OB-GYNs endorse hormone therapy in first menopause guideline since 2014

Overview

Updated Oct 26

The American College of Obstetricians and Gynecologists published its first menopause guideline update since 2014 on October 15. It makes hormone therapy the first choice for women under 60 or within 10 years of their last period, and it says the evidence does not support herbal or soy-based supplements, which the FDA does not regulate.

Two nonhormonal pills, fezolinetant (Veozah) and elinzanetant (Lynkuet), are now part of the toolkit. A pooled analysis of seven trials with 3,184 women found both eased sleep disruption within four weeks, and elinzanetant had the larger effect at 12 weeks. Australia and New Zealand's obstetricians published their own guideline on October 17.

Why it matters

Women with hot flashes and insomnia can now get hormone therapy first, plus two nonhormonal pills, while herbal remedies get no endorsement.

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Key Indicators

Years between ACOG menopause guideline updates (2014–2026)

The last comprehensive ACOG menopause guidance predates the two new nonhormonal drug approvals.

50–92%

Share of menopausal women reporting hot flashes or night sweats

Wide range reported across studies cited in the new ACOG guidance.

New FDA-approved nonhormonal drugs for hot flashes since 2023

Fezolinetant (Veozah, 2023) and elinzanetant (Lynkuet, 2025) target the brain's temperature-control center.

2.6

Fewer nighttime awakenings at 12 weeks on fezolinetant

Mean reduction from baseline in the Phase 4 OPTION-VMS real-world study, presented at the 2026 IMS World Congress.

3,184

Women in pooled analysis of both nonhormonal drugs

Seven placebo-controlled trials found fezolinetant and elinzanetant improved sleep within four weeks; elinzanetant showed the larger effect at 12 weeks.

Voices

Curated perspectives — historical figures and your fellow readers.

People Involved

Catherine Cansino

Obstetrician-gynecologist and chair of ACOG's Committee on Clinical Practice Guidelines

Co-author of the new menopause guidance

Robert Kauffman

Physician and co-author of the ACOG menopause guideline

Co-author presenting the new guidance

Organizations Involved

American College of Obstetricians and Gynecologists (ACOG)

Medical professional association

Publisher of the new menopause guideline

The United States' main professional association for obstetricians and gynecologists, whose guidance shapes how doctors treat women's health conditions.

American College of Physicians

Medical professional association

The largest medical specialty society in the United States, representing internal medicine physicians.

U.S. Food and Drug Administration

Federal regulator

Approved the two nonhormonal drugs cited in the new guideline

The US agency that approves and regulates drugs and medical devices.

Astellas Pharma

Pharmaceutical company

Markets fezolinetant (Veozah), one of the two nonhormonal drugs in the new guideline

Japanese drugmaker behind the nonhormonal hot flash treatment fezolinetant.

Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)

Medical professional association

Published menopause symptom guidelines on October 17, 2026

The professional body for obstetricians and gynaecologists in Australia and New Zealand.

Timeline

2014 October 2026

8 events Latest: October 17th, 2026 · 4 weeks ago

Tap a bar to jump to that date

October 2026
Australian and New Zealand obstetricians publish menopause guideline
Latest Guideline

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists issued guidance on when to use menopausal hormone therapy, options for women with a history of breast cancer, and annual reviews for women on therapy.
October 17th, 2026
ACOG publishes expanded menopause guideline
Guideline

ACOG releases Clinical Practice Guideline 13, its first menopause update since 2014, endorsing hormone therapy and new nonhormonal options.
October 15th, 2026
ACP endorses hormonal therapy as first-line
Guideline

American College of Physicians publishes its own guideline recommending estrogen-based therapy as first-line for vasomotor symptoms.
October 5th, 2026
Real-world data on Veozah presented at menopause congress
Research

Astellas presented Phase 4 OPTION-VMS data at the International Menopause Society's 2026 World Congress: fezolinetant cut bothersome hot flashes by week 4 and reduced nighttime awakenings by 2.6 on average at 12 weeks.
October 2nd, 2026
Pooled analysis finds sleep benefit from both nonhormonal drugs
Research

A review of seven placebo-controlled trials with 3,184 women found fezolinetant and elinzanetant improved sleep disturbance by four weeks, sustained through 24 weeks, with elinzanetant showing the larger effect.
October 2026
2025
FDA approves second neurokinin receptor blocker
Regulatory

FDA approves elinzanetant (Lynkuet), adding another nonhormonal option for hot flashes.
2025
2023
FDA approves first new-class hot flash drug
Regulatory

FDA approves fezolinetant (Veozah), a nonhormonal treatment for hot flashes.
2023
2014
ACOG last updates menopause guidance
Guideline

ACOG's prior comprehensive menopause management guidance, the baseline for the 2026 overhaul.
2014

Scenarios

Hormone therapy prescriptions climb as doctors shed post-2002 caution

Likely Resolves by Oct 15, 2027

Discussed by: ACOG and ACP guideline authors, who argue benefits outweigh risks for recently menopausal women

Backed by two major medical societies, physicians prescribe hormone therapy more freely to women under 60 or within 10 years of menopause. Growth would show up first in national prescription claims data within a year.

Veozah and Lynkuet become widely covered, routine options

Possible Resolves by Oct 15, 2027

Discussed by: ACOG guideline authors, who cite both drugs as new nonhormonal alternatives

The guideline's endorsement pushes insurers and Medicare to cover fezolinetant and elinzanetant without prior authorization, making them routine alternatives for patients who cannot take hormones. Resolution would appear in formulary listings.

Coverage gaps and lingering caution keep access uneven

Possible Resolves by Oct 15, 2028

Discussed by: Observers noting that past guideline updates took years to change real-world practice

Despite the endorsement, cost barriers, clinician reluctance and gaps in insurance coverage slow adoption. A survey of practicing OB-GYNs would reveal whether the guideline changed routine prescribing or mostly reinforced existing practice.

Head-to-head trial settles which nonhormonal drug works better for sleep

Possible Resolves by End of 2028

Discussed by: Researchers who pooled seven fezolinetant and elinzanetant trials, who said direct comparisons are still needed

The pooled analysis found elinzanetant produced larger sleep improvements than fezolinetant at four and 12 weeks, but no trial has compared the two drugs directly. Until one does, the comparison rests on indirect evidence from separate placebo-controlled studies.

Historical Context

2 moments from history that rhyme with this story — and how they unfolded.

July 2002

Women's Health Initiative trial halted (2002)

A landmark US government-funded trial was stopped early when combined estrogen-progestin therapy showed increased risks of breast cancer, heart attack, stroke and blood clots. Hormone therapy prescriptions in the United States plummeted in the years that followed.

Then

Doctors stopped prescribing HRT broadly and millions of women stopped taking it.

Now

Two decades of caution followed, with later analysis finding risks depended heavily on a woman's age when she started therapy.

Why this matters now

The new ACOG guideline directly confronts this legacy, declaring hormone therapy safety 'well-established' when started within 10 years of menopause or before age 60.

2014

ACOG's previous menopause guidance (2014)

ACOG last published comprehensive menopause management guidance, reflecting the conservative approach to hormones that followed the 2002 Women's Health Initiative findings.

Then

The guidance governed US menopause practice for 12 years.

Now

During that period the FDA approved the first nonhormonal drugs in a new class for hot flashes.

Why this matters now

The October 2026 update replaces this 2014 baseline with a broader, more individualized treatment approach.