Updated guidance on managing menopause-related vasomotor, sleep, and mood symptoms has been released by the American College of Obstetricians and Gynecologists, providing clinicians with a summary of the most current evidence on hormonal, nonhormonal, and nonpharmacologic options. 

The updated guidance covers the most recent data associated with risks of systemic hormonal therapy, including types that have only become available since the last guideline in 2014, according to Catherine Cansino, MD, MPH, chair of the ACOG Committee on Clinical Practice Guidelines in Gynecology.

“It really hasn’t been until the past couple of years that we’ve accumulated enough evidence to change or clarify guidelines,” Cansino said, noting that much of the science remains the same as in the previous guideline; the newer agents have only become available in the past few years. 

The new data include comparisons of transdermal estrogen with oral estrogen or conjugated estrogen as well as the newly available combination of estrogen and bazedoxifene. The guideline also covers the two nonhormonal neurokinin receptor agonists, fezolinetant and elinzanetant, that the US Food and Drug Administration approved in 2023 and 2025, respectively. 

Those two medications are “game-changers for women who cannot take hormones because not everyone does well on the other nonhormonal alternatives, and these are pretty effective,” said Nanette Santoro, MD, a professor of obstetrics and gynecologist at University of Colorado School of Medicine in Aurora. Santoro was not involved in developing the new guidelines. 

The new clinical practice guideline also incorporates information about supplements and compounded medications that were previously siloed into separate guidance. 

The new guideline “allows us to have an individualized approach for patients and have conversations that are more thoughtful because there are a lot more options,” Cansino said. She added, however, that “just because we have a lot of options doesn’t mean that those options are available to everyone,” and depend on access and insurance issues as well as contraindications. 

Stephanie Faubion, MD, MBA, director of the Mayo Clinic Center for Women’s Health in Jacksonville, Florida, and medical director of The Menopause Society, said she particularly appreciated that the updated guidance addresses more than just management of hot flashes. 

“It also includes sleep and mood, which is super helpful because a lot of guidelines just [discuss] hormones for hot flashes,” Faubion said. She was also glad to see the new guideline did not tier the recommendations, as some other medical societies have done. Tiering can lead pharmacy benefit managers and insurers to make decisions that may have unintended consequences regarding access and cost, she said. 

One thing Faubion would like to have seen more of in the new guideline is how to handle risk assessment and how that plays into clinical decision-making. 

The guideline very appropriately goes into cardiovascular risk assessment and breast cancer risk assessment, and notes different calculators, “but there’s no practical information on what to do with the calculations,” Faubion said. That said, she sees the guidelines as an excellent entry point for many healthcare providers.

“This is fantastic because it gives guidance for clinicians who may not feel comfortable managing menopause and need to know where to start,” Faubion said. “Where it gets complex for clinicians is what you do when they don’t have any contraindications, but maybe they have some cardiovascular risk factors, or they had a mother with breast cancer. That complex decision-making is why menopause management is not a cookie-cutter, black-and-white algorithmic thing.” 

The nuances involved in individualizing treatment for each person can be challenging, she said.

The guideline is another resource that clinicians can use in helping patients navigate the increasingly confusing information environment when it comes to understanding menopause care, Santoro said. 

“We live in a divided society, and this is no different with hormone therapy,” she said, noting that it can be a polarizing topic when the reality is that “everything is a tradeoff.” Every option has risks and benefits, and clinicians play an important role in clarifying those for patients. 

“Putting that into proper perspective with true medical evidence is getting harder and harder because midlife women are being carpet-bombed with information, some of which is high-quality and some of which is extremely low-quality and predatory,” Santoro said. 

Her advice to clinicians trying to maneuver in this morass is to “stay calm and carry on” when talking with new patients. 

“By the time someone comes in who has been reading a lot by one or another social media influencer, they have developed an emotional connection, a relationship with that person that has preceded your visit,” Santoro said, whereas you, the clinician, may be a stranger. 

One of her favorite phrases to use when talking with patients about what they’ve seen or heard online is, “Doesn’t that sound too good to be true?” Simply asking that question goes a long way in helping the patient consider whether what they’ve heard is accurate. 

What’s also key, said Santoro, is directing patients to a variety of evidence-based sites. Instead of pointing only to one source, she recommends they look at information on menopause from the American College of Obstetricians and Gynecologists, The Endocrine Society, The Menopause Society, the International Menopause Society, and evidence-based physician-influencers such as Jen Gunter, MD. 

The guideline used no external funding. Faubion and Cansino reported no relevant financial relationships. Santoro is a consultant for Ansh Labs and is on the scientific advisory board for Astellas, Bayer, Eli Lilly, Menogenix, Novo Nordisk, and Perrigo. 

Tara Haelle has been an independent science/health journalist for over 15 years, with work appearing in over two dozen trade and consumer publications. She is based in Dallas, Texas.