What works for hot flashes if I cannot take hormones?
Written and medically reviewed by Zahraa Sater, M.D., M.P.H.
Reviewed August 12, 2026 · Next review due August 12, 2028
Short answer
Several non-hormonal treatments work for hot flashes. Two neurokinin receptor blockers are FDA approved: fezolinetant, approved in May 2023, and elinzanetant, approved in 2025. Low dose paroxetine is the approved antidepressant option, and gabapentin and oxybutynin are used off label. Cognitive behavioural therapy, clinical hypnosis and weight loss also have supporting evidence.
Get urgent care if: you are taking fezolinetant or elinzanetant and develop
- Yellowing of the skin or the whites of the eyes.
- Dark urine or pale stools.
- Pain in the upper right abdomen, persistent nausea, or unusual fatigue.
Hot flashes can be treated without estrogen, and the options improved substantially after 2023. The FDA approved fezolinetant, sold as Veozah, on 12 May 2023 as the first neurokinin 3 receptor antagonist for moderate to severe hot flashes. Elinzanetant, sold as Lynkuet, followed with initial US approval in 2025. Both block the brain signalling that drives the flush rather than replacing hormones.
The neurokinin drugs and their monitoring
Fezolinetant is taken as one 45 mg tablet daily and carries a boxed warning for hepatotoxicity, requiring liver blood tests before starting and periodic testing during treatment. Elinzanetant is taken as 120 mg at bedtime, requires liver testing at baseline and at three months, and is contraindicated in pregnancy because it may cause pregnancy loss or stillbirth. Neither is a hormone, so neither is limited by a breast cancer history in the way estrogen is, though prescribing still needs an individual discussion.
Antidepressants and older options
Low dose paroxetine is the antidepressant approved specifically for hot flashes, and The Menopause Society names it as an FDA approved non-hormone option. Other SSRIs and SNRIs, gabapentin and oxybutynin are used off label with reasonable evidence in trials. Gabapentin taken at night suits women whose worst symptom is night sweats. The Menopause Society also identifies cognitive behavioural therapy, clinical hypnosis and weight loss as evidence supported approaches, which matters for women who cannot or prefer not to take medication.
What the evidence does not support
The Menopause Society states that acupuncture, dietary supplements, soy products and trigger avoidance have limited solid data available to evaluate their effectiveness, or have failed to show significant benefit in clinical trials. That covers most of what is sold for menopause online, including black cohosh and evening primrose oil. Money spent there is money not spent on a treatment with trial evidence behind it, and some botanical products interact with prescription medicines.
| Option | Status | Notes |
|---|---|---|
| Fezolinetant 45 mg daily | FDA approved 2023 | Boxed warning for liver injury, requires monitoring |
| Elinzanetant 120 mg at bedtime | FDA approved 2025 | Liver tests at baseline and 3 months, contraindicated in pregnancy |
| Low dose paroxetine | FDA approved | Avoid with tamoxifen, interacts through CYP2D6 |
| Gabapentin, oxybutynin, SNRIs | Off label | Useful, particularly for night symptoms |
| CBT, clinical hypnosis, weight loss | Supported by evidence | No drug interactions |
| Supplements, soy, acupuncture | Not supported | Limited data or failed trials |
Rank your symptoms before the appointment: daytime flushing, night waking and mood each point to a different first choice. If a neurokinin drug is prescribed, book the liver blood test at the same time rather than afterwards, and report dark urine, yellowing of the eyes, right upper abdominal pain or unusual fatigue immediately.
The clinical detail
Fezolinetant is a neurokinin 3 receptor antagonist dosed at 45 mg once daily; the current label carries a boxed warning for hepatotoxicity and requires baseline hepatic laboratory tests, then follow-up tests monthly for the first 3 months and again at 6 and 9 months. It is contraindicated with CYP1A2 inhibitors and is not recommended in cirrhosis, severe renal impairment or end stage renal disease. Elinzanetant is a dual neurokinin 1 and 3 receptor antagonist dosed at 120 mg nightly, reduced to 60 mg with moderate CYP3A4 inhibitors, with warnings for transaminase elevation, somnolence, seizure risk in those with a seizure history, and photosensitivity reported in 0.5 percent of patients.
Written and medically reviewed by Zahraa Sater, M.D., M.P.H.
Reviewed August 12, 2026 · Next review due August 12, 2028
Sources
- Hot Flashes. The Menopause Society
- Position Statements, including the 2023 Nonhormone Therapy statement. The Menopause Society. PMID 37252752
- FDA Approves Novel Drug to Treat Moderate to Severe Hot Flashes Caused by Menopause. U.S. Food and Drug Administration
- Veozah (fezolinetant) full prescribing information, including boxed warning for hepatotoxicity. DailyMed, U.S. National Library of Medicine
- Lynkuet (elinzanetant) full prescribing information. DailyMed, U.S. National Library of Medicine
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