ACP puts hormone therapy first for menopausal hot flushes, with a clear ladder after it

The edition in brief

Today's top clinical updates close on the American College of Physicians guideline for menopausal vasomotor symptoms. It strongly recommends oestrogen, with a progestogen if the uterus is present, as first-line treatment on high-certainty evidence. Venlafaxine or desvenlafaxine are suggested second, and escitalopram, paroxetine, gabapentin, fezolinetant or elinzanetant third, each conditionally. In a US trial of 3,220 people from underserved groups referred for lung cancer screening, adding financial incentives of up to $600 for biochemically confirmed quitting raised six-month abstinence to 8.8% from 4.3% with ask-advise-refer alone; free medication alone made no difference. A Brazilian adaptive trial of 399 adults with long COVID fatigue found fluvoxamine 100 mg twice daily reduced fatigue scores modestly against placebo at 60 and 90 days, while the metformin arm was inconclusive after a dose change and early stop. A BMJ systematic review of 461 trial reports, protocols and registrations found reporting of large language model trials was incomplete, with model versions, settings and harms often missing. The pearl explains why the route of oestrogen matters for clot risk.