For the first time in a dozen years, a leading group of US obstetrician-gynecologists has updated its advice on managing hot flashes, night sweats, sleep changes and other disruptive symptoms that often come with menopause1. The American College of Obstetricians & Gynecologists (ACOG) published the new guidance as Clinical Practice Guideline No. 13, dated November 2026, and it replaces the group’s Practice Bulletin No. 141 from January 20142.
ACOG called it its most comprehensive menopause guidance to date. It covers treatment options for what doctors call vasomotor symptoms (hot flashes and night sweats) as well as sleep and mood changes3. The group said separate guidance on vaginal and urinary symptoms of menopause is being written and will be published in 20273.
What the guidance says
The headline message is support for hormone therapy for many women. According to a summary for clinicians by Hippo Education, ACOG strongly recommends whole-body (“systemic”) hormone therapy for hot flashes, night sweats and the sleep problems they cause, in patients with no medical reason to avoid it4. That means estrogen plus a progestogen for women who still have a uterus, or estrogen alone for women who do not; both are rated strong recommendations based on moderate-quality evidence4.
The guidance gives more detail on the different forms of hormone therapy3. Whole-body versions come as pills, patches, sprays, gels and a vaginal ring and put hormones into the bloodstream at levels high enough to ease hot flashes. Low-dose vaginal estrogen, by contrast, leaves very little in the blood and is often used when vaginal dryness is the main complaint1.
Timing is a key point. ACOG says the decision to start should be shared between doctor and patient and weigh symptoms, age, medical history, and baseline risks of heart disease, breast cancer and blood clots in the veins3. If hormone therapy is chosen, ACOG recommends starting before age 60 or within 10 years of the start of natural menopause, in people with no medical reason to avoid it3. Hippo’s summary adds that starting later is not ruled out but needs an individual discussion, and that there is no set age or length of use at which therapy must stop4.
The Hippo summary also notes that, in a combined analysis of many studies cited in the guideline, estradiol delivered through the skin with a progestogen ranked as the most effective option for cutting how often hot flashes happen, with pill-based combinations also effective but ranked lower4.
Options beyond hormones
Some women cannot take hormones because of their medical history, and some prefer not to. For them, the guidance reviews non-hormone medicines3. These include fezolinetant and elinzanetant, drugs that ACOG describes as a new approach to treating hot flashes3. They work in the part of the brain that controls body temperature and block a source of hot flashes and night sweats1. The guidance also discusses certain antidepressants, known as SSRIs and SNRIs, which can help with hot flashes, depression, or both3.
ACOG also gives new recommendations on non-drug approaches for hot flashes, sleep and mood: cognitive behavioral therapy (a structured form of talk therapy), mindfulness-based programs, exercise, clinical hypnosis and acupuncture3. ACOG says these can be used alone but are generally recommended alongside hormonal or other medicines3.
Why the update matters to doctors
Menopause is defined as 12 months in a row without a period, and in the US it usually happens around age 501. ACOG’s guidance says 50% to 92% of women in menopause report hot flashes or night sweats, 16% to 66% of US women report menopause-related sleep problems, and more than a third of women around and after menopause worldwide report depressive symptoms3.
“Menopause is a normal and natural stage of life, but that doesn’t mean that women must suffer through the symptoms without help.”
That was ACOG President Camille Clare in the group’s announcement3. Dr. JoAnn Manson, a professor of medicine at Harvard Medical School, told the Associated Press there is growing agreement that “these symptoms should be treated”1.
Hormone therapy has had a troubled history. In 2002, a major study of women taking a combined estrogen and progestin pill was stopped early because of links to breast cancer, blood clots and other serious problems1. Later studies found that for many women the benefits of today’s hormone therapies outweigh the risks, but concerns lingered, and for more than 22 years every hormone-based menopause treatment carried a government warning1. Guideline coauthor Bruce Pier said misconceptions about the risks have made some doctors less willing to prescribe it and some patients less interested in using it3. (Biohack recently covered a study on modern hormone therapy and heart risks.)
The update follows the US Food and Drug Administration’s 2025 decision to change the labels of estrogen products, removing boxed warnings about heart disease, breast cancer and probable dementia4. The FDA announced it would remove the warning from more than 20 pills, patches and creams, and it has since approved updated labels for three more estrogen patches1.
What the guidance does not settle
This is not new research. ACOG says its guideline was based on a systematic review of existing studies, rated using an adapted version of a standard grading system called GRADE, with recommendations labeled by strength and quality of evidence2. Where the evidence was too thin for a formal recommendation, the guideline offers ungraded “good practice points” instead2.
Some questions stay open. According to Hippo’s summary, ACOG says there is not enough evidence to recommend for or against hormone therapy to treat menopause-related depression; people with major depression should be treated under depression guidelines4. The guideline notes some nuance: hormone therapy may improve depressive symptoms around the time of menopause, but in women after menopause, studies have not shown it works better than a placebo (a dummy treatment) for depression4.
Hormone therapy is also not for everyone. The guideline lists medical reasons to avoid it, including past or current breast cancer, heart disease, past blood clots, stroke or heart attack, liver disease and unexplained genital bleeding4. Manson told the AP it is not appropriate for all women but is a good option for many1.
Who wrote it
The guideline was developed by ACOG’s Committee on Clinical Practice Guidelines for gynecology together with Bruce Pier, Robert Kauffman and Catherine Cansino2. The writing team included specialists in reproductive hormones and fertility and a Menopause Society Certified Practitioner, and two authors screened the studies against set criteria2. The sources read for this article do not describe the authors’ financial ties or how the work was funded.
Hippo’s summary says the update brings ACOG more in line with The Menopause Society’s 2022 position on hormone therapy4. Dr. Stephanie Faubion, medical director at The Menopause Society, told the AP she was glad to see the guidance stress these treatments1.
What to watch next
Supply is one issue. Since the FDA label change, some women have reported trouble getting estrogen patches in certain doses and forms. FDA officials said they are not aware of “an imminent risk of a nationwide shortage” and noted that manufacturers have doubled their output over the past year1.
Next is ACOG’s planned 2027 guidance on vaginal and urinary symptoms of menopause3. Clare also warned about menopause misinformation online and said access to and insurance coverage for evidence-based care is critically important3.
