DESCRIPTION: The American College of Physicians (ACP) developed this clinical guideline on pharmacologic treatments for internal medicine physicians and other clinicians caring in outpatient settings for females with menopausal vasomotor symptoms.
METHODS: The ACP Clinical Guidelines Committee developed this guideline based on systematic reviews on effectiveness, comparative effectiveness, harms, public and patient values and preferences, and economic evidence of pharmacologic treatments for females with menopausal vasomotor symptoms using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.
RECOMMENDATION: In females who are seeking treatment of vasomotor symptoms.
First-line treatments.
ACP recommends that clinicians initiate one of the following (strong recommendation): estrogen in combination with progestogen in females with a uterus (high-certainty evidence) or estrogen monotherapy in females without a uterus (high-certainty evidence).
Second-line treatments.
ACP suggests that clinicians use one of the following in females who have contraindications to or do not tolerate first-line treatment (conditional recommendation): serotonin-norepinephrine reuptake inhibitors, either desvenlafaxine or venlafaxine (moderate-certainty evidence).
Third-line treatments.
ACP suggests that clinicians use one of the following in females who have contraindications to or do not tolerate first-line or second-line treatment (conditional recommendation): selective serotonin reuptake inhibitors, either escitalopram or paroxetine (low-certainty evidence); the gabapentinoid gabapentin (low-certainty evidence); or neurokinin receptor antagonists, either elinzanetant or fezolinetant (moderate-certainty evidence).
When selecting a treatment of vasomotor symptoms, clinicians should use an informed decision-making approach and discuss benefits, harms, contraindications, comorbid conditions, values and preferences, financial burden, and access to and availability of treatments.
| Discipline Area | Score |
|---|---|
| Family Medicine (FM)/General Practice (GP) |  |
| General Internal Medicine-Primary Care(US) | |
| Gynecology |  |
| Internal Medicine | |
This guideline addresses a highly relevant topic for primary care where menopausal vasomotor symptoms are frequently encountered. Although the recommendations largely reinforce established practice rather than introducing major new findings, the article provides a valuable and up-to-date summary of the evidence supporting both hormonal and non-hormonal treatment options and may help inform shared decision-making with patients.
This ACP guideline provides a clear and clinically useful evidence-based framework for the pharmacologic management of menopausal vasomotor symptoms, highly relevant for primary care physicians who frequently manage women seeking treatment for hot flashes and night sweats. A major strength is the rigorous GRADE methodology supported by a systematic review and network meta-analysis. The guideline confirms menopausal hormone therapy as the preferred first-line option when not contraindicated and offers a practical ranking of non-hormonal alternatives. Particularly noteworthy is the incorporation of newer neurokinin receptor antagonists alongside established treatments such as SNRIs, SSRIs, and gabapentin. Limitations include the short duration of most included trials and limited evidence regarding long-term safety.
The article is useful for gynecologists and clinicians dealing with menopausal medicine. Vasomotor symptoms (VMS) are the most common symptoms during perimenopause and into the postmenopausal period. Many pharmacologic treatments are currently available. Hormone therapy should be individualized in formulations, dose, route, and duration of therapy, according to the patient's needs and characteristics. Use of the lowest effective treatment dose and generic formulation (if available) for VMS to minimize risks is crucial. When selecting a treatment for VMS, clinicians should use an informed decision-making approach and discuss benefits, harms, contraindications, comorbidities, values, and preferences. Further research in this area is needed.
