Not every woman can take menopause hormone therapy, and not every woman wants to. The good news is that there are several non-hormonal options with real evidence behind them. The less good news is that the menopause supplement industry has grown into a multi-billion pound market, and most of what is sold does not have the evidence its packaging implies. Here is how to separate what works from what does not.
Options With Solid Evidence
SSRIs and SNRIs
Certain antidepressants, particularly low-dose venlafaxine, paroxetine, escitalopram, and citalopram, can meaningfully reduce hot flushes. Their effect on vasomotor symptoms is separate from their effect on mood, so they can be useful even for women who are not depressed. Paroxetine is the only SSRI licensed specifically for hot flushes in some countries.
Fezolinetant
Fezolinetant is a newer non-hormonal medication that targets a specific brain pathway (the NK3 receptor) involved in the temperature dysregulation of hot flushes. It has been approved in several countries in the past two years and offers a real alternative for women who cannot or do not want to take oestrogen. Liver function needs to be monitored during treatment.
Gabapentin
Originally an anti-seizure medication, gabapentin has moderate evidence for reducing hot flushes, particularly night-time symptoms. It can be helpful for women whose sleep is disrupted by night sweats.
Cognitive Behavioural Therapy
CBT is one of the most under-prescribed evidence-based interventions in menopause care. It has been shown to reduce the impact of hot flushes and improve sleep, mood, and quality of life. It does not stop hot flushes from occurring, but it changes how disruptive they feel.
Weight-Bearing and Resistance Exercise
This is the strongest evidence-based intervention for protecting bone density after menopause, and it also supports mood, sleep, and cardiovascular health. Two to three sessions a week of resistance training, alongside impact-based activity, is where the evidence is strongest.
Vaginal Moisturisers and Lubricants
For vaginal dryness and painful sex, water-based lubricants (for use during intercourse) and hyaluronic-acid based vaginal moisturisers (used regularly regardless of sexual activity) offer real relief. They do not treat the underlying tissue changes the way local vaginal oestrogen does, but they can be used alongside or on their own.
Options With Limited or No Evidence
The 2023 North American Menopause Society non-hormone position statement reviewed the evidence and recommended against a long list of interventions widely sold for menopause. These included:
Soy foods and soy extracts, including isoflavones and equol
Black cohosh
Evening primrose oil
Most herbal remedies and adaptogens marketed for menopause
Cannabinoids
Acupuncture (for vasomotor symptoms specifically)
Chiropractic interventions
Paced breathing techniques
This does not mean these interventions cause harm in most cases. It means the evidence does not support them as effective treatments for menopause symptoms. Where they are used, it should be with clear eyes about what they can and cannot offer.
Lifestyle Adjustments With Modest Evidence
Reducing alcohol, caffeine, and hot drinks can reduce vasomotor symptom triggers for some women. Regular movement, adequate sleep, and stress management all support how the transition feels, even if they do not directly change the hormonal picture.
Choosing an Approach
Non-hormonal options are not second-best. For some women they are the right first option, either because MHT is not suitable or because their symptoms are milder. The goal is to choose treatments that have evidence behind them rather than money behind them, which are not always the same thing.