Hot flashes are one of the hallmark symptoms of menopause, affecting about 75–80 percent of women in the U.S. Each uncomfortable and potentially disruptive episode can include the sudden onset of sweating and flushing, often followed by chills. Hot flashes are known as vasomotor symptoms, a category that also includes night sweats. Although the exact mechanism isn’t completely understood, they are thought to occur as the production of estrogen and progesterone begins to fluctuate erratically during the start of menopause. Both of these hormones play a role in the body’s ability to regulate temperature.
Although hormone therapy (HT) can help ease menopausal symptoms—especially hot flashes—it may not be for all women. If you have a history of stroke, heart attack, blood clots, liver disease, or breast cancer, the risks of HT may outweigh the benefits, as it could cause these issues to recur or worsen. Other women may simply prefer to go through menopause without replacing estrogen or progesterone. If you’re experiencing menopausal symptoms and can’t or don’t want to take hormones, you may be wondering what your options are.
The following are a few of the most promising nonhormonal treatments for hot flashes, available by prescription only.
Fezolinetant (Veozah). This once-daily pill was approved by the FDA in 2023—the first medication of its kind developed and given the green light specifically for hot flashes. It’s a neurokinin 3 (NK3) receptor antagonist, meaning it binds to and blocks the action of a brain receptor that plays a role in temperature regulation.
A 2023 clinical trial in The Lancet compared two different doses of Veozah to placebo in more than 500 women (average age 54) with moderate to severe hot flashes. Compared with women who took a placebo, those who took either 30 or 45 mg of Veozah a day had a significant reduction in the severity of their hot flashes four and 12 weeks later. They also experienced less frequent hot flashes, as early as one week after starting treatment. The improvements persisted after 52 weeks of treatment.
Because Veozah may affect the liver, blood tests to monitor liver function should be done before starting treatment and at various intervals during the first nine months. In December 2024, the FDA added a boxed warning to Veozah stating that it can cause rare but serious liver injury. Symptoms of liver damage—including nausea, vomiting, and yellowing of the skin and eyes—should be reported to your doctor immediately. Other side effects of Veozah include abdominal pain, diarrhea, insomnia, and back pain.
Another drug, elinzanetant, works similarly to fezolinetant but differs some in where it acts and may offer additional clinical benefits. Called a dual neurokinin (NK)-targeted therapy, the FDA approved it at the end of October under the brand name Lynkuet for treating moderate to severe menopausal hot flashes, based on clinical trials involving nearly 800 women. As with fezolinetant, this newest drug can cause liver damage (and other side effects); liver function tests are therefore also needed before and after starting it.
Paroxetine (Brisdelle). Brisdelle is a brand name of paroxetine; its other common brand name is Paxil. This medication is in a class of drugs called selective serotonin reuptake inhibitors (SSRIs), which are often prescribed for depression and certain anxiety disorders (as with Paxil). Although paroxetine is the active ingredient in both medications, Brisdelle is not meant for mental health—it’s a lower amount of paroxetine approved by the FDA only for the treatment of menopause-related hot flashes. It may help reduce hot flashes by rebalancing levels of serotonin and epinephrine, two brain chemicals that can affect temperature regulation.
Brisdelle was approved by the FDA in 2013 over the objections of an advisory panel, which voted 10–4 against it. The panel—which makes recommendations to the FDA—pointed out that the drug offered only minimal benefit, reducing the number of hot flashes a day by only one as compared with a placebo. But minimal was considered to be good enough, according to a 2014 perspective in the New England Journal of Medicine: “Recognizing that no hormone-free drug product had been approved to treat vasomotor symptoms, and after careful review of the efficacy results, the FDA concluded that Brisdelle offers a clinically meaningful benefit for some menopausal women.” In addition, “Brisdelle did not differ much from placebo with respect to reported adverse reactions.”
In addition, a 2015 article in the International Journal of Women’s Health reviewed four clinical trials of Brisdelle. It found that after six to 12 weeks of treatment, women taking Brisdelle had between a 33 and 67 percent reduction in hot flash frequency, compared with 14 to 38 percent in women taking a placebo. The benefits continued throughout the course of each study, with the longest study lasting 24 weeks. Participants reported mild to moderate side effects (such as insomnia, fatigue, headache, gastrointestinal symptoms, weight gain, headache, and weakness), mostly at higher doses. The researchers concluded that lower doses of Brisdelle (7.5–12.5 mg per day) seemed to provide the most beneficial ratio of symptom relief and side effects, and that Brisdelle could be considered as a first-line treatment for women who can’t or don’t want to take HRT.
In general, women with breast cancer who are being treated with tamoxifen should not take SSRIs, as they can interfere with tamoxifen metabolism. According to Tami Rowen, MD, an associate professor of obstetrics and gynecology at UC San Francisco and a member of our editorial board, venlafaxine (Effexor), an SNRI (serotonin-norepinephrine reuptake inhibitor), can be used off label for vasomotor symptoms in these women, and—when taken at a low dose—may be as or more effective than Brisdelle.
Gabapentin. This medication was developed to treat seizures and nerve pain but can also be used for hot flashes. The same FDA panel that advised against Brisdelle also voted 12–2 against approving an extended-release version of gabapentin for hot flashes in 2013.
This time, the FDA agreed with its panel and declined to approve a branded formula of the drug specifically for hot flashes, but gabapentin is being used off label for this purpose. The American College of Obstetricians and Gynecologists incudes it in its list of nonhormonal treatments to discuss with your doctor. It’s thought that gabapentin may help relieve hot flashes by binding to calcium channels, affecting the body’s ability to regulate temperature.
And there’s evidence that it can be helpful. A 2013 study in the Journal of Research in Pharmacy Practice compared estrogen with two different doses of gabapentin in 100 menopausal women. After 12 weeks of treatment, the benefits in the 300 mg/day gabapentin and the estrogen groups were similar: more than 60 percent reductions in both the severity and frequency of hot flashes. Those who took 100 mg of gabapentin had a 24 percent reduction in severity and 39 percent reduction in frequency of hot flashes. Side effects were similar in all three groups, and no participants experienced headache, dizziness, or disorientation.
Oxybutynin. This medication, normally prescribed to treat overactive bladder, works by relaxing the muscles in the bladder. Previous research on oxybutynin had noted a side effect of decreased sweating, making it a promising candidate for reducing hot flashes.
In its 2023 nonhormone therapy position statement, the North American Menopause Society included oxybutynin in its list of recommended treatments for hot flashes. The advisory panel of clinicians and research experts pointed to three studies showing that oxybutynin (either twice-daily doses of 2.5 mg or 5 mg, or up to 15 mg in an extended-release version) was associated with a significant improvement in moderate or severe hot flashes. Side effects usually increased with higher doses of oxybutynin, and the most common issues were dry mouth and difficulty emptying the bladder. The panel does point out that long-term use of oxybutynin, especially in older adults, may be associated with cognitive decline.
No meds, no sweat
For some women, incorporating lifestyle measures may be enough to keep cool and are worth trying before turning to any type of medication. These include drinking cold beverages; avoiding or limiting alcohol, caffeine, and other foods/beverages that may trigger hot flashes; not smoking; losing weight if you’re overweight; dressing in layers of lightweight, breathable clothing; and stress management techniques like deep breathing and meditating. You could also try a cooling mattress topper if night sweats are a particular problem. Carrying a portable fan with you may help take the heat off; you can find ones that are worn over or around your neck or are clipped to your shirt or pants.
What about “alternative” treatments? There’s some evidence that acupuncture may help. As for the long list of supplements touted for treating hot flashes—from black cohosh, red clover, and soy isoflavones to omega-3 fatty acids, wild yam, licorice root, and vitamin E—the evidence for most of them is mixed at best, with safety being of concern for some.
BOTTOM LINE: If you can’t take hormone therapy, or would just prefer not to, you don’t have to simply suffer through hot flashes—the treatments and lifestyle measures discussed above may help you stay cool and comfortable throughout menopause. But because all drugs (even nonhormonal ones) carry some risks and side effects, a thorough discussion with your doctor about which option is best for you is advised.
