shift in how the medical community views menopausal hormone therapy. After years in which safety concerns led many clinicians and patients to avoid estrogen-based treatment, accumulating evidence has allowed organizations to identify the women for whom hormone therapy offers the clearest net benefit, particularly those seeking relief from bothersome vasomotor symptoms. By naming estrogen therapy as first-line, ACP is signaling to internists and primary care physicians, who manage the majority of menopausal care, that withholding hormone therapy from appropriate candidates is no longer the default stance. The guideline’s tiered structure gives clinicians a practical pathway for the many patients who have contraindications to estrogen, such as those with a history of certain hormone-sensitive cancers or cardiovascular events, without leaving them without options.

For the roughly eight in ten women who will experience hot flashes or night sweats as they pass through the menopausal transition, the practical message of the new guideline is that effective treatments exist and that the choice among them can be tailored to individual health circumstances and preferences. Women with a uterus considering first-line therapy will receive estrogen plus progestogen; women without a uterus can receive estrogen alone; those who cannot take estrogen have a defined ladder of nonhormonal alternatives ranging from SNRIs to SSRIs, gabapentin, and neurokinin receptor antagonists. Equally important, the guideline reframes the clinical encounter itself, urging physicians to ask about symptoms that patients may not volunteer and to weigh cost and access alongside efficacy and safety. The full guideline and its accompanying evidence review are published in Annals of Internal Medicine, and together they provide the most current roadmap from the American College of Physicians for managing one of the most common and disruptive experiences in women’s health.

Subject of Research: Clinical guideline recommendations for pharmacologic treatment of menopausal vasomotor symptoms

Article Title: ACP recommends hormonal therapy as a first-line treatment for menopausal vasomotor symptoms

Article References: ACP recommends hormonal therapy as a first-line treatment for menopausal vasomotor symptoms. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: menopause, vasomotor symptoms, hot flashes, hormone therapy, estrogen, progestogen, SNRI, SSRI, gabapentin, neurokinin receptor antagonist, clinical guideline, Annals of Internal Medicine