Key Takeaways
- First-line treatment: The American College of Physicians (ACP) strongly recommends estrogen plus a progestogen (if you have a uterus) or estrogen alone (if you don’t) as first-line treatment for menopausal hot flashes and night sweats.
- Ranked alternatives: If hormone therapy isn’t an option, ACP suggests SNRIs as second-line, then SSRIs, gabapentin or neurokinin receptor antagonists as third-line options.
- Who it covers: The guideline applies to perimenopausal and postmenopausal women seeking drug treatment for vasomotor symptoms.
- Still individualized: Questions remain about how long to continue hormone therapy, so treatment should be revisited regularly with your clinician.
What Happened
On October 5, 2026, the American College of Physicians, the largest medical specialty organization in the U.S., released a new clinical guideline in the Annals of Internal Medicine titled “Pharmacologic Treatments for Females with Menopausal Vasomotor Symptoms.” It recommends hormone therapy as the first-line drug treatment for hot flashes and night sweats in perimenopausal and postmenopausal women who want treatment.
The ACP built the guideline using systematic reviews and the GRADE framework. Its recommendations are:
- First-line: Estrogen plus a progestogen for women with a uterus, or estrogen alone for women without one. This is a strong recommendation backed by high-certainty evidence.
- Second-line: The SNRIs desvenlafaxine or venlafaxine for women who can’t use or don’t tolerate hormone therapy (a conditional recommendation with moderate-certainty evidence).
- Third-line: The SSRIs escitalopram or paroxetine, gabapentin, or a neurokinin receptor antagonist (elinzanetant or fezolinetant) for women who can’t use or don’t tolerate the earlier options.
Why It Matters
Hot flashes and night sweats are the most recognized menopause symptoms, yet many women don’t bring them up and many clinicians have been unsure which treatment to offer first. ACP encourages physicians to ask patients about vasomotor symptoms directly, since patients may not raise them on their own. The guideline also builds on earlier guidance from The Menopause Society and adds newer evidence on neurokinin receptor antagonists.
It joins a wave of 2026 updates. ACOG’s own guideline, released ten days later, reached similar core conclusions about hot flashes (see our coverage of the ACOG guideline).
What This Means for Women in Perimenopause and Menopause
If hot flashes or night sweats are disrupting your life, you can ask your clinician about hormone therapy as a starting point rather than a last resort. If you can’t or don’t want to use hormones, ACP’s ranked list gives you and your clinician a roadmap for what to try next. The guideline notes that hormone changes starting in perimenopause can also bring sleep disturbance, weight changes, anxiety, depression and genitourinary symptoms, so it’s worth mentioning all of your symptoms. Our symptom trackers can help you keep a record, and our HRT 101 guide explains forms and doses.
Access and Availability
All of the treatments in the guideline are already available. Hormone therapy comes in several forms, including patches, and the FDA has said it is working to support supply (see our story on the FDA estradiol patch announcement). To find a clinician who focuses on midlife care, try our menopause specialist directory, and use the HRT price checker to compare costs and our FSA-eligible menopause products page to see what may qualify for FSA spending.
Benefits and Risks
The strongest evidence in the guideline supports hormone therapy for relieving hot flashes. As with any treatment, the right choice depends on your age, health history and preferences. Women with contraindications to estrogen need a different approach, which is why ACP lays out alternatives. Some questions are still open. The optimal duration of hormone therapy is unknown, though 3 to 5 years is common in practice, and clinicians are advised to reassess benefits and risks regularly. An accompanying editorial also noted that women who reach menopause later may be over 60 while still within 10 years of their final period, so decisions about timing need to be individualized.
Next Steps: What to Watch For
Expect more guidance and research on how long to continue hormone therapy and how newer nonhormonal drugs compare. Other societies are addressing the topic as well, including the VA and Defense Department, whose joint menopause guideline also covers hormonal and nonhormonal options. If you’re curious about testosterone, read our news story on the FDA’s testosterone discussion and our testosterone guide.
What This Means for Your Midlife Health
Major medical organizations are increasingly aligned: menopause symptoms deserve treatment, and hormone therapy has a clear place for many women. That’s a notable shift from the caution many women heard for years. The best next step is a conversation with a clinician about your symptoms and goals. We’ll keep following these guidelines so you’ll know when recommendations change.
Frequently Asked Questions
What does the ACP menopause guideline recommend?
It strongly recommends estrogen plus a progestogen (for women with a uterus) or estrogen alone (for women without a uterus) as first-line treatment for hot flashes and night sweats in perimenopausal and postmenopausal women.
What if I can’t take hormone therapy?
ACP suggests SNRIs (desvenlafaxine or venlafaxine) as second-line treatment. If those aren’t suitable, third-line options include SSRIs (escitalopram or paroxetine), gabapentin and neurokinin receptor antagonists (elinzanetant or fezolinetant).
How long should I stay on hormone therapy?
The optimal duration is unknown. Three to five years is common in practice, and clinicians are advised to regularly reevaluate the benefits and risks to decide when to stop.
How is the ACP guideline different from ACOG’s?
The ACP guideline focuses on drug treatments for hot flashes and night sweats. ACOG’s guideline is broader and also covers sleep and mood symptoms and non-drug approaches, though the two align on the core message about hot flashes.
This article is for informational purposes only and is not medical advice. Please consult a qualified healthcare provider about your symptoms and treatment options.
References
- ACP. (2026). ACP recommends hormonal therapy as a first-line treatment for menopausal vasomotor symptoms.
- Epocrates. (2026). ACP recommends hormone therapy first for menopausal hot flashes (summary of Qaseem et al., Annals of Internal Medicine).
- U.S. Pharmacist. (2026). ACP recommends hormone therapy first for menopausal VMS.