Non-Hormonal Treatments for Hot Flashes: What Works

The non-hormonal landscape

Hormone therapy is the most effective treatment for vasomotor symptoms, but it isn't suitable for everyone. The Menopause Society's 2023 nonhormone therapy position statement reviewed the evidence and sorted the alternatives into what it recommends and what it does not. The therapies with the strongest support (Level I evidence) are cognitive behavioral therapy, clinical hypnosis, SSRIs/SNRIs, gabapentin, and fezolinetant.

Two of these are drugs the FDA has approved specifically to treat hot flashes: low-dose paroxetine (an SSRI, 2013) and fezolinetant (a first-in-class neurokinin-3 receptor antagonist, 2023). The rest are used off-label or are behavioral approaches. The table below shows the full classification.

The Menopause Society graded each option by evidence level (I = strongest). "Not recommended" generally means the evidence for efficacy is insufficient or negative; it is not primarily a safety verdict.

Antidepressants, gabapentin, and clonidine

SSRIs and SNRIs (Level I) are among the best-studied non-hormonal drug options. In 2013 the FDA approved a low 7.5 mg dose of paroxetine as the first non-hormonal medicine indicated for moderate-to-severe hot flashes; its pivotal trials showed a modest but real advantage over placebo. Other SSRIs/SNRIs such as venlafaxine and escitalopram are used off-label for the same purpose.

Gabapentin (Level I) is another off-label option, sometimes favored when night sweats disrupt sleep. Clonidine, a blood-pressure drug long used for hot flashes, was reclassified as not recommended in the 2023 statement, reflecting weaker or inconsistent evidence relative to its side effects. Because SSRIs/SNRIs can themselves cause sweating and interact with other medicines, drug choice is individualized with a prescriber.

Fezolinetant (Veozah): a new mechanism

Fezolinetant is the first neurokinin-3 (NK3) receptor antagonist approved for hot flashes. It targets the brain's temperature-control pathway directly, rather than acting on serotonin or hormones. The FDA approved it on May 12, 2023 for moderate-to-severe vasomotor symptoms due to menopause.

In the phase 3 SKYLIGHT 1 trial (Lederman 2023), 527 women with an average of seven or more moderate-to-severe hot flashes a day were randomized to placebo or fezolinetant. Against placebo, the 45 mg dose reduced daily hot flash frequency by an additional 2.07 episodes at week 4 (p<0.001) and 2.55 episodes at week 12 (p<0.001), with reduced severity as well (both p<0.01). Improvement appeared within the first week.

In December 2024 the FDA added a boxed warning after a post-marketing case of serious liver injury, and now recommends liver blood tests before and periodically during treatment. Patients are advised to stop the drug and contact their prescriber if they notice symptoms such as fatigue, nausea, dark urine, or yellowing of the skin or eyes.

The chart shows how many more daily hot flashes fezolinetant 45 mg eliminated compared with placebo in SKYLIGHT 1; the effect grew from week 4 to week 12.

Behavioral options and what doesn't hold up

Two non-drug approaches earned Level I support: cognitive behavioral therapy (CBT) and clinical hypnosis. Neither stops hot flashes at their source, but both can reduce how bothersome symptoms feel and improve sleep and mood, with no medication side effects.

The same review found the evidence does not support several popular remedies for VMS relief: paced (slow) breathing, dietary supplements and herbal products, soy foods and soy extracts (including the metabolite equol), acupuncture, cooling techniques, and simple trigger avoidance were all classified as not recommended on efficacy grounds. That a remedy is common or 'natural' does not mean trials show it works better than placebo for hot flashes.

Choosing an option with a clinician

The best non-hormonal choice depends on symptom severity, sleep, other health conditions, current medications, and personal preference. Prescription options require monitoring: fezolinetant now carries liver-test recommendations, and SSRIs/SNRIs and gabapentin have their own considerations. Anyone weighing these treatments, or with new or severe symptoms, should talk with a healthcare professional. This page is general educational information, not medical advice, and not a basis for starting, stopping, or changing any treatment.

Methodology and limitations

This page compiles The Menopause Society's 2023 nonhormone therapy position statement (for the recommendation framework and evidence grades), the phase 3 SKYLIGHT 1 trial published in the Lancet (for fezolinetant efficacy figures), and FDA sources (for approval dates and the 2024 liver-injury boxed warning). The low-dose paroxetine approval is documented in the FDA action and a New England Journal of Medicine perspective. Each figure was traced to its source and confirmed.

Limitations: evidence grades and 'recommended / not recommended' labels come from one expert body's review and reflect efficacy evidence, not every safety consideration. Trial results (e.g., SKYLIGHT 1) describe average effects in study populations over defined periods and may not match individual experience; head-to-head comparisons between options are limited. 'Not recommended' means the reviewed evidence did not show benefit for hot flashes, not necessarily that a therapy is harmful. This is general educational information, not medical advice.

Frequently asked questions

What non-hormonal treatments work best for hot flashes?

The Menopause Society's 2023 statement gives Level I (strongest) evidence to SSRIs/SNRIs, gabapentin, cognitive behavioral therapy, clinical hypnosis, and fezolinetant. Two drugs are FDA-approved specifically for hot flashes: low-dose paroxetine and fezolinetant.

How well does fezolinetant (Veozah) work?

In SKYLIGHT 1, the 45 mg dose reduced daily hot flashes by about 2.55 more per day than placebo at week 12 (and 2.07 more at week 4), with lower severity too. Improvement began within the first week. It is a non-hormonal NK3 receptor antagonist approved in 2023.

Is fezolinetant safe?

In December 2024 the FDA added a boxed warning about rare but serious liver injury and now recommends liver blood tests before and during treatment. Patients should stop it and contact a prescriber if they notice fatigue, nausea, dark urine, or yellowing of the skin or eyes. Suitability is decided with a clinician.

Do antidepressants really help hot flashes?

Yes, modestly. SSRIs/SNRIs carry Level I evidence, and a low 7.5 mg dose of paroxetine was FDA-approved for hot flashes in 2013, the first non-hormonal drug for this use. Others like venlafaxine are used off-label. Effects are smaller than hormone therapy's.

What about supplements, soy, or acupuncture?

The 2023 statement classifies supplements and herbal remedies, soy foods and extracts (including equol), acupuncture, paced breathing, and trigger avoidance as not recommended for hot flash relief, because trials have not shown a reliable benefit over placebo.

Are behavioral therapies effective?

Cognitive behavioral therapy and clinical hypnosis both earned Level I support. They don't stop hot flashes at the source but can reduce how bothersome symptoms feel and improve sleep, without medication side effects.

Sources

Primary peer-reviewed studies and official sources first, then reviews and institutional framing (secondary).

1. The North American Menopause Society (The Menopause Society). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573–590. Level I: CBT, clinical hypnosis, SSRIs/SNRIs, gabapentin, fezolinetant. PubMed
2. 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. 45 mg vs placebo: −2.07 (wk 4) and −2.55 (wk 12) hot flashes/day. PubMed
3. US 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. FDA Drug Safety Communication, December 16, 2024 (Veozah approved May 12, 2023). FDA
4. Orleans RJ, Li L, Kim MJ, et al. FDA approval of paroxetine for menopausal hot flushes. N Engl J Med. 2014;370(19):1777–1779. Low-dose paroxetine (7.5 mg), first non-hormonal drug approved for VMS (2013). (secondary) NEJM

How to cite this page

Related reading on this site

• Hormone therapy for hot flashes: the evidence
• Antidepressants and sweating: incidence by drug class
• Menopause sweating statistics
• Can menopause cause sweating?
• Sweat and hormones: the topic hub