The American College of Obstetricians and Gynecologists (ACOG) has issued its most sweeping update on treating menopause symptoms since 2014, naming hormone therapy the first-line option for hot flashes, night sweats and related sleep problems in women who have no contraindications.
The new guidance, released this month, gives hormone therapy a "strong" recommendation, meaning the group judges that benefits generally outweigh risks for most symptomatic women. ACOG advises starting treatment before age 60 or within 10 years of a woman's final period, when it says the therapy is probably most beneficial, and recommends ongoing check-ins with a doctor rather than the strict dose-and-duration limits urged in 2014. Between half and roughly nine in ten women experience hot flashes or night sweats during menopause, according to the college.
New non-hormonal options
For women who cannot or prefer not to take hormones, the guidance newly endorses two neurokinin-receptor blockers, fezolinetant and elinzanetant, both approved by the Food and Drug Administration in the past three years to treat hot flashes without hormones; it also backs certain antidepressants and gabapentin. Non-drug approaches such as cognitive behavioral therapy and exercise are recommended as complements to medication rather than substitutes, while ACOG explicitly declines to endorse plant-based estrogens and herbal supplements, saying there is no reliable evidence they are safe or effective.
Hormone therapy is still not recommended for women with a history of certain cancers, blood clots, stroke, heart attack, liver disease or undiagnosed abnormal bleeding. Co-author Bruce Pier said the profession has been too cautious for too long.
"Misconceptions about the risks of hormone therapy have affected some clinicians' willingness to prescribe it."
Bruce Pier, ACOG guideline co-author
Harvard Medical School's JoAnn Manson, who was not involved in writing the guideline but studies menopause hormone therapy, said the update reflects a broader shift in medical opinion.
"There's growing consensus among professional societies that menopausal symptoms should be treated."
JoAnn Manson, Harvard Medical School
What's left unresolved
ACOG says the guidance reflects more than a decade of additional research since 2014 showing hormone therapy's risks were often overstated for healthy, recently menopausal women, but the group notes that individual risk still varies by age, health history and family history of breast cancer or blood clots — decisions it says should be made case by case with a physician. The college is also developing a separate, related guideline on genitourinary symptoms of menopause, due out in 2027. Coverage of the update, including NPR's reporting, also notes that supply shortages of some hormone patches have complicated access even as recommendations shift.
