- Design
- Clinical practice guideline based on GRADE systematic reviews
- Population
- Women seeking treatment for menopausal vasomotor symptoms in outpatient care
- Primary outcome
- Recommendations for first-, second- and third-line drug treatment
- Effect
- Oestrogen first line (strong, high certainty); SNRIs second (conditional, moderate certainty)
The American College of Physicians has issued a guideline on drug treatment for menopausal vasomotor symptoms in outpatients. It rests on a companion systematic review of 90 randomised trials, plus reviews of harms, patient values and cost.
The guideline strongly recommends starting oestrogen combined with a progestogen in women with a uterus, or oestrogen alone after hysterectomy, on high-certainty evidence. For women who cannot take or do not tolerate it, it suggests desvenlafaxine or venlafaxine. Third line, it suggests escitalopram, paroxetine, gabapentin, or a neurokinin receptor antagonist such as fezolinetant or elinzanetant.
The review found oestrogens reduced both frequency and severity of hot flushes and improved quality of life, and judged them of high economic value. Non-hormonal drugs reduced frequency but not clearly severity, and fezolinetant was judged low value on cost. Most trials were short, so long-term harms were not well captured.
For most clinicians this means hormone therapy should be discussed first rather than avoided by reflex, with a clear ladder for women who cannot take it. The availability of neurokinin antagonists in India is uncertain.
- Offer oestrogen, with a progestogen if the uterus is present, as first-line treatment when there is no contraindication
- For women who cannot take hormones, consider venlafaxine or desvenlafaxine next
- Escitalopram, paroxetine or gabapentin are third-line options; avoid paroxetine with tamoxifen
- Discuss cost and access openly: the newer neurokinin antagonists cost far more
- Use shared decision-making covering benefits, harms, comorbidities and preferences
Why it matters
It pushes back on the reflex to avoid hormone therapy and gives non-hormonal options a clear order.
Don't overread it
Most trials were short; the guideline does not resolve long-term risks of any option.
The statistics, in plain English
A strong recommendation on high-certainty evidence means the committee was confident benefits outweigh harms for most women. Conditional recommendations on low- or moderate-certainty evidence mean the choice depends more on the individual.
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