What the new guidance says
The American College of Obstetricians and Gynecologists (ACOG) has issued updated guidance on treating menopause symptoms, its first revision since 2014, NPR reported. The guidance was released Thursday. It covers symptoms such as hot flashes, insomnia and mood swings.
ACOG recommends hormone replacement therapy alongside certain antidepressants, nonhormonal medicines and other treatments. Catherine Cansino, an OB-GYN, chair of ACOG's Committee on Clinical Practice Guidelines and a co-author, said the change is "the breadth of options that we now have," which leaves clinicians "better equipped to be able to take an individualized approach for patients."
Cansino said the guidance underscores that the safety of hormone replacement therapy is now "well-established."
Hormone therapy and who should avoid it
For women with a uterus who have no contraindications, the guidelines support systemic hormone therapy combining estrogen and progestogen. Cansino explained that estrogen can stimulate growth of the uterine lining and raise the risk of endometrial cancer, and progestogen helps mitigate that risk. For women without a uterus, ACOG recommends estrogen alone. According to NPR, around half a million women have hysterectomies each year.
Robert Kauffman, a co-author, said at a Thursday press briefing that "Hormone therapy is probably the best option for symptomatic, newly menopausal women within 10 years of the final menstrual period or before the age of 60."
Reasons to avoid hormone therapy include undiagnosed abnormal genital bleeding, current or past histories of certain gynecologic cancers, blood clots, stroke, heart attack or liver disease, and a known or suspected pregnancy, according to the guidelines. As an alternative to estrogen-progestogen therapy, ACOG also recommends Duavee, a pill combining estrogen with bazedoxifene, a selective estrogen receptor modulator.
Newer drugs and other options
The guidelines highlight nonhormonal drugs, including fezolinetant (Veozah), which the Food and Drug Administration approved for hot flashes in 2023, and elinzanetant (Lynkuet), approved in 2025. According to the guidance, they block certain chemical messengers in the part of the brain that regulates body temperature and sleep/wake cycles. Cansino said they were studied based on an understanding of the physiology of thermoregulation and sleep.
Gabapentin, an anticonvulsant typically used for seizures, is also recommended for people who cannot tolerate hormones or the newer medicines.
Cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis and acupuncture can improve some symptoms, ACOG says. The guidelines note the evidence for these is weaker than for hormone therapy. Cansino said patients have their own preferences, and that many of her patients in California do not want pharmacologic treatment. She starts those conversations with "A healthy diet and regular physical exercise."
Background and demand
In 2002, the Women's Health Initiative suggested hormone therapy increased the risk of heart disease, breast cancer, stroke and pulmonary embolism. Researchers who later revisited the data noted limitations, including that most participants were 60 or older, making the findings hard to generalize to younger women in menopause or perimenopause. Cansino said more and better-quality studies now allow better-informed recommendations.
About 2 million women begin menopause each year, and the average age is 49.9, according to the guidelines. Symptoms can start years before the final period.
Demand for hormone therapy is rising. Last year the FDA removed the "black-box warning" from labels on certain estrogen therapies, and recent months have brought difficulty keeping estrogen products such as transdermal patches in stock. Cansino told NPR the shortage shows "all of this attention about hormone therapy, and not necessarily enough about other treatment options." She urged patients to talk with trusted clinicians and avoid "tunnel vision" about one option, and cautioned against "over-simplifying treatment based on tiers."
