Non-hormonal ways to treat perimenopause symptoms

Fezolinetant (Veozah)

Fezolinetant, brand name Veozah, was FDA-approved in May 2023 as the first drug in a new, non-hormonal class specifically for moderate to severe hot flashes. It's a neurokinin 3 (NK3) receptor antagonist: it works on a group of neurons in the hypothalamus that helps regulate body temperature, calming the overactive signaling that estrogen decline causes. It's taken as a daily pill. The FDA added a warning about rare cases of serious liver injury, so it requires liver function monitoring, particularly early in treatment.

SSRIs and SNRIs

Certain antidepressants, at doses often lower than those used for depression, are established off-label and in some cases specifically studied treatments for hot flashes: options include low-dose paroxetine (the only SSRI with FDA approval specifically for hot flashes), venlafaxine, and desvenlafaxine. These can also help with the mood symptoms and irritability that often accompany perimenopause, which makes them a reasonable option when both are present.

Gabapentin and other prescription options

Gabapentin, typically used for nerve pain and seizures, has evidence for reducing hot flash frequency and severity, and is sometimes preferred for women whose hot flashes are worse at night since it can also aid sleep. Clonidine, a blood pressure medication, has some evidence too but is used less often due to side effects like dry mouth and drowsiness.

CBT and lifestyle changes

Cognitive behavioral therapy (CBT), specifically adapted for menopause symptoms, has good evidence for reducing how much hot flashes and night sweats interfere with daily life, even when it doesn't eliminate the physical sensation itself. It also helps with the anxiety and sleep disruption that often ride along with vasomotor symptoms.

• Layered clothing, a cooler bedroom, and avoiding personal triggers like alcohol, caffeine, or spicy food can reduce hot flash frequency for some women.
• Regular exercise and weight management have modest evidence for symptom reduction and stronger evidence for overall midlife health.
• Paced breathing and mindfulness-based stress reduction have some evidence for reducing hot flash bother, though effect sizes are generally smaller than medication.

What lacks good evidence

Many supplements marketed for menopause - black cohosh, evening primrose oil, red clover, wild yam cream - have inconsistent or weak trial evidence, and some interact with medications or aren't well regulated for purity and dose. That doesn't mean none of them help any individual woman, but it does mean they shouldn't be assumed to work the way a studied prescription drug does, and it's worth telling a doctor about anything you're taking.