ACOG updates menopause treatment guidelines for first time since 2014

The American College of Obstetricians and Gynecologists has updated its menopause treatment guidelines for the first time since 2014. The guidance strongly recommends hormone replacement therapy before age 60 or within 10 years of menopause onset, affirming its safety. For patients with contraindications or preferences against hormones, ACOG highlights nonhormonal drugs like fezolinetant, SSRIs, and lifestyle interventions amid ongoing shortages of transdermal estrogen patches.

ACOG menopause guidelines timeline

• ▪The American College of Obstetricians and Gynecologists published updated guidelines for treating menopause symptoms on October 15, 2026, marking its first update since 2014
• ▪The American College of Obstetricians and Gynecologists announced it will publish complementary guidance on managing the genitourinary syndrome of menopause in 2027

Guideline publication and authors

• ▪ACOG's new menopause treatment guidelines were published in the journal Obstetrics & Gynecology, which dedicated its entire November issue to menopause
• ▪ACOG's new menopause treatment guidelines were developed by the American College of Obstetricians and Gynecologists' Committee on Clinical Practice Guidelines in collaboration with Dr. Bruce Pier, Dr. Robert Kauffman, and Dr. Catherine Cansino

Prevalence of menopause symptoms

• ▪The American College of Obstetricians and Gynecologists noted that more than one in three perimenopausal and postmenopausal women report depressive symptoms
• ▪The American College of Obstetricians and Gynecologists noted that between 50% and 92% of menopausal women experience hot flashes or night sweats, and 16% to 66% experience sleep disruptions

Hormone replacement therapy recommendations

• ▪The American College of Obstetricians and Gynecologists guidelines recommend systemic hormone replacement therapy with estrogen and progestogen for women with a uterus to mitigate endometrial cancer risk from estrogen-stimulated uterine lining growth, or estrogen alone without
• ▪The American College of Obstetricians and Gynecologists guidelines recommend Duavee, combining estrogen and bazedoxifene, as an alternative to estrogen-progestogen therapy for women with a uterus
• ▪The American College of Obstetricians and Gynecologists guidelines strongly recommend initiating menopausal hormone therapy before age 60 or within 10 years of the final menstrual period

Safety and contraindications of hormone therapy

• ▪American College of Obstetricians and Gynecologists committee chair Dr. Catherine Cansino stated that the safety of hormone replacement therapy for managing menopausal symptoms is now well-established
• ▪Contraindications to menopausal hormone replacement therapy identified in ACOG's updated menopause treatment guidelines include undiagnosed abnormal genital bleeding and histories of gynecologic cancers, blood clots, stroke, heart attack, liver disease, or pregnancy
• ▪In 2002, the Women's Health Initiative (WHI) study suggested hormone replacement therapy increased risks of heart disease, breast cancer, stroke, and pulmonary embolism, though subsequent re-evaluations noted limitations including an older participant demographic

Nonhormonal menopause treatment options

• ▪The Food and Drug Administration approved fezolinetant (brand name Veozah) in 2023 and elinzanetant (brand name Lynkuet) in 2025 to treat menopausal hot flashes by blocking chemical messengers regulating body temperature and sleep cycles
• ▪The American College of Obstetricians and Gynecologists guidelines recommend gabapentin, an anticonvulsant used for seizures, as a nonhormonal option to manage menopause symptoms for patients unable to tolerate hormones
• ▪The American College of Obstetricians and Gynecologists guidelines give conditional recommendations to cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis, and acupuncture for menopausal symptom relief, noting weaker evidence than for hormone therapy
• ▪The American College of Obstetricians and Gynecologists guidelines recommend selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, and neurokinin receptor agonists for menopausal patients contraindicated to hormone therapy

Patient-centered treatment decisions

• ▪Dr. Catherine Cansino, chair of ACOG's Committee on Clinical Practice Guidelines, emphasized that menopause treatment decisions should involve individualized shared decision-making and discussions with trusted clinicians regarding benefits and risks
• ▪Dr. Catherine Cansino warned against oversimplifying menopause treatments into rigid tiers, stating patients may reasonably choose less effective options if fully informed

Transdermal estrogen patch shortages

• ▪Dr. Catherine Cansino stated that shortages of transdermal estrogen therapy reflect excessive focus on hormone replacement therapy and a relative lack of awareness regarding nonhormonal menopause treatment options
• ▪Increased demand and recent removal of Food and Drug Administration black-box warnings on certain estrogen product labels have contributed to pharmacies experiencing shortages of transdermal estrogen patches