ACOG Guideline Backs Early Hormone Therapy for Menopause Symptoms

— Updated guidelines join the chorus of clinical consensus on menopause treatment best practices

Updated guidelines from the American College of Obstetricians and Gynecologists (ACOG) expand on previous recommendations and align with a growing cross-specialty consensus on how to manage menopause symptoms.

For managing vasomotor symptoms and related sleep disturbances, ACOG strongly recommended systemic hormone therapy with estrogen and a progestogen for women with a uterus, or estrogen alone for those who do not require endometrial protection. This applies to women without contraindications to hormone therapy and is based on moderate-quality evidence.

Importantly, the guidelines strongly recommended that menopausal hormone therapy be initiated before age 60 or within 10 years of the start of natural menopause for appropriate patients.

ACOG also strongly recommended selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) for managing vasomotor and depressive symptoms, and neurokinin receptor agonists for managing vasomotor symptoms and related sleep disturbances, in menopausal patients contraindicated to hormone therapy. Both of these recommendations are based on moderate- to high-quality evidence.

These guidelines, which replace 2014 guidance, were put together by ACOG's Committee on Clinical Practice Guidelines–Gynecology in collaboration with Bruce Pier, MD, Robert Kauffman, MD, MSCP, and Catherine Cansino, MD, MPH, and were published in Obstetrics & Gynecologyopens in a new tab or window; the entire November issue is dedicated to menopause.

Kauffman noted on a press call that ACOG's review of the evidence found that "menopausal hormone therapy is safe and certainly effective for many newly menopausal women."

JoAnn E. Manson, MD, MPH, DrPH, of Harvard Medical School in Boston and past president of the Menopause Society, told MedPage Today that the timing element is crucial.

Manson, who was not involved in the guidelines, also pointed out that ACOG's recommendations are very similar to the American College of Physicians' recent guidelines,opens in a new tab or window as well as those of other professional societies.

"I think the good news here is that there's a growing consensus among professional societies that menopausal symptoms should be treated and that hormone therapy should be the first-line of treatment," she said, adding that many women suffer in silence through menopausal symptoms.

Between 50% and 92% of women experience hot flashes or night sweats during menopause, and 16% to 66% experience menopause-related sleep disruptions, the ACOG committee noted. Additionally, more than one in three peri- and postmenopausal women report depressive symptoms.

Manson said that menopausal hormone therapy is underutilized, in part because there were black box warnings on several products for two decades based on initial findings from the pivotal Women's Health Initiative (WHI) studyopens in a new tab or window; Manson was one of the investigators on that study.

However, in the decades since, research has helped to paint a better picture of which patients are appropriate candidates and which non-hormonal and nonpharmacological alternatives can support women who shouldn't take hormones.

During the presser, Kauffman said ACOG is "trying to allay this fear that has been out there for the past 20-plus years that menopausal hormone therapy is dangerous, and we're seeing a sort of a paradigm shift in the tone of the various recommendations." Indeed, earlier this year, FDA approved safety warning label changesopens in a new tab or window to several hormone therapy products.

ACOG President Camille Clare, MD, MPH, added that, as menopause awarenessopens in a new tab or window has "grown dramatically in recent years, so has the amount of misinformation."

"That's why ACOG is expanding our focus on menopause this year, increasing the resources available to both ob/gyns and their patients," Clare said on the press call.

The updated guidance focuses on peri- and postmenopausal people assigned female at birth with vasomotor, sleep, and mood symptoms related to natural or induced menopause. ACOG noted in a press releaseopens in a new tab or window that complementary guidance on managing the genitourinary syndrome of menopause will be published in 2027.

"While much of the general principles regarding menopause care, including foundational elements related to the indications and contraindications to these options, have not changed for decades, the availability of newer treatment options to manage menopause-related symptoms is contributing to a renewed interest in menopause education among clinicians," said Cansino during the press call.

For this guideline, the team conducted a literature search on Medline, Ovid, PubMed, and the Cochrane database. They included data from relevant human-only English-language studies conducted in countries ranked "very high" on the United Nations Human Development Index. An exception was made for acupuncture studies from China, which ranked as "high." Studies were published from 2013 to March 2024.

Strong recommendations for a therapy mean that the benefits clearly outweighed harms and burdens, while conditional recommendations indicated that benefits and risks vary by patient characteristics and that individualized, shared decision-making should be utilized.

Gabapentin, cognitive behavioral therapy, mindfulness-based interventions, exercise, clinical hypnosis, and acupuncture all received conditional recommendations for some symptom relief when other preferred therapies are not options.

ACOG also looked at health inequalities, noting that women of color, trans people, and other marginalized groups may have different experiences with menopause symptoms and treatments.