New Guidelines Put Hormone Therapy First for Menopausal Hot Flashes

CATEGORY: WOMEN’S HEALTH

Hot flashes and night sweats reach up to 80% of women in menopause, and the American College of Physicians now says hormone therapy, meaning estrogen, usually paired with a second hormone, should be the first treatment offered for them.¹ Ten days later, the American College of Obstetricians and Gynecologists published its own guideline reaching the same conclusion.² If you remember two decades of warnings about hormones, that’s a genuine reversal. It deserves a careful reading.

Estrogen First, Then a Ranked List of Alternatives

ACP’s new guideline puts estrogen plus progestogen first for women who have a uterus, and estrogen alone for women who don’t. The progestogen is there to protect the uterine lining. That first-line call carries the college’s strongest backing: it’s graded as resting on high-certainty evidence. None of that evidence comes from people picking their own treatment. The grades are built on a systematic review of trials in which a random draw, not a patient or a doctor, decided who got the drug and who got a placebo. For women who can’t take estrogen or don’t tolerate it, the guideline suggests the antidepressants desvenlafaxine or venlafaxine next, on moderate-certainty evidence. Behind those sit escitalopram, paroxetine, and gabapentin, each on low-certainty evidence, along with the newer hormone-free drugs elinzanetant and fezolinetant, on moderate-certainty evidence. Those two work nothing like estrogen. They block a brain signal called neurokinin, quieting the faulty thermostat that fires a hot flash in the first place, which is why they’re an option for women whose cancer history takes hormones off the table. ACOG’s guideline, published October 15, lands close by. It strongly recommends systemic hormone therapy for hot flashes in women without contraindications, and names antidepressants and the hormone-free drugs for everyone else.²

Why Hormones Spent Twenty Years in the Doghouse

In 2002, a large federal trial of estrogen plus progestin was stopped early over safety worries, and hormone prescriptions collapsed almost overnight. The years since have complicated that story. Much of the concerning data came from women who started hormones well past menopause. For younger women near their final period, the balance of benefit and harm reads differently, and both new guidelines are built around that distinction. ACOG states it as a strong recommendation: start before age 60, or within 10 years of the final menstrual period.² ACP’s guideline notes the same common practice, along with a typical limit of three to five years of use and a check at 8 to 12 weeks to see whether the treatment is working.¹

Who the First Choice Isn’t For, and What It Doesn’t Cover

Neither document calls hormone therapy right for everyone. The ACP guideline lists current or past breast cancer, a history of blood clots in the veins, and recent clot-driven events such as heart attack or stroke among the conditions that rule estrogen out.¹ That’s what the ranked alternatives are for. Both colleges also ask clinicians to weigh an individual woman’s health conditions, preferences, costs, and access before anything is prescribed. And the scope is narrow on purpose. This advice covers hot flashes and night sweats. It isn’t a judgment about hormones for memory, weight, aging, or anything else menopause brings.

Key Takeaways

• Two major physician groups, ACP and ACOG, now rank estrogen-based hormone therapy as the first-line treatment for menopausal hot flashes and night sweats, a sharp turn from twenty years of caution.
• The guidance applies to symptom relief started before age 60 or within 10 years of the final period, and it says nothing about hormones for other menopause complaints.
• Women with breast cancer, clot history, or recent heart attack or stroke are steered instead to ranked alternatives: desvenlafaxine or venlafaxine first, then escitalopram, paroxetine, gabapentin, or the hormone-free drugs elinzanetant and fezolinetant.
• Up to 80% of women get hot flashes in menopause, so few findings this year touch more people.

References

1. Qaseem A, Mackey K, Yost J, et al. Pharmacologic Treatments for Females With Menopausal Vasomotor Symptoms: A Clinical Guideline From the American College of Physicians. Annals of Internal Medicine. 2026; DOI 10.7326/ANNALS-26-01205. link
2. American College of Obstetricians and Gynecologists. Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms: ACOG Clinical Practice Guideline No. 13. Obstetrics & Gynecology. 2026;148(5):e345–e369. link