US gynaecologists put hormone therapy first in updated menopause guidelines

“Hormone replacement therapy is now the first line” for vasomotor symptoms including hot flashes, night sweats and sleep issues, said Dr. Kameelah Phillips, an OB-GYN and menopause specialist.

For more than a decade, clinicians had worked from the American College of Obstetricians and Gynecologists' 2014 guidance. Phillips recalled a common response to women seeking help: “Here's an antidepressant. Make sure you work out. Why don't you try a glass of wine?” She said: “All of those were not helpful.”

On 15 October 2026, ACOG released updated menopause-treatment guidelines, its first such update since 2014. The organisation calls them its most comprehensive menopause management guidance to date.

The guidance strongly recommends hormone replacement therapy as the first treatment for women with hot flashes and night sweats who have no contraindications. For women with a uterus, ACOG recommends systemic hormone therapy containing estrogen and a progestogen. It recommends estrogen alone for those who do not require endometrial protection.

ACOG advises starting hormone therapy before age 60 or within 10 years of the start of natural menopause for appropriate patients. Its central message is individual care, with treatment decisions shaped by each patient's symptoms, medical history, risk factors, goals and preferences. The organisation also recommends shared decision-making that considers baseline risks for cardiovascular disease, breast cancer and venous thromboembolism.

There is no single point at which every patient should stop hormone therapy, ACOG said.

The need for treatment can be substantial. ACOG says 50% to 92% of women in menopause experience vasomotor symptoms, including hot flashes and night sweats. It says 16% to 66% of US women report menopause-related sleep disruption.

Steep falls in estrogen and progesterone usually occur in a woman's late 40s or early 50s and cause most menopause symptoms. More than one-third of perimenopausal and postmenopausal women worldwide report depressive symptoms. Low levels of the two hormones can also reduce bone density, raising the risk of osteoporosis or fractures.

For patients who cannot use hormone therapy, ACOG strongly recommends selective serotonin reuptake inhibitors, or SSRIs, and serotonin and norepinephrine reuptake inhibitors, or SNRIs, for vasomotor and depressive symptoms. It also strongly recommends neurokinin receptor agonists for vasomotor symptoms and related sleep disturbances.

The guidelines cover menopausal hormone therapy, nonhormonal medicines and nonpharmacologic treatments. “We're using hormones mainstream now,” Phillips said of the change in clinical practice.