Non-Hormonal Options That Have Evidence

Plenty of women can't take hormone therapy, or shouldn't, or simply don't want to. Until recently the alternatives were thin. That has changed materially in the last three years, and the options now available are worth knowing by name.

The Menopause Society reviewed the evidence systematically in 2023 and produced a recommended list. What follows is drawn from that review, with subsequent approvals added.

The new class of drugs

The most significant development. Researchers identified the specific neurons responsible for hot flushes — KNDy neurons in the hypothalamus, which become hyperactive when estrogen falls — and developed drugs that block their signalling.

Fezolinetant (Veozah) blocks the NK3 receptor. FDA-approved in May 2023 as the first drug of this class. Reduces frequency and severity of moderate to severe hot flushes substantially in trials. Requires liver function monitoring, and the FDA has issued additional warnings regarding liver injury since approval, so bloods before starting and periodically after.

Elinzanetant (Lynkuet) blocks both NK1 and NK3 receptors. Approved in the UK, Canada, Australia and Switzerland, and by the FDA in October 2025. Taken once daily at bedtime. Trial data showed marked reductions in hot flushes, with additional benefit for sleep — the NK1 component appears to contribute there.

Both are non-hormonal, which makes them relevant for women with breast cancer history, in whom treatment-induced hot flushes are often severe. Both are new enough that long-term data is still accumulating, and both cost more than older options.

Talking treatments, which perform better than expected

Cognitive behavioural therapy is recommended at the highest evidence level in the 2023 review, and NICE added it to its guidance in 2024 for hot flushes, night sweats and menopause-related sleep problems.

The mechanism is worth understanding, because "therapy for hot flushes" sounds implausible. CBT doesn't stop the physiological event. It addresses the response to it — the anticipatory monitoring, the catastrophic interpretation, the distress that amplifies the experience. Trials find reductions in how problematic women rate their symptoms, even where frequency changes less. Given that "how problematic" is what actually affects your life, that's a meaningful outcome.

Clinical hypnosis also made the recommended list, at the same evidence level, with trial data showing substantial reductions in hot flush frequency. It's under-used largely because provision is patchy.

Medications originally developed for something else

SSRIs and SNRIs. Venlafaxine, escitalopram, citalopram, paroxetine and desvenlafaxine all have evidence for hot flushes at doses generally lower than those used for depression. In the US, low-dose paroxetine (7.5 mg) is FDA-approved specifically for vasomotor symptoms.

One important caution: paroxetine and fluoxetine inhibit the enzyme that converts tamoxifen to its active form, so they're generally avoided in women taking tamoxifen. Venlafaxine is commonly preferred in that situation.

Gabapentin. Evidence for hot flushes, and its sedating effect makes it particularly useful where night sweats dominate. Taken at night.

Oxybutynin. An anticholinergic originally for overactive bladder, with evidence for hot flushes. Anticholinergic burden is a consideration, particularly with long-term use in older women.

Weight loss, in women with higher body weight, made the recommended list — one of the few lifestyle interventions that did.

What the same review did not recommend

This part surprises people, and it's worth reading in the right spirit.

Not recommended for hot flushes on current evidence: paced breathing, cooling techniques, avoiding triggers, exercise, yoga, mindfulness-based interventions, relaxation, dietary modification, soy foods and soy extracts, supplements and herbal remedies, acupuncture, cannabinoids, chiropractic interventions, clonidine, and pregabalin.

Two things about that list.

First, "not recommended" means the evidence didn't support efficacy for hot flushes specifically. Exercise appears there, and exercise remains one of the best things you can do for cardiovascular health, bone density, muscle mass, mood and sleep. It just hasn't been shown to reduce flushes.

Second, if something on that list works for you, the evidence review isn't an instruction to stop. Trial averages don't dictate individual experience. The value of the list is different: it tells you that if you've been managing flushes solely through trigger avoidance and cooling and they're still ruining your life, the failure isn't yours.

How to use this

If hormone therapy isn't an option for you, the useful move is to go into an appointment naming specific things rather than asking what else there is.

"I can't take estrogen. I'd like to discuss the neurokinin antagonists, and whether CBT is available locally" is a different conversation from "is there anything non-hormonal". Awareness of the newer drugs varies considerably among clinicians, and naming them changes the odds.

Sources

- The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573–590. - National Institute for Health and Care Excellence. Menopause: identification and management (NG23), CBT recommendations. Updated 2024. - US Food and Drug Administration. Approval of fezolinetant (Veozah), May 2023, and subsequent safety communications on hepatic injury. - US Food and Drug Administration. Approval of elinzanetant (Lynkuet), October 2025. - Hunter MS. Cognitive behavioral therapy for menopausal symptoms. Climacteric. 2021;24(1):51–56.