The American College of Physicians published a guideline in October 2026 on drug treatment for menopausal vasomotor symptoms in outpatients who want treatment. It was built on GRADE-rated systematic reviews of benefit, harm, patient values and cost.
The first-line recommendation is strong, on high-certainty evidence: oestrogen with a progestogen for women with a uterus, or oestrogen alone after hysterectomy. For women who cannot take or tolerate hormones, the conditional second line is an SNRI, desvenlafaxine or venlafaxine. Third line, also conditional, is an SSRI (escitalopram or paroxetine), gabapentin, or a neurokinin receptor antagonist (elinzanetant or fezolinetant), the last on moderate-certainty evidence.
The practical shift for physicians is the ordering: hormone therapy is presented as the default for a woman seeking treatment, not a last resort. Contraindications still need screening — previous breast cancer, venous thromboembolism, stroke and active liver disease among them. Neurokinin antagonists are not widely available in India and cost is high, which the guideline itself names as part of the decision.
- Offer oestrogen with a progestogen to women with a uterus who want treatment for hot flushes.
- Use oestrogen alone after hysterectomy.
- Screen for contraindications to hormone therapy before prescribing.
- Move to venlafaxine or desvenlafaxine when hormones are contraindicated or not tolerated.
- Keep paroxetine away from women on tamoxifen, since it inhibits tamoxifen activation.
Why it matters
Many physicians still treat hormone therapy as a last resort; this guideline places it first.
Don't overread it
The second- and third-line recommendations are conditional, and several rest on low-certainty evidence.
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