Nonhormonal options for hot flashes and sleep

In brief

• What this helps with. Nonhormonal treatments for hot flashes and sleep.
• One thing to do. Ask how the new treatment is going, once.
• One thing to ask. "Anything you'd want to run past the clinician?"

She mentioned that the clinician suggested an antidepressant for her hot flashes, and you thought that sounded odd. It is not. It is one of a short list of nonhormonal treatments with solid evidence behind them, and knowing the list helps you avoid saying the wrong thing about whatever she chooses.

The options with evidence

In 2023 The Menopause Society reviewed the nonhormonal approaches to hot flashes and night sweats and sorted them by evidence. A short list made the recommended cut, and these are the ones she is most likely to be offered. Every prescription option needs a clinician's evaluation, and each has trade-offs.

Cognitive behavioral therapy. A short, structured course, usually four to six sessions in a group, one to one or as guided self-help, that changes how she responds to a flash rather than the flash itself. In the MENOS 2 trial, women who took a group or self-help course reported that their hot flashes and night sweats were far less of a problem at six weeks and six months, with better sleep and mood too. It does not reduce how many flashes she has as much as it reduces how much they run her day.

Clinical hypnosis. Delivered by a trained practitioner, with recordings to practice at home, it reduced hot flash frequency in controlled trials.

SSRIs and SNRIs. These antidepressants, often at lower doses than are used for depression, reduce hot flashes for many women within a few weeks. One low-dose paroxetine product is approved by the Food and Drug Administration specifically for hot flashes. Nausea, dry mouth and sleep changes are common early on and often fade. Sexual side effects can persist, and some of these medicines interact with other drugs, including certain breast cancer treatments.

Gabapentin. Originally developed for seizures and nerve pain, it reduces hot flashes. Drowsiness and dizziness are the usual trade-offs, and drowsiness matters less when it is taken at bedtime for night sweats. It can make you very sleepy, which is why we recommend taking it at night. Also some new studies suggest that long term use can contribute to neurological changes so we don't want to be on it forever.

Fezolinetant. The first of a new type of drug that acts on the brain's KNDy neurons. Approved in 2023, it works on the brain's temperature control directly by blocking a receptor called neurokinin 3. In the SKYLIGHT 1 trial it reduced the frequency and severity of moderate-to-severe hot flashes compared with placebo at four and twelve weeks. Its safety record is shorter than the older options, and the FDA has added a warning about rare but serious liver injury, so it comes with liver blood tests and symptoms to act on, covered below.

Elinzanetant. A second neurokinin receptor antagonist, approved by the FDA in 2025, after the 2023 statement was written, and tested against placebo for moderate-to-severe hot flashes. Its track record is the shortest of all, and newer does not mean better. Whether it suits her is her clinician's call.

Oxybutynin. A bladder medicine that also reduces hot flashes. Dry mouth and constipation are the usual trade-offs.

Weight loss. For a woman carrying extra weight, losing some of it is associated with fewer hot flashes. This is one to hear from a clinician, not from you.

What did not make the cut

The same statement found the evidence too weak to recommend a longer list for hot flashes specifically. Supplements and herbal remedies, cooling techniques, avoiding triggers, exercise, yoga, mindfulness, acupuncture, soy, cannabinoids, paced breathing and dietary changes all fell into that category.

Read that carefully, because it is narrower than it sounds. Exercise still protects her heart, bones, sleep and mood. A cool bedroom still makes a night sweat easier to get through. What the evidence does not support is the idea that any of them will make the flashes go away. So keep the fan, the cold water and the walks, and stop expecting them to do a medicine's job.

Sleep has its own treatment

When broken sleep is her main complaint, cognitive behavioral therapy for insomnia has strong evidence. In a trial of perimenopausal and postmenopausal women with hot flashes, a short telephone-delivered course produced meaningful improvements in insomnia that were still there six months later. It works on the habits and thoughts that keep her awake after a sweat has passed, which is why it helps even when the sweats continue. The British guideline NICE recommends cognitive behavioral therapy for hot flashes, sleep problems and low mood in the transition, alongside or instead of hormone therapy.

Who these options suit

Some women cannot use hormone therapy. A history of breast cancer is the most common reason, and the MENOS 1 trial showed that group cognitive behavioral therapy reduced how much hot flashes and night sweats troubled breast cancer survivors, with the benefit holding at six months.

Some women simply prefer not to, and that preference needs no justification. Others combine approaches, a nonhormonal medicine for flashes with vaginal estrogen for dryness, or hormone therapy with cognitive behavioral therapy for sleep. The right mix is a conversation between her and her clinician.

Your role

Do not rank the options for her. You are not the one weighing her history, her other medicines and what she is willing to put up with, and "why don't you just take the hormones?" is not support.

Understand what she is trying. If she is on an SSRI for flashes, know that it takes weeks to work and that early side effects are common. If she is doing cognitive behavioral therapy, know that it involves practice between sessions. If she has started fezolinetant, know that the blood tests are part of the plan, not a sign that something has gone wrong.

Expect early side effects, and do not read them as failure. Many settle. Persistent or worrying side effects are a reason to contact the clinician rather than wait for the next appointment or stop quietly.

Never call it "just an antidepressant." The medicine is doing a specific job at a specific dose, and the phrase suggests her hot flashes are a mood problem. They are not.

Where to start this week

• Ask "how is the new treatment going?" once, and then wait to be told.
• If she is doing a therapy course, take whatever is on her plate during the session hour and the practice time, or if you live apart, keep that hour free of calls.
• Keep the bedroom cool and the water cold anyway. Comfort counts even when it is not a treatment.
• Do not suggest supplements, apps or remedies you have read about.
• If she is on fezolinetant, know the liver symptoms and what to do about them.

Related reading

• Hormone therapy, explained for supporters
• Why she is not sleeping, and how to help
• Before you buy her a supplement
• When symptoms need help now

Frequently asked questions

Sources

• The Menopause Society. The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society. Menopause. 2023;30(6):573-590.
• Ayers B, Smith M, Hellier J, Mann E, Hunter MS. Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause. 2012;19(7):749-759.
• Mann E, Smith MJ, Hellier J, et al. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial. Lancet Oncology. 2012;13(3):309-318.
• Lederman S, Ottery FD, Cano A, et al. Fezolinetant for treatment of moderate-to-severe vasomotor symptoms associated with menopause (SKYLIGHT 1): a phase 3 randomised controlled study. Lancet. 2023;401(10382):1091-1102.
• U.S. Food and Drug Administration. FDA approves novel drug to treat moderate to severe hot flashes caused by menopause. Press announcement, May 2023.
• U.S. Food and Drug Administration. FDA adds warning about rare occurrence of serious liver injury with use of Veozah (fezolinetant) for hot flashes due to menopause. Drug Safety Communication, 2024.
• U.S. Food and Drug Administration. Drug Trials Snapshots: LYNKUET. Elinzanetant, approved 2025.
• McCurry SM, Guthrie KA, Morin CM, et al. Telephone-based cognitive behavioral therapy for insomnia in perimenopausal and postmenopausal women with vasomotor symptoms: a MsFLASH randomized clinical trial. JAMA Internal Medicine. 2016;176(7):913-920. n=106.
• National Institute for Health and Care Excellence. Menopause: identification and management (NG23). Updated November 2024.

Disclaimer

This article is for education and support. It is not medical advice, and it is not a substitute for care from a qualified healthcare provider. Decisions about treatment, including hormone therapy and other prescription medicines, belong to the person experiencing menopause and her clinician.