New Menopause Treatment Guidelines ‘Correct’ a Treatment Concern That Left Many Women Underserved

Menopause has been a hot topic for years, but guidance around the best and safest ways to treat symptoms has been lagging, both for providers and patients. Now, the American College of Obstetricians and Gynecologists (ACOG) has released its first major update to menopause guidance since 2014 in an effort to close that gap.

What’s new? The update expands on previous recommendations and strongly recommends hormone therapy as a first-line treatment for symptoms of menopause. It also addresses nonhormonal treatments for women who don’t want to use hormonal therapies or have contraindications to them.

Doctors who treat women in menopause say the update is overdue. “For more than two decades, many women have been told to avoid hormone therapy or to suffer through menopause,” says Brittany Katz, M.D., director of menopause and midlife health for the Katz Institute for Women’s Health in Westchester. “That left a generation of women undertreated and many clinicians hesitant to prescribe.”

The new guidance “corrects” that concern by clearly laying out the current evidence regarding its favorable safety profile, Dr. Katz says. “It also recognizes that hot flashes, night sweats, sleep disruption, and mood changes are real medical symptoms that affect women’s health, work, and families and deserve treatment,” she adds.

Lauren Streicher, M.D., a clinical professor of obstetrics and gynecology at the Northwestern University Feinberg School of Medicine in Chicago, says that the update was needed years ago. “We need appropriate guidelines. This echoes what menopause experts have been doing for years,” she says. “Everyone is excited about this, but it’s like telling a psychiatrist that you finally learned to prescribe antidepressants—we know it’s important.”

But doctors say the guidelines are still needed. “Ultimately, these recommendations help establish a more consistent standard of care,” says Jessica Shepherd, M.D., ob/gyn and author of Generation M. “Women deserve to be informed about their options, have their symptoms taken seriously, and participate in decisions about their health.”

Here’s what the updated guidelines recommend, plus what doctors who treat women in menopause want patients to keep in mind.

Meet the experts: Lauren Streicher, M.D., a clinical professor of obstetrics and gynecology at the Northwestern University Feinberg School of Medicine in Chicago; Brittany Katz, M.D., director of menopause and midlife health for the Katz Institute for Women’s Health in Westchester; Sherry Ross, M.D., ob/gyn and women’s health expert at Providence Saint John’s Health Center in Santa Monica, Calif.; Jessica Shepherd, M.D., ob/gyn and author of Generation M.

What do the updated menopause treatment guidelines say?

First, they address how common it is for women to experience disruptive symptoms during menopause. Per the report, 50% to 92% of women say they have vasomotor symptoms like hot flashes and night sweats, and 16% to 66% experience menopause-related sleep disruptions. The guidelines also note that more than a third of women in perimenopause and postmenopause experience symptoms of depression.

Then the updated guidance goes on to address what providers and patients can do about it:

• Hormone therapy use should be based on shared decision-making that considers the patient’s symptoms, along with the possible risks and benefits based on factors like their age, medical history, and potential risks of conditions like cardiovascular disease, breast cancer, and venous thromboembolism.

• Hormone therapy should be started before age 60 or within 10 years of the start of menopause in people who are able to use hormones.

• Hormone therapy is considered a first-line treatment for symptoms of menopause, including hot flashes.

• Nonhormonal pharmacologic options are available for people who don’t want to use hormones. The guidance recommends using a specific class of drugs called neurokinin receptor antagonists (including fezolinetant and elinzanetant) for vasomotor symptoms. Antidepressants like SSRIs and SNRIs are also available for vasomotor symptoms and depression.

• Certain therapies may be helpful for sleep and mood, including cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis, and acupuncture. These can be used alone or with hormonal or other medications.

• Evidence does not support the use of phytoestrogens or herbal supplements for symptoms of menopause. These are a potential risk to health and are not regulated by the FDA, ACOG points out.

• Women should talk to their doctor before discontinuing hormone therapy. This conversation should include potential risks and benefits of stopping hormone therapy.

Why is hormone therapy considered a first-line treatment?

Hormone therapy has had a rocky history in the U.S. In 2002, preliminary results from the Women’s Health Initiative (WHI) clinical trial suggested that hormone therapy used to treat symptoms of menopause was linked to a higher risk of developing breast cancer, stroke, and heart disease. As a result, the clinical trial was stopped and use of hormone therapy for menopause plummeted.

Since then, research has found flaws or limitations in that original study, including the older age of participants and the particular formulations of HRT analyzed. Many studies released since have found that hormone therapy in menopause offers plenty of perks for women, like better bone density and heart health. In a follow-up analysis released in 2024, the original WHI trial investigators concluded that hormone therapy is a safe and effective treatment for menopause symptoms.

Many menopause care providers have been using hormone therapy as a first-line treatment for symptoms of menopause for years, but ACOG’s guidance now provides information for all healthcare providers, including primary care physicians. “It works better than anything else we have,” Dr. Katz says. “This is particularly true for insomnia and brain fog.”

ACOG’s guidance gave hormone therapy a “strong” recommendation for vasomotor symptoms—hot flashes and night sweats—and the insomnia they cause, “meaning that for most healthy women with these symptoms, the benefits outweigh the risks,” Dr. Katz says.

Still, she says that hormone therapy isn’t for everyone. “The decision should be individualized, but for appropriate candidates, it should be offered first, not as a last resort,” Dr. Katz says. As Dr. Streicher adds, “It is the safest and most effective way to treat hot flashes and vasomotor symptoms.”

Of course, “this is not a recommendation to prescribe hormones universally,” Dr. Shepherd says. “Treatment must be individualized.”

Timing for beginning hormone therapy is important for a few reasons.

The risk-benefit balance is best when hormone therapy is started before age 60 or within 10 years of the start of menopause, Dr. Katz says. “Women in that window are less likely to have underlying cardiovascular disease, and the risks seen in older women who started hormones later in life don’t apply in the same way,” she says.

While that group carries less risk, it doesn’t mean women outside it can’t begin hormone therapy. Dr. Streicher stresses that women can still start hormone therapy outside of that 10-year window—it just might not be quite as advantageous as it would be if it began earlier. “A lot of people think that they missed the boat,” she says. “The reality is that they may have fewer benefits and they may be at higher risk.”

Dr. Katz flags that ACOG has also moved away from the old “lowest dose for the shortest time” rule. “There’s no arbitrary stopping point; duration should be revisited with each woman based on her symptoms, health history, and goals,” Dr. Katz says.

Nonhormonal therapies are important to address, according to doctors.

Not everyone can use hormone therapy or wants to. “Hormone therapy cannot be given to women with a history of blood clots, stroke, or certain breast cancers, so nonhormonal options are welcomed by this group who have fewer treatment options,” says Sherry Ross, M.D., ob/gyn and women’s health expert at Providence Saint John’s Health Center in Santa Monica, Calif.

Nonhormonal medications, including Veozah, Lynkuet, SSRIs, and SNRIs are now recommended by ACOG. “It’s exciting to have effective alternatives for treating disruptive hot flashes beyond hormone therapy,” Dr. Ross says.

Dr. Streicher stresses that these medications are FDA-approved, safe, and shown to be effective.

Ultimately, doctors say it’s crucial to speak with your healthcare provider about your options if you’re dealing with uncomfortable symptoms of menopause. “Every woman can find a treatment that fits her needs,” Dr. Katz says.

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