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Non-Hormonal Treatment Options for Hot Flashes

Hot flashes and night sweats (also referred to as vasomotor symptoms (VMS)) affect as many as 80% of menopausal women and often begin during perimenopause. They are the most reported unwanted symptom of menopause. Hot flashes and night sweats are characterized by feelings of warmth that spread over the body and can last as long as a few minutes. They may be accompanied by redness of the skin, excessive sweating, tingling fingers, increased heart rate, anxiety, and chest tightness. Night sweats are hot flashes during sleep, and they often wake you up. African American and Hispanic women are more likely to experience hot flashes for longer. These symptoms can have a significant impact on the lives of the women experiencing them. VMS usually last for approximately 2 years, but some women suffer with them for as long as 10 years.

Although menopause hormone therapy (MHT) remains the most effective treatment for hot flashes and night sweats, it can be less appropriate for some women, such as those with a history of some cancers like breast cancer and some endometrial cancers, blood clots, liver disease, at high risk for cardiovascular disease, or who have unwanted side effects from MHT. In addition, some women simply prefer not to use MHT. In good news for all those women, multiple non-hormone treatments are currently available, and research in this area is rapidly progressing.

According to The Menopause Society, evidence is available to support multiple non-hormone treatments for hot flashes. There is no evidence or the evidence does not support the use of several other options.

Let's start with drugs. There are a few drugs that were designed to treat other problems but have been found to coincidentally reduce VMS, as well as a new class of drugs specifically designed and FDA-approved to treat hot flashes.

  • Fezolinetant (Veozah) is a first-in-class neurokinin 3 (NK3) receptor antagonist that was FDA-approved in 2023 specifically for management of vasomotor symptoms. NK3 receptors are located in the brain in the hypothalamus, which plays a role in body temperature regulation. Patients who have cirrhosis, severe renal damage, or end-stage renal disease should not take fezolinetant. Another drug called elinzanetant, which targets the same receptors, is in development.

  • Selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) were developed to treat depression but have been found to improve VMS. The exact mechanism by which SSRIs/SNRIs reduce hot flashes is not currently known, but we do know that norepinephrine and serotonin are involved in temperature regulation. Unfortunately, both classes of drugs have some annoying side effects, but many improve with time - nausea, vomiting or diarrhea, headache, drowsiness, dry mouth, insomnia, nervousness, agitation or restlessness, dizziness, sexual problems such as reduced sexual desire or difficulty reaching orgasm, and impact on appetite, which can lead to weight loss or weight gain. Women with epilepsy or an elevated risk for epilepsy should avoid these drugs. Women who are taking tamoxifen after having breast cancer also should avoid SSRIs/SNRIs since they interfere with the effectiveness of tamoxifen.

    • Recommended drugs: paroxetine (Brisdelle*, Pexeva, Paxil), citalopram (Celexa), escitalopram (Lexapro), desvenlafaxine (Pristiq), venlafaxine (Effexor)

  • Gabapentin also has been shown to help with VMS. Gabapentin was first FDA-approved in 1993, and currently is FDA-approved for nerve pain after shingles, restless leg syndrome, and as an adjunct treatment for epilepsy. Scientists believe that it might work for hot flashes by altering signaling in the thermoregulatory center in the brain. The most serious side effects are sleepiness and trouble breathing, but the risk of those is significantly reduced unless you are taking other sedating medication or have an underlying breathing condition like COPD.

  • Oxybutynin reduces moderate to severe VMS; however, in older adults, long-term use may be associated with cognitive decline. Oxybutynin belongs to the group of medicines called antispasmodics (anticholinergics) and is often used to treat urinary urgency. How it works to reduce VMS is not clear.

For non-drug options, cognitive behavioral therapy (CBT) and clinical hypnosis have been shown to improve VMS. Weight loss also improves VMS, but dietary modifications and exercise do not appear to be reliably helpful in alleviating symptoms. Note that exercise and a healthy diet are unequivocally useful for overall health and disease prevention - they just don't appear to have much effect on VMS frequency or intensity.

The evidence for using acupuncture for treatment of VMS remains mixed, but acupuncture does have other positive health effects and anecdotally can reduce VMS in some women. There is developing research to recommend mindfulness, paced breathing, or other relaxation techniques to reduce VMS symptoms. Although the evidence is mixed, these techniques are likely to help with overall health, particularly stress reduction.

There is not evidence-based research supporting the use of any over-the-counter supplement or herbal therapy for treating VMS. Similarly, cannabinoids and soy foods, extracts, or metabolites also are not recommended. Research studies have not concluded that cooling techniques or avoiding triggers changes the frequency or severity of VMS, but they may make you more comfortable. Chiropractic interventions for treating VMS are not supported by data and not recommended. Future research should provide more insight into the evidence-based efficacy and safety of these therapies.

In summary, estrogen is still the gold standard for relief of menopausal VMS; however, for women who cannot, should not, or desire not to take estrogen, there are other evidence-based treatment options. The Menopause Society supports the use of fezolinentant, some SSRIs/SNRIs, and gabapentin to treat VMS of menopause because the evidence supports their efficacy and relative lack of serious side effects. Other treatment options include oxybutynin, but it has a higher possibility of serious side effects/complications. Weight loss has the least amount of evidence supporting its use for VMS, but weight loss has significant overall health benefit so there are few downsides, particularly in overweight women. Menopausal women should seek advice from their doctor about which treatment option(s) will work best for them. You can find a menopause specialist at The Menopause Society website.

*Paroxetine mesylate (Brisdelle) was approved by the FDA in 2013 specifically for the treatment of hot flashes associated with menopause. The same drug at a higher dose is marketed as Pexeva and received FDA approval in 2003 for the treatment of Major Depressive Disorder (MDD). Paxil contains a slightly different form of paroxetine called paroxetine hydrochloride, but clinical studies suggest that both forms of paroxetine work similarly in the body. Paxil received FDA approval in 1992 for use in treating a myriad of psychological conditions.

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