First: who cannot be given hormone therapy?
Systemic hormone therapy is not used in the following situations:
- Past or active breast cancer
- Other hormone-sensitive gynaecological tumours — a history of womb cancer, certain ovarian tumours, uterine sarcoma
- Vaginal bleeding of unexplained cause — treatment is not started until the cause of the bleeding has been established
- Active or past blood clot (deep vein thrombosis, pulmonary embolism)
- Active liver disease
- A recent heart attack or coronary heart disease
- Past stroke or transient ischaemic attack
- High blood pressure that is not under control
One distinction matters: oestrogen taken by mouth is not suitable for people at risk of clots; oestrogen given through the skin, by contrast, may be considered as an option after assessment by the relevant specialist. The same approach applies to migraine with aura, gallbladder disease and high triglycerides.
Non-hormonal medicines
Guidelines describe several groups of medicine for these women. It is stated clearly that none of them is as effective as hormone therapy; even so, they can reduce symptoms appreciably.
Neurokinin receptor blockers
This is the newest group. They act in the brain's temperature control centre by directly blocking the signal from nerve cells that become over-active as oestrogen falls.
- They have been reported to reduce the frequency of hot flushes by more than 50% compared with placebo, with the effect beginning within the first week.
- In a large network meta-analysis this group was found to be significantly more effective than the other non-hormonal options, and at 12 weeks its effect was close to that of standard hormone therapy.
- Liver safety: cases of liver toxicity have been seen after these medicines came to market. Liver function tests are therefore needed before treatment and at regular intervals during it.
Licensing and availability of these medicines differ from country to country. Please ask your doctor about the position in Türkiye.
Antidepressant-group medicines (SSRIs / SNRIs)
They produce a moderate reduction in hot flushes, of between 20% and 66%. They may also help mood and quality of life.
A critical warning for women being treated for breast cancer: in people taking tamoxifen, paroxetine and fluoxetine must not be used — they block the enzyme that activates tamoxifen in the body. The preferred option in these women is venlafaxine; escitalopram and citalopram may also be used.
Possible side effects: nausea, dizziness, a temporary increase in anxiety at the start, sexual difficulties, and withdrawal symptoms when the medicine is stopped.
Gabapentin and pregabalin
These reduce the frequency and severity of hot flushes, and may also improve sleep quality and the muscle and joint pains associated with the menopause. Some people are reported to tolerate pregabalin better.
Side effects are dose-related: drowsiness, dizziness, dry mouth and weight gain. These medicines are in a controlled class and, because they can cause dependence, caution in prescribing is advised.
Other options
- Oxybutynin: originally a medicine for overactive bladder; it has been found effective in reducing hot flushes and general sweating. It is used with care because of dry mouth, constipation and, particularly in older people, a risk of cognitive decline.
- Clonidine: slightly more effective than placebo, but clearly weaker than the other options. It should not be stopped abruptly but tapered, and it is not suitable for people with low blood pressure.
Cognitive behavioural therapy (CBT)
Among non-hormonal approaches this is the method recommended in international guidelines with the strongest level of evidence (Level 1).
Knowing how it works sets the right expectation: CBT does not remove the number of hot flushes. It reduces the way you perceive them, strengthens your belief that you can cope, and lessens the sense of being overwhelmed that they create.
In studies, group or self-help programmes of 4–6 sessions, once a week, clearly improved the distress caused by hot flushes, sleep problems, anxiety and mildly low mood, and this effect persisted at 26-week follow-up. It has been reported to improve quality of life both in women in natural menopause and in those being treated for breast cancer.
Lifestyle and herbal products: an honest account
Exercise and yoga
In a randomised controlled trial, aerobic exercise, yoga and omega-3 supplements could not be shown to be superior to placebo for the frequency of hot flushes.
That does not mean exercise is unnecessary — it is always recommended for muscle mass, mood and bone health. It should simply not be undertaken with the sole expectation of reducing hot flushes.
Herbal products
- Black cohosh: a Cochrane review found no clear superiority over placebo, though some recent meta-analyses report a general easing of symptoms. The important point is that cases of serious liver toxicity have been reported.
- St John's wort: not recommended, because it causes very serious interactions with chemotherapy and many other medicines.
- Phytoestrogen / isoflavone supplements: not recommended in women with a history of a hormone-sensitive tumour.
In summary, the sources say this: non-hormonal methods show limited benefit over placebo and are most likely less effective than hormone therapy; but in people who cannot or do not wish to take hormone therapy, they may help.
If your symptoms do not settle
If non-hormonal treatments do not relieve your symptoms, or troublesome side effects persist, guidelines recommend referral to a health professional experienced in the menopause.
Frequently Asked Questions
I cannot take hormone therapy — is there nothing for me?
No. Guidelines describe several non-hormonal options: neurokinin receptor blockers, antidepressant-group medicines (SSRIs/SNRIs), gabapentin and pregabalin, oxybutynin and clonidine. Cognitive behavioural therapy is also recommended with the strongest level of evidence. None is as effective as hormone therapy, but they can reduce symptoms appreciably.
When can hormone therapy definitely not be given?
Past or active breast cancer, hormone-sensitive gynaecological tumours, vaginal bleeding of unexplained cause, active or past blood clot, active liver disease, a recent heart attack or coronary heart disease, past stroke, and high blood pressure that is not under control.
I am being treated for breast cancer — which medicines should I be careful about?
If you take tamoxifen, paroxetine and fluoxetine must not be used — they block the enzyme that activates tamoxifen in the body. The preferred option is venlafaxine. St John's wort is also not recommended because it interacts seriously with chemotherapy, and phytoestrogen supplements are not suitable with a history of a hormone-sensitive tumour.
Will cognitive behavioural therapy stop my hot flushes?
It is important to set the right expectation: CBT does not remove the number of hot flushes. It changes how you perceive them, strengthens your belief that you can cope, and lessens the sense of being overwhelmed. In studies, 4–6 weekly sessions clearly improved distress, sleep problems and anxiety, and the effect persisted at 26 weeks.
Do exercise and yoga help with hot flushes?
In a randomised controlled trial aerobic exercise, yoga and omega-3 supplements could not be shown to be superior to placebo for the frequency of hot flushes. That does not make exercise unnecessary — it is always recommended for muscle mass, mood and bone health. It should just not be done with the sole expectation of reducing hot flushes.
Aren't herbal products safer?
Being “natural” does not mean being safe. For black cohosh a Cochrane review found no clear superiority over placebo, and cases of serious liver toxicity have been reported. St John's wort interacts seriously with many medicines. Phytoestrogen supplements are not recommended with a history of a hormone-sensitive tumour.
Can I get the newer medicines?
Neurokinin receptor blockers are the newest group; they have been reported to reduce the frequency of hot flushes by more than 50%, with the effect beginning within the first week. However licensing and availability differ from country to country. These medicines also require regular liver function tests before and during treatment.
What if none of it works?
If non-hormonal treatments do not relieve your symptoms, or troublesome side effects persist, guidelines recommend referral to a health professional experienced in the menopause. The treatment options are then reassessed individually.
Sources
- British Menopause Society — Tool for Clinicians: Prescribable alternatives to HRT, and Consensus Statement: Non-hormonal-based treatments for menopausal symptoms.
- NICE and North American Menopause Society (NAMS) recommendations — the place of non-hormonal treatments, cognitive behavioural therapy, and choice of medicine in women taking tamoxifen.
- MENOS 1 and MENOS 2 randomised trials — the effects of menopause-specific cognitive behavioural therapy on hot flush distress, sleep and mood.
- MS-FLASH randomised controlled trial — the effect of aerobic exercise, yoga and omega-3 supplements on the frequency of hot flushes.
- Cochrane review — the effect of black cohosh on hot flushes.
The information on this page is based on the national and international guidelines listed above. The page is reviewed whenever those guidelines are updated.
Practice and Contact Details
The information on this page is general. Please speak to your doctor about your own situation.
- DoctorOp. Dr. Murat Alpay — Specialist in Obstetrics and Gynaecology
- AddressOp. Dr. Murat Alpay Practice, Tekelioğlu Cd. No:51 B Kat:2, Filo Apt., 07160 Muratpaşa / Antalya
- Telephone0505 351 77 88
- HoursMonday – Saturday 09:00 – 18:00 · Closed on Sunday