Michele Vetter spent years asking two doctors the same question: Could hormone therapy ease her hot flashes? Eventually, one doctor referred her to a compounding pharmacy that never returned her calls.
Now the 52-year-old has something to hand them—guidelines from two major physician groups saying hormone therapy should be the first treatment considered for most women with hot flashes and night sweats.
That frustration is common. For two decades, women have shuttled between doctors for information about a treatment many physicians have been reluctant to discuss. The new guidelines give patients a concrete document. However, they address only one component of menopause, and for some women, the answer will be that hormone replacement therapy (HRT) isn’t right for them. Experts say other options exist.
What the Guidelines Say About Hot Flashes
In the past month, the American College of Obstetricians and Gynecologists (ACOG) and the American College of Physicians (ACP) have each upgraded HRT to the most effective treatment for hot flashes, night sweats, and sleep disturbances.
These symptoms, known as vasomotor symptoms, affect as many as 80 percent of women in menopause, according to Dr. Jan Carney, president of the ACP.
“Women may not talk about night sweats and hot flashes, in part, because the safety, effectiveness, and availability of treatments are not widely known to them,” she told The Epoch Times.
A decrease in estrogen is the main cause of vasomotor symptoms. As estrogen levels fall, the brain’s temperature control center, the hypothalamus, becomes disrupted, and hot flashes can be triggered by stress, temperature changes, smoking, alcohol, and spicy foods or drinks. Symptoms can include sweating, skin flushing, and sometimes a racing heart.
The guidelines recommend estrogen combined with a second hormone, a progestogen, for women with a uterus because estrogen alone can raise the risk of uterine cancer. Women who have had a hysterectomy can take estrogen alone. Treatment should begin before age 60 or within 10 years of menopause, and be limited to three to five years. The latter is a guideline; women may still have hot flashes and may decide to continue with treatment under a doctor’s supervision.
HRT isn’t recommended for women with certain conditions, including a history of cardiovascular disease, breast cancer, or certain blood clots.
For women who can’t or don’t want to take hormones, the guidelines point to several nonhormonal drugs. These include antidepressants that have the highest nonhormonal evidence rating for hot flashes. There are two classes commonly prescribed for depression: Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Both can reduce hot flashes, though they come with certain side effects. Another recently recommended class of nonhormonal medications, neurokinin receptor antagonists, can also treat nausea and help regulate body temperature.
“The drugs are not equivalent to estrogen,” Dr. Wendy Warner, a functional medicine gynecologist, told The Epoch Times.
“You lose the other cardiovascular and bone benefits you get with estrogen, not to mention the impact on vaginal dryness and skin changes.”
What the Guidelines Leave Out
The guidance is incomplete. ACOG is expected to publish guidance in 2027 on genitourinary issues, including urinary tract infections, incontinence, and vaginal dryness, burning, and itching. Recommendations also don’t address other menopause concerns, such as using HRT to protect the bones or the heart.
In a study of 25,389 postmenopausal women published in Osteoporosis International, women taking hormones had 28 percent fewer fractures and 34 percent fewer hip fractures over a four-year period compared with women taking a placebo.
When it comes to heart health, HRT’s effect is still unclear. Oral HRT was associated with an overall increased risk of heart disease, stroke, and heart attack, while observational evidence suggests transdermal hormones (patches, creams, and gels) may carry a lower risk. HRT started soon after menopause can offer a more favorable benefit-to-risk profile.
Neither organization announced plans to consider bone or heart health for HRT recommendations. Warner said that could be due to such a wide array of hormones and the fact that some forms, such as oral estrogen and synthetic progestins, can make heart issues worse.
“Any recommendation would have to be extremely specific and distinguish among the various forms of HRT,” she said, noting that medical organizations don’t seem ready to address them.
Why Hormone Therapy Fell Out of Favor
Many doctors hesitate to prescribe HRT, and many women hesitate to ask about it, because of misconceptions, said Dr. Bruce Pier, coauthor of the ACOG guidance, said in a press release. Those misconceptions trace back to a 2002 Women’s Health Initiative study. It effectively stopped HRT recommendations after finding a slight rise in breast cancer risk in the group of women taking combined hormones that included progestin, a synthetic version of progesterone that carries its own risks.
Critics say the study’s design skewed the picture. It enrolled women up to age 79, and about 83 percent were more than five years past menopause, so it tested HRT in women well past the stage when it is thought to help most.
“People are so scared of breast cancer,” integrative family practitioner Dr. Cammy Benton told The Epoch Times. “It was just all shut down. They threw the baby out with the bathwater.”
Hormones Aren’t the Only Solution
The biggest problem with HRT isn’t that it doesn’t work but that it may not be a panacea for menopause discomfort, something a lot of women—and doctors—aren’t aware of, Warner said. Whether a woman uses HRT or not, she’s likely to need more support.
“I write a lot of HRT prescriptions, both for symptom control and prevention of cognitive decline, cardiovascular disease and bone loss,” she said. “But I always ask women to address the imbalances as well.” In her view, hormones aren’t addressing the underlying factors behind vasomotor symptoms: glucose dysregulation and stress hormone imbalance.
Stress and sleep loss can affect metabolic function, causing blood sugar swings and a vicious cycle that disrupts the body’s stress-response system, known as the hypothalamic-pituitary-adrenal axis, and can result in hot flashes.
Nonpharmacologic approaches can also help. ACOG has added several to its hot flash guidelines, including cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis, and acupuncture. Herbal supplements didn’t make the list—study results are inconsistent or insufficient—but some clinicians use them instead of HRT or before prescribing medicines.
Not all women need hormone support, Benton said, especially those who don’t eat sugar, exercise frequently, and get proper sleep. “I’ve tried to give them hormones when they were already very balanced. They didn’t tolerate it,” she said. “I do think that more women need it than not.” Benton said she herself needed HRT even though she was doing everything else possible to ease her symptoms.
Vetter’s experience fits the pattern. She was already eating well, exercising, avoiding alcohol, and using breathing exercises when she asked about HRT. Her symptoms worsened with certain foods and especially with stress: they began as she cared for her ailing father, then intensified when she moved across the country.
She has doubled down on limiting screens, taking more walks, and reading her Bible more. “That’s also helped a little bit,” she said. Supplements she tried didn’t work, and she still has occasional symptoms even though life has slowed down.
The key is to consider each woman individually, Benton said, but many end up with a standard protocol from their doctor or online.
“HRT is such an industry now—you can get it from online ‘clinics’ who have cookie-cutter protocols that are used without seeing someone as an individual,” Warner said.
Getting Doctors on Board
Women who want HRT may still have to push their doctors, who can sometimes be slow to change protocols, Benton said. “More and more doctors are doing it because their patients are coming to them wanting it and then those doctors get curious,” she said. Years ago, she added, she wouldn’t prescribe HRT even when patients asked.
Part of the problem is training. Many doctors never learned about menopausal hormones in medical school. A generation of doctors was taught that HRT is dangerous and passed that along to patients, Warner said. “They ended up for a long time saying, ‘Suck it up.’ That, fortunately, is starting to change.”
The result is a generation of women who may not qualify for HRT under the new guidelines but could still be struggling. For them, nonhormonal tools can be a part of symptom management. That’s why, Warner said, education should be central to care—ideally starting as early as possible and including conversations beyond HRT and medical interventions.
“I mean true menopause education: the actual science of what triggers [vasomotor symptoms] and why estrogen is good but not always sufficient,” she said. “And that we need to address cardiovascular disease risk, bone health long before our final periods, the whole thing.”
Carney said it’s time for doctors to start conversations they might have avoided and to look for ways to help women improve their quality of life during the menopausal transition. “I think it’s essential to focus on what women will gain from these recommendations.”
It’s also a chance for patients to initiate follow-up conversations with doctors. Vetter’s biggest hesitation is safety. With that in mind, patients can ask their doctors:
Am I a good candidate for HRT based on my medical history?
Which risks apply to me?
Which form of HRT would be best for me?
If you don’t recommend HRT, why, and what options do you recommend instead?
For Vetter, the recognition of HRT came a bit late; she struggled through several difficult years.
“I am thankful that they are making changes,” she said, but she hopes that someday the education can be more up to date with what research has found.
