If you were once told hormone therapy was too risky, or that hot flashes were something to wait out, it may be time for another conversation. In October 2026, the American College of Obstetricians and Gynecologists released new recommendations, its first major update to menopause guidance since 2014, covering hot flashes, night sweats, sleep disruption, and mood. Here's what changed.

Hormone therapy is still the strongest recommendation

For bothersome hot flashes and night sweats in people without contraindications, ACOG strongly recommends systemic hormone therapy: estrogen with a progestogen if you have a uterus, or estrogen alone if endometrial protection isn't needed. This is one approach, not two competing ones. Estrogen treats the symptoms; a progestogen protects the uterine lining.

Route may matter. In a network meta-analysis of 32 randomized trials, transdermal estradiol with a progestogen ranked as the most effective option for reducing how often hot flashes happen, with oral regimens also showing benefit but ranking lower.

Timing is now central to the decision

ACOG strongly recommends starting hormone therapy before age 60 or within 10 years of natural menopause. In the evidence ACOG summarizes, people who started in that window had a lower risk of coronary heart disease and a similar risk of stroke compared with placebo, though a higher risk of blood clots. Starting more than 10 years out raised the risk of both clots and stroke.

Risk isn't zero. Estrogen–progestogen therapy over a median of 5.6 years was associated with about 5 additional strokes, 10 additional blood clots, and 5 additional cases of invasive breast cancer per 1,000 women. Estrogen-only therapy showed no increased breast cancer risk, but about 8 additional strokes and 5 additional clots per 1,000. Worth knowing when you read those numbers: nearly 67% of Women's Health Initiative participants were 60 or older, which makes the findings hard to apply to someone in her early fifties.

Separately, the FDA approved the first updated hormone therapy labels in February 2026, removing boxed warnings for cardiovascular disease, breast cancer, and probable dementia. The endometrial cancer warning for estrogen-alone products stays. That doesn't make hormone therapy risk-free, but it changes where the conversation starts.

Two non-hormonal medications now carry a strong recommendation

This is the most substantive addition since 2014. ACOG now strongly recommends neurokinin receptor antagonists for hot flashes and related sleep disturbance in people who don't want hormone therapy or can't take it. They block a brain signal involved in temperature regulation rather than replacing estrogen.

• Fezolinetant (Veozah), 45 mg daily. Approved 2023. The label carries a boxed warning requiring liver function testing before starting, monthly for three months, then at months 6 and 9.
• Elinzanetant (Lynkuet), 120 mg daily. Approved 2025. The label recommends liver function testing before treatment and at three months. Headache and fatigue were the most commonly reported side effects.

Antidepressants also moved up

ACOG now strongly recommends SSRIs or SNRIs for menopausal vasomotor and depressive symptoms in people who don't want or can't take hormone therapy. Low-dose paroxetine at 7.5 mg daily is the only one FDA-approved specifically for hot flashes; escitalopram, venlafaxine, desvenlafaxine, and others have shown benefit but are prescribed off-label. ACOG says none of them is established as superior.

One interaction matters: fluoxetine and paroxetine should generally be avoided with tamoxifen, because they interfere with converting it to its active form. Gabapentin got a weaker, conditional recommendation for when other non-hormonal options haven't worked.

What the guidance doesn't support

• Progestogen alone, DHEA, and testosterone, for hot flashes, sleep, or mood.
• Clonidine as a primary option, and oxybutynin, which worked in two trials but carries side effects including cognitive decline in women over 65.
• Hormone therapy as a treatment for depressive symptoms, where ACOG found the evidence insufficient either way. Antidepressants and cognitive behavioral therapy remain first-line.

ACOG does suggest cognitive behavioral therapy, mindfulness, exercise, clinical hypnosis, and acupuncture as conditional recommendations meant to work alongside medication. We cover those in our piece on sleep and mood in menopause.

Navigating menopause with Maven Clinic

With Maven Clinic, you have a care team in your corner, including OB-GYNs and menopause specialists, who look at the full picture of your health. We look at your symptoms, health history, and goals to help you decide whether hormone therapy, a non-hormonal option, or a combination of both is right for you. .

Discover our approach to hormone care.