The ACOG menopause guidelines have been updated for the first time since 2014, with the American College of Obstetricians and Gynecologists recommending hormone therapy alongside certain antidepressants, newer nonhormonal medicines, and other approaches to manage hot flashes, sleep disturbances, and mood changes.
“What’s changing is the breadth of options we now have. The benefit is we are better equipped to take an individualized approach for patients,” said Catherine Cansino, MD, MPH, chair of ACOG’s Committee on Clinical Practice Guidelines and a co-author of the new guidance.
What’s new in the ACOG menopause guidelines
The guidance, released Thursday, focuses on specific menopausal symptoms and states that the safety of hormone replacement therapy is now well established, according to Cansino.
Concerns about hormone therapy stemmed from the 2002 Women’s Health Initiative, which linked treatment to higher risks of heart disease, breast cancer, stroke, and pulmonary embolism. Researchers later noted key limitations, including that most trial participants were age 60 or older, making the findings difficult to apply to younger women in menopause or perimenopause.
“Hormone therapy is probably the best option for symptomatic, newly menopausal women within 10 years of the final menstrual period or before age 60,” said Robert Kauffman, MD, MSCP, a co-author of the guidelines, during a Thursday briefing.
Hormonal and nonhormonal treatments
Beyond hormone therapy, the guidelines highlight newer nonhormonal options for vasomotor symptoms. These include fezolinetant, brand name Veozah, approved by the FDA in 2023 for hot flashes, and elinzanetant, brand name Lynkuet, approved in 2025. The medications act by blocking certain chemical messengers involved in thermoregulation and sleep-wake cycles.
About 2 million women begin menopause each year, and the average age of menopause is 49.9 years, according to the guidance. Symptoms can start years before the final menstrual period.
The recommendations support systemic hormone therapy using estrogen plus progestogen for women with a uterus who have no contraindications. Progestogen is added because unopposed estrogen can stimulate the uterine lining and raise the risk of endometrial cancer. For women without a uterus, ACOG recommends estrogen alone.
As an alternative to estrogen-progestogen therapy, the guidance includes a pill sold as Duavee, which combines estrogen with bazedoxifene, a selective estrogen receptor modulator that blocks estrogen’s effects in some tissues such as the breast while preserving benefits like bone protection.
Gabapentin, an anticonvulsant commonly used for seizures, is also recommended as an option for those who cannot tolerate hormones or the newer medicines.
Behavioral and lifestyle approaches
ACOG notes that cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis, and acupuncture can improve some symptoms, though the evidence is weaker than for hormone therapy. Patient preferences matter, Cansino said, and many people opt to start with lifestyle changes. “A healthy diet and regular physical exercise is going to go a long way,” she said, adding that treatments can be layered based on goals and tolerance.
Cansino cautioned against ranking options too rigidly. As with contraception, some patients may choose a less potent option if they understand the trade-offs. “As long as they understand the pros and cons, such a decision is perfectly OK.”
Access, safety, and demand
Demand for hormone therapy has been rising. The FDA removed the black-box warning from certain estrogen therapies last year, and pharmacies have struggled at times to keep transdermal estrogen patches in stock. Cansino said the patch shortages underscore the need to consider the full range of treatments rather than focusing on one product.
Reasons to avoid hormone therapy include undiagnosed abnormal genital bleeding, and current or past histories of certain gynecologic cancers, blood clots, stroke, heart attack, liver disease, or a known or suspected pregnancy.
Cansino emphasized discussing risks and benefits with a trusted clinician and avoiding tunnel vision around a single therapy. She added that helping each patient find the right fit is central to the new guidance. “There’s a lot of misinformation and exaggerated claims about hormone therapy, and some people end up taking risks when they shouldn’t.”
