The American College of Obstetricians and Gynecologists issued updated clinical guidance Thursday recommending hormone replacement therapy as a leading option for women facing hot flashes and night sweats, marking the organization’s first comprehensive update on the topic since 2014.
The guidance, published in the journal Obstetrics & Gynecology, supports systemic hormone therapy for individuals experiencing vasomotor symptoms and related sleep disturbances, provided they do not have specific health risks. The recommendations advise that patients who choose hormone therapy should begin treatment before turning 60 or within 10 years of starting menopause, Contemporary OB/GYN reported.
For patients with a uterus, the group recommends pairing estrogen with a progestogen to guard against endometrial cancer, while prescribing estrogen alone for women who have had a hysterectomy. Roughly half a million women in the U.S. undergo hysterectomies annually, according to NPR.
Revisiting decades of safety questions
The updated recommendations represent a notable shift from decades of caution that followed a 2002 Women’s Health Initiative study. That earlier trial raised alarms by linking hormone therapy to elevated rates of breast cancer, stroke, heart disease and blood clots. However, researchers later determined that because the vast majority of trial participants were 60 or older, the conclusions could not be broadly applied to younger women entering perimenopause and menopause, CBS News reported.
Last year, the Food and Drug Administration removed boxed warnings for cardiovascular disease, breast cancer and probable dementia from menopausal hormone product labels, according to Contemporary OB/GYN.
The medical organization cautioned that hormone replacement therapy remains unsafe for certain individuals. Patients with a personal history of breast cancer, heart attack, stroke, blood clots, liver disease or unexplained genital bleeding should avoid hormone therapies, ACOG stated.
Expanding nonhormonal and behavioral therapies
For individuals who cannot safely take hormones or prefer not to use them, the updated guidance highlights several alternative medical and lifestyle treatments. The recommendations strongly endorse neurokinin receptor antagonists, a newer class of drugs that target brain receptors involved in temperature regulation and sleep patterns.
These options include fezolinetant, which received FDA approval in 2023 under the brand name Veozah, and elinzanetant, sold as Lynkuet following its approval in 2025, NPR reported. Both medications require monitoring of liver function during treatment. The guidelines also recommend certain antidepressants, such as selective serotonin reuptake inhibitors, and suggest the anticonvulsant gabapentin when other medications are not suitable.
Beyond prescription drugs, the panel suggested nonpharmacologic interventions, including cognitive behavioral therapy, regular exercise, mindfulness practices, clinical hypnosis and acupuncture to help alleviate sleep disruption and mood changes. While evidence supporting lifestyle adjustments is less robust than clinical data for hormone therapy, specialists emphasized that care plans should be tailored to individual preferences.
Supply issues and upcoming guidance
Surging patient demand has already triggered logistical hurdles. Pharmacies have recently encountered difficulties maintaining stock of transdermal estrogen patches, NPR reported, prompting physicians to urge patients to consider all clinically approved alternatives rather than focusing exclusively on a single delivery method.
An estimated two million women enter menopause each year in the U.S. at an average age of 49.9 years, though symptoms frequently emerge during perimenopause years prior. ACOG indicated that it is currently preparing companion guidelines addressing genitourinary syndrome of menopause, with publication expected in 2027.
