ACP Guideline Recommends First-Line Hormone Therapy For Hot Flashes

The American College of Physicians has issued a strong recommendation for estrogen combined with progestogen as first-line therapy for women with a uterus experiencing vasomotor symptoms. This new clinical guideline is based on high-certainty evidence and marks a decisive shift in managing the most common symptoms of menopause.

Amir Qaseem, a guideline author, and colleagues based the recommendations on a systematic review and meta-analysis led by Susan Diem of the VA Health Care System in Minneapolis. The review included 90 trials from 102 publications, with studies spanning from 1980 to 2024 and primarily conducted in North America and Europe. The randomized controlled trials had a median treatment duration of 12 weeks and enrolled generally healthy, postmenopausal women, most often white and between the ages of 49 and 57, who experienced several episodes of symptoms daily.

Understanding vasomotor symptoms and their impact

Hot flashes and night sweats-collectively known as vasomotor symptoms-are the most prevalent menopause-related symptoms, affecting up to 80% of women. These symptoms can begin in perimenopause due to declining and fluctuating reproductive hormone levels and often persist into postmenopausal years. Their frequency and severity can greatly disrupt daily life activities, sleep, and overall quality of life. Other symptoms linked to declining hormones include sleep disturbance, weight fluctuations, anxiety, depression, and genitourinary symptoms.

Treatment options beyond first-line hormone therapy

For women who cannot or choose not to use hormone therapy, the guideline outlines clear alternatives. The recommendations are structured in tiers based on the certainty of evidence supporting each option.

The ACP suggests an SNRI as a second-line treatment for those with contraindications or intolerance to estrogen. For third-line options, clinicians can consider an SSRI, gabapentin, or an NK receptor antagonist. The authors note that more evidence is needed for populations contraindicated to hormone therapy and on newer non-hormonal agents.

Context: evolving understanding of hormone therapy risks and benefits

Although hormone therapy has long been known to be effective, its use declined sharply over the past two decades. This was due to findings from the Women's Health Initiative study, which raised concerns about increased risks of cardiovascular disease and breast cancer, leading to boxed warnings. However, subsequent re-analyses of that data suggest better outcomes for women who start hormone therapy closer to menopause onset. For women under 60 who are within 10 years of menopause and have no contraindications, the current risk-benefit ratio is now considered favorable for treating vasomotor symptoms. This updated understanding supports the guideline's strong recommendation.

Guideline emphasizes proactive patient conversations and shared decision-making

The ACP urges clinicians to initiate discussions about menopause, as many women may not bring up their symptoms. The college emphasizes using an informed decision-making process that weighs benefits, harms, personal values, financial burden, and access to treatments. In an accompanying editorial in the Annals of Internal Medicine, Stephanie Faubion and Regina Castaneda of the Mayo Clinic noted that the decline in hormone therapy use reflects persistent patient and clinician concerns and misconceptions. "It is therefore noteworthy that the guideline encourages clinicians to proactively initiate conversations about menopause and provide education," they wrote. They added that "explicitly incorporating these actions into the guideline reinforces their importance as part of comprehensive menopause care." The editorial states that the historical concerns, along with barriers to accessing care, have contributed to the undertreatment of disruptive vasomotor symptoms. Clinicians are now encouraged to make these proactive conversations a standard part of care.