Hot Flushes, Sleepless Nights and Mood Changes: What the New ACOG Menopause Guideline Means for You
By Dr. Deemanthe Weerasuriya (Dr. Dee)
For many women, menopause arrives quietly and then announces itself loudly: a sudden wave of heat in a meeting, soaked sheets at 3 a.m., a short temper that feels unfamiliar, or a low mood that does not lift. Too often, these experiences are dismissed as something to be “endured”. The science says otherwise.
This month, the American College of Obstetricians and Gynecologists (ACOG) published its most comprehensive menopause guidance to date: Clinical Practice Guideline No. 13 — Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms. It replaces ACOG’s previous guidance from 2014, and it brings welcome clarity on what genuinely helps. In this article, I summarise the key messages in plain language.
How common are these symptoms?
According to the guideline, between half and nine in ten women report hot flushes and night sweats (known medically as vasomotor symptoms) around menopause. Between 16% and 66% of women report menopause-related sleep disruption, and more than one in three perimenopausal and postmenopausal women worldwide report depressive symptoms.
In other words, if you are struggling, you are far from alone — and you are not imagining it.
A small but meaningful note on language: the guideline prefers the term “hot flush” to “hot flash”, because the sensation is not momentary. It typically lasts between one and five minutes.
Understanding the guideline’s language
ACOG grades each recommendation by strength and by the quality of the evidence behind it:
“ACOG recommends” is a strong recommendation: the benefits clearly outweigh the harms, and most patients should be offered the option.
“ACOG suggests” is a conditional recommendation: the right choice depends on the individual’s circumstances and preferences, and should be made through shared decision-making with a clinician.
This distinction matters, and I will refer to it throughout.
1. Menopausal hormone therapy: the most effective option
The guideline strongly recommends systemic menopausal hormone therapy (MHT) for hot flushes, night sweats and the sleep disturbance they cause, in women who have no contraindications to hormones. Women who still have a uterus require a progestogen alongside estrogen to protect the lining of the womb; women who have had a hysterectomy can usually take estrogen alone.
Key points on timing and safety:
ACOG strongly recommends starting MHT before age 60, or within 10 years of natural menopause. Women who start in this window appear to have a more favourable balance of benefit and risk than those who start later.
The decision should be individual, taking into account age, medical history, and personal risk of heart disease, breast cancer and blood clots.
Any persistent or unexpected bleeding after starting MHT should be investigated.
When and how to stop MHT should also be an individual decision, reviewed over time.
The guideline also notes that much of the fear surrounding hormone therapy came from earlier research in which the majority of participants were aged 60 or older — a group that does not represent most women seeking relief at the time of menopause.
2. Effective non-hormonal medicines
Hormone therapy is not suitable or desired for everyone. For women in this situation, the guideline strongly recommends two groups of medication:
Certain antidepressants (SSRIs or SNRIs), which can reduce hot flushes and also help with depressive symptoms. Women taking tamoxifen should generally avoid fluoxetine and paroxetine.
Neurokinin receptor antagonists (fezolinetant and elinzanetant), a newer class of medicines that act on the brain’s temperature-control centre. They reduce hot flushes and related sleep disturbance, and require liver function monitoring. Availability varies from country to country, so please discuss this with your doctor.
Gabapentin is suggested as a further option when other non-hormonal medicines have not worked or are not tolerated. Clonidine is not recommended as a first-line treatment, and oxybutynin’s side effects limit its use, particularly in older women.
All of these medicines must be prescribed and monitored by a qualified medical doctor.
3. Mind–body and lifestyle approaches now have a formal place
This is the part of the guideline that I find most encouraging. For the first time, ACOG gives formal, graded recommendations for non-drug approaches. Each of the following is suggested (a conditional recommendation):
Approach | What the guideline says it may help |
Cognitive behavioural therapy (CBT) | Hot flushes, sleep disturbance and mood |
Mindfulness-based interventions | Sleep disturbance and mood |
Physical exercise | Sleep disturbance and mood |
Clinical hypnosis | Hot flushes, sleep disturbance and anxiety |
Acupuncture | Hot flushes, sleep disturbance and mood |
In the interest of honesty, I must point out that the evidence for these approaches ranges from low to moderate quality, and for clinical hypnosis and acupuncture it is rated as low. The benefits are generally small to moderate, and for CBT they may fade over time. ACOG nonetheless regards them as reasonable, low-risk options. They may be used on their own, but are generally recommended alongside hormonal or non-hormonal medical treatment, as part of a multimodal approach.
As a practitioner who works with clinical hypnosis and therapeutic approaches to the mind, I welcome this recognition. The mind and the body are not separate systems. How we interpret, anticipate and respond to symptoms such as hot flushes and broken sleep can meaningfully influence how distressing they feel and how well we cope. At the same time, I believe these approaches work best when they complement good medical care — not when they replace it.
4. What the guideline does not support
The guideline states that the evidence does not support the effectiveness or safety of:
Phytoestrogens, such as soy isoflavones; and
Herbal supplements, which are not tested or regulated for safety, effectiveness or purity in the way that medicines are.
This is an important message for anyone spending money on products marketed as “natural menopause relief”.
5. Mood and depression deserve proper care
The guideline is clear that there is not yet enough evidence to recommend hormone therapy specifically for menopause-related depressive symptoms. Women who meet the criteria for major depression, or for whom low mood is the main concern, should be treated according to established depression guidelines.
If your mood has changed significantly, please do not simply put it down to “hormones”. Speak to a doctor or a qualified mental health professional.
Practical takeaways
Your symptoms are real and treatable. You do not have to simply endure them.
Speak to your doctor early. Timing matters for hormone therapy, and the window before age 60 or within 10 years of menopause is significant.
There is more than one path. Hormonal, non-hormonal and mind–body options can be combined in a plan tailored to you.
Be cautious with supplements. “Natural” does not mean proven or safe.
Look after your mind as well as your body. CBT, mindfulness, exercise and clinical hypnosis all have a recognised, evidence-informed role.
If you are navigating menopause and would like to explore how mind-based therapies may support you alongside your medical care, you are welcome to contact my practice at DrDeWeera.com.
Disclaimer: This article is for general educational purposes only and does not constitute medical advice. Decisions about hormone therapy and prescription medicines must be made with a qualified medical doctor who can assess your individual health history and risks.
Scientific reference
American College of Obstetricians and Gynecologists’ Committee on Clinical Practice Guidelines–Gynecology. ACOG Clinical Practice Guideline No. 13: Management of Menopause-Related Vasomotor, Sleep, and Mood Symptoms. Obstetrics & Gynecology. 2026;148(5):e345–e369. doi:10.1097/AOG.0000000000006428
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