ACOG Issues New Menopause Guidelines, Drops 'Lowest Dose, Shortest Time' Rule for Hormone Therapy

The American College of Obstetricians and Gynecologists released its most detailed menopause management guidelines to date on October 15, 2026, making a significant shift in how hormone therapy is recommended.

The new guidance strongly supports menopausal hormone therapy as a first-line treatment for vasomotor symptoms such as hot flashes and night sweats, as well as sleep disturbances. ACOG recommends that therapy begin before age 60 or within 10 years of the onset of spontaneous menopause to maximize benefits and reduce risks.

The previous "lowest dose for the shortest time" rule has been dropped. In its place, ACOG calls for individualized decisions based on ongoing, periodic risk-benefit assessments between the patient and their clinician. There is no predetermined age or time limit for stopping therapy under the new framework.

For patients who cannot or prefer not to use hormone therapy, ACOG recommends several alternatives. These include neurokinin receptor antagonists such as fezolinetant and elinzanetant, SSRIs and SNRIs for managing symptoms and associated depression, and gabapentin for patients who cannot tolerate other options.

Nonpharmacological approaches such as cognitive behavioral therapy, mindfulness, exercise, clinical hypnosis, and acupuncture are also cited as effective supplemental options.

The guidelines explicitly address racial, cultural, and socioeconomic factors in menopause care, noting that disparities in access and treatment must be recognized and addressed by clinicians.

ACOG said it is developing separate guidance on genitourinary syndrome of menopause, expected in 2027.