Hormone therapy is the reference treatment for menopause symptoms, but it is not the only option and it is not right for everyone. In short: if you cannot or prefer not to take hormones, there are alternatives backed by solid evidence — a new drug approved specifically for hot flashes, certain antidepressants in low doses, gabapentin, cognitive behavioural therapy and lifestyle changes. Which one suits you depends on your main symptom, your medical history and your preferences, so an informed conversation with a clinician is worth having.
| Option | What it is | Effect on hot flashes | Evidence |
|---|---|---|---|
| Fezolinetant (Veozah) | An NK3 antagonist, from the first class of medicine designed specifically for vasomotor symptoms | 45 mg daily reduced frequency significantly versus placebo at weeks 4 and 12 — roughly 50-60% | FDA-approved in May 2023; phase 3 SKYLIGHT 1 and 2 trials (The Lancet, 2023) |
| Low-dose antidepressants (SSRIs/SNRIs) | Paroxetine, venlafaxine, desvenlafaxine, escitalopram and citalopram | Paroxetine 40-65%; venlafaxine and desvenlafaxine 40-60% and the best of this group for night sweats | Paroxetine is FDA-approved for hot flashes as Brisdelle, 7.5 mg; MsFLASH trial (Joffe et al., JAMA Internal Medicine 2014, 339 women) — venlafaxine 75 mg cut symptoms by 47.6% versus 28.6% with placebo |
| Gabapentin | A non-hormonal medicine that is especially useful for night sweats | 40-60% | Usually started at 300 mg at bedtime; common side effects are drowsiness and headache |
| Cognitive behavioural therapy and clinical hypnosis | Mind-body approaches rather than medicines | They do not reduce the frequency of flashes, but they reduce how much they bother you | Level I evidence (The Menopause Society 2023, NICE 2026) |
| Dietary supplements | Soy, black cohosh, evening primrose oil, vitamin E, cannabinoids | Not recommended | The Menopause Society does not recommend them because rigorous evidence is lacking; a 2024 evidence map found 57 randomised controlled trials of complementary therapies, but the methods were too varied to draw firm conclusions |
When non-hormonal options fit:
There are several situations in which the non-hormonal route is the natural choice: some women have conditions that make hormone therapy inadvisable, others prefer to avoid hormones, and others want to add a non-hormonal option alongside HRT. The key difference: hormonal treatments replace the hormones that are falling, while non-hormonal options work through other pathways — receptors in the brain involved in temperature regulation, neurotransmitters, or the way you perceive symptoms.
How non-hormonal medicines act on the thermostat:
The brain keeps body temperature inside a narrow comfort range. Estrogen helps keep that range wide. As estrogen falls, the range narrows. Small changes in temperature then feel like a large rise, and the brain reacts as if you were genuinely overheating.
The cooling response is the flash. Blood vessels near the skin open, so the face, neck and chest flush. Sweat glands switch on. The heart beats faster for a moment. When the heat has gone, the vessels narrow again and you feel cold and clammy.
Hormone therapy works by restoring estrogen, which widens the range again. Non-hormonal options take other routes.
- Some act on the temperature circuit in the brain itself, rather than replacing estrogen
- Some change the balance of chemical messengers that carry signals between nerve cells
- Some change how strongly the body reacts to a heat signal
- Some do not touch the biology at all. They change how much attention and alarm a flash gets
That last group explains something that looks odd at first. A treatment can leave the number of flashes unchanged while making them far less disruptive. This is not the same as doing nothing. It targets the part of the symptom that spoils your day.
What is fezolinetant (Veozah)?
- It is an NK3 antagonist, from the first class of medicine designed specifically for vasomotor symptoms
- FDA-approved for hot flashes in May 2023
- In the phase 3 SKYLIGHT 1 and 2 trials (The Lancet, 2023), 45 mg daily significantly reduced vasomotor symptom frequency versus placebo at weeks 4 and 12
- Hot flash frequency falls by roughly 50-60%, against a placebo response of about 20-66% in non-hormone trials
- Improvement appears within the first week and was sustained over 52 weeks in extension studies
- The most common side effect is headache; there is also a rare, reversible rise in liver enzymes, so periodic monitoring is recommended
Do low-dose antidepressants help hot flashes?
- Paroxetine reduces hot flashes by 40-65% and is FDA-approved for them as Brisdelle, 7.5 mg
- Venlafaxine and desvenlafaxine reduce symptoms by 40-60% and are considered the best of this group for night sweats
- Escitalopram and citalopram are also effective
- In the MsFLASH trial (Joffe et al., JAMA Internal Medicine 2014, 339 women), low-dose venlafaxine at 75 mg cut vasomotor symptoms by 47.6%, versus 28.6% with placebo
Gabapentin and pregabalin:
- Gabapentin reduces hot flashes by 40-60% and is especially useful for night sweats; it is usually started at 300 mg at bedtime
- Common side effects are drowsiness and headache
CBT, hypnosis and lifestyle:
- Cognitive behavioural therapy has Level I evidence for reducing hot flash bother and improving sleep (The Menopause Society 2023, NICE 2026)
- CBT does not reduce the frequency of flashes, but it significantly reduces how much they bother you
- Clinical hypnosis also has Level I evidence
- Avoiding triggers — coffee, alcohol, spicy food — does not change frequency, but it can lower the discomfort
- Paced breathing at the start of a flash, plus cooling strategies such as fans, layered clothing and cold drinks, can make episodes easier to manage
What the placebo response teaches us:
In non-hormone trials for vasomotor symptoms, the placebo response ranges from 20% to 66%, and women with higher anxiety tend to show a stronger placebo response. That does not make the effect 'not real' — it means expectation, routine and a sense of control shape how we experience symptoms. It is also why mind-body approaches such as CBT and hypnosis earn a legitimate place in a treatment plan.
Matching the option to the symptom:
Non-hormonal treatments are not interchangeable. They differ in what they are best at. Your main problem should guide the choice.
| If your main problem is | The option usually discussed |
|---|---|
| Frequent daytime hot flashes | Fezolinetant, or an SSRI or SNRI |
| Night sweats that break your sleep | Gabapentin, or an SNRI |
| Flashes that dominate your day | CBT or clinical hypnosis, alongside a medicine |
| Low mood or anxiety alongside the flashes | An SSRI or SNRI, discussed with your clinician |
| You want to start with something you can do yourself | Cooling habits, paced breathing and a trigger record |
Three things shape the rest of the decision: what your main symptom is, what else you take or have, and which side effects you could live with. Bring all three to the appointment.
What a fair trial looks like:
A medicine needs time to show what it can do. Judging it straight away is unfair to you and to the treatment.
Decide in advance what you are measuring. Frequency and bother are different things. You may have the same number of flashes and care about them far less. Both are real results.
Change one thing at a time. If you start a new medicine and a new supplement in the same week, you cannot tell which one helped or which one caused a side effect. It also makes the next decision harder for your clinician.
Write side effects down as you notice them, even mild ones, and note when they began. Most settle. Some are a reason to change the plan. Neither is a reason to stop on your own. Some medicines are reduced gradually rather than stopped all at once, so ask first.
Agree a review point before you start. Then you both know when the decision gets made, instead of drifting.
What these options do not treat:
Non-hormonal treatments are chosen for a particular symptom. It is worth being clear about what they do not cover.
- A medicine that reduces flashes will not, by itself, settle broken sleep, low mood or aching joints
- Vaginal dryness, discomfort during sex and urinary symptoms have their own treatments, which are separate from hot-flash treatment
- Bone and heart health are looked at separately, and the transition is a natural moment to review both
- Brain fog and poor concentration have no medicine that simply switches them off
This matters because one prescription can give the impression that everything is now handled. If several symptoms are troubling you, list them all. A common plan is one medicine for flashes, a mind-body approach for sleep and mood, and a separate conversation about genitourinary symptoms.
If the first option falls short:
Trying an option and finding it is not enough is common. It is information, not failure.
- Your clinician may be able to change how much you take
- A different class may suit you better than a larger amount of the same one
- A mind-body approach can be added to a medicine rather than replacing it
- It may be worth revisiting hormone therapy, in the light of your history
Ask what the next option would be before you leave. A plan with a next step is easier to live with than a dead end. It also helps to know that response varies between women for reasons that are not always clear.
Questions worth bringing to the appointment:
It is easy to leave with a prescription and no clear idea of what to expect. A short written list prevents that.
- What are the options for my main symptom, and why this one first?
- What should this do, and how would I know it is working?
- How long before we judge whether it helps?
- Which side effects should make me call you?
- Does it interact with anything I already take?
- What happens if it does not work?
- Is there anything I should stop or avoid while taking it?
- When would you like to see me again?
Take notes, or ask whether you may record the main points. If a word is unfamiliar, ask what it means in plain language. Asking is not being difficult. A plan you understand is a plan you can follow.
Are supplements worth trying for hot flashes?
Supplements that appear constantly in adverts — soy, black cohosh, evening primrose oil, vitamin E, cannabinoids — are not recommended by The Menopause Society because rigorous evidence is lacking. A 2024 evidence map identified 57 randomised controlled trials of complementary therapies, but the methods were too varied to draw firm conclusions. If you are still considering a supplement, talk to your clinician first, and do not swap a proven option for an unproven product.
In short:
When hormone therapy is not an option or not wanted, validated alternatives exist: fezolinetant for hot flashes, low-dose antidepressants, gabapentin, CBT and hypnosis, plus lifestyle adjustments. Each has different benefits and side effects, and the placebo response is a reminder of how much mind-body approaches matter. Talk to your clinician about what fits your profile — and do not rely on supplements without evidence.