ACP Recommends Hormonal Therapy as First-Line Care for Menopause

ACP Names Hormonal Therapy the Primary Option for Vasomotor Symptoms

The American College of Physicians (ACP) now recommends hormonal therapy as the primary medical treatment for menopausal vasomotor symptoms (VMS). Published in Annals of Internal Medicine, the clinical guideline advises clinicians to evaluate patients during both perimenopause and postmenopause.

Vasomotor symptoms include hot flashes and night sweats, which stem from declining and fluctuating reproductive hormone levels. According to the guidance, these symptoms affect up to 80% of females and frequently disrupt sleep, daily routines, and overall quality of life.

Hormone Regimens Depend on Uterine Status

The recommendation distinguishes between patients based on surgical history. For individuals with an intact uterus, the guideline recommends combining estrogen with a progestogen. For individuals without a uterus, the panel recommends estrogen monotherapy.

The guideline panel determined that these two hormonal approaches provide the most favorable balance of benefits compared with harms for reducing symptom frequency and severity.

Non-Hormonal Options Form Second-Line and Third-Line Care

For individuals who have medical contraindications to estrogen or cannot tolerate hormonal treatments, the ACP outlines specific alternative pathways. The recommendations rank non-hormonal medications in distinct tiers rather than treating all options identically.

• Second-line care: Serotonin-norepinephrine reuptake inhibitors (SNRIs), specifically desvenlafaxine or venlafaxine.
• Third-line care: Selective serotonin reuptake inhibitors (SSRIs), specifically escitalopram or paroxetine.
• Alternative third-line agents: Gabapentin.
• Neurokinin receptor antagonists (NKRAs): Fezolinetant or elinzanetant as additional third-line options.

Vasomotor Symptoms Coincide with Metabolic and Mood Shifts

The ACP guideline notes that vasomotor symptoms often occur alongside other physiological changes during perimenopause and postmenopause. These related issues include weight fluctuations, sleep disturbance, anxiety, depression, and genitourinary symptoms.

Because hormonal fluctuations drive both temperature instability and disruptions to sleep and body weight, treating vasomotor symptoms directly addresses one of the primary drivers of physical distress during this reproductive transition.

Guidance Emphasizes Shared Decision-Making and Treatment Access

The ACP emphasizes that selecting a treatment requires active collaboration between patients and clinicians. Many females do not raise vasomotor symptoms during standard visits, prompting the ACP to urge physicians to ask about symptom history proactively.

Discussions should review individual contraindications, coexisting medical conditions, personal preferences, and drug availability. Patients can review these therapeutic options with their clinician to determine whether a hormonal or non-hormonal path aligns with their medical history.