On October 5, 2026, the American College of Physicians (ACP), the national organization of internal-medicine physicians, published a clinical guideline in Annals of Internal Medicine naming estrogen-based hormone therapy as the first-line treatment for hot flashes and night sweats (menopausal vasomotor symptoms, or VMS). It covers perimenopausal and postmenopausal patients who are seeking treatment. Patients with a uterus would take estrogen plus a progestogen, and those without a uterus would take estrogen alone. ACP concluded that these regimens had "the most favorable benefits compared with harms."

Why It Matters

In practice, menopause care is set by primary care, not specialist menopause societies, and ACP's guidance is what internists follow. A first-line endorsement from that group, along with the label changes, normalizes hormone therapy for the clinicians most women actually see. That is a demand tailwind for the menopause telehealth platforms (Midi, Evernow, Hers' estrogen offering) and for brands selling into the midlife sexual-wellness market, where vasomotor symptoms, sleep and libido usually show up together. There are two catches. First, supply: Afterglow has already tracked [estradiol patch shortages](/stories/estradiol-patch-shortage-fda-action) as prescriptions surged after the boxed-warning removal, and a first-line recommendation adds demand to a tight market. Second, the ranking puts the newest and most expensive non-hormonal drugs (fezolinetant, elinzanetant) in **third** place next to cheap generics. That positioning could complicate payer coverage and the commercial plans of the companies behind them. Note also that the guideline addresses vasomotor symptoms only. Genitourinary symptoms such as vaginal dryness and painful sex are mentioned as part of menopause but are not what this guideline ranks.

The guideline then ranks the alternatives for patients who can't or won't use estrogen. Second line is an SNRI, either desvenlafaxine or venlafaxine. Third line includes the SSRIs escitalopram and paroxetine, gabapentin, and the newer non-hormonal NK3 receptor antagonists elinzanetant and fezolinetant. ACP says VMS affect up to 80% of females. It tells clinicians to raise the subject themselves, because many patients won't, and to use informed decision-making that covers contraindications, cost and access. "Too many females silently suffer from disruptive hot flashes and night sweats without ever receiving effective treatment," ACP president Dr. Jan K. Carney said in the release.

As Medical Daily notes, the guideline comes after years of hesitancy that followed the Women's Health Initiative. In November 2025, HHS announced that the FDA would remove boxed warnings about cardiovascular disease, breast cancer and probable dementia from hormone-therapy labels. The endometrial-cancer warning stays on systemic estrogen-alone products, and updated labels for six products followed in February 2026. Not everyone agrees with the ranking. On October 6 the Physicians Committee for Responsible Medicine asked ACP to make diet change the first step. It cited its own WAVS trial, which reported an 88% reduction in moderate-to-severe hot flashes on a low-fat vegan diet with daily soybeans.

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Update — 2026-10-09

Initial entry — story first created.

Update — 2026-10-16

Ten days after the internists, the gynecologists say it louder. On October 15, 2026, the American College of Obstetricians and Gynecologists (ACOG) published Clinical Practice Guideline No. 13, "Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms," in Obstetrics & Gynecology. ACOG calls it the most comprehensive menopause guidance it has published to date. Healio reports that ACOG strongly recommends systemic menopausal hormone therapy, estrogen plus a progestogen for women with a uterus or estrogen alone otherwise, for both vasomotor symptoms and vasomotor-related sleep disturbance in women without contraindications. It suggests conjugated estrogen plus bazedoxifene as an alternative to estrogen-progestogen therapy.

What ACOG adds to the ACP guidance. Timing: if hormone therapy is chosen, ACOG recommends starting it before age 60 or within 10 years of spontaneous menopause, with the decision made jointly with the patient based on baseline cardiovascular, breast-cancer and VTE risk. Decisions on stopping should also be individualized. Non-hormonal drugs: the NK3 antagonists fezolinetant and elinzanetant are presented as an option for women who can't or won't use hormones, alongside SSRIs and SNRIs. Non-drug options: CBT, mindfulness, exercise, clinical hypnosis and acupuncture, usually alongside medication. Supplements: ACOG says the evidence does not support the safety or efficacy of phytoestrogens or herbal supplements for menopausal symptoms and notes they are "heavily marketed" and unregulated. Depression: ACOG found the evidence insufficient to recommend for or against menopause-specific treatment. Genitourinary syndrome of menopause guidance, which covers dryness and painful sex, is due separately in 2027.

What changed: Two major US physician bodies have now put hormone therapy first within ten days. ACOG's guideline goes further than ACP's in covering sleep and in explicitly ruling out supplements, which hits the cash-pay "menopause gummy" market directly. Sexual-wellness brands now face a gap: the vaginal-dryness and libido symptoms that drive midlife purchases of lubricants, moisturizers and devices are the part neither guideline has covered yet. Lovehoney stepped into that gap the same day with an air-pulse device sold as menopause care in Boots (see lovehoney-sheherme-menopulse-boots).

New Sources