Updated Advice Offers New Options for Menopause Symptoms

For the first time in 12 years, a major OB-GYN organization has revised its advice on treating hot flashes, night sweats, sleep problems and other symptoms that can disrupt life during menopause.

Medical experts emphasized hormone therapy, which some women are again considering after federal safety warnings were rolled back. Federal officials also said efforts are underway to make sure the Food and Drug Administration has enough supply available.

The newly issued guidance from the American College of Obstetricians & Gynecologists, or ACOG, also outlines several nonhormonal treatment options.

“We would love our patients to go to their OB-GYNs regarding questions about menopause and really advocate for getting the treatment that they need,” said Dr. Camille Clare, the group’s president.

Menopause is defined as 12 straight months without a menstrual period. In the United States, it typically occurs around age 50. The years leading up to it are known as perimenopause, when estrogen and progesterone levels drop sharply.

Symptoms are common. ACOG says more than half of women in menopause experience vasomotor symptoms such as hot flashes and night sweats. Up to two-thirds report sleep disruption related to menopause, and more than one-third of perimenopausal and postmenopausal women worldwide report depressive symptoms.

Doctors said women often used to endure these problems in silence.

There is increasing agreement that “these symptoms should be treated,” said Dr. JoAnn Manson, a professor of medicine at Harvard Medical School. “This should help to empower women to discuss their symptoms with their health care provider.”

Hormone therapy remains a leading option

Manson said ACOG’s new guidance is in line with recommendations from other medical groups.

“Moderate to severe or bothersome menopausal symptoms should be treated with hormone therapy as the first line of treatment,” she said. Although it is not suitable for everyone, it can be an effective choice for many patients.

Still, some women have remained cautious.

A major study in 2002 involving women taking an oral combination of estrogen and progestin was halted early after it was linked to breast cancer, blood clots and other serious risks. Although later research showed that the benefits of current hormone therapies outweigh the risks for many patients, concern persisted. For more than 22 years, all hormone-based menopause treatments carried a government warning, which Manson said discouraged both patients and doctors from using them.

Last year, the FDA said it would remove the boxed warning from more than 20 pills, patches and creams containing estrogen and progestin.

Since that labeling change, some women have said it has been harder to find estrogen patches in certain doses and formulations.

FDA officials said that despite those reports, they are not aware of “an imminent risk of a nationwide shortage.”

Dr. Stephanie Faubion, medical director at The Menopause Society, said she welcomes the emphasis ACOG placed on these therapies.

“It’s undisputed that hormone therapy is the first line and most effective therapy for hot flashes,” she said.

ACOG’s review of the latest evidence includes detailed information on the different forms of hormone treatment. Whole-body therapies, available as pills, patches, sprays, gels and a vaginal ring, deliver hormones into the bloodstream at levels high enough to affect symptoms such as hot flashes. Low-dose vaginal estrogen, by contrast, is applied directly and results in very little hormone circulating in the blood.

The group says hormone therapy decisions should be made together by doctors and patients, taking into account the patient’s age and medical history as well as the potential benefits and risks. When appropriate, ACOG advises starting treatment before age 60 or within 10 years of menopause.

Other treatments can help, too

Not all patients want full-body hormone therapy, and some are told to avoid it because of their medical history or other conditions.

For those patients, doctors pointed to other medicines. One is fezolinetant, which acts on the part of the brain that controls body temperature and blocks a trigger for hot flashes and night sweats. Another is elinzanetant, which works in a similar way.

Experts also said some antidepressants can ease hot flashes as well as depression in patients who struggle with one or both conditions.

ACOG said there is also evidence supporting several non-drug approaches for hot flashes, night sweats and sleep or mood issues. These include cognitive behavioral therapy, mindfulness, exercise, clinical hypnosis and acupuncture, which may be used alone or alongside medication.

Clare said women may encounter misinformation and disinformation about menopause care online, and she urged patients to bring their questions to a doctor.

“Women have options. They have lots of options, hormonal and nonhormonal,” Faubion said. “They shouldn’t be told that nothing can be done about their symptoms. Because again, we have evidence for many different things that can help.”

A low-dose estrogen skin patch is shown in a file photo.