New menopause clinical practice guideline helps keep women ‘optimized for the fight’
The Department of Veterans Affairs and Department of Defense have jointly released the 2026 Clinical Practice Guideline on Menopause to help clinicians provide consistent and unified standards of high-quality care for women experiencing perimenopause and menopause.
“We want both patients and clinicians to know there are safe and effective treatments for women who are experiencing bothersome symptoms of perimenopause and menopause,” said Air Force Maj. (Dr.) Kathleen Pombier, chief of Defense Health Agency’s women’s health clinical management teamco-champion for the CPG. “Individualized treatment is key. The focus needs to be on whole-person care.”
The CPG’s 43 evidence-based recommendations address diagnosis and management of menopausal symptoms including hot flashes, problems sleeping, depression and anxiety, and cognitive issues like brain fog. The CPG also provides guidance on genitourinary syndrome of menopause and sexual dysfunction, bone health,weight management, cardiovascular disease and breast cancer risk, and treatment safety during this transition.
Focus on female beneficiaries, as they grow their military presence and roles
Pombier said women are an increasing and essential part of the military force as well as the fastest-growing group within the veteran population and among VA healthcare beneficiaries. The CPG provides a common framework for continuity of care across both healthcare systems.
“When we look at the VA, the average age of those patients is within the perimenopausal and menopausal range,” said Army Col. (Dr.) Erin Keyser, director of medical education at Brooke Army Medical Center, San Antonio, Texas, and co-champion for the CPG. “This is a very important issue for these patients.”
Perimenopause and menopause are natural life transitions during which a woman’s menstrual periods stop permanently, and she is no longer able to become pregnant — with perimenopause referring to the time leading up to menopause, according to the National Institutes of Health.
Shifting hormone levels can cause symptoms which can disrupt sleep, mood, cognition, and daily functioning for some patients, ultimately impacting readiness, Pombier said.
“When your sleep’s affected, you’re not going to do your job as well,” she emphasized. “When you are having mood changes, it can impact your ability to do your job as well.”
The guidelines provide actionable recommendations for the early detection and treatment of bothersome perimenopause and menopause symptoms to optimize warfighter medical readiness and care, Pombier said: “By having clinicians identify symptoms earlier and recognize that it’s not something women just have to deal with — it’s actually something we can treat — it ensures we have every woman optimized for the fight.”
Providing effective care not only supports warfighter retention, it also alleviates stigma with symptoms, paving the path for women to continue thriving in their military careers, Keyser noted.
“Being able to manage this hopefully keeps women in the job longer — not leaving service, not stepping away from leadership opportunities because of stigma or feeling ashamed from not being able to manage their menopausal symptoms,” she said.
Treatment and individualized care to keep warfighters ready
Pombier said shared decision-making around treatment should be guided by the symptoms affecting each patient, as well as the patient’s health history, preferences, and safety considerations.
She noted diagnosis of perimenopause and menopause is generally symptom-based. “Diagnosis is not based upon lab work — it should be based off of a discussion with the patient.”
For vasomotor symptoms, commonly known as hot flashes and night sweats, the CPG has recommendations focusing on both hormonal treatments as well as nonhormonal treatments. “The CPG mentions therapies like estrogen and progestogens, which are mainstays of hormonal therapy,” Pombier said, adding nonhormonal treatments such as antidepressants and gabapentin can also be effective for women with medical reasons to avoid systemic hormones, or who are more comfortable nonhormonal options.
The CPG also specifies recommendation for breast cancer survivors, Pombier noted: “Many breast cancer survivors don’t know local estrogen is still an option even with a history of breast cancer. We also have multiple other nonhormonal options for this specific patient population which are covered in the CPG.”
Sleep, mood, genitourinary, and sexual-health concerns may also arise during menopause, Pombier said. “For sleep symptoms, we talk a lot about cognitive behavioral therapy for insomnia, which is one of the strong evidence-based methods we can use to help women when they’re struggling.”
If women are experiencing genitourinary or sexual-health symptoms, the CPG recommends “local vaginal estrogen, systemic estrogen, vaginal dehydroepiandrosterone, and moisturizers,” she added, as well as “therapies for sexual interest or arousal concerns.”
Pombier stressed the CPG is not a one-size-fits-all treatment guide, and true patient care requires an open, individualized dialogue.
“We need to recognize the midlife transition, talk to our patient, assess their symptoms, understand their priorities, review with them the risks and the benefits, and ultimately use shared decision-making to figure out how we should best treat them,” she said.
Quick-reference clinical tools in action
Central features of the CPG are four algorithms serving as flowcharts for diagnosis and treatment, and the pocket card which allows providers to quickly cross-reference symptoms and recommended treatments. Pombier said these tools are designed for use during a clinical encounter.
The menopause CPG is intended to work alongside existing clinical guidance. Keyser said it directs clinicians to related CPGs when patients need more comprehensive evaluation or treatment for concerns such as overweight and obesity.
“The CPG gives a structured, practical framework,” she said. “It’s something you can quickly pull up while you’re in clinic and say, ‘Okay, my patient’s experiencing A, B, and C. What is the best option for this patient who’s in front of me right now?’”
Keyser said these encounters are when providers can conveniently use the pocket card to identify if a single treatment approach may address multiple concerns, noting the card “breaks things down into a simplistic fashion.”
For military hospitals and clinics in remote locations where there may not be an obstetrician or gynecologist on staff, reference tools within the CPG empower front-line clinicians “to use these algorithms and feel more comfortable prescribing therapies,” Keyser said, noting this delivers medical warrior currency across the enterprise.
Joint, integrated, consistent care for beneficiaries
The unified clinical care standards support active duty across all military hospitals and clinics and service members transitioning to VA care, Keyser said, providing joint medical capabilities for all beneficiaries across both health systems in alignment with the strategic Lines of Effort designed to reinforce DHA as a combat support agency.
“Everyone deserves to have high-quality care regardless of where they’re stationed,” she added.
For Pombier, the joint integration of these capabilities is a cornerstone of the CPG, “reducing any unwarranted variation and making sure patients are getting consistent care as they move from primary care to women’s health to behavioral health to sleep medicine and to specialty care.”
The CPG’s working group used patient focus groups, key clinical questions, and systematic evidence reviews to develop the recommendations. The process considered the quality of available evidence, potential benefits and harms, patient preferences, and implementation factors such as equity, resources, accessibility, and feasibility, Pombier said.
“We wanted to be transparent on the basis for care,” she emphasized. “Here is the evidence that we have, here is how strong or weak it is, but also here are the areas where we think we need more evidence before we can make firm recommendations.”
The guideline also signals menopause-related concerns should be heard, evaluated, and treated with the same seriousness as other health issues affecting beneficiaries and the force, underscored Keyser.
“We are taking this subject seriously, and we care about the women in our healthcare system,” she said. “We want to provide them high-quality care.”
CPG and resources
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