NHS GP & Women’s Health Specialist

Dr Sylvia Kama-Kieghe

You can’t take HRT — or you’ve decided you don’t want to — and now you’re being told to “manage your symptoms.” Which translates to: figure it out yourself. That is not good enough – especially when struggling with menopause hot flashes.

I understand the dilemma. There are real, evidence-based options for women navigating menopause without hormone therapy.

This is the full list — what works, what doesn’t, and what to ask for.

Watch First: Can’t Take HRT? This Changes Everything — Fezolinetant Explained

Why Some Women Cannot — or Will Not — Take HRT

There are clinically valid reasons you may not be on HRT (hormone replacement therapy):

• Personal history of breast, ovarian, or endometrial cancer
• Active or previous deep vein thrombosis (DVT) or pulmonary embolism
• Known clotting disorders or significant cardiovascular risk
• Active liver disease
• Personal preference — and that preference deserves to be respected

What is not a valid reason: being told “we don’t usually offer HRT to women your age / your background / your weight” without proper individualised assessment.

If your only barrier to HRT is a clinician’s reluctance, request a second opinion or ask for referral to a specialist menopause clinic. That is your right.

For everyone else for whom HRT genuinely is not an option — here is what the evidence supports.

Option 1: Fezolinetant (Veozah) — The Newest Non-Hormonal Prescription

This is the most significant development in non-hormonal menopause care in over 20 years.

Fezolinetant is the first non-hormonal prescription medicine specifically licensed in the UK and US for moderate to severe vasomotor symptoms — menopause hot flushes and night sweats — in women who cannot or choose not to take HRT.

How it works:

It targets a specific brain pathway (neurokinin B) that becomes overactive in menopause and disrupts the brain’s temperature regulation. By blocking this signal, it reduces the frequency and severity of hot flushes — without using hormones.

What you need to know:

• Available on prescription in the UK
• Requires liver function blood tests before starting and during treatment
• Not for women with a history of breast cancer, oestrogen-dependent cancers, or active liver disease
• Most women report improvement within 4–12 weeks
• Can be used long-term under monitoring

NICE Guideline NG23: Menopause — Diagnosis and Management

British Menopause Society: Tools for Clinicians on Non-Hormonal Treatments

Option 2: SSRIs and SNRIs — Repurposed Antidepressants for Hot Flushes

Certain antidepressants — at lower doses than used for depression — have been shown to reduce hot flushes by up to 60%. They work by influencing the same brain temperature-regulation pathway that menopause disrupts.

Most evidence:

• Venlafaxine (an SNRI)
• Paroxetine and escitalopram (SSRIs)
• Citalopram

Important note: Paroxetine should NOT be used by women on tamoxifen (a breast cancer drug) as it interferes with how tamoxifen works. Venlafaxine is the preferred choice in this group.

Option 3: Gabapentin and Clonidine

Gabapentin — originally developed for nerve pain and epilepsy — can reduce hot flushes, particularly night sweats. Useful for women whose main complaint is sleep disruption.

Clonidine — a blood pressure medication — is one of the older non-hormonal options. It is sometimes useful for vasomotor symptoms. It is less effective than the newer options and has more side effects, so it is generally not first choice today.

Option 4: Vaginal Oestrogen (For Genitourinary Symptoms Only)

This is an important distinction many women may not be aware of: vaginal oestrogen is different from systemic HRT.

Local vaginal oestrogen — applied as a cream, pessary, or ring — works only in the vaginal area.

Very little enters into the bloodstream. Therefore, we believe it is safe for the vast majority of women — including most women with a previous history of breast cancer, after specialist discussion.

Using vaginal oestrogen treats: vaginal dryness, painful sex (dyspareunia), recurrent UTIs, and the genitourinary symptoms of menopause (GSM).

It does NOT treat: hot flushes, night sweats, mood, or other systemic menopause symptoms.

Watch: No HRT? Try These 5 Natural Menopause Fixes – LIVE

Option 5: Lifestyle Strategies That Are Genuinely Evidence-Based

Not “drink more water and try yoga.” Here are the lifestyle interventions with real evidence.

Cognitive Behavioural Therapy (CBT) for Menopause Hot Flushes

CBT specifically adapted for menopausal symptoms has strong evidence — recommended by NICE — for reducing the impact of hot flushes, sleep problems, and mood symptoms. Available on the NHS via self-referral to NHS Talking Therapies (IAPT).

Weight Management

Having a higher BMI can lead to more frequent and severe hot flushes. Losing a modest amount of weight — 5–10% of body weight in women carrying excess weight — can help to reduce vasomotor symptoms.

Regular Exercise

Regular aerobic and resistance exercise improves sleep, mood, bone density, and cardiovascular health — all of which decline in menopause. It does not directly stop hot flushes but improves overall quality of life and metabolic health.

Sleep Hygiene

Cool bedroom (around 17°C), moisture-wicking nightwear, no caffeine after midday, no alcohol within 3 hours of bed. Boring, but effective for the night-sweat-driven sleep disruption.

Option 6: Supplements and Herbal Remedies — What the Evidence Actually Says

Be cautious with this category — the supplement industry markets aggressively, and the clinical evidence is often poor.

Important: Always tell your GP about any supplements you’re taking — particularly if you’re on cancer treatment, blood thinners, or any prescription medication.

Red Flags — When to Seek Help

The Bottom Line

You have far more options for managing menopause without HRT than you have probably been told.

Fezolinetant has changed the landscape for women who cannot use hormones, repurposed antidepressants and gabapentin offer real symptom relief, and vaginal oestrogen is safe for nearly everyone.

Lifestyle changes work best when combined with the right clinical support — not as a substitute for it.

If you have been told “you’ll just have to put up with it” — that is not the standard of care you deserve. Take this list to your next appointment and ask for a proper discussion of your options.

What’s worked for you when HRT wasn’t on the table? Share what helped — there’s a woman about to ask exactly that question and your story could be the answer. → Join the free AskAwayHealth community

Similar Topics

• Managing Menopause Flushes: Tips and Tricks for Finding Relief
• Anxiety Rash Explained: 4 Effective Treatments You Can Use Today
• Eight Reasons (Natural) Non Hormonal Birth Control May Suit You
• 6 Surprising Science-Backed Reasons Your Antidepressant Is Not Working
• Can Fibroids Go Away On Their Own? Natural Treatment Options Explained