- Design
- Clinical practice guideline based on systematic reviews (GRADE)
- Population
- Women seeking treatment for menopausal vasomotor symptoms in outpatient care
- Primary outcome
- Recommended order of pharmacological treatment
- Effect
- Oestrogen first line (strong, high certainty); SNRIs second (conditional, moderate); SSRIs, gabapentin, neurokinin antagonists third
The American College of Physicians has issued a GRADE-based guideline on drug treatment for menopausal vasomotor symptoms in outpatient care.
First line, as a strong recommendation on high-certainty evidence, is oestrogen — combined with a progestogen in women with a uterus, alone in women without. Second line, for those who cannot take or tolerate it, is an SNRI (desvenlafaxine or venlafaxine). Third line is an SSRI (escitalopram or paroxetine), gabapentin, or a neurokinin receptor antagonist (elinzanetant or fezolinetant). Choice should be shared, taking account of contraindications, comorbidity, cost and access.
The useful thing for a generalist is the order. Many women with troublesome flushes are steered away from hormone therapy by outdated fears, or straight to an antidepressant without discussion. In India, oestrogen, venlafaxine, escitalopram and gabapentin are widely available; the neurokinin antagonists' status with CDSCO is not established here.
- Ask women in the menopause transition directly about hot flushes and night sweats.
- Offer hormone therapy first where there is no contraindication, with a progestogen if the uterus is intact.
- Use venlafaxine or desvenlafaxine for women who cannot take hormones.
- Keep SSRIs, gabapentin and neurokinin antagonists for when first and second line fail or are unsuitable.
- Review contraindications such as breast cancer, venous thromboembolism and active liver disease before prescribing oestrogen.
Why it matters
It puts hormone therapy back at the top of the ladder for symptom relief, where avoidance has often left women untreated.
Don't overread it
This guideline covers symptom treatment, not hormone therapy for preventing chronic disease.
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