The American College of Physicians updated guidance recommending estrogen-based hormone therapy as first-line treatment for menopausal hot flashes and night sweats. The guideline also positions SNRIs, SSRIs, gabapentin, and neurokinin receptor antagonists as alternatives, reflecting an expanding menu for symptoms while keeping a preference hierarchy. The update matters for prescribing patterns across primary care, where menopausal symptom management is often fragmented between patient preference, contraindication risk, and limited structured recommendations. The guidance also signals that non-estrogen options remain important when estrogen is unsuitable, shaping how clinicians will counsel across risk profiles and treatment goals.