Menopausal hot flushes: oestrogen remains the most effective and best-value drug option

Design

Systematic review and meta-analysis of randomised trials

Population

90 trials in peri- and postmenopausal women with vasomotor symptoms

Primary outcome

Hot flush frequency and severity, quality of life, sleep, harms

Effect

Oestrogen reduced frequency and severity; non-hormonal drugs reduced frequency only

A systematic review for the American College of Physicians, published in Annals of Internal Medicine on 6 October 2026, pooled 90 randomised trials of at least eight weeks in women with vasomotor symptoms. Certainty of evidence was low to moderate for most comparisons.

Against placebo, oestrogen with or without a progestogen, conjugated oestrogen with bazedoxifene, and oxybutynin reduced both the frequency and severity of hot flushes. Neurokinin receptor antagonists, SNRIs, SSRIs, gabapentin and progestogens reduced frequency but not severity. Oestrogen efficacy varied with dose but not route. Sleep improved with gabapentin, neurokinin antagonists, oxybutynin, SNRIs and SSRIs. Oestrogen was judged of high economic value; fezolinetant of low value.

For a general physician, this sets out the order of options clearly. Most trials were short and not designed to capture long-term harms, so the individual risk discussion around hormone therapy still applies.

• Offer hormone therapy as the most effective option to women without contraindications who are troubled by hot flushes.
• Add a progestogen for women with a uterus who take oestrogen.
• For women who cannot or will not take hormones, SSRIs, SNRIs, gabapentin or oxybutynin reduce frequency; choose by comorbidity and side effects.
• Consider gabapentin or an SNRI where poor sleep is the main complaint.
• Weigh the high cost of neurokinin receptor antagonists against modest added benefit.

Why it matters

Many women are steered to non-hormonal options first, though the evidence puts oestrogen ahead on effect and value.

Don't overread it

Mostly short trials not designed for long-term harms; it does not settle breast or cardiovascular risk questions.

The statistics, in plain English

Certainty of evidence was mostly low to moderate, meaning further trials could change the size of effects. 'Reduced frequency but not severity' means fewer hot flushes but not milder ones.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.