The American College of Obstetricians and Gynecologists (ACOG) has released its first updated guidelines for menopause treatment since 2014. The new recommendations address common symptoms such as hot flashes, night sweats, and insomnia, emphasizing a broader range of therapeutic options for patients.
“What’s changing is the breadth of options that we now have,” said Catherine Cansino, MD, MPH, who chairs ACOG’s Committee on Clinical Practice Guidelines. “And the benefit of that is that we are better equipped to be able to take an individualized approach for patients.”
Expanded Hormone Therapy Recommendations
The updated guidance underscores that the safety of hormone replacement therapy (HRT) is now well-established for specific demographics. The committee recommends systemic HRT, which combines estrogen and progestogen, for women with a uterus who have no contraindications to hormones.
Robert Kauffman, MD, MSCP, a co-author of the guidelines, noted that hormone therapy is likely the best option for symptomatic, newly menopausal women within 10 years of their final menstrual period or before age 60.
This stance marks a shift from earlier concerns. In 2002, the Women’s Health Initiative suggested that hormone replacement therapy increased the risk of heart disease, breast cancer, stroke, and pulmonary embolism. However, subsequent reviews of that data revealed limitations, including the fact that most participants were 60 years or older. These findings were difficult to generalize to younger women experiencing menopause or perimenopause.
Progestogen is included in the recommended regimen for women with a uterus because estrogen alone can stimulate the growth of the uterine lining, increasing the risk of endometrial cancer. For women who have had a hysterectomy, ACOG recommends estrogen alone.
Contraindications for hormone therapy remain strict. Patients with undiagnosed abnormal genital bleeding, a history of certain gynecologic cancers, blood clots, stroke, heart attack, liver disease, or known or suspected pregnancy should avoid these treatments.
New Nonhormonal and Alternative Options
In addition to hormone therapy, the guidelines highlight several nonhormonal medications. These include fezolinetant, sold under the brand name Veozah, which the FDA approved in 2023, and elinzanetant, brand name Lynkuet, approved in 2025.
These medications work by blocking specific chemical messengers in the brain that regulate body temperature and sleep-wake cycles. Cansino noted that these options were specifically studied based on current understanding of thermoregulation and sleep physiology.
For patients who cannot tolerate hormones or the newer nonhormonal drugs, the guidelines also recommend gabapentin, an anticonvulsant typically used to treat seizures. Another alternative is Duavee, a pill combining estrogen with bazedoxifene, a selective estrogen receptor modulator that blocks estrogen in certain tissues while mimicking its benefits for bone density.
Non-pharmacologic interventions such as cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis, and acupuncture are also mentioned. However, the guidelines note that the evidence supporting these methods is weaker than the evidence for HRT.
Demand for hormone therapy has risen significantly, leading to shortages of transdermal estrogen patches in recent months. Cansino warned that this shortage highlights a need for greater awareness of alternative treatment options. She advised patients to discuss the pros and cons of various treatments with their clinicians to avoid making decisions based on misinformation or tunnel vision.
Source: NPR
