The American College of Physicians has issued a clinical guideline for internists and other outpatient clinicians on drug treatment of menopausal vasomotor symptoms, built on GRADE-graded systematic reviews of benefits, harms, patient preferences and cost.
First line, as a strong recommendation on high-certainty evidence: oestrogen with a progestogen in women with a uterus, or oestrogen alone without one. Second line, for those with contraindications or intolerance: venlafaxine or desvenlafaxine (conditional, moderate certainty). Third line: escitalopram or paroxetine, gabapentin (both low certainty), or a neurokinin receptor antagonist, elinzanetant or fezolinetant (moderate certainty).
For many physicians the change is one of stance. Hormone therapy has often been withheld by reflex since the early-2000s safety scares; this guideline places it first for women seeking treatment, with the choice individualised for contraindications, comorbidity, preferences, cost and access. Neurokinin antagonists are newer and may not be available or affordable everywhere, including in India.
- Offer hormone therapy first to women seeking treatment for hot flushes, after checking contraindications.
- Add a progestogen to oestrogen in any woman with a uterus.
- Consider venlafaxine or desvenlafaxine when hormone therapy is contraindicated or not tolerated.
- Keep SSRIs, gabapentin and neurokinin antagonists for third line, as their evidence is weaker or newer.
- Discuss benefits, harms, cost and availability, and record the woman's preference.
Why it matters
It challenges the reflex to avoid hormone therapy and gives a clear order for the alternatives.
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