Hot Flashes Treatment: New Guideline Puts Hormone Therapy First
Updated: 4 days ago
Written and medically reviewed by Dr. Baraa Alnahhal, MD · Last reviewed: October 2026
If you are looking for the most effective hot flashes treatment, a new clinical guideline from the American College of Physicians (ACP), published October 6, 2026, gives a clear answer: estrogen-based hormone therapy is now the recommended first choice for most women with bothersome hot flashes and night sweats. Non-hormonal medicines are recommended as second- and third-line options for women who cannot or do not want to take estrogen [1] [3].
Quick Answer: What is the first-choice treatment for hot flashes?
Hot flash treatment guidance from the American College of Physicians recommends estrogen-based hormone therapy as the first choice for most women with bothersome hot flashes and night sweats, plus a progestogen if the uterus is present. Non-hormonal medicines such as venlafaxine, SSRIs, gabapentin or fezolinetant are later options. Some medical histories, such as breast cancer, may rule out hormones. [3]
What the research says
Hot flashes often last much longer than people expect. In a US study that followed 3,302 women through menopause, the 1,449 women with frequent hot flashes had them for a median of 7.4 years, and symptoms continued for a median of 4.5 years after their last period (Avis et al., JAMA Internal Medicine, 2015). [4]
Long-term follow-up of hormone therapy trials did not show a higher risk of death. Among 27,347 women aged 50 to 79 who were randomly assigned to hormone therapy or placebo, death from any cause over 18 years was 27.1% with hormone therapy versus 27.6% with placebo, a difference that was not statistically significant (Manson et al., JAMA, 2017). [5]
A newer non-hormonal pill helps, but more modestly. In a 52-week trial of 628 postmenopausal women, elinzanetant cut moderate to severe hot flashes by 5.4 per day at week 12, compared with 3.5 per day on placebo (a difference of about 1.6 per day). Treatment-related side effects were more common with the drug (30.4% vs 14.6%) (Panay et al., JAMA Internal Medicine, 2025). [6]
Key takeaways
The ACP now recommends estrogen (plus a progestogen if you still have a uterus) as the first-line hot flashes treatment [1].
If estrogen is not safe or not tolerated, the SNRIs venlafaxine or desvenlafaxine are recommended next [3].
SSRIs (escitalopram or paroxetine), gabapentin, and the newer neurokinin receptor blockers (elinzanetant or fezolinetant) are third-line options [3].
The review behind the guideline pooled 90 randomized trials; estrogen was the option shown to reduce both how often and how severe hot flashes are [2].
Hormone therapy is not right for everyone. A personal history of breast cancer, blood clots, stroke, heart disease, or liver disease may make it unsuitable [8].
What did the new guideline actually recommend?
Hot flashes and night sweats, which doctors call vasomotor symptoms, affect about 80% of women around menopause and can continue for years after periods stop [3]. The ACP guideline, written for doctors who care for women in outpatient clinics, ranks drug treatments in three steps [1] [3]:
First line: estrogen combined with a progestogen for women who have a uterus, or estrogen alone for women who do not. [3]
Second line: the SNRI antidepressants desvenlafaxine or venlafaxine, for women who cannot take estrogen or do not tolerate it. [3]
Third line: the SSRI antidepressants escitalopram or paroxetine, gabapentin, or a neurokinin receptor antagonist (elinzanetant or fezolinetant). [3]
The guideline also asks doctors to make the choice together with each patient, talking through benefits, harms, other health conditions, personal preferences, cost, and access to the medicine [3].
Which hot flashes treatment comes first now?
The short answer is estrogen. The systematic review that informed the guideline included 90 randomized trials. Compared with placebo, estrogen (with or without a progestogen) reduced both the frequency and the severity of hot flashes and improved menopause-related quality of life [2]. The non-hormonal options (neurokinin receptor antagonists, SNRIs, SSRIs, and gabapentin) reduced how often hot flashes happened, but in the pooled trials they did not clearly reduce how severe they were [2].
Cost mattered too. The reviewers rated estrogen therapy as high economic value, while the newer neurokinin drug fezolinetant was rated low value [2].
The table below summarizes how the options compare.
Treatment step | Medicines named | Who it is for | What the evidence showed |
|---|---|---|---|
First line | Estrogen, plus a progestogen if you have a uterus | Most women with bothersome symptoms and no reason to avoid estrogen | Fewer and less severe hot flashes; better quality of life |
Second line | Venlafaxine or desvenlafaxine (SNRIs) | Women who cannot take or tolerate estrogen | Fewer hot flashes; better quality of life and sleep |
Third line | Escitalopram or paroxetine (SSRIs), gabapentin, elinzanetant or fezolinetant | Women for whom the first two steps are not suitable | Fewer hot flashes; most also improved sleep |
Is hormone therapy safe for hot flashes?
For many healthy women near menopause, the benefits are likely to outweigh the risks, especially when treatment starts before age 60 or within 10 years of the last period [7]. Women who still have a uterus need a progestogen together with estrogen, because estrogen alone raises the risk of cancer of the uterine lining [7].
Hormone therapy is still a medicine with real risks. It may increase the risk of heart disease, stroke, blood clots, breast cancer, and gallbladder disease, and it may not be suitable for people with a history of those conditions or liver disease [8]. The reassuring long-term mortality data from large randomized trials do not cancel those individual risks; they mean your own health history should guide the decision [5].
The review also found that how well estrogen worked depended on the dose, but not on how it was taken, such as a pill versus a skin patch [2].
What if you cannot take estrogen?
You still have effective choices. The guideline places the SNRIs venlafaxine and desvenlafaxine next in line, followed by SSRIs, gabapentin, and the neurokinin receptor antagonists [1] [3]. They tend to reduce how often hot flashes occur and can improve sleep [2].
Everyday steps can help alongside any hot flashes treatment: dressing in layers, limiting hot drinks, spicy food, and caffeine, practicing stress reduction, not smoking, and losing weight if you are carrying extra weight [7].
What are the limits of this evidence?
Most trials in the review were short and were not designed to detect rare or long-term harms, and the reviewers did not include observational studies that could address those harms [2]. Little head-to-head evidence compares the medicines directly with each other [2]. The guideline covers prescription medicines only; it does not rank lifestyle approaches or supplements.
Frequently asked questions
What is the best hot flashes treatment according to the new guideline?
The ACP recommends estrogen-based hormone therapy as the first-line hot flashes treatment: estrogen with a progestogen if you have a uterus, or estrogen alone if you do not [1].
Is hormone therapy safe for menopause symptoms?
For many healthy women under 60 or within 10 years of menopause, benefits often outweigh risks. It may not be suitable if you have had breast cancer, blood clots, stroke, heart disease, or liver disease [7] [8].
What can I take for hot flashes if I cannot use estrogen?
The guideline recommends venlafaxine or desvenlafaxine next, then escitalopram, paroxetine, gabapentin, elinzanetant, or fezolinetant [3].
How long do hot flashes last?
Often longer than expected. In one large US study, frequent hot flashes lasted a median of 7.4 years in total and a median of 4.5 years after the final period [4].
Do estrogen patches work as well as pills for hot flashes?
In the review behind the guideline, estrogen's effect depended on the dose rather than the route, such as a pill or a patch [2]. Your doctor may still prefer one form based on your health history.
Health information, not medical advice. This article explains published research and guidelines in plain language. It does not replace a consultation with your own doctor, who can weigh your symptoms, medical history, and preferences before recommending any treatment. Do not start, stop, or change a medicine without professional advice.
Sources
Qaseem A, et al. Pharmacologic Treatments for Females With Menopausal Vasomotor Symptoms: A Clinical Guideline From the American College of Physicians. Annals of Internal Medicine. 2026. PMID 42832802. https://doi.org/10.7326/ANNALS-26-01205
Diem S, et al. Pharmacologic Treatments for Female Menopausal Vasomotor Symptoms: A Systematic Review and Meta-analysis for the American College of Physicians. Annals of Internal Medicine. 2026. PMID 42832800. https://doi.org/10.7326/ANNALS-26-00943
American College of Physicians. ACP recommends hormonal therapy as a first-line treatment for menopausal vasomotor symptoms. ACP Newsroom. October 5, 2026. https://www.acponline.org/acp-newsroom/acp-recommends-hormonal-therapy-as-a-first-line-treatment-for-menopausal-vasomotor-symptoms
Avis NE, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Internal Medicine. 2015;175(4):531-9. PMID 25686030. https://doi.org/10.1001/jamainternmed.2014.8063
Manson JE, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women's Health Initiative Randomized Trials. JAMA. 2017;318(10):927-938. PMID 28898378. https://doi.org/10.1001/jama.2017.11217
Panay N, et al. Elinzanetant for the Treatment of Vasomotor Symptoms Associated With Menopause: A Phase 3 Randomized Clinical Trial. JAMA Internal Medicine. 2025;185(11):1319-1327. PMID 40920404. https://doi.org/10.1001/jamainternmed.2025.4421
Mayo Clinic Staff. Hot flashes: Diagnosis and treatment. Mayo Clinic. September 3, 2026. https://www.mayoclinic.org/diseases-conditions/hot-flashes/diagnosis-treatment/drc-20352795
Mayo Clinic Staff. Hormone therapy: Is it right for you? Mayo Clinic. April 18, 2025. https://www.mayoclinic.org/diseases-conditions/menopause/in-depth/hormone-therapy/art-20046372
About the author: Dr. Baraa Alnahhal, MD, is a medical doctor and the founder of Rinnit. Dr. Baraa Alnahhal reviews new medical research and translates it into clear, evidence-based health information for everyday readers.
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