Menopause is treated with a combination of approaches tailored to your specific symptoms, ranging from hormone therapy for hot flashes and bone loss to local treatments for vaginal dryness and non-hormonal options for people who can’t or prefer not to use hormones. There is no single treatment plan that works for everyone, and most women benefit from addressing their most bothersome symptoms first.
Hormone Therapy for Hot Flashes and Night Sweats
Hormone therapy remains the most effective treatment for the hot flashes and night sweats that define menopause for many women. It works by replacing the estrogen your ovaries no longer produce in significant amounts. For women under 60, or within 10 years of their last period, the benefits generally outweigh the risks when symptoms are bothersome.
If you still have your uterus, you’ll need both estrogen and a progestogen. The progestogen protects the uterine lining from thickening abnormally, which estrogen alone can cause. If you’ve had a hysterectomy, estrogen alone is sufficient.
You have several ways to take it. Estrogen comes as daily pills, skin patches worn on the lower abdomen or hip, gels, sprays, creams, and even small pellets placed under the skin. Patches deliver estrogen directly into the bloodstream, bypassing the liver, which may lower the risk of blood clots compared to pills. Low-dose options are now standard: a patch delivering as little as 0.025 mg per week or an oral dose of 0.5 mg of estradiol per day can relieve symptoms effectively. The progestogen component is usually taken as a pill, though some combination patches include both hormones.
Who Should Avoid Hormone Therapy
The timing of when you start matters significantly. Women who begin hormone therapy more than 10 years after menopause onset, or after age 60, face higher absolute risks of heart disease, stroke, blood clots, and dementia. For these women, the benefit-risk balance shifts, and non-hormonal options are typically a better fit. Women with a history of hormone-sensitive cancers, unexplained vaginal bleeding, or active liver disease are also generally steered away from systemic hormone therapy.
For those who do use it, there’s no fixed expiration date. The current consensus from The Menopause Society is that longer use is appropriate for persistent symptoms, as long as you and your clinician periodically reassess whether the benefits still justify continuing.
Non-Hormonal Medications for Hot Flashes
If hormone therapy isn’t right for you, several prescription alternatives can reduce hot flashes. The first option many clinicians reach for is a low-dose antidepressant. Paroxetine at 7.5 mg taken at bedtime is the only non-hormonal medication FDA-approved specifically for hot flashes. Venlafaxine, another antidepressant, is also commonly used at doses ranging from 37.5 to 150 mg per day. Neither eliminates hot flashes entirely, but both can meaningfully reduce how often and how intensely they occur.
A newer class of drug works differently. Fezolinetant (sold as Veozah) is the first non-hormonal medication that targets the brain’s temperature-control center directly. During menopause, falling estrogen levels destabilize this center, which is why your body suddenly perceives normal temperatures as too hot. Fezolinetant blocks the chemical signal responsible for that destabilization. Taken as a single 45 mg tablet daily, it reduced both the frequency and severity of hot flashes in multiple clinical trials. It does require regular liver monitoring.
Treating Vaginal Dryness and Discomfort
Vaginal dryness, irritation, and pain during sex are among the most persistent menopause symptoms because, unlike hot flashes, they tend to worsen over time rather than fade. First-line treatment is simple: over-the-counter vaginal moisturizers used regularly (not just during sex) and lubricants during intercourse. Staying sexually active also helps maintain vaginal tissue health.
When those aren’t enough, low-dose vaginal estrogen is highly effective and works locally, meaning very little estrogen reaches the rest of your body. Options include a small tablet inserted into the vagina (10 micrograms of estradiol, used daily for two weeks then twice weekly), a flexible ring that sits in the upper vagina and releases a tiny dose over 90 days, or vaginal creams applied on a schedule that tapers from daily use to once or twice a week. Because the doses are so small, vaginal estrogen is sometimes considered even for women who can’t use systemic hormone therapy, though that decision requires a conversation with a clinician.
For women who want to avoid estrogen entirely, ospemifene is an oral prescription pill that acts like estrogen on vaginal tissue without being a hormone. It was specifically approved for painful intercourse caused by menopause-related vaginal changes.
Cognitive Behavioral Therapy and Hypnosis
These may sound unconventional for a physical symptom like hot flashes, but the clinical data is surprisingly strong. Cognitive behavioral therapy (CBT) doesn’t reduce how many hot flashes you have as much as it changes how much they disrupt your life. Across multiple studies, CBT reduced daily interference from hot flashes by 39% to 59%, and improved sleep quality and anxiety alongside it. Online CBT programs have shown similar benefits, making this accessible even without in-person sessions.
Clinical hypnosis goes a step further. In controlled studies, it reduced hot flash frequency by about 64% and daily interference by 69%, results that held up at 12-week follow-up. One study found hypnosis performed comparably to gabapentin, a prescription medication sometimes used off-label for hot flashes. Both CBT and hypnosis are worth considering as add-ons to other treatments, or as primary options for women who can’t take medications.
Protecting Your Bones
Bone loss accelerates sharply in the years around menopause due to declining estrogen. Hormone therapy, in addition to relieving symptoms, reduces the risk of spine, hip, and other fractures. Data from the Women’s Health Initiative confirmed this even in women who weren’t at high risk for osteoporosis. For women with premature ovarian insufficiency (menopause before age 40), estrogen-based therapy is considered the treatment of choice for bone protection specifically.
Regardless of whether you use hormone therapy, adequate calcium and vitamin D intake matters. The British Menopause Society recommends 1,000 mg of calcium and 1,000 IU of vitamin D daily. Most women can meet the calcium target through diet (dairy, fortified foods, leafy greens) and supplement only the gap. Vitamin D is harder to get from food alone, so a supplement is common. Weight-bearing exercise, like walking, jogging, or resistance training, further strengthens bone and reduces fracture risk.
Herbal Supplements
Black cohosh and soy isoflavones are the most studied herbal options. A recent randomized, double-blind, placebo-controlled trial found that a combination of black cohosh, soy isoflavones, and flaxseed lignans reduced overall menopause symptom scores by 48% compared to placebo, with improvements across physical, psychological, and urogenital symptoms. Side effects were minimal and temporary. That said, the hormonal changes these supplements produced were modest, and the evidence base is smaller and less consistent than for prescription treatments. They’re a reasonable option for women with mild to moderate symptoms who prefer a supplement-based approach, but they’re unlikely to match hormone therapy for severe hot flashes.