New Guidance Offers Updated Approach to Menopause Symptom Management

The American College of Obstetricians and Gynecologists (ACOG) has issued new guidance on managing menopause symptoms, marking the first update in over a decade. The recommendations address disruptive issues such as hot flashes, night sweats, and sleep changes, emphasizing the importance of both hormone therapies and nonhormonal treatments.

Menopause is defined as 12 consecutive months without a menstrual period, typically occurring around age 50 in the U.S. The preceding phase, perimenopause, is characterized by a sharp decline in estrogen and progesterone production. These hormonal shifts can lead to significant symptoms, with over half of women experiencing vasomotor issues like hot flashes and night sweats, and as many as two-thirds reporting sleep disruption. Depressive symptoms are also reported by over a third of women worldwide during perimenopausal and postmenopausal stages.

Historically, many women have suffered in silence, but there is a growing consensus that these symptoms warrant treatment. "We would love our patients to go to their OB-GYNs regarding questions about menopause and really advocate for getting the treatment that they need," said Dr. Camille Clare, ACOG president. "It's undisputed that hormone therapy is the first line and most effective therapy for hot flashes," added Dr. Stephanie Faubion, medical director at The Menopause Society.

Hormone therapies, which include estrogen and progestin in pills, patches, sprays, gels, and vaginal rings, are highlighted as a primary treatment. These therapies deliver hormones into the bloodstream to alleviate symptoms like hot flashes. For women experiencing primarily vaginal dryness, low-dose vaginal estrogen therapy is often prescribed.

The use of hormone therapy has seen renewed interest following the removal of federal safety warnings. In 2002, a major study linked combined estrogen and progestin therapy to increased risks of breast cancer and blood clots, leading to a long-standing boxed warning on menopause treatments. However, subsequent research indicated that for many women, the benefits of current hormone therapies outweigh the risks. Last year, the Food and Drug Administration (FDA) announced it would remove the boxed warning from over 20 hormone-based treatments. This year, the FDA approved updated labeling for three additional estrogen-based patches.

Despite the updated guidance and labeling, some women have reported difficulties obtaining certain estrogen patches. The FDA has stated it is unaware of an imminent nationwide shortage, noting that manufacturers have doubled their output of these products over the past year. Officials are working to ensure an adequate supply.

For women who cannot or choose not to use full-body hormonal medications, ACOG's guidance details alternative options. These include nonhormonal prescription medications like fezolinetant and elinzanetant, which target the brain's temperature regulation to reduce hot flashes. Certain antidepressants can also help manage hot flashes and depressive symptoms.

The updated guidance also acknowledges evidence supporting non-drug treatments, such as cognitive behavioral therapy, mindfulness, exercise, clinical hypnosis, and acupuncture. These approaches can be used independently or in conjunction with medications.

ACOG recommends that decisions about hormone therapy be made jointly by doctors and patients, considering individual benefits, risks, age, and medical history. Treatment is generally advised to begin before age 60 or within 10 years of menopause onset.

"Women have options. They have lots of options, hormonal and nonhormonal," Faubion said. "They shouldn't be told that nothing can be done about their symptoms. Because again, we have evidence for many different things that can help."