Treatment without systemic hormones

Part 9 of 12 · All topics on the menopause

The choice is not just between hormones and putting up with it

Some women deliberately do not want systemic hormone therapy. Others have medical reasons that speak against it. Others again mainly need treatment for sleeplessness, vaginal symptoms or symptoms of depression – and so may not need systemic hormone therapy at all. The good news is that between “taking hormones” and “doing nothing” there are several evidence-based options.

The most important step is not to lump all approaches together under the heading “natural alternatives”. Psychological treatments, prescription medicines, locally applied active substances and simple comfort measures have different aims, different evidence of effectiveness and different risks. This page deals with treatments for which medical research allows a well-founded decision. Everyday measures and dietary supplements are only discussed on the pages What you can influence yourself and Supplements and myths.

Menopause-specific cognitive behavioural therapy

Cognitive behavioural therapy, CBT for short, looks among other things at how thoughts, attention, judgements and behaviour are linked to distress. Menopause-specific programmes focus, for example, on the distress caused by hot flushes, unhelpful sleep patterns or worries about symptoms. They do not claim that physical symptoms arise only in the mind. Rather, they help you cope better with the effects of these symptoms and, in part, have been shown to reduce them.

NICE recommends considering menopause-specific CBT for hot flushes, certain sleep problems and symptoms of depression – on its own or in addition to other treatment, depending on the situation. This is a clinical recommendation, not a claim that every woman must have therapy. [1]

For chronic insomnia, targeted CBT-I is different from general tips such as “drink less coffee in the evening”. Among other things, it works on the link between bed, lying awake and sleep pressure. A randomised trial with 106 women showed positive effects of a programme supported by telephone. Such treatment takes time and effort; in return it can teach lasting skills that do not depend on a medicine. [2]

Hypnosis and other psychological approaches

In its evidence review, the Menopause Society rates clinical hypnosis as one of the non-hormonal options with proven effectiveness for treating vasomotor symptoms. This refers to structured clinical methods, not to any internet offer that promises miracle results. Here too, the type and quality of the programme are what matter. [3]

Mindfulness exercises or relaxation can be helpful for you personally, especially when stress and tension play a part. For directly and reliably reducing hot flushes, however, the results are not convincing for every method. A reliable guide should not confuse benefit for general wellbeing with specific proof of effectiveness against vasomotor symptoms.

Certain antidepressants for hot flushes – without a diagnosis of depression

Some active substances from the groups of selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) can reduce hot flushes. In treating vasomotor symptoms they are not necessarily used because a depression is present, but because certain neural pathways influence temperature regulation. In some countries or for some indications this use is not expressly approved; availability varies. [3]

Choosing among them is a task for a doctor. Tolerability, interactions, sleep, sexual function, blood pressure and, where relevant, other medicines have to be taken into account. For patients taking tamoxifen it is particularly relevant that some antidepressants that strongly inhibit CYP2D6 can impair the conversion of this breast cancer medicine. A treatment must therefore not be taken from a general list without regard to the individual medication.

For hot flushes, NICE continues to give priority to hormone therapy where it is suitable, and does not recommend SSRIs/SNRIs routinely as first-line treatment for isolated vasomotor symptoms. This does not contradict the existence of scientific evidence of effectiveness. As well as effectiveness, guidelines take into account alternatives, side effects, national approval and the conditions of care. [1]

Gabapentin and other medicines

Gabapentin has also been studied against hot flushes in controlled trials and is named by professional societies as a possible non-hormonal treatment. Depending on the product and on national approvals, it may be used outside the indication for which it was originally approved. Typical practical questions concern daytime tiredness, dizziness, risk of falls, interactions and suitability where other conditions are present. Treatment should not be started or suddenly changed without medical advice. [3]

Other active substances, such as oxybutynin, have also been studied. That a medicine can reduce hot flushes does not mean, however, that it is a good choice for every woman because of possible anticholinergic side effects. Especially with long-term use, possible effects on daily life, memory and other aspects of health must be weighed up carefully.

Neurokinin receptor antagonists: new effectiveness, new safety questions

A more recent drug approach does not act directly on the sex hormones but on neural pathways of temperature regulation. Fezolinetant blocks neurokinin-3 receptors. In the randomised phase III trial SKYLIGHT 1, the frequency and severity of moderate to severe hot flushes were reduced compared with placebo. Its scientific importance lies in showing that a non-hormonal, targeted treatment of vasomotor symptoms is possible. [4]

What matters, however, is the time after approval. Rare, sometimes serious drug-induced liver injury has been reported with fezolinetant. The European Medicines Agency therefore published additional measures for monitoring liver function. According to the current product information, corresponding checks are necessary before treatment starts and in the early phase of treatment; the exact requirements must be checked against the current product information immediately before every prescription. Anyone who develops signs such as yellowing of the skin, dark urine, unusual nausea or severe tiredness should seek medical help without delay. [5]

Elinzanetant works in a similar but not identical way: it also acts on neurokinin signalling pathways. The randomised OASIS-1 and OASIS-2 trials found a reduction in vasomotor symptoms compared with placebo. In the EU it has been approved under the name Lynkuet. The fact that two medicines belong to one family of active substances does not mean that they have an identical side-effect profile or the same monitoring plan. Which option is available and sensible depends on national availability, the current product information and your personal situation. [6] [7]

Rule of thumb: “Without hormones” does not mean “without side effects”. For new medicines it is especially important to read the effectiveness trials and the later safety information together.

Treating sleep problems in a targeted way

If the main complaint is chronic insomnia, it should be treated as such. CBT-I is an effective psychotherapeutic method. If sleep apnoea, restless legs syndrome, depression or other causes in sleep medicine are suspected, a suitable examination is needed. Sleeping tablets can play a role in certain situations, but should not automatically be used as a lasting solution for an unexplained sleep problem.

The principle is simple: good treatment should, as far as possible, take account of the mechanism of the problem. Someone who keeps waking because of night sweats starts from a different place than someone whose sleep is disturbed by persistent brooding or pauses in breathing. More on this distinction can be found on the page Hot flushes and sleep, without our repeating all of the biology of sleep here.

Local treatment for vaginal and urinary symptoms

Low-dose vaginal oestrogen is among the best-studied treatments for the genitourinary syndrome of the menopause. It is not systemic hormone therapy in the usual sense, although small amounts can enter the bloodstream. For suitable symptoms it can, for example, improve dryness and pain. Some guidelines also recommend it for recurrent urinary tract infections in suitable postmenopausal groups. [8] [9]

In addition, non-hormonal vaginal moisturisers and lubricants are available. They can be sensible, especially for mild symptoms or as a supporting measure. How long they work and what they are for differ; lubricants mainly reduce friction during a particular activity, while moisturisers can be used regularly.

Further local options such as vaginal DHEA products or other prescription treatments are available depending on the country, the indication and your medical history. Not all of them have the same level of evidence. After earlier breast cancer, and especially during certain cancer treatments, agreement with the treating oncology team is important. Here too, “local” would not be a synonym for “harmless for every person”. [1]

Treatment options at a glance

The table names categories of treatment, not individual prescriptions. The suitable option depends on age, symptoms, other conditions, medicines and preferences. The evidence-based comparison rests mainly on NICE, the Menopause Society and the current GSM guideline. [1] [3] [9]

What you can ask before deciding

Four questions are helpful: Which symptom is the treatment meant for? How large is the expected benefit compared with no treatment? Which side effects and checks matter? And when will it be reviewed whether the treatment has actually helped? A specific trial of treatment, evaluated together, is often more sensible than the search for one remedy that is supposed to solve all symptoms at once.

When hormones do not suit you or are not wanted

The term “non-hormonal” at first says only what a treatment does not contain. It does not automatically describe a weaker effect or lower risks. Some non-hormonal medicines act specifically on neural systems; others were originally developed for other conditions and can reduce how often hot flushes occur or how much they bother you. Psychological approaches, in turn, can improve how you cope with sleep problems and symptoms, without claiming the same biological effect as drug treatment. The suitable option depends on exactly what is to be treated. [3]

In its 2023 position statement, the Menopause Society summarised a number of effective non-hormonal options for vasomotor symptoms. They include menopause-specific cognitive behavioural therapy, clinical hypnosis, certain SSRIs/SNRIs, gabapentin and fezolinetant. The recommendations do not say that each of these measures is equally effective or suitable for every woman. They show that the choice between treatment and no treatment is considerably more nuanced than it used to be. [3]

Different aims, different methods

If the main aim is to cut the number of hot flushes, you will look at different outcomes than for a woman who lies awake for a long time at night and dreads the next morning. Menopause-specific cognitive behavioural therapy can reduce the felt distress caused by hot flushes and the sleep problems that go with them. It need not change the number of physical episodes to the same extent. Knowing this difference helps you understand the studies better and judge your own response more realistically.

For chronic insomnia, cognitive behavioural therapy aimed specifically at sleep problems can help. It often includes work on sleep times, habits and unhelpful expectations about sleep. This is not the same as the blanket advice to “just relax” before going to bed. The randomised MsFLASH trial showed relevant improvements in sleep from such a method in perimenopausal and postmenopausal women. [2]

Hypnosis, too, should not be understood as a stage act. Clinical hypnosis is a structured therapeutic method and is named in some scientific recommendations as an option for vasomotor symptoms. The quality and training of those providing it are decisive. Personal success stories are interesting, but a method should be judged on controlled studies.

Medicines originally developed for other conditions

Certain antidepressants from the SSRI and SNRI groups can reduce hot flushes even if the woman being treated does not have depression. Their effect on vasomotor symptoms must not be confused with the treatment of a diagnosed depression. The choice depends, among other things, on interactions, possible nausea, changes in sleep and sexual side effects. With some cancer medicines taken at the same time, certain active substances are unsuitable. That is why an individual check is important.

Gabapentin is another substance that has been studied; it is originally used for other indications. Tiredness and dizziness in particular can limit its use. Some women therefore prefer another approach first, while for others its effects and side effects may suit better. A health guide should not give doses for treating yourself, because these depend on approval, other conditions and medical supervision.

The NICE guideline and the Menopause Society position statement differ in how they weigh individual non-hormonal medicines. NICE does not recommend SSRIs/SNRIs or clonidine routinely as a first choice for vasomotor symptoms alone. This does not mean that these substances are generally ineffective; it reflects different routes to recommendations and different care settings. [1] [3]

What the new neurokinin receptor antagonists can do

Neurokinin receptor antagonists intervene in pathways that take part in temperature regulation. Fezolinetant was studied in randomised phase III trials in moderate to severe vasomotor symptoms. Elinzanetant is another active substance with positive results from the OASIS trials and EU approval since November 2025. These developments are scientifically interesting, but must not be presented as a risk-free “hormone replacement solution”. [4] [6] [7]

Fezolinetant in particular shows why the assessment of a medicine goes on after approval. Authorities warned of serious liver injury and required liver function checks before and during treatment. The exact conditions, intervals between checks and reasons for exclusion are set out in the current product information; this must be checked at every prescription. An overview of risks is necessary on these pages, but the practical carrying out belongs to medical care. [5]

National reimbursement is a different matter from approval. A substance can be approved in the EU and still be reimbursed in individual health systems only under certain conditions. These pages therefore give no lasting price or reimbursement details, but refer to the current information from the authorities and the product information.

Local symptoms often need local answers

For vaginal dryness or pain in the intimate area, it would be a mistake to choose a medicine for hot flushes automatically. Vaginal oestrogen products, certain other locally acting remedies and moisturising products have been studied separately for such symptoms. The decision depends, among other things, on the symptoms and the medical history. After earlier breast cancer, cooperation with the oncology team is often needed. [8] [1]

“Local” does not mean that a treatment is, in principle, free of systemic absorption or of risks. Dose, pharmacology and evidence differ between products. This should be explained factually on these pages, without making access to effective treatment harder through blanket warnings.

Why a trial supervised by a doctor says more than a product promise

The success of a treatment should be defined beforehand in reasonably concrete terms. For example: fewer awakenings at night, fewer distressing hot flushes during the working day, or less pain during sex. After an agreed period you can then look at whether there is an improvement, whether side effects have appeared, and whether the effort fits your situation. This is not a perfect experiment: symptoms fluctuate, and expectations play a part. Even so, it is better than switching uncritically from one product to another.

If a method does not help enough, there are several possibilities. Perhaps the original diagnosis was incomplete. Perhaps it was used for too short a time, the side effect was too burdensome, or the chosen approach did not fit the main problem. An unsuccessful treatment does not say anything about all the other treatments. An informed decision remains a process, not a one-off test of your willpower.

Caution with blanket claims about safety

In conversations about alternatives you often hear: “That’s not a hormone, so it can’t do any harm.” But non-hormonal medicines, too, have interactions and contraindications. Conversely, a known side effect does not automatically make a medicine unsuitable; it has to be weighed against the possible improvement and your personal risk. The aim is neither freedom from fear by ignoring risks, nor safety by giving up altogether. It is a well-founded decision with realistic monitoring.

Before a prescription, therefore, ask not only about the expected benefit, but also about the time until it might work, typical side effects, necessary checks and possible interactions with your other medicines. These questions apply to everything and help regardless of whether a new active substance or a therapy in common use for years is being discussed.

A table is only as good as the question it compares

When you compare treatment options, first ask about the aim. A therapy for hot flushes cannot simply be judged against pain during sex, memory problems or osteoporosis. Conversely, a targeted treatment for sleep is not weak just because it does not change hormone levels. Good comparisons need the same outcome, a similar starting situation and, as far as possible, direct study data.

Many advertising graphics put different studies side by side as if the remedies had been tested directly against each other. That can mislead. A small study with short follow-up is not automatically comparable with a large study lasting several months. Placebo effects, different starting values and the definition of a “severe” hot flush also change the result.

Side effects are part of effectiveness

Some medicines reduce the number of symptoms markedly but cause tiredness or other problems that weigh more heavily for the individual woman than the original benefit. Others require regular laboratory monitoring. The question “Does it work?” is therefore not enough for a treatment decision. Equally relevant is: “How much better do I feel, and what price do I pay for it in my daily life?”

With fezolinetant this question has become especially visible. After approval, serious liver injury was reported, and the EMA then published new recommendations on checking liver function. The effectiveness data from the randomised trials remain important, but must be assessed together with the current safety information. [4] [5]

If a treatment does not help

There are various possible reasons: perhaps another cause of the symptoms was overlooked. Perhaps the chosen measure was not suited to the main problem. Perhaps it was used for too short a time to judge any effect, or the side effects were not tolerable. Not every treatment starts to work after the same length of time. That is why a specific point in time for the assessment should be agreed at the start.

Changing treatment is not a personal failure. Medical decisions often come about in several steps, especially when symptoms, risks and wishes change. The task of the healthcare professional is to go through the options with you, not to persuade you towards a particular product. Your task is not to read all the studies yourself – but to ask for the information you need for a decision.

The right treatment begins with the right question

Non-hormonal therapies are a varied group. They do not all work in the same way and do not treat the same symptoms. If you mainly suffer from hot flushes, other options come first than for a separate insomnia, depressive illness or vaginal dryness. The first task is therefore to name the main complaint as precisely as possible. Without this distinction even effective treatments can disappoint, because they are being used for the wrong aim.

An example: a woman reports sleep problems. In conversation it turns out that she regularly wakes because of night sweats and can then easily fall asleep again. For her, reducing the vasomotor symptoms might improve sleep indirectly. A second woman rarely has hot flushes but lies awake for a long time almost every evening, worrying about the next night. For her, treatment of chronic insomnia can be aimed at the problem directly. A medicine for hot flushes does not automatically solve the second problem.

This distinction is also important for interpreting studies. One intervention can reduce the distress caused by hot flushes without greatly reducing the number of episodes. Another changes the frequency but has side effects that affect quality of life. When advertising simply claims “effective against the menopause”, the really decisive information is missing: against what exactly?

What has been studied in behavioural therapy

Menopause-specific cognitive behavioural therapy and cognitive behavioural therapy for insomnia are related but not identical approaches. The first can help to reduce the distress caused by hot flushes, night sweats, or the thoughts and patterns of behaviour that go with them. The second is aimed particularly at persistent sleep problems. What they have in common is that they use structured methods that can be learned, not just soothing conversations.

In the MsFLASH trial with 106 women, insomnia treatment supported by telephone led to relevant improvements in sleep. The study was relatively small and tested one particular programme; its results therefore cannot be carried over without limit to every app or online offer. But it shows that targeted psychological treatment is an option to be taken seriously for sleep problems in the menopause. [2]

A treatment can also be helpful when it does not remove a physical cause. If hot flushes still occur but no longer lead to a long time awake every night, quality of life can rise markedly. This distinction between the symptom event and the felt distress is important both scientifically and in practice.

Understanding the main groups of medicines

Certain SSRIs and SNRIs influence messenger substances in the nervous system and can reduce the distress caused by vasomotor symptoms. Among other things, they are also used for depression or anxiety disorders, but their use against hot flushes does not have to mean that the woman has a mental illness. The suitable substance and its possible interactions are individual questions. A treatment should not be started on your own or stopped suddenly.

Gabapentin has also been studied for treating hot flushes. Its mode of action and side-effect profile differ from the SSRIs/SNRIs. Dizziness or tiredness in particular can matter, for example if the woman operates machinery at work or has to stay especially alert in daily life. Not every medically effective option therefore also fits a person’s life in practice. [3]

The number of recommended methods must not be equated with a ranking of effectiveness. Some studies include direct comparisons, others only comparisons with placebo. A sensible shared decision takes into account what evidence exists for exactly this product and the symptom in question.

Neurokinin receptor antagonists and their limits

Fezolinetant and elinzanetant act on neural pathways that take part in the regulation of hot flushes. Randomised trials show effectiveness against moderate to severe vasomotor symptoms. Elinzanetant received EU approval in November 2025. Approval means that an authority has assessed benefits and risks for the approved indication; it is not a guarantee that the medicine suits every person. [4] [6] [7]

With fezolinetant, a relevant safety warning became known after approval: serious drug-induced liver injury can occur. Liver function checks are therefore required before and during treatment. The EMA communication describes the exact recommendations; the currently valid product information must be consulted before any specific treatment. A short passage on these pages cannot replace this obligation. [5]

For the reader the message is twofold: new non-hormonal medicines widen the options, but “non-hormonal” does not mean “without risks”. As with other medicines, the indication, other medication, existing conditions and follow-up checks are important.

Why medicines do not solve every sleep problem

Someone who wakes because of night sweats can benefit from effective treatment of hot flushes. If a separate chronic insomnia exists, treatment from sleep medicine is also sensible. Someone who often snores or has pauses in breathing may need to be checked for sleep apnoea. These different causes can also be present together. A treatment plan should keep them apart.

Long-term sleeping tablets are not an unproblematic substitute for this assessment. Depending on the active substance, risks of dependence, daytime sleepiness or other side effects can matter. Medical advice should therefore ask not only about getting to sleep as quickly as possible tonight, but about the cause and about strategies that are suitable in the long term.

Non-hormonal does not mean herbal

Some women use “non-hormonal” as a synonym for “natural”. In medicine it means something else. Non-hormonal treatments can include prescription medicines, psychotherapeutic methods, and physical and local measures. Herbal products are only one possible subgroup and are often much less well studied. Their effect must not be inferred from the effectiveness of modern non-hormonal medicines.

The Menopause Society position statement offers a helpful overview: for certain medicines and psychological methods there is good evidence; many dietary supplements, by contrast, are not recommended as a specific treatment for vasomotor symptoms. The recommendations refer to specific outcomes, not to a general assessment of all lifestyle measures. [3]

What you can write down before deciding

A small table with three columns is often enough: My main complaint, What should specifically improve? and Which treatment options would I like to discuss? Add possible contraindications, other medicines and your experience so far. That makes it quicker in the appointment to tell whether a therapy is mainly meant for vasomotor symptoms, sleep problems, mood or genitourinary symptoms.

Ask about the expected time until it works, the usual length of a trial of treatment, typical side effects and necessary checks. If several options come into question, you can agree an order together with the healthcare professional. A reasonable decision does not need certainty that nothing can go wrong. It needs a realistic weighing up and the possibility of adjusting the plan if necessary.

When a combination of different approaches can make sense

A woman does not always have to choose between purely drug treatment and purely psychological treatment. Some have severe hot flushes and, at the same time, a separate sleep disorder. Then targeted treatment of the vasomotor symptoms can be combined with an intervention from sleep medicine. Others mainly have vaginal dryness and need local treatment, while sleep or mood problems are assessed separately. What matters is that the individual measures have different aims and that their possible interactions are taken into account.

A combination should not include an arbitrary number of products. The more medicines and supplements are taken at the same time, the harder it can be to tell which effects and side effects belong to which. Interactions also become more important. A good plan therefore states which measure is meant for which problem, when its effect will be reviewed, and who keeps an eye on the medication as a whole.

What a sensible comparison of therapies should contain

A comparison of treatment options needs at least five pieces of information: the symptom treated, the quality of the evidence of effectiveness, the expected benefit, common or serious risks, and the practical use. To these are added particular questions such as necessary laboratory tests or contraindications. This information is far more helpful than a simple ranking from “natural” to “strong”.

With new medicines in particular, scientific research on effectiveness should be linked with the current regulatory safety assessment. The phase III trials of fezolinetant showed a relevant effect on hot flushes; after approval, however, serious liver injury was reported, which is why the EMA requires additional measures for liver monitoring. An account that cites only the early effectiveness studies would be incomplete for the reader. [4] [5]

When access and cost become a problem

Not every medically suitable option is available everywhere to the same extent. EU approval of a medicine does not automatically mean that it is reimbursed on the same terms in every country. Specialised behavioural therapy or sexual health counselling may also be more or less easy to reach in different regions. This situation of care should be taken into account in a personal decision, without confusing medical effectiveness with reimbursement status.

A website can offer an advantage here: the actual medical information stays on these pages, while current details on approvals and reimbursement are added through linked pages of the authorities. For specific questions about cost, asking your doctor, pharmacy or insurer is often more reliable than a price that is years old on these pages.