Obstetricians' group says hormone therapy should be the default treatment for menopause symptoms

The American College of Obstetricians and Gynecologists on Wednesday issued its most sweeping update in more than a decade to how doctors should treat menopause symptoms, formally recommending hormone therapy as the primary option for hot flashes, night sweats and related sleep disruption in women who have no medical reason to avoid it.

The new document, Clinical Practice Guideline No. 13, was published online October 15 in the journal Obstetrics & Gynecology and replaces a practice bulletin that had stood since January 2014. It is the organization's first comprehensive rewrite of its menopause recommendations since then, and it arrives less than a year after federal regulators began stripping some of the most severe warning language from hormone therapy drug labels.

What the guideline changes

The core shift is one of sequencing. Where earlier guidance treated hormone therapy as one option among several, ACOG now gives it a strong recommendation as first-line treatment for vasomotor symptoms, the clinical term for hot flashes and night sweats, and for the sleep disturbance that often accompanies them, in women without contraindications such as a history of blood clots, stroke, liver disease or breast cancer. Women who still have a uterus should generally take estrogen combined with a progestogen, to protect against endometrial cancer, while women without a uterus can take estrogen alone. The guideline also lists a combination of conjugated estrogen and bazedoxifene as an alternative, and gives strong recommendations to several nonhormonal medications, including SSRIs, SNRIs and a newer class of drugs called neurokinin receptor antagonists, for women who cannot or do not want to take hormones.

ACOG also addresses timing directly: it favors starting treatment before age 60 or within ten years of a woman's final period, the window in which research has generally found the treatment's benefits most clearly outweigh its risks. Persistent or unscheduled bleeding while on hormone therapy, the guideline notes, still warrants evaluation for endometrial cancer, and the organization says evidence remains too limited to recommend hormone therapy specifically as a treatment for menopause-related depression.

The numbers behind the symptoms

The scale of the symptoms the guideline addresses is large. Citing the medical literature it reviewed, the guideline and accompanying coverage put the share of women reporting vasomotor symptoms during the menopause transition at somewhere between 50 percent and 92 percent, with 16 percent to 66 percent of women in the United States reporting menopause-related sleep disruption. ACOG President Dr. Camille A. Clare has noted that women spend roughly a third of their lives in the postmenopausal stage, a span the organization says has long been under-treated.

How caution hardened into dogma

The reversal traces back to 2002, when the Women's Health Initiative, a federally funded trial of more than 16,000 postmenopausal women, was stopped early after a safety board found that one combined estrogen-progestin regimen increased the risk of invasive breast cancer, heart disease and stroke. The findings, published in JAMA that July, triggered a sharp and lasting drop in hormone therapy use nationwide and led the Food and Drug Administration to require a boxed warning, the agency's strongest label alert, covering those risks on estrogen-containing products.

Later analyses complicated that picture considerably. Researchers found the original trial had enrolled women who were on average more than a decade past menopause, far older than the women who typically seek treatment for hot flashes, and that risk varied substantially by age, by how soon therapy began after menopause, and by the specific hormone formulation used. That reassessment fed into a federal regulatory shift: in labeling changes the FDA approved beginning in November 2025, the agency removed references to cardiovascular disease, breast cancer and probable dementia from the boxed warning on hormone therapy products for women who start treatment before 60 or within ten years of menopause, while keeping an endometrial cancer warning on estrogen-only products. Dozens of drug companies have since submitted revised labels for approval. ACOG's new guideline builds directly on that regulatory turn, folding it into formal clinical practice.

Who the change reaches

The guideline's reach is broad by design: it applies to any woman approaching or past menopause, typically in her late 40s to mid-50s, who has symptoms affecting daily life or sleep. ACOG also flags equity concerns largely absent from the 2014 bulletin, noting that Black women, sexual minority women, and transgender and gender-diverse people often carry a heavier symptom burden while facing greater barriers to specialized care. Coauthor Dr. Catherine D. Cansino has said racial, cultural and socioeconomic factors shape how people experience menopause and how readily they can get appropriate treatment, a gap the guideline urges clinicians to account for rather than treat symptoms in isolation.

What clinicians and outside experts are saying

Physicians who treat menopause patients described the update as catching medical practice up to where the evidence already stood. Coauthor Dr. Bruce Pier called hormone therapy "a really important tool we have to help with menopause symptom management," while cautioning, along with fellow coauthor Dr. Robert P. Kauffman, that it may not be appropriate for every patient despite its elevated status in the new guidance.

"Hormone replacement therapy is now the first line," said Dr. Kameelah Phillips, an OB-GYN and menopause specialist, describing a shift away from the antidepressants, exercise regimens and other substitutes doctors once reached for first. "We're using hormones mainstream now."

Not every reaction has been purely celebratory. Dr. Regina Castaneda, a postdoctoral fellow at the Mayo Clinic who was not involved in writing the guideline, has argued that recommendations like ACOG's matter only if patients can actually get the care they describe, pointing to persistent gaps in insurance coverage, menopause training among general practitioners, and access to specialists, particularly outside major metropolitan areas.

What happens next

ACOG says it is developing a companion guideline on genitourinary syndrome of menopause, the cluster of vaginal and urinary symptoms not covered in this document, expected in 2027. In the near term, the practical effect will depend on how quickly primary care doctors and gynecologists, many trained under the older, more cautious guidance, update their own counseling, and on how fast insurers and pharmacy formularies adjust to a relabeled generation of hormone products now carrying fewer warnings than they did a year ago.