The American College of Obstetricians and Gynecologists (ACOG) released updated clinical guidelines on Thursday for the treatment of menopause symptoms. This marks the first update to these protocols since 2014, incorporating new medical evidence and nonhormonal drug options for managing symptoms such as hot flashes, insomnia, and mood swings.
The new guidance follows years of shifting medical perspectives on hormone replacement therapy (HRT). In 2002, the Women's Health Initiative reported that HRT increased risks for heart disease, breast cancer, stroke, and pulmonary embolism. However, ACOG noted that subsequent analysis revealed limitations in that study, such as a majority of participants being over age 60, which made it difficult to apply those findings to younger women.
ACOG now recommends hormone therapy as a primary option for symptomatic women who are within 10 years of their final menstrual period or under age 60. For women with a uterus, the guidelines recommend a combination of estrogen and progestogen to mitigate the risk of endometrial cancer. For the approximately 500,000 women who undergo hysterectomies annually, the group recommends estrogen alone.
In addition to hormones, the guidelines highlight newer nonhormonal treatments. These include fezolinetant, approved by the Food and Drug Administration (FDA) in 2023, and elinzanetant, approved in 2025. Other options mentioned include gabapentin, cognitive behavioral therapy, and clinical hypnosis, though ACOG noted the evidence for these interventions is weaker than that for HRT.
For the individual patient, this update signals a shift toward a broader range of pharmaceutical and behavioral options. A person experiencing hot flashes or insomnia may notice their physician offering newer drugs like fezolinetant or elinzanetant, which work by blocking chemical messengers in the brain's temperature and sleep regulation centers. Those who cannot use hormones due to contraindications—such as a history of blood clots, heart attack, liver disease, or certain cancers—will have formalized access to alternatives like gabapentin or bazedoxifene.
The guidelines also address a growing market demand that has already led to supply issues. The FDA recently removed "black-box warnings" from certain estrogen labels, and transdermal patches have recently been difficult for pharmacies to keep in stock. By detailing nonhormonal alternatives, ACOG officials stated they hope to reduce "tunnel vision" regarding a single treatment type. What happens next depends on individual consultations between patients and clinicians to determine personalized treatment plans based on these new standards.