ACOG Issues First Menopause Treatment Guideline Update Since 2014

"What's changing is the breadth of options that we now have … And the benefit of that is that we are better equipped to be able to take an individualized approach for patients," said Catherine Cansino, an obstetrician-gynecologist who chairs ACOG's Committee on Clinical Practice Guidelines and co-authored the guidance. She said the update focuses on specific menopausal symptoms and underscores that the safety of hormone replacement therapy is now "well-established."

The revision follows years of reassessment of the 2002 Women's Health Initiative, which suggested hormone replacement therapy increased the risk of heart disease, breast cancer, stroke and pulmonary embolism. Researchers who revisited that data later identified limitations, including that a majority of participants were 60 or older, which made the findings difficult to generalize to younger women going through menopause or perimenopause. Cansino said more and better-quality studies now allow physicians to review the evidence and make better-informed recommendations.

"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," co-author Robert Kauffman said at a press briefing Thursday.

The guidance also highlights newer nonhormonal options, including fezolinetant, sold as Veozah, which the Food and Drug Administration approved in 2023 to treat hot flashes, and elinzanetant, sold as Lynkuet, approved in 2025. Cansino said the drugs were studied specifically on the basis of what is understood about the physiology of thermoregulation and sleep. They work by blocking certain chemical messengers in the part of the brain that regulates body temperature and manages sleep and wake cycles.

About 2 million women begin menopause each year, and the average age at menopause is 49.9 years, according to the guidelines. Symptoms can begin years before a woman's final menstrual period.

The recommendations support systemic hormone replacement therapy combining estrogen and progestogen for women who have a uterus and no contraindications to hormones. Reasons to avoid hormone therapy include undiagnosed abnormal genital bleeding and current or past histories of certain gynecologic cancers, blood clots, stroke, heart attack or liver disease, or a known or suspected pregnancy. Progestogen is included for women with a uterus because estrogen can stimulate growth of the uterine lining and raise the risk of endometrial cancer; progestogen helps mitigate that risk, Cansino said. Roughly half a million women have hysterectomies each year, and for women without a uterus, ACOG recommends estrogen alone.

As an alternative to estrogen-progestogen therapy, ACOG recommends a pill sold under the brand name Duavee, which combines estrogen with bazedoxifene, a selective estrogen receptor modulator that blocks estrogen from acting in certain areas such as breast tissue while mimicking its benefit for bone density. The guidelines also recommend gabapentin, an anticonvulsant normally used for seizures, for people who cannot tolerate hormones or the other new medicines.

Cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis and acupuncture can improve some symptoms, ACOG says, though the guidelines note the evidence for these interventions is weaker than for hormone replacement therapy. Cansino said patients may have their own preferences and goals, and that in her California practice many patients do not necessarily want pharmacological therapy, so she holds many conversations about non-drug options. A healthy diet and regular physical exercise "is going to go a long way," she said, before deciding what other interventions to add. Asked in a follow-up email whether she favored one medication or tool over another, she warned against over-simplifying treatment.