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The American College of Obstetricians and Gynecologists (ACOG) published updated recommendations for menopause management in Obstetrics & Gynecology on October 15.
These expanded recommendations are the most comprehensive guidance to date. They include new clinical guidelines for menopause hormone therapy (MHT), nonhormonal medications, and nonpharmacological treatment of vasomotor symptoms (VMS), which include hot flashes and night sweats, and sleep and mood changes.
According to the ACOG guidance, 50%–92% of females experiencing menopause report VMS.
Around 16%–66% of females in the United States report menopause-related sleep issues, and more than one-third of perimenopausal and postmenopausal females report experiencing depressive symptoms.
“In recent years, misconceptions about the risks of hormone therapy have been widespread, which has made some clinicians reluctant to prescribe it and some patients hesitant to use it,” Bruce Pier, MD, clinical professor and associate fellowship director at the University of North Carolina and collaborator on the ACOG clinical practice guidelines, told Healthline.
“This guidance offers a comprehensive review of the evidence to support individualized counseling and shared decision making. Our hope is that it clears up those misconceptions and expands access to treatment.”
The ACOG is also developing companion guidance for genitourinary syndrome of menopause, expected in 2027.
ACOG hormone therapy recommendations for VMS and sleepThe ACOG strongly recommends the use of MHT with estrogen and progestogens (or estrogen alone for people without a uterus) for both VMS and vasomotor-related sleep disturbance, in individuals who can use hormones.
It also conditionally recommends conjugated estrogen plus bazedoxifene (Duavee) as an alternative for these issues.
According to a meta-analysis from 2021 that was cited by the guidelines, estrogen therapy, with or without progestogens, significantly reduced VMS frequency and severity compared to a placebo or no treatment. A 2017 meta-analysis ranked transdermal estradiol plus a progestogen as the most effective option for reducing VMS frequency.
A 2022 systematic review and meta-analysis, also cited by the guidelines, found that MHT was associated with improved self-reported sleep quality. Once again, transdermal therapies showed some of the largest effects.
ACOG recommendations for starting MHTThe ACOG recommends initiating MHT before age 60 or within 10 years of the onset of natural menopause..
It also suggests that the decision to start MHT for VMS and vasomotor-related sleep disturbances should be based on a shared decision making discussion about an individual’s symptoms and the benefits and risks of therapy. Consideration should also be taken regarding an individual’s:
Research shows that factors such as race, culture, socioeconomic status, gender identity, and sexual orientation can influence how individuals experience menopause and the care they receive.
According to the SWAN study, Black women reported more menopause symptoms than white women but were less likely to be treated for them.
“This updated document shines a light on these inequities. Clinicians can proactively help right now by asking every patient in midlife about symptoms, rather than waiting for them to bring it up. Long term, we hope this document drives more research funding to understand these gaps and begin closing them,” said Pier.
ACOG MHT recommendations for depressive symptomsThe ACOG stated in the guidelines that, “The available evidence is insufficient to recommend for or against the use of estrogen–progestogen or estrogen-only MHT for the treatment of menopause-related depressive symptoms.”
It recommends that perimenopausal and postmenopausal individuals who meet the diagnostic criteria for major depressive disorder (MDD) or those whose most noticeable symptom is depression should be treated according to depression management guidelines.
Current treatment guidelines for depression include therapy, medication, or a combination of the two.
Psychological treatments for depression include psychotherapy, such as cognitive behavioral therapy (CBT), while antidepressants are among the most commonly prescribed medications.
ACOG recommendations for nonhormonal treatmentsThe ACOG strongly recommends the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) for the management of menopausal symptoms like VMS and depression in individuals who don’t want to use MHT or can’t use it.
Currently, paroxetine is the only antidepressant that is approved by the Food and Drug Administration (FDA) for the management of VMS.
The ACOG also strongly recommends the use of neurokinin receptor antagonists to manage VMS and vasomotor-related sleep disturbances in people who don’t desire hormone therapy or can’t use it.
There are currently two neurokinin receptor antagonists approved by the FDA to manage menopause symptoms. Fezolinetant (Veozah) was approved in 2023 to help manage hot flashes. In 2025, the FDA approved elinzanetant (LYNKUET) for the management of moderate to severe VMS due to menopause.
Another nonhormonal treatment for VMS that the ACOG conditionally recommends is gabapentin.
ACOG recommendations for nonpharmacologic treatmentsThere are various nonpharmacologic treatments that the ACOG conditionally recommends for the management of VMS, vasomotor-related sleep disturbances, and mood changes. These are treatments that don’t involve the use of medications.
The nonpharmacologic treatments conditionally recommended include:
It is generally recommended that these interventions are used alongside hormonal or nonhormonal medications.
The ACOG noted that there is not enough evidence to support the efficacy or safety of phytoestrogens, such as soy isoflavones, or herbal supplements, which are not regulated by the FDA in the same way medications are for safety, purity, or efficacy.
“Menopause is finally getting the attention it deserves, and this document shows what evidence-based care should look like in this space. It lays out a range of safe, effective options for managing menopause symptoms. My message to anyone struggling with these symptoms is simple: talk to your clinician. You don’t have to suffer through them,” said Pier.