• ACOG’s guidance strongly recommends hormone therapy for vasomotor symptoms and sleep disturbance.
• The guidance also recommends nonhormonal and nonpharmacologic options.

ACOG has expanded its recommendations for managing menopause symptoms, including more information about certain symptoms and the timing of treatment.

“Perimenopause and menopause are normal and expected phases of life, but symptoms such as hot flashes, sleep disturbances and vaginal symptoms can have a profound effect on health, quality of life and daily functioning,” ACOG President Camille A. Clare, MD, MPH, CPE, FACOG, said during a press briefing.

According to Clare, women spend roughly one-third of their lives in the postmenopausal stage, “and untreated symptoms can affect physical health, emotional well-being, workplace productivity and long-term health outcomes.”

“While awareness of menopause has grown dramatically in recent years, so has the amount of misinformation,” she said. “That’s why ACOG is expanding our focus on menopause this year, increasing the resources available to both OB/GYNs and their patients.”

The organization strongly recommends the use of systemic menopausal hormone therapy (MHT), with estrogen and a progestogen in women with a uterus or estrogen alone “if endometrial protection is not needed,” for managing vasomotor symptoms and vasomotor-related sleep disturbance in women without contraindications to hormone use. ACOG suggests a “combination of conjugated estrogen and bazedoxifene as an alternative to estrogen-progestogen therapy.”

Current evidence is insufficient to make a recommendation for or against treatment options for menopausal depression symptoms, according to the organization. Because of this, perimenopausal and postmenopausal women for whom depression is the predominant symptom or who meet the criteria for major depressive disorder “should be treated according to depression management guidelines,” the guidance states.

Initiating MHT for vasomotor symptoms and sleep disturbance should be based on shared decision-making, ACOG said, with considerations for risks and benefits and the patient’s symptoms; age; individualized treatment priorities and goals; medical history; and baseline risks for breast cancer, CVD and venous thromboembolism.

ACOG recommends initiating MHT for these conditions before age 60 years or within 10 years of the start of natural menopause.

Shared decision-making should also be used for deciding when and how to discontinue MHT, the guidance states, while persistent and unscheduled bleeding after starting MHT “warrants evaluation for endometrial intraepithelial neoplasia/atypical endometrial hyperplasia and endometrial cancer.”

“Hormone therapy is a really important tool we have to help with menopause symptom management,” guidance coauthor Bruce Pier, MD, FACOG, said in a press release. “Unfortunately, misconceptions about the risks of hormone therapy have affected some clinicians’ willingness to prescribe it and some patients’ interest in using it.”

ACOG strongly recommends selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) for women with menopausal vasomotor or depression symptoms who do not desire or have a contraindication to hormone therapy.

For vasomotor-related sleep disturbance in such patients, neurokinin receptor antagonists like fezolinetant (Veozah, Astellas Pharma) and elinzanetant (Lynkuet, Bayer) are recommended.

ACOG suggests gabapentin for managing vasomotor symptoms when other recommended nonhormonal pharmacologic treatments are ineffective or are poorly tolerated.

ACOG recommends physical exercise, cognitive behavioral therapy, acupuncture, mindfulness-based interventions and clinical hypnosis for one or more menopausal symptoms, including vasomotor symptoms, sleep disturbance, mood and anxiety.

The organization said these interventions can be used alone but “are generally recommended as options to be used in combination with hormonal or other medications.”

Current evidence does not support phytoestrogens, such as soy isoflavones and herbal supplements, for vasomotor or other menopausal symptoms, ACOG said.

These supplements “may be easily accessible and heavily marketed to patients; however, they are a potential risk, as they are not regulated by the FDA and have not been tested for safety, efficacy or purity,” the release said.

According to ACOG, vulnerable populations, including Black women, sexual minority women, transgender people and gender-diverse people, may experience greater menopausal symptom burden and difficulty receiving quality care.

For example, there is no expert consensus on the definition of menopause among gender-diverse and transgender people “because factors such as the use of gender-affirming hormone therapy and sex assigned at birth affect the timing and symptoms experienced as well as the individual perception of the physiologic changes,” the guidance states.

Regina Castaneda, MD, a postdoctoral research fellow at Mayo Clinic, who was not involved with ACOG’s guidance, told Healio she was especially pleased that the recommendations highlight inequities and barriers as “these are fundamental issues that must be addressed if we are to advance menopause care.”

ACOG’s core messages about the treatment of vasomotor symptoms align with those recently published by the American College of Physicians (ACP), Castaneda said.

“Both ACP and ACOG place systemic estrogen, with a progestogen when needed for endometrial protection, as the most effective treatment for vasomotor symptoms,” she said. “The main difference is in how nonhormonal options are framed.”

Specifically, ACP “uses a tiered approach, with SNRIs as second-line therapy and SSRIs, gabapentin and neurokinin receptor antagonists as third-line options — a placement partly driven by cost considerations,” Castaneda said.

She added that ACOG’s guidance is “broader in scope” as it “addresses sleep disturbances and mood symptoms, provides a more comprehensive discussion of nonpharmacologic interventions and offers practical recommendations for hormone therapy initiation, monitoring, management of unscheduled bleeding and treatment discontinuation.”

This wider scope, Castaneda explained, “better reflects the lived experience of the menopause transition and acknowledges its multidimensional impact on the quality of life for millions of women.”

Menopause care should be individualized, evidence-based and “take a holistic approach that extends beyond the management of hot flashes alone and considers overall health, well-being and quality of life,” Castaneda said.

But guidelines like ACOG’s “are only meaningful if patients can actually access the care they describe,” she said.

“Despite major advances in menopause management, important barriers remain, including inadequate insurance coverage for newer therapies and evidence-based nonpharmacologic interventions, as well as persistent disparities in care,” Castaneda said. “At the same time, significant research gaps remain, particularly regarding symptom management in special populations such as breast cancer survivors.”

Expanding patient and clinician education and doing more high-quality research will be necessary to move menopause care forward, she said.

“Ultimately, clinical guidelines serve as a framework to inform care, but they should support, not replace, individualized decision-making that reflects each patient’s symptoms, values, preferences and overall health goals,” she said.

Regina Castaneda, MD, can be reached at primarycare@healio.com.