New ACOG guidance expands menopause treatment options

Clinical takeaway: Offer systemic menopausal hormone therapy (MHT) for bothersome hot flashes and related sleep disruption in eligible patients; use SSRIs/SNRIs or neurokinin receptor antagonists when hormones are contraindicated or unwanted. Match treatment to the dominant symptoms, review drug interactions, and arrange liver monitoring when prescribing neurokinin antagonists.

ACOG’s Clinical Practice Guideline No. 13 replaces its 2014 menopause bulletin, addressing vasomotor, sleep, and mood symptoms associated with spontaneous or induced menopause at age 40 or older. The update gives clinicians a broader treatment framework while keeping individualized risk assessment central.

Systemic estrogen remains a recommended treatment for vasomotor symptoms and associated sleep disturbance, with a progestogen added for patients with a uterus. Conjugated estrogen/bazedoxifene is a conditionally recommended alternative to estrogen–progestogen therapy.

For eligible patients choosing MHT, ACOG recommends initiation before age 60 or within 10 years of natural menopause onset, following discussion of cardiovascular, breast cancer, and thromboembolic risks. Assess efficacy and tolerability after 3 months and annually thereafter; persistent or unscheduled bleeding warrants evaluation.

For patients avoiding hormones, SSRIs/SNRIs receive a strong recommendation for vasomotor and depressive symptoms. Paroxetine 7.5 mg/day is FDA-approved for vasomotor symptoms, while other antidepressant regimens are off-label for this indication; generally avoid paroxetine and fluoxetine with tamoxifen because they can impair its conversion to active endoxifen.

Neurokinin receptor antagonists also receive a strong recommendation for vasomotor symptoms and related sleep disruption. Options include fezolinetant 45 mg/day, a neurokinin-3 antagonist, and elinzanetant 120 mg/day, a dual neurokinin-1/3 antagonist.

Liver monitoring differs between these agents: fezolinetant carries a boxed warning for hepatotoxicity and requires testing before treatment, monthly for the first 3 months, and at months 6 and 9. Elinzanetant labeling recommends testing before treatment and at 3 months; headache, fatigue, and somnolence are relevant adverse effects.

Gabapentin is conditionally suggested when other recommended nonhormonal medications are ineffective or poorly tolerated, with bedtime administration potentially helpful when sedation is desirable. Clonidine is not recommended as a primary treatment, and oxybutynin’s anticholinergic effects—including cognitive concerns in older patients—limit its usefulness.

ACOG does not recommend phytoestrogens, herbal supplements, or other dietary supplements because evidence of efficacy and safety remains insufficient.

Hormone therapy should not substitute for depression care: evidence is insufficient to recommend for or against MHT for menopause-related depressive symptoms. Treat major depressive disorder, or presentations dominated by depression, according to depression-management guidelines.

ACOG conditionally supports cognitive behavioral therapy for vasomotor, sleep, and mood symptoms, and mindfulness or exercise for sleep and mood. Clinical hypnosis and acupuncture are additional conditional options, supported by low-quality evidence.

Treatment duration remains individualized rather than dictated by age alone. “Continuation of MHT past age 60 years may be necessary to manage persistent symptoms that affect patients’ quality of life,” the guideline authors write.

What's changed

• Expanded scope: Dedicated recommendations now address menopause-related sleep disturbance and mood symptoms.
• New drug class: Fezolinetant and elinzanetant join recommended nonhormonal treatments, with distinct liver-monitoring requirements.
• Narrower roles: Gabapentin is reserved for failure or intolerance of other recommended nonhormonal drugs; clonidine is discouraged as primary therapy.
• Broader behavioral care: Graded recommendations address CBT, mindfulness, exercise, hypnosis, and acupuncture.

Source: American College of Obstetricians and Gynecologists. (2026 Nov) Obstet Gynecol. Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms