THE ARISING · Longevity & Healthspan
ACOG's First Menopause Guideline Since 2014 Strongly Backs Hormone Therapy
For the first time since 2014, the American College of Obstetricians and Gynecologists (ACOG) has updated its guidance on treating menopause symptoms, and it says the safety of hormone therapy is now "well-established."
The guidance was released Thursday, according to NPR. It recommends hormone replacement therapy alongside certain antidepressants, nonhormonal medicines and other treatments for symptoms such as hot flashes, insomnia and mood swings. This is professional guidance, not a new trial.
Catherine Cansino, chair of ACOG's Committee on Clinical Practice Guidelines and a co-author, said the change is "the breadth of options that we now have." She said that allows a more individualized approach.
Timing is a central point. Robert Kauffman, another co-author, said hormone therapy is "probably the best option for symptomatic, newly menopausal women within 10 years of the final menstrual period or before the age of 60." Menopause comes at an average age of 49.9, according to the guidelines. Symptoms can start years before the final period.
The timing window traces back to the Women's Health Initiative. In 2002, that study suggested hormone therapy raised the risk of heart disease, breast cancer, stroke and pulmonary embolism. Researchers later noted limits in the data. Most participants were 60 or older, so the findings were hard to apply to younger women in menopause or perimenopause.
The type of hormone therapy depends on anatomy. For women with a uterus and no contraindications, ACOG supports estrogen combined with progestogen. Estrogen can stimulate growth of the uterine lining and raise endometrial cancer risk, and progestogen helps offset that. For women without a uterus, ACOG recommends estrogen alone. A pill combining estrogen with bazedoxifene, sold as Duavee, is another option.
Reasons to avoid hormone therapy include undiagnosed abnormal genital bleeding. They also include current or past certain gynecologic cancers, blood clots, stroke, heart attack or liver disease, and known or suspected pregnancy.
The guideline also lists nonhormonal drugs. Fezolinetant (Veozah) was approved by the FDA for hot flashes in 2023, and elinzanetant (Lynkuet) in 2025. Both block chemical messengers in the brain region that regulates body temperature and sleepwake cycles. Gabapentin, an anticonvulsant, can help people who cannot tolerate hormones or the new medicines.
Cognitive behavioral therapy, mindfulness, exercise, clinical hypnosis and acupuncture can improve some symptoms, according to ACOG. The guidelines note the evidence for these is weaker than for hormone therapy. Cansino warned against "over-simplifying treatment based on tiers" and said a person who understands the pros and cons can reasonably choose a less effective method.
Demand is already rising. The FDA dropped the black-box warning on certain estrogen products last year, and transdermal patches have been hard to find in pharmacies. Cansino said the shortage shows attention on hormone therapy but not enough on other options. She also cited "a lot of misinformation" about it.
A separate piece we ran October 21 covered FIGO and the International Menopause Society on early menopause. That is different guidance from different bodies, and it adds a focus on women who lose ovarian function early.
What to watch next
How pharmacies and clinics handle the transdermal estrogen shortage as demand grows.