The American College of Physicians built this guideline from systematic reviews of benefit, harm, patient preference and cost, graded with GRADE. It covers outpatient women seeking treatment for menopausal vasomotor symptoms.
First line, as a strong recommendation on high-certainty evidence: oestrogen with a progestogen for women with a uterus, or oestrogen alone after hysterectomy. Second line, for women who cannot take or tolerate that: venlafaxine or desvenlafaxine, a conditional recommendation on moderate-certainty evidence. Third line: escitalopram or paroxetine, gabapentin, or the neurokinin receptor antagonists fezolinetant or elinzanetant, all conditional.
This gives generalists an explicit ladder rather than a list, and it places hormone therapy plainly at the top for women who want treatment. The guideline asks clinicians to decide with the patient, weighing contraindications, other conditions, preference, cost and access. The neurokinin antagonists may not be available in India, and their place here is third line.
- Offer oestrogen, with a progestogen if the uterus is present, as first-line treatment for troublesome hot flushes
- Screen for contraindications such as breast cancer, prior clots, stroke or active liver disease before starting
- Use venlafaxine or desvenlafaxine when hormone therapy is unsuitable or not tolerated
- Keep escitalopram, paroxetine, gabapentin or a neurokinin antagonist for third line
- Avoid paroxetine in women taking tamoxifen, because it blocks CYP2D6
Why it matters
It removes the hesitancy many generalists still have about prescribing hormone therapy for symptoms.
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