Non-hormonal treatments

Non-hormonal treatments ease menopause symptoms without replacing estrogen. Most are medicines first made for something else, such as depression or epilepsy, which is why the British Menopause Society notes that using them for menopause symptoms is often off-licence. Off-licence means the medicine is licensed, just not for this use, so your doctor should explain why it is being suggested.

Some options are not medicines at all. CBT is one, and Women's Health Concern teaches slow, paced breathing as part of it. On its own, the Australasian Menopause Society finds too little evidence to back paced breathing for flushes.

Fezolinetant

A newer tablet that blocks a brain signal the BMS links to hot flushes and night sweats. NICE recommends it when HRT is unsuitable, and the PMS table lists liver tests before and during treatment. Full page: fezolinetant.

SSRIs and SNRIs

These are antidepressants. The PMS table lists paroxetine and escitalopram (SSRIs) and venlafaxine and desvenlafaxine (SNRIs) for hot flushes. The BMS notes that paroxetine and fluoxetine can make tamoxifen less effective, while citalopram, escitalopram and venlafaxine have much less effect on it, or none. The NHS website adds that antidepressants can help mood symptoms where depression or anxiety has been diagnosed. More on SSRIs for menopause.

Gabapentin

An epilepsy and nerve-pain medicine. The PMS table lists it as an off-label option for flushes at night and badly broken sleep. The BMS lists dry mouth, dizziness and drowsiness among its side effects.

Oxybutynin

An anticholinergic medicine. The PMS table lists it as off-label for flushes and notes it may suit women who also have overactive bladder symptoms (see bladder and urinary symptoms). The Australasian Menopause Society advises caution in older women, because of a risk of decline in memory and thinking.

Clonidine

A blood pressure medicine. The NHS website says it can help reduce hot flushes and night sweats, and the BMS notes it is the only licensed option on its list of alternatives. It is not in the PMS table. For women who have had breast cancer, the British Menopause Society includes clonidine among the non-hormonal options it recommends for hot flushes.

Beyond tablets

The PMS recommendations mention stellate ganglion block, an injection near the neck, as a second-line option for specialist use, with small trials so far (sections 6 and 7.1.2). The Menopause Society, in the US, says it might help some women with moderate to very severe flushes, but warns that it is a procedure with risks and needs careful weighing.

Clinical hypnosis is the other. The Menopause Society recommends it for flushes and rates the evidence as strong; it can be done with a trained practitioner or through a smartphone app. No UK body we checked names either option.

NICE NG23 recommends offering HRT first for hot flushes and night sweats, in women who can take it (1.5.1). For women for whom HRT is unsuitable, it recommends fezolinetant as an option. It also says: "Do not routinely offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or clonidine as first-line treatment for vasomotor symptoms alone."

The Menopause Society grades the options for flushes: CBT, clinical hypnosis, SSRIs and SNRIs, gabapentin and fezolinetant on strong evidence, oxybutynin on strong to limited evidence, and weight loss and stellate ganglion block on more limited evidence. The European Menopause and Andropause Society (EMAS) adds that the non-hormonal medicines tend to work less well than HRT.

That NICE line matters in Pakistan. An audit of 250 women aged 45 to 55 diagnosed with depression at a Rawalpindi hospital, presented at a conference in 2024, found that 78% had significant perimenopausal symptoms that had been missed (Gul, 2024).

See your doctor if side effects are bothering you, or if a treatment has not helped after a fair trial. Talk to whoever prescribed it before you stop: the PMS table notes that several of these medicines need to be reduced gradually when you come off them.

If you take tamoxifen or any other long-term medicine, say so before anything new is started.

Being handed an antidepressant for hot flushes can sting. The BMS notes that mental health is not really talked about in South Asian communities, so the prescription can feel like a label. It may not be one: several of these medicines are used for the flushes themselves. Ask what it is for, and ask out loud.

Some women prefer to avoid hormones for reasons of faith. Whether a particular medicine is permissible is a question for a qualified scholar. When to take it on a fasting day belongs with whoever prescribes it.