The American College of Physicians has published a guideline in Annals of Internal Medicine (6 October) for clinicians treating menopausal vasomotor symptoms in outpatient care, based on GRADE-rated systematic reviews of benefit, harm, patient values and cost.
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, where hormones are contraindicated or not tolerated: venlafaxine or desvenlafaxine. Third line: escitalopram, paroxetine, gabapentin, or a neurokinin receptor antagonist (fezolinetant or elinzanetant).
Many internists still steer away from hormone therapy by habit. This guideline puts it plainly first for symptomatic women without contraindications, with shared decision-making about risks, comorbidity and cost. In Indian practice, cost and availability will shape the second and third lines; neurokinin antagonists may not be locally available, so check before discussing them.
- Offer oestrogen plus a progestogen (or oestrogen alone after hysterectomy) first, if no contraindication
- Screen for contraindications: breast cancer, prior venous thrombosis, stroke, active liver disease
- Use venlafaxine or desvenlafaxine when hormones are unsuitable
- Avoid paroxetine in women taking tamoxifen, because of the interaction
- Discuss cost and access openly; lower-cost options sit in the second and third lines
Why it matters
It removes the hesitation that leaves many symptomatic women on less effective non-hormonal options.
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