Menopause in Primary Care: Expert Insights From TMS 2026

Vasomotor symptoms (VMS), including hot flashes and night sweats, are the most common symptoms of menopause and occur in up to 80% of menopausal women, according to The Menopause Society.1 For many patients, these symptoms are far from brief. In the Study of Women's Health Across the Nation (SWAN), the median total duration of frequent VMS was 7.4 years, with symptoms often persisting well past the final menstrual period.2

Most midlife women receive their routine care in primary care, which places family physicians and internists on the front line of menopause management. Yet new data presented at the meeting suggest menopause is rarely documented in primary care visits, and clinicians say they often lack the confidence to treat it. To learn how primary care physicians (PCPs) can close these gaps, Patient Care Online sat down with 3 experts at The Menopause Society 2026 Annual Meeting, held October 20-24 in San Diego, California, to discuss menopause diagnosis and prescribing patterns, when night sweats signal something other than menopause, and how to counsel patients starting elinzanetant, a nonhormonal treatment for VMS.

Menopause is underdiagnosed in primary care

“We found that menopause diagnoses are quite rare and don't really correlate to the symptom burden that we know patients experience,” Arina Chesnokova, MD, MPH, assistant professor of obstetrics and gynecology at the University of Pennsylvania, said in an interview with Patient Care Online.

Chesnokova and colleagues analyzed 666 606 outpatient encounters among 109 937 women aged 45 to 60 years in the University of Pennsylvania Health System between January 2022 and April 2026. Only 7.8% of encounters included a menopause-related diagnosis code, and 28.0% of patients had at least 1 such encounter during the study period.3 Menopause was significantly more likely to be coded in OB/GYN than in family medicine (adjusted odds ratio [aOR], 3.88; 95% CI, 3.73-4.04).3

Coding did increase over time, but it remains far below what clinicians would expect given how common symptoms are. “In the first year that we look at in 2022, only about 4% of the time are folks in family medicine, OB/GYN, and internal medicine coding for menopause,” Chesnokova said. “In 2026, we're closer to 12%, but again, it's nowhere close to reflective of the symptomatology that people experience as they undergo the transition.”

As an OB/GYN, Chesnokova said she sees a heavy referral burden, and she believes routine menopause care belongs in primary care. “Primary care delivers way more women's healthcare than we do or will ever be able to do,” she told Patient Care. “Truly, we should exist for folks with contraindications, folks who have tried a couple of things and it's not working…we should be like the second or the third tier of care.”

Disparities in diagnosis

The analysis also found lower rates of menopause coding among racially minoritized and publicly insured patients. Chesnokova pointed to several likely drivers, including bias, a higher burden of comorbidities, and differences in how patients advocate for themselves during visits.

“There's just a lot to take care of in a very short visit,” she said, describing what she heard from primary care colleagues in low-resource settings. “If somebody [isn't] up to date on their mammogram and their Pap and their colon cancer screening, you just don't get there.” Even when menopause care is offered, she added, it may not be accepted if it is not delivered in a way that is culturally sensitive and congruent with a patient's background.

Rising inappropriate prescribing

The study also flagged a safety concern. Among patients with a documented contraindication to hormone therapy (HT), such as a history of breast cancer or venous thromboembolism, 3.8% received HT or combined hormonal contraception at the index encounter. That rate rose from 3.2 per 10 000 encounters in 2022 to 14.8 in 2025 and 23.1 through April 2026.3

“The raw numbers are still really small,” Chesnokova said. “There's more prescriptions being written, true, but there's also more prescriptions being written that are inappropriate. And so I just want to caution people…that this isn't a benign engagement necessarily.”

Building a pathway, with a human “cushion”

After the quantitative analysis, Chesnokova's team interviewed close to 30 primary care clinicians about why they don't provide more menopause care. Nearly all wanted to do more, she said, but felt they “fumble and don't feel confident” when patients ask for help.

What clinicians requested was a simple, evidence-based algorithm built into the electronic health record. Chesnokova's team is preparing to launch a menopause pathway in Epic, built with AgileMD, that walks clinicians through whether a patient has a uterus, her age, her breast cancer risk, and any contraindications to HT, ending in an easy-to-place order and prewritten patient education.

An algorithm alone isn't enough, however. “I would love to do more of it, but sometimes I have a question,” Chesnokova said, paraphrasing what she heard from clinicians. “The algorithm can't exist by itself without…a little bit of a cushion, human cushion as well.”

The work was part of a larger federally funded learning health system grant, a portion of which never arrived, according to Chesnokova, who said she is continuing the project “a little bit on a shoestring.” Once the pathway is tested in her health system, she hopes to make it available to other health systems.

Check out our full interview with Dr Chesnokova for more on menopause diagnosis and prescribing in primary care.

When night sweats aren't menopause

Once menopause is on the clinical radar, the next challenge is recognizing when it is not the explanation. At the meeting, Cheryl Cox Kinney, MD, FACOG, MSCP, president of The Menopause Society and director of the Dr. Cheryl Kinney Center for Female Health and Hormone Disorders in Dallas, Texas, presented “Night Sweats: What If It's Not Menopause?”

Kinney was quick to note that, for most midlife patients, menopause is the right answer. “Most clinicians, when they see a midlife patient who's complaining of hot flashes and night sweats—it is going to be menopause,” she said in an interview with Patient Care Online. “It's only when the scenario is out of line with what we know is kind of a menopause construct that your antennas need to go up.”

According to Kinney, the following features should prompt clinicians to look beyond estrogen deprivation:

• Symptoms that return years after stopping HT. A woman in her 60s or 70s who stopped HT 6 to 10 years ago and has been symptom-free should be evaluated for another cause if night sweats reappear.
• Rapid onset and severe, drenching sweats that soak bedclothes and sheets.
• High-risk accompanying signs, including fever, lymphadenopathy, and weight loss.
• No improvement with VMS treatment.

“Those symptoms really prompt a full, aggressive evaluation for causes other than estrogen deprivation,” Kinney told Patient Care.

When night sweats persist despite treatment, Kinney recommends being direct with patients: “You need to say, ‘We would have expected improvement by now, so we need to start looking for things other than menopause as a cause of your night sweats.’”

When there's more than one cause

Night sweats in midlife may also have overlapping causes, such as menopause plus a medication or a sleep disorder. The first task is determining whether menopause explains the full picture, which can usually be done with a history and physical examination, Kinney said.

In select cases, however, laboratory testing can help. “Most menopause providers don't draw blood tests routinely or hormone tests routinely, but this is one of the cases where an estrogen blood test is very helpful,” Kinney explained. “If we draw the estrogen blood test and the patient's estrogen level is in the normal range, she's on treatment, we know it's adequate. We automatically start thinking of what other things could be causing this, and the number one thing we usually look at for midlife women are their medications.”

Check out our Q&A and video interview with Dr Kinney for more on evaluating night sweats in midlife women.

Elinzanetant: setting expectations with a nonhormonal option

For patients whose symptoms are due to menopause but who cannot or prefer not to use HT, nonhormonal options continue to expand. In October 2025, the FDA approved elinzanetant (Lynkuet, Bayer) for moderate to severe hot flashes due to menopause. According to the manufacturer, it is the first FDA-approved therapy to target both the neurokinin-1 (NK1) and neurokinin-3 (NK3) receptors.4 Its approval was supported in part by the phase 3 OASIS-1 and OASIS-2 trials, which showed reductions in VMS frequency and severity, along with improvements in sleep disturbances and menopause-related quality of life vs placebo.5

At this year's meeting, JoAnn V. Pinkerton, MD, MSCP, of University of Virginia Health, presented several post hoc analyses of the OASIS trials. “Now we want to know who else does it work for,” Pinkerton said in an interview with Patient Care Online.

Efficacy in US women, sleep, and late perimenopause

In a pooled analysis of 410 US participants from OASIS-1 and OASIS-2, 66.9% of women receiving elinzanetant achieved at least a 50% reduction in VMS frequency by week 12, compared with 40.5% of those receiving placebo.6 “A 50% reduction in hot flushes is considered clinically meaningful,” Pinkerton said. “By 26 weeks, it was 75% of women [who] had at least a 50% response, and about 30% had a 90% response, which is pretty dramatic and very similar to what we see with hormone therapy.”

In a separate sleep analysis, the proportion of women reporting poor or very poor sleep quality fell from 65.6% to 20.5% with elinzanetant, vs from 57.8% to 38.7% with placebo.7 “These women were not enrolled because of sleep disturbances; they were enrolled because of hot flushes,” Pinkerton noted, adding that the difference was clinically meaningful.

Pinkerton also presented findings in late perimenopause, a group in which few nonhormonal therapies have been studied. In a small post hoc analysis of 32 women classified as late perimenopausal using STRAW+10 criteria, results for hot flash frequency and severity, sleep, and quality of life were consistent with those of the overall trial populations.8 No statistical testing was performed, and Pinkerton acknowledged that the sample “limits the generalizability,” but called the findings encouraging for a future randomized trial in this population.

Counseling on adverse effects

Headache, fatigue, and somnolence were the most common treatment-emergent adverse events in a pooled safety analysis of 1 phase 2 and 3 phase 3 trials (n = 765 receiving elinzanetant 120 mg; n = 754 receiving placebo).9

Through 12 weeks, headache occurred in 7.6% of women receiving elinzanetant vs 4.4% of those receiving placebo, fatigue in 5.4% vs 1.3%, and somnolence in 3.4% vs 4 events in the placebo group (cumulative incidence was not estimated for fewer than 5 events). Among women receiving elinzanetant, 73.7% of headache events, 43.9% of fatigue events, and 73.1% of somnolence events resolved within 12 weeks of onset.9

Most first-time events occurred within 2 weeks of starting treatment, and all were mild or moderate in intensity except for 1 severe headache.9 In a separate phase 1 study of 64 healthy women aged 40 to 65 years, elinzanetant taken at bedtime showed no clinically relevant next-morning effects on simulated driving performance.10

“Providers need to talk about the most common side effects, which…include fatigue and headache and somnolence,” Pinkerton told Patient Care. “What's important is that these did improve over time…women, if they know that they might have these side effects, are going to be able to tolerate them, realizing that they're going to improve over time.”

When to expect relief

Pinkerton emphasized that patients may notice benefit quickly, with continued gains over months. “Patients should expect very rapid improvements within a week in their hot flushes, but then they're going to have continued improvements over time, so that at 4 weeks, and 12 weeks, and at 26 weeks, and even at 52 weeks, we're going to see this continued improvement,” she said. “Most of the nonhormonals take 2 to 6 weeks to work.”

For patients with a slower response, she advised patience on both sides of the exam table: “Their providers need to be patient, just to say this is going to get better over time.”

Check out our interview and video with Dr Pinkerton for more on counseling patients starting elinzanetant.

A note to primary care

Across all 3 interviews, a common message emerged: PCPs are well positioned to manage most menopause care, as long as they know when a presentation falls outside the expected pattern and when to ask for help.

For clinicians who don't yet feel confident, Chesnokova offered reassurance. “I know that folks feel inadequate in the space. That's what we heard over and over and over again from primary care docs, and that's okay,” she told Patient Care Online. “It's actually better to feel like you don't know and to still send somebody to a place where they can get evidence-based care…I would hate for people to scrounge something together just because they feel desperate or don't want to admit a gap in their knowledge.”

References

1. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573-590. doi:10.1097/GME.0000000000002200
2. Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539. doi:10.1001/jamainternmed.2014.8063
3. Chesnokova A, Bayes B, Blady S, Hamm R. Patterns of menopause diagnosis and prescribing in a large academic health system. Abstract P-19. Presented at: The Menopause Society 2026 Annual Meeting; October 20-24, 2026; San Diego, CA.
4. Bayer. FDA approves Lynkuet (elinzanetant). News release. October 24, 2025. [Editor: add Bayer press release URL and access date]
5. Pinkerton JV, Simon JA, Joffe H, et al. Elinzanetant for the treatment of vasomotor symptoms associated with menopause: OASIS 1 and 2 randomized clinical trials. JAMA. 2024;332(16):1343-1354.
6. Pinkerton JV, Tough DeSapri K, Clark A, et al. Proportion of postmenopausal participants achieving ≥50% reduction in moderate-to-severe vasomotor symptom frequency with elinzanetant: pooled US population data from OASIS-1 and OASIS-2. Abstract S-5. Presented at: The Menopause Society 2026 Annual Meeting; October 20-24, 2026; San Diego, CA.
7. [Editor: add sleep quality abstract citation]
8. [Editor: add late-perimenopause subgroup abstract citation]
9. Simon JA, Nappi RE, Maki PM, et al. Headache, fatigue, and somnolence as adverse events across elinzanetant's clinical trials: a pooled safety analysis. Abstract S-3. Presented at: The Menopause Society 2026 Annual Meeting; October 20-24, 2026; San Diego, CA.
10. Francke K, et al. [Editor: add full title] Clin Transl Sci. 2025;18(7):e70282.