The Internists Say: Estrogen First
America’s largest physician specialty group now recommends estrogen as the first treatment for hot flashes and night sweats, not a last resort. The American College of Physicians released new clinical guidance placing hormonal therapy at the front of the line for menopausal vasomotor symptoms, in both perimenopause and after menopause.
Women who still have a uterus would take estrogen with a progestogen. The guidance ranks other options only for women who cannot take or tolerate estrogen: first venlafaxine or desvenlafaxine, then SSRIs or gabapentin, then the newer hormone-free drugs fezolinetant and elinzanetant.
No spam. Unsubscribe anytime.
The group also flagged a persistent problem: many women never bring up their symptoms at all. The ACP urged doctors to ask directly rather than waiting for patients to raise it.
The shift matters because many physicians stayed cautious about prescribing estrogen first after a widely-publicized reading of the 2002 Women’s Health Initiative study raised concerns about breast cancer and heart disease risk. Subsequent research clarified that the risks depend heavily on age and timing of treatment. Major medical societies have been updating guidance ever since, but practice has not always followed.
The ACP represents internists, who see a large share of women in midlife. Consistent first-line guidance across both primary care and specialty medicine could mean women start treatment faster, with fewer detours through options that work less well for most.