Non-hormonal options for menopause symptoms

If hormone replacement therapy (HRT) is unsuitable, has not helped or is not what you want, other treatments are available. The choice depends on the symptom you want help with, such as hot flushes or vaginal dryness.

Advice has changed recently. NICE now recommends fezolinetant for a specific group, and elinzanetant has approvals in the UK and US. Before prescribing a newer medicine, your clinician needs to discuss it with you, including the safety checks.

CBT for flushes and disrupted sleep

Menopause-specific cognitive behavioural therapy, or CBT, is an option for hot flushes and sweats. NICE says it can be considered alongside HRT, when HRT cannot be used, or when someone prefers not to take it. It also recommends considering CBT for sleep problems associated with these symptoms.

The Menopause Society includes CBT and clinical hypnosis among non-prescription approaches for hot flashes. Ask a clinician what is available and what the sessions aim to help with. Start with how symptoms affect your day, perhaps at work or when you’re trying to sleep.

Fezolinetant: the recommendation and the checks

Fezolinetant is a non-hormonal prescription medicine for moderate to severe hot flushes. It acts on a pathway involved in the brain’s temperature control. NICE’s recommendation is limited to use when HRT is unsuitable.

NICE’s current guideline refers to TA1143, 2026. The appraisal specifies NHS funding in England for the recommended population when it is the most suitable option. It reports benefits compared with placebo, but comparisons with other non-hormonal medicines are uncertain.

The FDA warns that fezolinetant can cause rare but serious liver injury. A clinician needs to check liver blood tests before and during treatment. Ask who arranges the tests and how you will hear about the follow-up. These checks need to be part of the treatment plan from the start.

Elinzanetant: another prescription option

Elinzanetant, also called Lynkuet, is a non-hormonal medicine that acts on temperature-control signals in the brain. MHRA has approved it for moderate to severe menopausal hot flushes, and the FDA also lists approval for this use. Ask your prescriber about local access; the NHS recommendation for fezolinetant does not automatically apply here.

Its US patient information describes liver blood tests before treatment and during follow-up. It also warns about difficulty staying awake, fatigue and dizziness. If these effects occur, the leaflet advises avoiding driving and hazardous activities until they have gone away.

Tell the prescriber about liver problems, any seizure history and all medicines or supplements you use. Elinzanetant can interact with other medicines. Its US label says it is unsuitable during pregnancy, so discuss the possibility of pregnancy during your assessment. Follow the prescribed instructions. Ask your prescriber to explain the pregnancy-testing and contraception requirements.

Contact your prescriber immediately (UK, US and elsewhere), or an urgent medical service if unavailable, if you think you may be pregnant while taking elinzanetant. Follow the leaflet’s urgent safety instructions immediately; do not wait for a callback to follow them.

Other prescription options differ by country

The Menopause Society describes certain antidepressants, gabapentin and oxybutynin as off-label options for hot flashes: they are used for this purpose even though approved for other conditions. Antidepressants have been studied for hot flashes in women without depression.

UK NICE advice differs in emphasis. It says not to routinely offer antidepressants called SSRIs or SNRIs, or clonidine as the first treatment for hot flushes and sweats alone. You can still discuss these medicines with your clinician. Your GP or doctor can explain what suits your symptoms and history.

Vaginal moisturisers and lubricants

For vaginal dryness or related discomfort, NICE recommends considering non-hormonal vaginal moisturisers or lubricants when vaginal oestrogen is unsuitable or unwanted. These can also be used alongside vaginal oestrogen. Ask a pharmacist or clinician about suitable products.

Herbal products and other medicines

There is very little evidence about how well products such as black cohosh and red clover work or how safe they are. Herbal products are not necessarily easier to use or safer than other treatments. Some can cause serious side effects when combined with other medicines. Tell your pharmacist or doctor about them.

When to contact the prescriber

Seek medical attention immediately through your local emergency medical service (UK, US and elsewhere) if you have a seizure or lose consciousness while taking elinzanetant.

Contact your prescriber immediately (UK, US and elsewhere), or an urgent medical service if unavailable, for new unusual tiredness, nausea or vomiting, yellow skin or eyes, dark urine, pale stools, unusual itching or abdominal pain while taking fezolinetant or elinzanetant. This also applies to reduced appetite while taking elinzanetant, or abdominal swelling while taking fezolinetant. Follow the leaflet’s urgent safety instructions immediately; do not wait for a routine blood test or a callback to follow them.

Book a GP review in the UK, or see your doctor in the US and elsewhere, if treatment is not helping or side effects persist. Bring the medicine names and the symptoms you most want to improve. Ask whether specialist menopause advice would help.