ACOG Updates Menopause Guidelines for Holistic, Individualized Care

The American College of Obstetricians and Gynecologists issued its updated Practice Guideline No. 13 on October 15, 2026. It replaces a 2014 bulletin and provides new recommendations for managing widespread menopausal symptoms like vasomotor episodes and sleep disturbance.

ACOG strongly recommends systemic menopausal hormone therapy for managing vasomotor symptoms and related sleep disturbance in women without contraindications. Treatment should be initiated before age 60 or within 10 years of the start of natural menopause. The guideline supports the combination of conjugated estrogen and bazedoxifene as an alternative to estrogen-progestogen therapy. All decisions must be based on shared decision-making, weighing individual risks, benefits, and medical history.

Guideline Recommends Hormone and Nonhormonal Therapies

For patients who cannot or prefer not to use hormone therapy, ACOG strongly recommends neurokinin receptor antagonists. These FDA-approved agents include fezolinetant and elinzanetant. The organization also strongly recommends selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors for women with vasomotor or depression symptoms. Gabapentin is conditionally recommended when other nonhormonal treatments are ineffective.

For nonpharmacologic intervention, ACOG endorses physical exercise, cognitive behavioral therapy, acupuncture, mindfulness-based interventions, and clinical hypnosis. These can be used alone or alongside medications. The guideline states current evidence does not support phytoestrogens, such as soy isoflavones and herbal supplements, for symptom relief.

Symptoms Are Widespread and Impact Health Equity

Vasomotor symptoms affect 50% to 92% of women in menopause. Between 16% and 66% report menopause-related sleep disruption. More than one-third of perimenopausal and postmenopausal women worldwide report depressive symptoms. ACOG President Camille A. Clare noted these symptoms profoundly affect health, quality of life, and daily functioning. Women spend about one-third of their lives postmenopausal, and untreated symptoms can impact long-term health outcomes.

Vulnerable populations face a greater burden. Black women, sexual minority women, transgender people, and gender-diverse people may experience more severe symptoms and greater difficulty accessing quality care. Significant research gaps persist, especially for groups like breast cancer survivors. Regina Castaneda, a postdoctoral research fellow at Mayo Clinic, said highlighting these inequities and barriers is fundamental to advancing care.

Care Must Be Individualized and Holistic

The guideline urges a holistic approach that looks beyond hot flash management to consider overall health and well-being. It calls for monitoring risks like venous thromboembolism and evaluating persistent unscheduled bleeding. The FDA removed boxed warnings for cardiovascular disease, breast cancer, and probable dementia from hormone therapy labeling in 2025.

ACOG's guidance is broader than some other frameworks, addressing sleep, mood, and offering practical recommendations for therapy initiation and discontinuation. It aligns with recommendations for systemic estrogen as the most effective treatment for vasomotor symptoms but provides a more comprehensive discussion of nonpharmacologic options.

Clinical guidelines should support, not replace, individualized decision-making that reflects each patient’s symptoms, values, and health goals. Expanding patient and clinician education and conducting more high-quality research are necessary to advance menopause care.