ACOG's 2026 Menopause Guideline: What Primary Care Clinicians Need to Know About Hormone Therapy

The American College of Obstetricians & Gynecologists (ACOG) just released a new Clinical Practice Guideline on managing menopause-related vasomotor, sleep, and mood symptoms (Clinical Practice Guideline No. 13, November 2026). It replaces Practice Bulletin No. 141 from 2014, making it ACOG's first full update on menopause symptom management in more than a decade. It also brings ACOG more in line with The Menopause Society's 2022 hormone therapy position statement.

This guideline comes after the major 2025 FDA labeling change to estrogen products, which removed black box warnings for cardiovascular disease, breast cancer, and probable dementia.

Here's what primary care clinicians need to know about what ACOG now says about menopausal hormone therapy (MHT), often called hormone replacement therapy (HRT).

Key Takeaways

• ACOG strongly recommends systemic hormone therapy for hot flashes, night sweats, and vasomotor-related sleep problems in patients without contraindications.

• Start before age 60 or within 10 years of menopause for the most favorable balance of benefits and risks. Starting later is not prohibited but requires individualized shared decision-making.

• There is no set age or duration at which hormone therapy must stop. Discontinuation is individualized.

• Evidence is insufficient to recommend hormone therapy for depressive symptoms. Treat major depression according to depression guidelines.

• Evaluate bleeding that occurs or continues after the first 6 months of hormone therapy.

Does ACOG Recommend Hormone Therapy for Hot Flashes?

Yes. ACOG recommends systemic MHT for vasomotor symptoms (hot flashes and night sweats) and for vasomotor-related sleep disturbance in patients without contraindications. MHT may include estrogen plus a progestogen (if the patient has a uterus) or estrogen alone (if the patient does not have a uterus). Both are strong recommendations based on moderate-quality evidence. (ACOG's guideline uses the term "hot flush" because the sensation typically lasts 1–5 minutes rather than a moment).

In a network meta-analysis cited in the guideline, transdermal estradiol combined with a progestogen was the most effective treatment for reducing hot flash frequency. Oral estrogen–progestogen regimens were also effective but ranked lower.

As an alternative for patients with a uterus, ACOG suggests conjugated estrogen plus bazedoxifene (Duavee®). This is a conditional recommendation based on low-to-moderate–quality evidence. Bazedoxifene is a selective estrogen receptor modulator (SERM) that takes the place of the progestogen and reduces estrogen's stimulation of the endometrium and breast tissue. This makes it a good option for patients who want to avoid the vaginal bleeding and breast tenderness that can come with progestogen use.

Is Hormone Therapy Recommended for Menopause-Related Depression?

ACOG states that the evidence is insufficient to recommend for or against estrogen-progestogen or estrogen-only MHT to treat menopause-related depressive symptoms. Patients who meet diagnostic criteria for major depressive disorder (MDD), or whose predominant symptom is depression, should be treated according to depression-management guidelines. In those patients, SSRIs or SNRIs and cognitive behavioral therapy (CBT) remain first-line.

ACOG acknowledges that there is some nuance here, noting that for perimenopausal patients, MHT may improve depressive symptoms and may enhance the effects of antidepressants. In postmenopausal patients, studies have not shown MHT to be more effective than placebo for depression.

Who Is a Good Candidate for Hormone Therapy?

Decisions about starting MHT should be based on shared decision-making. It should take into account the patient's symptoms, age, medical history, baseline risks of cardiovascular disease, breast cancer, and venous thromboembolism (VTE), and personal treatment goals.

ACOG's guideline includes a clear list of contraindications to menopausal hormone therapy:

1. Undiagnosed abnormal genital bleeding

2. Active or past breast cancer

3. Active or past high-grade or advanced-stage endometrial cancer or uterine sarcoma

4. Active or past low-grade serous ovarian cancer, endometrioid ovarian cancer, or granulosa cell tumors

5. Coronary heart disease

6. Active or past VTE

7. Active or past arterial thromboembolic disease (e.g., stroke or myocardial infarction)

8. Known thrombophilic disorders

9. Hepatic impairment or disease

10. Known or suspected pregnancy

With shared decision-making and in consultation with a gynecologic oncologist, MHT can be considered in patients with a history of early-stage (stage I–II) endometrial cancer or high-grade serous ovarian cancer.

Before starting MHT, clinicians should:

• Estimate cardiovascular risk with a validated calculator. ACOG points to the American College of Cardiology's ASCVD Risk Estimator; the American Heart Association's PREVENT calculator is another validated option.

• Carefully assess personal and family history of VTE, and consider transdermal estrogen. Observational data suggest transdermal estradiol (with or without micronized progesterone) carries a lower VTE risk than oral conjugated equine estrogen with or without medroxyprogesterone acetate.

• Assess breast cancer risk with a validated tool such as the National Cancer Institute's Breast Cancer Risk Assessment Tool or the IBIS (Tyrer-Cuzick) model.

• Assess the continued need for contraception until age 55. Off-label, a 52-mg levonorgestrel IUD can provide both endometrial protection and contraception; replace it after 5 years when used for MHT.

When Should Hormone Therapy Be Started?

ACOG recommends starting MHT before age 60 or within 10 years of the start of natural menopause in patients without contraindications (strong recommendation, low-to-moderate–quality evidence). For most patients with bothersome vasomotor symptoms who are aged 50–59 or within 10 years of menopause onset, and who have no contraindications, the benefits outweigh the risks.

After age 60, or more than 10 years after menopause onset, baseline risks of VTE, stroke, and coronary heart disease (CHD) rise with age. Starting MHT then may further increase those risks, particularly VTE and stroke. However, the guideline does not prohibit starting MHT later. The decision should be based on shared decision-making that reviews the patient's symptoms, treatment goals, and risks of VTE, stroke, and CHD.

What About the Women's Health Initiative and the FDA Boxed Warning?

Much of the safety data on MHT comes from the Women's Health Initiative (WHI). Compared with placebo, estrogen–progestogen therapy (median 5.6 years) was associated with about 5 additional strokes, 10 additional VTEs, and 5 additional invasive breast cancers per 1,000 women. Estrogen alone (median 7.2 years) did not increase invasive breast cancer, but was associated with about 8 additional strokes and 5 additional VTEs per 1,000 women.

ACOG emphasizes important caveats regarding these findings. Nearly 67% of WHI participants were 60 or older, which makes the findings hard to apply to younger, recently menopausal patients, whose absolute cardiovascular risk is very low. The WHI also tested only one regimen: oral conjugated equine estrogen with or without medroxyprogesterone acetate.

The guideline also notes that in 2025 the FDA called for major labeling updates to MHT products. These included removing the boxed warnings for cardiovascular disease, breast cancer, and probable dementia, and adding guidance to start MHT before age 60 or within 10 years of menopause onset.

How Should Bleeding on Hormone Therapy Be Managed?

Vaginal bleeding is one of the most frustrating potential side effects of MHT. ACOG notes that unscheduled bleeding is common in the first 3 months of use. Bleeding that occurs or continues after the first 6 months warrants evaluation for endometrial intraepithelial neoplasia/atypical endometrial hyperplasia and endometrial cancer.

How Often Should Patients on Hormone Therapy Be Followed Up?

Assess efficacy and tolerability 3 months after starting MHT, then review every 12 months for as long as treatment continues, unless an earlier visit is clinically indicated.

Is "Lowest Dose, Shortest Duration" Still the Rule?

For decades, clinicians were taught to use menopausal hormone therapy at the lowest effective dose for the shortest possible time. The new guideline drops that framing. Instead, ACOG says, "The decision about when and how to discontinue MHT should be individualized based on ongoing risk factor assessment and a shared decision-making discussion of the benefits and risks."

The guideline notes that continuing MHT past age 60 may be necessary to manage persistent symptoms that affect quality of life, with routine review of benefits and risks. If you and your patient decide to stop, MHT can be tapered or stopped abruptly. Patients should be counseled that their symptoms may return.

What If My Patient Can't or Doesn't Want to Take Hormones?

For patients who don't want or can't take hormone therapy, ACOG strongly recommends two classes of nonhormonal medication (moderate-to-high–quality evidence):

• Neurokinin receptor antagonists: fezolinetant (Veozah®) and elinzanetant (Lynkuet®), for vasomotor symptoms and vasomotor-related sleep disturbance. Both labels include liver function testing guidance, and fezolinetant carries a boxed warning.

• SSRIs and SNRIs: for vasomotor symptoms and depression. Paroxetine 7.5 mg (Brisdelle®) is the only antidepressant FDA-approved for vasomotor symptoms. Avoid paroxetine and fluoxetine in patients taking tamoxifen.

ACOG suggests gabapentin when those options are ineffective or poorly tolerated.

References

1. American College of Obstetricians and Gynecologists. Management of menopause-related vasomotor, sleep, and mood symptoms. Clinical Practice Guideline No. 13. Obstet Gynecol. 2026;148(5):e345–e369.