Key takeaways
- The Menopause Society's 2023 position statement is a detailed review of non-hormonal options, and it separates what works from what does not.
- Talking therapies (CBT and clinical hypnosis) are recommended and have no drug side effects.
- Prescription options include certain SSRIs and SNRIs, gabapentin, oxybutynin and the newer neurokinin receptor blockers. All are prescription decisions after assessment.
- Women taking tamoxifen should avoid paroxetine and fluoxetine, as NICE advises.
- Herbal products vary in quality and can interact with other medicines. Tell your doctor about anything you take.
Who needs non-hormonal options?
There is a misunderstanding I want to clear first. Some women believe that if they can't take hormones, or don't want to, there is nothing for them except "adjusting". That is not true. Hormone therapy is the most effective treatment for many women, but it is not for everyone. Non-hormonal routes are commonly used by women who: - Have had breast cancer or are at high risk of it - Have had a blood clot, stroke or certain liver conditions - Have side effects on hormones - Simply prefer not to take hormones
Every one of these is a valid reason. Symptoms are symptoms, and they deserve treatment whichever route you choose. See Who should not take menopausal hormone therapy?
What has good evidence?
The Menopause Society's 2023 non-hormone therapy position statement reviewed the research and recommended the following for hot flushes:
| Option | What it is | Points to know |
|---|---|---|
| Cognitive behavioural therapy (CBT) | A structured talking therapy, usually over several sessions | Helps flushes feel less bothersome and improves coping and sleep. No drug side effects |
| Clinical hypnosis | Guided sessions with a trained therapist | Shown to reduce the number and severity of flushes |
| Low-dose SSRIs or SNRIs | Antidepressant-class medicines used here for temperature control | Mild to moderate improvement. Side effects vary by medicine, and some interact with tamoxifen |
| Gabapentin | A nerve-pain and seizure medicine | Reduces frequency and severity; side effects and timing of doses are discussed before starting |
| Oxybutynin | A bladder medicine | Helps moderate to severe flushes, but long-term use has been linked to cognitive decline, especially in older women |
| Neurokinin receptor blockers (fezolinetant, elinzanetant) | Newer medicines that act directly on the brain's temperature centre | Approved in the US. Fezolinetant carries an FDA warning about rare serious liver injury, so liver tests are needed. May not be available in India |
| Weight loss | For women carrying extra weight | May reduce flushes for some, especially early in menopause |
| Stellate ganglion block | An injection near a nerve bundle in the neck | Specialist procedure, considered for moderate to very severe flushes |
How do the newer medicines work?
See, I'll tell you the simple picture. Deep in your brain there is a thermostat. Falling estrogen makes a group of brain cells near it, called KNDy neurons, overactive. They release more of a chemical messenger called neurokinin B, which narrows the body's comfortable temperature band, so the smallest warmth sets off the alarm. Neurokinin receptor blockers target this exact step, like putting a hand over the alarm button. Fezolinetant was approved in the US in 2023 and elinzanetant in October 2025.
Fezolinetant received an FDA boxed warning in December 2024 about rare but serious liver injury. Liver blood tests are recommended before starting, monthly for the first three months, and at six and nine months. Availability in India may be limited or changing, so please ask your doctor what is realistically accessible and suitable for you.
How does NICE view these options?
The UK's NICE guideline (NG23) takes a slightly more cautious line on antidepressants. It advises not to routinely offer SSRIs, SNRIs or clonidine as first-line treatment for hot flushes alone, largely because hormone therapy is more effective for women who can take it. For women who cannot, these medicines are still used. NICE also specifically advises against offering paroxetine or fluoxetine to women taking tamoxifen, because they interfere with how tamoxifen works.
The point is, both views fit together: if hormone therapy is suitable, it is usually the most effective option. If not, there are proven alternatives.
What does not have good evidence?
The same Menopause Society review did not recommend the following for reducing hot flushes, because trials did not show reliable benefit: - Paced breathing and relaxation techniques - Supplements and herbal remedies - Soy products - Exercise and yoga - Cooling techniques and avoiding triggers - Acupuncture - Dietary changes - Clonidine and pregabalin - Cannabinoids
This does not mean they are useless for everything. Exercise and yoga are wonderful for mood, sleep, bones and heart. A fan by the bed makes nights more bearable. But if your flushes are disrupting your life, these alone are unlikely to be enough, and you have not "failed" if they don't work. It's not your fault.
On herbal products, NICE notes that isoflavones and black cohosh may relieve symptoms for some women, but product quality and safety are uncertain and interactions with other medicines occur. St John's wort can interact seriously with other drugs, including tamoxifen. Many ayurvedic and over-the-counter "menopause" products in Indian pharmacies have little published evidence, so please show your doctor the label.
What about vaginal dryness and other symptoms?
Non-hormonal options exist for other symptoms too: - Dryness and discomfort: regular vaginal moisturisers and lubricants. NICE advises trying these first in women who have had breast cancer. Low-dose vaginal estrogen may still be an option for some, after specialist discussion. - Sleep: CBT for insomnia. See Night sweats and waking at 3 am. - Mood and anxiety: CBT and, where appropriate, antidepressants. See Anxiety, irritability and mood changes in perimenopause.
How I approach this at Dr Tvacha
At Cocoon × Dr Tvacha in Thane West, I discuss non-hormonal options with exactly the same care as hormone therapy, check your other medicines (including tamoxifen, if relevant) and coordinate with your oncologist where needed. You choose the route; the plan, review dates and fees are set out in writing. Read about the Right Stop Programme on our women's health page, and see Hot flushes: why they happen and what helps.
Frequently asked questions
What is the most effective non-hormonal treatment for hot flushes?
There is no single right option for everyone. The Menopause Society recommends CBT, clinical hypnosis, certain SSRIs and SNRIs, gabapentin, oxybutynin and neurokinin receptor blockers. The newer neurokinin blockers act directly on the brain's temperature centre but may not be readily available in India. I match the choice to your health, your other medicines and your side effect concerns.
Will I have to take an antidepressant if I am not depressed?
Some SSRI and SNRI medicines are used at low doses for hot flushes because of their effect on temperature control, not because you are depressed. They give mild to moderate relief. If you would rather not take one, CBT, clinical hypnosis or gabapentin are alternatives. The choice is yours after we discuss benefits and side effects.
Are herbal supplements safe for hot flushes?
Not necessarily. The Menopause Society does not recommend supplements and herbal remedies for hot flushes, because trials have not shown reliable benefit. NICE notes that product quality varies and some, such as St John's wort, interact with other medicines including tamoxifen. Please always tell your doctor about any supplement or ayurvedic product you use.
What can I take for hot flushes after breast cancer?
Women who have had breast cancer are usually advised against systemic hormone therapy. Non-hormonal options such as CBT, clinical hypnosis, gabapentin and some SNRIs are commonly considered. If you take tamoxifen, NICE advises avoiding paroxetine and fluoxetine. These decisions are best made with your oncologist and gynaecologist working together.
Does soy or flaxseed help hot flushes?
Many Indian women try soy, flaxseed (alsi) or methi. The Menopause Society review did not recommend soy products for hot flushes because studies were inconsistent. As part of a balanced diet, soya and flaxseed are healthy foods with protein and fibre, but please don't rely on them as treatment if your flushes are disrupting your life.
Written by
Dr Anagha KarkhanisGynaecologist and Fertility Specialist · Reg. No. 2006/02/1187Leads midlife women's health at Cocoon × Dr Tvacha, Thane.
Sources
- The Menopause Society 2023 nonhormone therapy position statement, press release
- NAMS releases statement on non-hormone therapy for hot flashes and night sweats (Breastcancer.org)
- Menopause: identification and management (NICE guideline NG23), recommendations
- FDA issues boxed warning for fezolinetant over rare but serious liver injury risk (Pharmacy Times)
- FDA approves elinzanetant, a hormone-free option for hot flashes in menopause (AJMC)
- Overview of KNDy neurons (Patient Care Online)
This article is for general education and does not replace a consultation. Medicines and treatments are prescribed only after a doctor's assessment. Last reviewed 25 October 2026.