ACP guideline on hot flushes: hormone therapy first, then a defined order of alternatives

The American College of Physicians has issued a guideline for clinicians treating menopausal vasomotor symptoms in outpatients, built on GRADE-rated systematic reviews of benefits, harms, patient preferences and costs.

First line, a strong recommendation on high-certainty evidence, is hormone therapy: oestrogen with a progestogen for women with a uterus, oestrogen alone for those without. Second line, for women who cannot take or tolerate it, is an SNRI, desvenlafaxine or venlafaxine (conditional, moderate certainty). Third line is an SSRI (escitalopram or paroxetine) or gabapentin, both low certainty, or a neurokinin receptor antagonist, elinzanetant or fezolinetant, at moderate certainty. Shared decision-making on harms, comorbidities, cost and access runs through all of it.

For physicians, the shift is a clear default: hormone therapy is not a last resort. Contraindications still apply, such as a history of breast cancer, venous thromboembolism or active liver disease, and the choice between agents rests on individual risk. Whether the neurokinin antagonists are available in India is not known from this guideline.

• Offer hormone therapy as first choice for troublesome vasomotor symptoms when there is no contraindication.
• Add a progestogen whenever the uterus is present.
• If hormone therapy is unsuitable, consider venlafaxine or desvenlafaxine next.
• Paroxetine strongly inhibits CYP2D6; avoid it in women taking tamoxifen.
• Discuss cost and access openly; the third-line options vary widely in both.

Why it matters

Many physicians still reach for non-hormonal options first; this guideline puts hormone therapy back at the front for eligible women.

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