The main professional group for obstetricians and gynecologists in the United States has changed its advice on menopause. For the first time since 2014, the American College of Obstetricians and Gynecologists (ACOG) has updated its guidelines for treating common menopause symptoms1. The new guidance says hormone therapy should be a first choice for easing hot flashes, night sweats and the sleep problems they cause2.
ACOG released the guidance on Thursday, October 15, 202623. It gave hormone therapy a “strong” rating, meaning the group believes the benefits outweigh the risks for most women with these symptoms, as reported by The New York Times2. That does not apply to women with medical reasons to avoid hormones, such as past blood clots, a stroke or some cancers2.
What happened
The document is called Clinical Practice Guideline No. 13, “Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms.” It replaces ACOG’s 2014 practice bulletin on the same subject4. “Vasomotor symptoms” is the medical term for hot flashes and night sweats3.
ACOG says the guideline rests on a systematic review of the evidence, a structured search and grading of existing studies, and that each recommendation is graded by strength and by quality of evidence4. In the guideline’s wording, “ACOG recommends” marks a strong recommendation, while “ACOG suggests” marks a conditional one that depends on a person’s circumstances and preferences5.
The symptoms are common. ACOG says 50% to 92% of women in menopause have hot flashes or night sweats2. Between 16% and 66% of US women report menopause-related sleep disruption, and more than a third of women around and after menopause worldwide report depressive symptoms4. About 2 million women begin menopause each year, and the average age is 49.9, according to the guidelines1.
What the guideline recommends on hormones
The guideline strongly recommends systemic hormone therapy, meaning hormones that act throughout the body, for hot flashes, night sweats and the sleep disturbance they cause, in women with no medical reasons to avoid hormones5. For women who still have a uterus, that means estrogen plus a progestogen; for women without one, estrogen alone3. The progestogen is there because estrogen alone can thicken the uterine lining and raise the risk of endometrial cancer1.
Timing is a central part of the advice. For women who choose hormones, ACOG advises starting before age 60 or within 10 years after menopause begins2. “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,” said Robert Kauffman, a co-author of the guidelines, at a press briefing1.
The decision is meant to be shared between patient and clinician, weighing symptoms, age, medical history, baseline risks of heart disease, breast cancer and blood clots, and personal goals4. That is a shift from ACOG’s 2014 advice, which urged doctors to prescribe the lowest dose for the shortest time2. The new guidance calls for regular check-ins rather than strict limits, and some women may need to stay on hormones past 60 if symptoms linger, The Times reported2.
Reasons to avoid hormone therapy listed in coverage of the guideline include undiagnosed abnormal genital bleeding, current or past certain gynecologic cancers, blood clots, stroke, heart attack, liver disease, and known or suspected pregnancy1. People with a personal history of breast cancer should also avoid it, according to ACOG6. As an alternative to estrogen plus progestogen, ACOG also recommends a pill sold as Duavee, which combines estrogen with a drug called bazedoxifene1.
Options for women who don’t take hormones
For women who cannot or prefer not to take hormones, the guideline strongly recommends two groups of medicines5. One is certain antidepressants known as SSRIs or SNRIs, which can reduce hot flashes and also help with depressive symptoms5. The other is a newer class called neurokinin receptor antagonists, which includes fezolinetant (Veozah), approved by the FDA for hot flashes in 2023, and elinzanetant (Lynkuet), approved in 20251. These drugs block certain chemical messengers in the part of the brain that regulates body temperature and sleep-wake cycles1. They require liver function monitoring5.
Gabapentin, a seizure medicine, is suggested as a further option when other nonhormonal medicines have not worked or are not tolerated51. Clonidine is not recommended as a first-line treatment5.
For the first time, ACOG also gives graded recommendations for non-drug approaches: cognitive behavioral therapy (a type of talk therapy), mindfulness, exercise, clinical hypnosis and acupuncture5. These are conditional suggestions and are generally recommended alongside medicine rather than instead of it5. Plant estrogens such as soy isoflavones and herbal supplements did not make the list; ACOG said the evidence does not support their safety or effectiveness and that they are not tested by the FDA for safety, effectiveness or purity4.
Why the advice changed
Much of the caution about hormone therapy traces back to 2002, when the Women’s Health Initiative suggested hormone therapy increased the risk of heart disease, breast cancer, stroke and blood clots in the lungs1. When researchers revisited the data, they noted limits, including that most participants were 60 or older, which made it hard to apply the findings to women going through menopause or perimenopause1. The guideline itself notes that the fear came largely from research in an older group that does not represent most women seeking relief at menopause5.
“Unfortunately, misconceptions about the risks of hormone therapy have affected some clinicians’ willingness to prescribe it and some patients’ interest in using it.”
That was Dr. Bruce Pier, a coauthor of the guidance, in an ACOG news release2. Catherine Cansino, chair of ACOG’s Committee on Clinical Practice Guidelines and a co-author, said the safety of hormone therapy is now “well-established”1.
Some clinicians welcomed the clarity. “I’m glad they finally came out and said the first-line treatment for VMS is estrogen and [a progestogen] if the patient has a uterus. They didn’t really say that before,” said Dr. Angela McCool-Pearson, an OB-GYN and medical advisor to the site ThisIsMenopause3. ACOG’s 2014 guidance already called hormone therapy the most effective treatment for hot flashes; the update extends that to sleep symptoms and adds the timing advice3.
What the guideline does not settle
A guideline is a judgment about existing studies, not a new experiment. Several limits show up in the coverage:
- Mood. ACOG found the evidence is not strong enough to recommend or discourage specific treatments for mood symptoms; people whose main symptom is depression should be treated under standard depression guidelines3.
- Non-drug approaches. The evidence for these ranges from low to moderate quality, and is rated low for hypnosis and acupuncture; benefits are generally small to moderate and may fade over time for talk therapy5.
- Disagreement between groups. The Menopause Society’s 2023 statement does not recommend exercise or acupuncture for hot flashes, while ACOG’s new guideline includes both4.
- Access to the full text. The full guideline is open only to ACOG members, so much public reporting relies on ACOG’s public page and announcement4.
Some coverage has linked hormone therapy to slower biological aging, citing a 2024 study of over 10,000 women6. That claim comes from news reporting, not from the guideline’s recommendations, and the sources here do not describe that study’s design.
The sources reviewed do not describe how the guideline work was funded or whether its authors have ties to drugmakers.
How it fits the wider shift
The guidance follows other changes. In November 2025, the FDA announced it would remove the “black box” warnings about heart disease, breast cancer and probable dementia from most hormone therapy products; updated labels are being rolled out product by product, and a boxed warning about endometrial cancer remains on estrogen-only products3.
“There’s growing consensus among professional societies that menopausal symptoms should be treated, and that hormone therapy should be the first line of treatment,” JoAnn Manson, a professor of medicine at Harvard Medical School, told The Times2. McCool-Pearson said the guidance may be especially useful for primary care doctors, who she said have historically taken patients off hormone therapy or told them they don’t need it3.
What to watch next
ACOG plans separate guidance in 2027 on genitourinary syndrome of menopause, which covers vaginal and urinary changes4. Also worth following: how quickly the FDA’s label changes reach individual products3, and whether other medical groups, including the Menopause Society, align their advice on non-drug options with ACOG’s4.
