Beyond hot flashes: What VA/DoD’s first menopause guideline means for prescribing

Clinical takeaway: Diagnose typical perimenopause and menopause clinically, without routine hormone testing, and match treatment to symptoms, uterine status, comorbidities, and patient preferences. For bothersome hot flashes, discuss systemic hormone therapy alongside nonhormonal options; use local vaginal treatment when genitourinary symptoms predominate.

VA/DoD’s first menopause clinical practice guideline offers 43 recommendations spanning diagnosis, symptom management, and treatment safety. Most recommendations are conditional, underscoring the need for shared decision-making rather than a single prescribing pathway.

For vasomotor symptoms in women with a uterus, the guideline strongly recommends systemic estradiol plus progesterone and conditionally supports conjugated estrogen/bazedoxifene as an alternative. For women without a uterus, it suggests systemic estradiol alone; progestogen monotherapy is discouraged.

Nonhormonal options include elinzanetant, fezolinetant, SSRIs/SNRIs, and gabapentin, all with conditional recommendations. Hormone therapy is favored over venlafaxine or gabapentin when there is no contraindication, but evidence is insufficient to favor hormone therapy over either neurokinin antagonist.

Prescribers should review drug interactions and hepatic monitoring requirements when considering neurokinin antagonists. Fezolinetant requires liver testing before treatment, monthly for the first three months, and at months 6 and 9 because of the risk of serious liver injury.

For genitourinary syndrome of menopause (GSM), the guideline suggests local vaginal estrogen, including for breast cancer survivors after individualized counseling and coordination with oncology. This differs from systemic hormone therapy, which is discouraged in survivors of hormone-positive breast cancer.

Vaginal estrogen or vaginal dehydroepiandrosterone (DHEA) is suggested for dyspareunia; vaginal dryness options also include moisturizers and ospemifene. Vaginal lasers are discouraged.

Sexual desire concerns receive specific prescribing guidance: transdermal testosterone is suggested for menopausal sexual dysfunction, particularly interest, desire, or arousal symptoms, and flibanserin for hypoactive sexual desire disorder. Testosterone use in women remains off-label and requires monitoring; flibanserin’s modest benefits should be weighed against hypotension, syncope, and alcohol and drug interactions.

One notable recommendation allows consideration of systemic estrogen for significant vasomotor symptoms in selected women with established cardiovascular disease who are younger than 60 and within 10 years of menopause onset. The discussion limits this approach to patients with remote events and low current cardiovascular risk after shared decision-making; oral hormone therapy should not be prescribed to prevent cardiovascular disease or stroke.

Cognitive behavioral therapy receives strong recommendations for hot flashes and menopause-related depressive or anxiety symptoms, with mindfulness-based stress reduction also strongly supported for mood symptoms. Hormone therapy is discouraged solely for cognitive complaints, and evidence is insufficient to support its use solely for sleep symptoms or dementia prevention.

The authors also challenge the appeal of hormone panels, writing that “laboratory testing adds limited clinical value and may, in fact, be misleading.” Testing remains appropriate in selected circumstances, including suspected primary ovarian insufficiency.

Key Recommendations

• Diagnose clinically; avoid routine FSH or anti-Müllerian hormone testing.
• Select systemic hormone therapy according to uterine status and individual risk.
• Offer nonhormonal hot-flash drugs with appropriate safety monitoring.
• Consider local vaginal estrogen for GSM, including in breast cancer survivors.
• Address sexual dysfunction with targeted treatment and counseling.
• Use CBT for hot flashes and mood symptoms; avoid hormone therapy solely for cognitive complaints.

Source: VA/DoD. (2026 Sep) VA/DoD Clinical Practice Guideline for Menopause