For the first time since 2014, the American College of Obstetricians and Gynecologists has updated its guidelines for treating symptoms commonly associated with menopause.
BSIP/Universal Images Group/Getty Images
hide caption
BSIP/Universal Images Group/Getty Images
For the first time since 2014, the American College of Obstetricians and Gynecologists has updated its guidelines for treating symptoms commonly associated with menopause. The group of doctors, known as ACOG, recommends hormone replacement therapy alongside certain antidepressants, nonhormonal medications and other treatments to treat symptoms such as hot flashes, insomnia and mood swings.
“What’s changing is the breadth of options we have now…And the upside is we’re better equipped to be able to take an individualized approach for patients,” said Catherine Cansino, MD, MPH, obstetrician/gynecologist, chair of the ACOG Committee on Clinical Practice Guidelines and co-author of the new guidelines.
The guidelines, released Thursday, focus on specific symptoms of menopause and emphasize that the safety of hormone replacement therapy is now “well established,” Cansino said.
In 2002, the Women’s Health Initiative suggested that hormone replacement therapy increased the risk of heart disease, breast cancer, stroke and pulmonary embolism.
However, when researchers re-examined this data years later, they noticed some limitations (including that a majority of participants were aged 60 or older), making it difficult to generalize the findings to younger women going through menopause or perimenopause.
With more and better studies, doctors are able to review the evidence and make more informed recommendations, Cansino said.
“Hormone therapy is probably the best option for symptomatic, newly menopausal women within 10 years of the last menstrual period or before age 60,” Robert Kauffman, MD, MSCP, co-author of the guidelines, said during a press briefing Thursday.
In addition to hormone replacement therapy, the guidelines highlight new non-hormonal options for treating menopause symptoms, including the drug fezolinetant, branded as Veozah, which the Food and Drug Administration approved to treat hot flashes in 2023, and elinzanetant, branded as Lynkuet, which was approved in 2025.
“What’s so exciting about these treatment options is that they have been specifically studied based on the understanding we have of the physiology of thermoregulation and sleep,” Cansino said.
The drugs work by blocking certain chemical messengers in the part of the brain that regulates body temperature and manages sleep/wake cycles, according to guidelines.
Around 2 million women begin menopause each year. The average age of a postmenopausal woman is 49.9 years, according to the guidelines. However, menopausal symptoms can appear years before a woman’s last period.
The new recommendations support the use of systemic hormone replacement therapy, or HRT, with a combination of estrogen and progestins in women whose uterus has no contraindications to hormones.
Reasons for avoiding hormone therapy include undiagnosed abnormal genital bleeding and a current or past history of certain gynecologic cancers, blood clots, stroke, heart attack, liver disease, or known or suspected pregnancy.
The reason progestins are recommended for women with a uterus is because estrogen can stimulate the growth of the uterine lining and increase the risk of endometrial cancer. Progestin therapy helps mitigate this risk, Cansino explained.
About half a million women undergo hysterectomies each year, and for women without a uterus, ACOG recommends estrogen alone.
As an alternative to estrogen-progestin therapy, ACOG also recommends a pill, sold under the brand name Duavee, that combines estrogen and a medication called bazedoxifene. Bazedoxifene is a “selective estrogen receptor modulator,” which blocks estrogen from acting in certain areas of the body, such as breast tissue, while mimicking the benefits of estrogen on bone density, for example.
Another medication recommended in the new guideline is gabapentin, an anticonvulsant typically used to treat seizures. It can also manage menopausal symptoms in people who cannot tolerate hormones or other new medications.
Cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis, and acupuncture can all improve some symptoms, ACOG says, but the guidelines also note that the evidence for these interventions is weaker than that for HRT.
Still, patients may have their own preferences and goals, Cansino said.
“I live in California and have a practice where many patients don’t necessarily want pharmacological treatment,” Cansino said. So she tends to have a lot of conversations about non-pharmacological treatment options with her patients.
“A healthy diet and regular exercise will be very helpful. So let’s start with that,” then discuss what other interventions to add to the diet, she said.
When asked in a follow-up email whether Cansino was recommending one drug or tool over another, she cautioned against “oversimplifying treatment based on levels.”
Just like with contraception, she noted that patients may choose a certain method, knowing that it is less effective. “As long as they understand the pros and cons, such a decision is perfectly acceptable.”
Meanwhile, demand for HRT is already increasing. Last year, the FDA removed the “black box” from the labels of some estrogen therapies.
In recent months, estrogen products like transdermal patches have been difficult for pharmacies to keep in stock.
“I think the lack of transdermal estrogen therapy highlights the fact that we’re paying all this attention to hormone therapy, and not necessarily enough to other treatment options,” Cansino told NPR.
She also emphasized the need for patients to talk to trusted clinicians about the pros and cons of treatments and to avoid having “tunnel vision” about just one option.
The level of care that obstetrician-gynecologists provide in helping each patient find the right treatment is one of the most important aspects of the new guidelines, Cansino said.
“There’s a lot of misinformation and exaggerated claims about hormone therapy, and some people end up taking risks when they shouldn’t,” she added.
Gn headline
