Alternatives to HRT: What Actually Works (and What Doesn't)
Can't take HRT, or prefer not to? What NICE now recommends — including CBT — plus non-hormonal medicines and which supplements lack evidence.
Part of the Complete Hormone Replacement Therapy Guide.
Key fact: The November 2024 NICE update formally recommends CBT for hot flushes, night sweats, sleep and mood — a real, evidence-backed option for women who can't or won't take hormones.
HRT is the most effective treatment for menopausal symptoms — but it isn't right, or wanted, for everyone. Women with a history of hormone-sensitive breast cancer, those advised against HRT, and those who simply prefer a non-hormonal route have real options. The November 2024 update to NICE guideline NG23 strengthened this area considerably, formally recommending CBT for several menopause symptoms. Here's an honest tour of the evidence.
Discuss Your Options Online
Access Doctor's pharmacist independent prescribers can advise on both hormonal and non-hormonal routes following a GPhC-regulated online consultation.
Start a consultation →CBT — now NICE-recommended
Cognitive behavioural therapy tailored to menopause is recommended by NICE for hot flushes and night sweats, menopause-related sleep problems, and low mood or anxiety — used alongside HRT or on its own. It doesn't change hormone levels; it changes the distress-amplification loop around symptoms, and trials show meaningful reductions in how bothersome flushes are, plus improved sleep. Access routes include NHS talking-therapy services (self-referral in England), private therapists, and structured self-help based on CBT.
Non-hormonal prescription medicines
| Medicine | Evidence | Notes |
|---|---|---|
| SSRIs/SNRIs (e.g. venlafaxine, citalopram) | Reduce hot flush frequency moderately | Useful after breast cancer; avoid paroxetine/fluoxetine with tamoxifen |
| Gabapentin | Moderate flush reduction | Sedation can help night symptoms; side effects limit use |
| Clonidine | Licensed in UK for flushes | Modest effect; blood pressure side effects |
| Oxybutynin | Reduces flushes | Dry mouth common |
| Fezolinetant (NK3 antagonist) | New drug class targeting the brain's temperature circuit; MHRA-approved | Availability and funding vary; a genuine advance for women who can't take oestrogen |
None matches HRT's ~75% flush reduction, but several are worthwhile — especially where oestrogen is contraindicated.
For vaginal and urinary symptoms
Genitourinary symptoms deserve their own plan, HRT or not: vaginal moisturisers (e.g. Replens MD) and lubricants help immediately, and low-dose vaginal oestrogen has minimal systemic absorption — it can often be used even by women avoiding systemic HRT, sometimes including after breast cancer with specialist agreement. See our vaginal oestrogen guide.
Lifestyle measures that genuinely help
- Exercise — regular aerobic plus resistance training improves sleep, mood, weight and bone density (though evidence it reduces flushes is weak)
- Weight management — higher BMI is associated with worse vasomotor symptoms
- Alcohol and caffeine reduction — common flush triggers
- Stopping smoking — smoking worsens flushes and brings menopause earlier
- Sleep habits and cooling — layered bedding, cooler rooms, moisture-wicking nightwear
Supplements: mostly weak evidence
Black cohosh, red clover, evening primrose oil and soy isoflavones show inconsistent or minimal benefit in trials, and quality control varies; black cohosh has rare liver-toxicity reports, and phytoestrogens are generally discouraged after hormone-sensitive cancers. St John's Wort has some flush evidence but serious drug interactions (including tamoxifen). If you take supplements, tell your prescriber.
Check for interactions: "Natural" doesn't mean risk-free. St John's Wort and phytoestrogens can interact with medicines including tamoxifen — always tell your prescriber what you're taking.
Building a non-hormonal plan
A realistic combination looks like: CBT for flushes/sleep/mood + a non-hormonal prescription if flushes remain severe + local vaginal treatment + exercise and trigger management. And the decision isn't forever — many women revisit HRT later; see Is HRT safe? for a current view of the risk evidence, or the full Hormone Replacement Therapy guide.
Want to Discuss Your Options?
Our GPhC-registered pharmacist independent prescribers can advise on both hormonal and non-hormonal routes and, where appropriate, prescribe with discreet next-day delivery.
Start a consultation →Frequently Asked Questions
What is the best alternative to HRT for hot flushes?
CBT (NICE-recommended) plus, where needed, a prescription option such as an SSRI/SNRI or fezolinetant. Effectiveness varies individually.
Can I treat menopause naturally?
Lifestyle changes help overall health and modestly help symptoms; supplement evidence is weak. "Natural" compounded hormones are unregulated — see our body-identical HRT guide.
What can I take after breast cancer?
Non-hormonal options: CBT, SSRIs/SNRIs chosen to avoid tamoxifen interactions, gabapentin, oxybutynin, fezolinetant (with oncology input), vaginal moisturisers, and sometimes vaginal oestrogen with specialist agreement.
Does CBT really help hot flushes?
Trials show it significantly reduces how problematic flushes are and improves sleep and mood — enough for NICE to recommend it in the 2024 update.
Is fezolinetant available in the UK?
It's MHRA-approved; access depends on local NHS funding decisions and private availability. Ask your clinician about current status.
Whether you lean hormonal or non-hormonal, Access Doctor's pharmacist independent prescribers can talk through the options in a confidential online consultation and, where appropriate, prescribe with discreet next-day delivery.
References
- NICE. Menopause: identification and management (NG23). 2015, updated November 2024. nice.org.uk
- Hunter MS et al. MENOS trials of CBT for menopausal symptoms. pubmed.ncbi.nlm.nih.gov
- NHS. Menopause — treatment. nhs.uk
- Lederman S et al. Fezolinetant for VMS (SKYLIGHT trials). Lancet 2023. pubmed.ncbi.nlm.nih.gov
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.