ACOOG Endorses National Guidance on the Management of Menopause Symptoms
ACOOG Endorses National Guidance on the Management of Menopause Symptoms
ACOOG endorses ACOG Clinical Practice Guideline No. 13, Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms.
Statement
The American College of Osteopathic Obstetricians and Gynecologists (ACOOG) has reviewed and endorses Clinical Practice Guideline No. 13, Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms, published by the American College of Obstetricians and Gynecologists (ACOG) on October 15, 2026, in Obstetrics & Gynecology.
The guideline replaces Practice Bulletin No. 141 (2014). It provides an evidence-based framework for evaluating and treating hot flashes, night sweats, sleep disturbance, and mood symptoms during perimenopause and menopause.
ACOOG supports the guideline's emphasis on early patient education, shared decision-making, and access to the full range of hormonal, nonhormonal, and nonpharmacologic treatment. These principles align with the osteopathic approach to care, which treats each patient as a whole person.
ACOOG encourages its members to incorporate these recommendations into clinical practice and to discuss menopause symptoms with every midlife patient.
Clinical significance
Menopause symptoms are common and affect health, work, and daily function. According to the guideline:
- 50% to 92% of women in menopause report vasomotor symptoms.
- 16% to 66% of women in the United States report menopause-related sleep disruption.
- About 36% of perimenopausal and postmenopausal women worldwide report depressive symptoms.
Treatment gaps persist. In the Study of Women's Health Across the Nation (SWAN), Black women reported a higher symptom burden than White women and were less likely to receive treatment.
Guideline highlights
About this summary
The highlights below summarize selected recommendations from ACOG Clinical Practice Guideline No. 13. They do not reproduce the guideline and omit its full evidence review and clinical detail. For complete clinical guidance, refer to the original document.
Menopausal hormone therapy (MHT)
- Systemic MHT is strongly recommended for vasomotor symptoms and related sleep disturbance in patients without contraindications.
- Patients with a uterus receive estrogen plus a progestogen. Patients without a uterus receive estrogen alone. Conjugated estrogens with bazedoxifene are suggested as an alternative to estrogen-progestogen therapy.
- When MHT is chosen, initiation is recommended before age 60 or within 10 years of the onset of natural menopause. Initiation outside this window requires individualized assessment of risk for venous thromboembolism, stroke, and coronary heart disease.
- Treatment decisions follow shared decision-making based on age, medical history, baseline risks of cardiovascular disease, breast cancer, and venous thromboembolism, and patient goals.
- The guideline notes the 2025 U.S. Food and Drug Administration (FDA) recommendation to remove boxed warnings for cardiovascular disease, breast cancer, and probable dementia from MHT labeling.
Monitoring and discontinuation
- Assess efficacy and tolerability 3 months after initiation, then every 12 months.
- Evaluate for endometrial intraepithelial neoplasia, atypical hyperplasia, or endometrial cancer when bleeding occurs or persists beyond the first 6 months.
- Individualize decisions on discontinuation and counsel patients about possible symptom recurrence.
- Continue to assess contraception needs until age 55.
Nonhormonal pharmacologic treatment
- Neurokinin receptor antagonists (fezolinetant and elinzanetant) are strongly recommended for vasomotor symptoms. Both require liver function testing according to product labeling.
- Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are strongly recommended for vasomotor and depressive symptoms. Fluoxetine and paroxetine generally should be avoided in patients taking tamoxifen.
- Gabapentin is suggested when other recommended nonhormonal options are ineffective or poorly tolerated.
- Clonidine is not recommended as primary treatment. Adverse effects limit the use of oxybutynin.
Nonpharmacologic interventions
- Cognitive behavioral therapy (CBT), mindfulness-based interventions, exercise, clinical hypnosis, and acupuncture are conditionally recommended for vasomotor, sleep, and mood symptoms.
- These interventions are generally recommended in combination with hormonal or nonhormonal medication.
Treatments not supported by evidence
- Phytoestrogens, including soy isoflavones, and herbal supplements. These products are not regulated by the FDA or tested for safety, efficacy, or purity.
- Progestogen monotherapy, dehydroepiandrosterone (DHEA), and testosterone for vasomotor, sleep, or mood symptoms.
Mood symptoms
Evidence is 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.
Forthcoming guidance
ACOG is developing complementary guidance on the genitourinary syndrome of menopause (GSM), expected in 2027. ACOOG will review this guidance upon publication.
The need for clinician education
Guidelines improve care only when clinicians apply them. In 2024, ACOOG published a national needs assessment in the Journal of Osteopathic Medicine examining how OB/GYN and primary care clinicians manage menopausal vasomotor symptoms. The study surveyed 349 clinicians from 45 states and found:
- Only 57% of clinicians raise vasomotor symptoms with all patients of appropriate age. About 20% wait for the patient to bring them up.
- More than 70% agreed their patients view vasomotor symptoms as a normal part of aging and do not report them. A similar share agreed fear of hormone therapy keeps patients from accepting treatment.
- Clinicians rated their current ability below their desired ability on every treatment competency, including discussing risks and benefits and selecting route and dose.
- The largest gap involved identifying ethnic, cultural, and social factors affecting patients.
These findings align with the new guideline's call for earlier patient education, shared decision-making, and attention to disparities in care. ACOOG remains committed to closing these gaps through continuing medical education for physicians at every career stage.
Continuing Medical Education
Related CME activities
ACOOG CME HQ offers continuing medical education (CME) on menopause and midlife care, updated as new guidance becomes available.
References
- American College of Obstetricians and Gynecologists. Management of menopause-related vasomotor, sleep, and mood symptoms. Clinical Practice Guideline No. 13. Obstet Gynecol. 2026;148:e345-e369. View the guideline
- American College of Obstetricians and Gynecologists. ACOG expands recommendations for management of menopause symptoms. News release. October 15, 2026. Read the release
- Hubka TA, Crim A, Koh JY, et al. Uncovering gaps in management of vasomotor symptoms: findings from a national need assessment. J Osteopath Med. 2024. doi:10.1515/jom-2024-0011. Read the article
Disclaimer
This statement provides a summary for educational purposes only. It is not a substitute for the original guideline, which remains the authoritative source for complete recommendations, evidence ratings, and clinical detail. Patient care should be individualized. Physicians should apply their own clinical judgment based on each patient's history, preferences, and circumstances. This statement does not constitute medical or legal advice and does not establish a standard of care.
American College of Osteopathic Obstetricians and Gynecologists
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