ACOG issues first full menopause treatment update since 2014, strengthens hormone therapy recommendation

The American College of Obstetricians and Gynecologists has issued its first full update to menopause treatment guidance in more than a decade, strengthening its recommendation for hormone therapy and pushing clinicians away from the cautious, time-limited approach that has shaped American menopause care since the early 2000s. The new guideline, published online Oct. 15 in the journal Obstetrics & Gynecology, replaces a 2014 practice bulletin and is ACOG's most comprehensive menopause guidance to date.

Clinical Practice Guideline No. 13, "Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms," strongly recommends systemic menopausal hormone therapy for hot flashes, night sweats and related sleep disturbance in patients without contraindications, and recommends starting it before age 60 or within 10 years of a patient's final period. The timing matters clinically: starting hormone therapy within that window is associated with a more favorable balance of benefits and risks than starting it later, which is part of why the guideline moves away from blanket caution toward a case-by-case judgment made with each patient.

The numbers

ACOG's guideline cites vasomotor symptoms — hot flashes and night sweats — in 50 to 92 percent of menopausal women, sleep disruption in 16 to 66 percent, and depressive symptoms in roughly 36 percent of women globally during the menopause transition. For patients who still have a uterus, the guideline recommends combined estrogen and progestogen; for those who do not, estrogen alone. It lists conjugated estrogen with bazedoxifene as a conditional alternative, and moves away from the 2014 guidance's "lowest dose, shortest time" framing in favor of individualized, ongoing decision-making between doctor and patient — meaning some women may now continue hormone therapy well past 60 if it continues to help and risks remain acceptable. For patients who cannot or do not want to use hormones, the guideline gives a strong recommendation to SSRIs, SNRIs, and the newer neurokinin-3 receptor antagonists fezolinetant and elinzanetant, with gabapentin as a conditional second-line option. It gives only conditional support to cognitive behavioral therapy, mindfulness, exercise, clinical hypnosis and acupuncture, and explicitly does not endorse phytoestrogens or herbal supplements, which it says remain unregulated and unproven.

How menopause care got here

The new guideline follows the Food and Drug Administration's 2025 decision to strip boxed warnings about cardiovascular disease, breast cancer and dementia risk from hormone-therapy labels, warnings that had been added after the Women's Health Initiative trials of the early 2000s. ACOG's guideline notes that roughly two-thirds of the Women's Health Initiative's participants were 60 or older when they enrolled, limiting how directly its findings on cardiovascular and cancer risk apply to patients who are newly menopausal today — a distinction that has taken more than two decades to work its way into mainstream clinical guidance. The guideline also flags a racial disparity documented in the long-running SWAN study: Black women report a higher burden of menopause symptoms but receive treatment at lower rates than white women, a gap ACOG says deserves more attention from clinicians. The guideline does not spell out why the disparity exists, framing it instead as evidence that menopause research and treatment patterns have not served all patients equally.

"It is critically important that women have access to and coverage for evidence-based care." — ACOG President Dr. Camille A. Clare

Reaction

Clare, in ACOG's own announcement of the guideline, also pointed to persistent misinformation about menopause as a barrier to care. Dr. Bruce Pier, a co-author of the guideline, said in the same release that "misconceptions about the risks of hormone therapy" have discouraged both clinicians and patients from pursuing treatment that could help them, even as the evidence base supporting its safety for newly menopausal patients has strengthened. National coverage of the release framed the update as part of a broader cultural shift in how seriously menopause symptoms are taken in American medicine, after years in which many women say their symptoms were dismissed or undertreated.

Who is affected

The guideline affects tens of millions of American women who are approaching, in the midst of, or past the menopause transition, as well as the obstetrician-gynecologists, family physicians and nurse practitioners who counsel them. Pharmacies have already reported supply shortages of estradiol patches, a sign that demand for hormone therapy may be climbing even before many clinicians have updated their own default counseling to match the new guidance, a trend trade publications covering obstetrics and gynecology have also flagged. Insurance coverage for an expanded standard of care remains an open question; ACOG's statement calls for better coverage but does not have authority to require it. The guideline's superseding of the 2014 bulletin, catalogued in the National Library of Medicine's PubMed database, means the new recommendations immediately become the reference standard many malpractice and insurance-coverage disputes are likely to cite going forward.

What happens next

ACOG says a companion guideline on genitourinary syndrome of menopause — the vaginal and urinary symptoms that hormone-therapy guidance has historically addressed separately — is expected in 2027, a timeline confirmed in follow-up coverage aimed at practicing clinicians. In the near term, physicians are expected to begin revising their default counseling scripts, and medical groups and patient advocates will be watching whether insurers adjust coverage policies to match a guideline that explicitly extends hormone therapy's recommended use well past the "lowest dose, shortest time" era. Whether the estradiol patch shortages ease as manufacturers respond to rising demand remains, for now, an open question with no public timeline attached.