ACOG Issues Expanded Guideline on Managing Menopause-Related Vasomotor, Sleep, and Mood Symptoms

The American College of Obstetricians & Gynecologists (ACOG) has published new clinical guidance on managing menopause-related vasomotor symptoms (VMS), sleep disturbance, and mood symptoms, calling it the organization's most comprehensive menopause guidance to date.¹

Clinical Practice Guideline No. 13, published online October 15, 2026, in Obstetrics & Gynecology, replaces Practice Bulletin No. 141 from January 2014, and covers hormonal, nonhormonal, and nonpharmacologic treatment options.²

“Perimenopause and menopause symptoms can be debilitating, interfering with women’s overall health, their ability to care for their families, and their work and career. Menopause is a normal and natural stage of life, but that doesn’t mean that women must suffer through the symptoms without help,” ACOG President Camille A. Clare, MD, MPH, said in a press release.¹ “It is critically important that women have access to and coverage for evidence-based care, especially as menopause misinformation continues to flourish.”

According to the guidance, 50% to 92% of women experiencing menopause report VMS, 16% to 66% of US women report menopause-related sleep disruption, and approximately 36% of perimenopausal and postmenopausal women worldwide report depressive symptoms.²

Hormone therapy: timing and shared decision-making

ACOG strongly recommends systemic MHT for VMS and vasomotor-related sleep disturbance in patients without contraindications. The guideline specifies estrogen plus a progestogen for patients with a uterus and estrogen alone when endometrial protection is not needed. Conjugated estrogen combined with bazedoxifene is suggested as an alternative to estrogen-progestogen therapy, particularly for patients who want to avoid progestogen-related bleeding or breast tenderness.²

When MHT is chosen, ACOG recommends starting it before age 60 years or within 10 years of the onset of natural menopause. After that window, higher baseline risks of venous thromboembolism (VTE), stroke, and coronary heart disease mean that initiation should be individualized.²

The decision to start MHT should be made through shared decision-making. That discussion should consider the patient's age, medical history, baseline risks of cardiovascular disease, breast cancer, and VTE, and treatment goals.² Guideline coauthor Bruce Pier, MD, noted that "misconceptions about the risks of hormone therapy" have discouraged some clinicians from prescribing it and some patients from considering it.¹

The guideline also notes that in 2025 the FDA recommended removing the boxed warnings for cardiovascular disease, breast cancer, and probable dementia from MHT labeling. It cautions that the Women's Health Initiative findings are difficult to generalize to younger, recently menopausal patients, because nearly two-thirds of participants were 60 years or older.²

Additional practice points for your patients on MHT²:

• Assess efficacy and tolerability 3 months after starting, then every 12 months.
• Evaluate for endometrial intraepithelial neoplasia, atypical hyperplasia, or endometrial cancer if bleeding occurs or persists beyond the first 6 months.
• Individualize decisions on when and how to stop, and counsel patients that symptoms may recur.
• Continue to assess contraception needs until age 55 years.

The evidence was insufficient to recommend for or against MHT for menopause-related depressive symptoms. Patients who meet criteria for major depressive disorder, or whose predominant symptom is depression, should be treated according to depression-management guidelines.²

Nonhormonal pharmacologic options

For patients who cannot or prefer not to use hormone therapy, ACOG strongly recommends SSRIs or SNRIs for VMS and depression. Low-dose paroxetine (7.5 mg/d) is the only antidepressant FDA-approved for VMS, but other agents, including citalopram, escitalopram, venlafaxine, and desvenlafaxine, have also reduced VMS frequency and severity. Fluoxetine and paroxetine generally should be avoided in patients taking tamoxifen.²

ACOG also strongly recommends neurokinin receptor antagonists, which block neurokinin B signaling in the hypothalamic thermoregulatory center²:

• Fezolinetant (Veozah) targets the neurokinin-3 receptor. Its label carries a boxed warning requiring liver function testing at baseline, monthly for the first 3 months, and at months 6 and 9.
• Elinzanetant (Lynkuet) targets both neurokinin-1 and neurokinin-3 receptors and is approved for VMS, with evidence of benefit for sleep. Its label recommends liver function testing before treatment and at 3 months.

Gabapentin is suggested when other recommended nonhormonal options are ineffective or poorly tolerated. Bedtime dosing may help with sleep and limit daytime drowsiness. The guideline does not recommend clonidine as primary treatment and notes that adverse effects limit the use of oxybutynin.²

Nonpharmacologic interventions

ACOG conditionally recommends cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis, and acupuncture for various vasomotor, sleep, and mood symptoms. These approaches can be used alone but are generally recommended alongside hormonal or nonhormonal medications.^1,2

The guideline states that evidence does not support the safety or efficacy of phytoestrogens, such as soy isoflavones, or herbal supplements for menopausal symptoms. ACOG noted that these products are widely marketed but are not regulated by the FDA or tested for safety, efficacy, or purity. Progestogen monotherapy, dehydroepiandrosterone, and testosterone are also not supported for these symptoms.^1,2

Implications for primary care

The guideline emphasizes earlier and more comprehensive patient education so that patients recognize menopausal symptoms and seek treatment sooner.^1,2 It also highlights disparities in menopause care. For example, Black women in the Study of Women's Health Across the Nation (SWAN) had higher symptom burden than White women but were less likely to receive treatment.²

ACOG is developing separate guidance on the genitourinary syndrome of menopause, expected in 2027.¹

References:

1. American College of Obstetricians & Gynecologists. ACOG expands recommendations for management of menopause symptoms. News release. Published October 15, 2026. Accessed October 16, 2026. https://www.acog.org/news/2026/10/acog-expands-recommendations-for-management-of-menopause-symptoms/
2. Management of menopause-related vasomotor, sleep, and mood symptoms. Clinical Practice Guideline No. 13. American College of Obstetricians & Gynecologists. Obstet Gynecol. 2026;148:e345-e369.