The Problem

Twelve years. That’s how long American College of Obstetrics and Gynecology’s (ACOG) menopause guidance sat on the shelf. On October 15, ACOG replaced Practice Bulletin No. 141, published in January 2014, with Clinical Practice Guideline No. 13. Days earlier, the American College of Physicians (ACP) released its own guideline on hot flashes. And on September 17, the FDA convened a public workshop on testosterone in menopausal women.

Three major institutions in one month. I’m celebrating that—truly. But progress is not the same as finished. If you treat women every day, you already know where the guidelines stop and your patients’ needs keep going.

 

The Evidence: What the Guidelines Say

Both guidelines name hormone therapy as the first-line treatment for hot flashes. ACP rates the evidence high-certainty (Qaseem et al., 2026). ACOG recommends systemic hormone therapy for hot flashes and the sleep disruption they cause, and it advises starting before age 60 or within 10 years of menopause (ACOG, 2026). A network meta-analysis cited in the guideline ranks transdermal estradiol with a progestogen highest for reducing hot flashes.

Then come the limits. ACOG finds the evidence insufficient to recommend for or against hormone therapy for depressive symptoms. It lists testosterone among the treatments the evidence does not support for hot flashes, sleep, or mood. And it pairs its 10-year window with shared decision-making for each patient.

The FDA workshop ended with no ruling. The agency confirmed that no testosterone product is approved for women in the United States. It named the gaps it wants filled: long-term cardiovascular and breast cancer data, and safety data beyond 24 months. It also raised concern about very high testosterone levels (FDA, 2026).

 

Where the Academy Stands

Let’s start with where we agree. Hormone therapy comes first, and route matters. A 2026 BMJ study of Danish women linked oral estrogen to higher rates of clots, stroke, and heart attack, while transdermal therapy did not show higher clot or stroke rates (Berggreen et al., 2026). The study’s one transdermal exception, a heart attack signal with combined cyclic therapy, rested on 12 cases and synthetic progestins—not progesterone. That is why we teach transdermal estradiol with progesterone.

 

Now, where we go further.

Timing. 

Earlier is better—we agree. But we do not support a hard cutoff. In Medicare data on 10 million women, estrogen alone beyond age 65 was associated with 19 percent lower mortality, and risk reductions were greater with lower doses, transdermal or vaginal routes, and estradiol over conjugated estrogen (Baik et al., 2024). In a randomized trial, women 10 or more years past menopause on estradiol showed no faster artery thickening than placebo (Hodis et al., 2016). 

I’ll be direct about the other side, too. A Women’s Health Initiative analysis found higher cardiovascular risk in women 70 and older who took oral conjugated estrogen (Rossouw et al., 2025). That is why formulation and route matter, and why the Academy does not support conjugated equine estrogen.

 For older women, we teach case-by-case decisions: transdermal delivery, lower doses, close monitoring, and informed consent.

Mood. 

ACOG calls the evidence on hormone therapy for depressive symptoms insufficient. We disagree. In a randomized trial, transdermal estradiol with progesterone cut the onset of depressive symptoms in perimenopausal women—17.3 percent versus 32.3 percent on placebo (Gordon et al., 2018). A second trial found transdermal estradiol lowered anxiety and anhedonia (Lozza-Fiacco et al., 2022). The International Federation of Gynecology and Obstetrics now prefers transdermal estradiol for managing mood swings (Khadilkar et al., 2026). 

Add what providers with decades of BHRT experience see in their clinics—women whose moods lift once their hormones are optimized—and the evidence deserves more weight than ACOG gave it.

Testosterone. 

No approved product exists for women. We say that plainly. Testosterone is the most abundant active sex steroid in a woman’s body, it persists after menopause, and a 2026 review describes its roles in bone, muscle, metabolism, blood vessels, cognition, and mood—not just desire (Hernandez et al., 2026). 

BHRT practitioners have prescribed testosterone off-label for decades and have seen improvement where it fits clinically. A meta-analysis of 36 randomized trials confirmed benefit for sexual function in postmenopausal women and favored non-oral routes (Islam et al., 2019). An international guideline calls for informed consent and monitoring within the physiologic premenopausal range (Parish et al., 2021). 

We teach the same: start low, dose physiologically, monitor, and obtain informed consent. We do not recommend high doses.

Then there is delivery. A woman needs a fraction of a man’s dose. Handing her a male product and telling her to use a dab from a packet is guesswork. Compounding lets the provider dispense the strength she actually needs. Guideline groups note that compounded products lack trial data, and that is true. It is also true that a dab is not a dose. 

Presenters at the FDA workshop named the Schedule III classification as a barrier to prescribing. We support removing it for physiologic dosing in women.

The Vision

Picture a woman who walks into her provider’s office and hears “let’s talk about your options” instead of “that’s just aging.” Her provider understands timing, route, and dosing. Nobody tells her to wait for a pharmaceutical company, or for another decade of studies, while her sleep, mood, and energy slip away. We do not support that wait.

Bottom line: The new guidelines are the floor, not the ceiling. They confirm what this movement has said for 30 years—hormone therapy belongs at the front of the line. The Academy takes it further, with evidence and clinical experience behind every step.

What this means for you: If you want to master hormone therapy—timing, route, dosing, and monitoring—explore the BHRT Training Academy certification. Our mission is 100,000 providers helping 100 million women. We would be glad to have you with us.

 

Donna White is The Hormone Defender and Founder of the BHRT Training Academy, which trains providers in comprehensive, evidence-based bioidentical hormone care.

 

Sources

  • American College of Obstetricians and Gynecologists. ACOG Clinical Practice Guideline No. 13: Management of menopause-related vasomotor, sleep, and mood symptoms. Obstet Gynecol. 2026;148(5):e345-e369. https://doi.org/10.1097/AOG.0000000000006428. PMID 42878500.
  • Baik SH, Baye F, McDonald CJ. Use of menopausal hormone therapy beyond age 65 years and its effects on women’s health outcomes by types, routes, and doses. Menopause. 2024;31(5):363-371. https://doi.org/10.1097/GME.0000000000002335. PMID 38595196.
  • Berggreen J, Pourhadi N, Wood-Kurland H, Løkkegaard E, Torp-Pedersen C, Meaidi A. Contemporary menopausal hormone therapy and thrombotic disease: nationwide nested case-control study. BMJ. 2026;394:e100688. https://doi.org/10.1136/bmj-2026-100688. PMID 42778212.
  • Gordon JL, Rubinow DR, Eisenlohr-Moul TA, Xia K, Schmidt PJ, Girdler SS. Efficacy of transdermal estradiol and micronized progesterone in the prevention of depressive symptoms in the menopause transition: a randomized clinical trial. JAMA Psychiatry. 2018;75(2):149-157. https://doi.org/10.1001/jamapsychiatry.2017.3998. PMID 29322164.
  • Hernandez BS, Covarrubias A, Perez-Grego PG, et al. Beyond libido: the multifaceted • role of testosterone in women. Sex Med Rev. 2026;14(4). https://doi.org/10.1093/sxmrev/qeag072. PMID 42867946.
  • Hodis HN, Mack WJ, Henderson VW, et al. Vascular effects of early versus late postmenopausal treatment with estradiol. N Engl J Med. 2016;374(13):1221-1231. https://doi.org/10.1056/NEJMoa1505241. PMID 27028912.
  • Islam RM, Bell RJ, Green S, Page MJ, Davis SR. Safety and efficacy of testosterone for women: a systematic review and meta-analysis of randomised controlled trial data. Lancet Diabetes Endocrinol. 2019;7(10):754-766. https://doi.org/10.1016/S2213-8587(19)30189-5. PMID 31353194.
  • Khadilkar S, Divakar H, Benedetto C, et al. FIGO best practice recommendations for the mental health of women at menopausal age. Int J Gynaecol Obstet. 2026;173(2):588-601. https://doi.org/10.1002/ijgo.70943. PMID 41902367.
  • Lozza-Fiacco S, Gordon JL, Andersen EH, et al. Baseline anxiety-sensitivity to estradiol fluctuations predicts anxiety symptom response to transdermal estradiol treatment in perimenopausal women: a randomized clinical trial. Psychoneuroendocrinology. 2022;143:105851. https://doi.org/10.1016/j.psyneuen.2022.105851. PMID 35809362.
  • Parish SJ, Simon JA, Davis SR, et al. International Society for the Study of Women’s Sexual Health clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. J Sex Med. 2021;18(5):849-867. https://doi.org/10.1016/j.jsxm.2020.10.009. PMID 33814355.
  • Qaseem A, Mackey K, Yost J, Shekelle PG, Shamliyan TA, Cross JT, et al. Pharmacologic treatments for females with menopausal vasomotor symptoms: a clinical guideline from the American College of Physicians. Ann Intern Med. 2026. https://doi.org/10.7326/ANNALS-26-01205. PMID 42832802.
  • Rossouw JE, Aragaki AK, Manson JE, et al. Menopausal hormone therapy and cardiovascular diseases in women with vasomotor symptoms: a secondary analysis of the Women’s Health Initiative randomized clinical trials. JAMA Intern Med. 2025;185(11):1330-1339. https://doi.org/10.1001/jamainternmed.2025.4510. PMID 40952729.
  • U.S. Food and Drug Administration. Public workshop: testosterone use in menopausal women. September 17, 2026. https://www.fda.gov/consumers/womens-health-events/fda-public-meeting-testosterone-use-menopausal-women-09172026. Docket FDA-2026-N-5479.
  • Federal Register. Testosterone use in menopausal women; public workshop; request for comments. 91 FR 53417. August 18, 2026. https://www.federalregister.gov/documents/2026/08/18/2026-16829/testosterone-use-in-menopausal-women-public-workshop-request-for-comments.