Several effective options exist for managing menopause symptoms, ranging from hormone therapy and newer non-hormonal prescriptions to over-the-counter supplements and lifestyle changes. The right choice depends on which symptoms bother you most, your health history, and your comfort level with different treatments. Here’s what’s available and what the evidence says about each.
Hormone Therapy: The Most Effective Option for Hot Flashes
Hormone therapy remains the single most effective treatment for the hallmark symptoms of menopause: hot flashes, night sweats, and the sleep disruption that comes with them. It works by replacing the estrogen your body has stopped producing, which directly addresses the hormonal shift causing these symptoms. Estrogen comes in several forms: skin patches, gels, sprays, and pills. Transdermal options (patches and gels) deliver estrogen through the skin, which may carry a lower risk of blood clots compared to pills because they bypass the liver.
If you still have your uterus, you’ll need progesterone alongside estrogen. Estrogen alone can cause the uterine lining to thicken abnormally, and progesterone prevents that. If you’ve had a hysterectomy, estrogen alone is typically sufficient.
The risks are real but often smaller than people assume. For combined estrogen-plus-progesterone therapy, the increased breast cancer risk amounts to fewer than one additional case per 1,000 women per year of use, or roughly three additional cases per 1,000 women over five years. The American College of Obstetricians and Gynecologists recommends revisiting the decision to continue hormone therapy annually with your provider, weighing your current symptoms against your individual risk profile. There’s no fixed cutoff for how long you can stay on it.
Non-Hormonal Prescriptions for Hot Flashes
If hormone therapy isn’t right for you, whether because of a history of breast cancer, blood clots, or personal preference, a new class of medications has changed the landscape. These drugs work directly on the brain’s thermostat rather than replacing hormones.
Fezolinetant, approved in 2023, was the first in this class. It blocks a specific receptor in the hypothalamus that becomes overactive when estrogen drops, which is what triggers hot flashes in the first place. In clinical trials, it significantly reduced both the frequency and severity of hot flashes within four weeks, with improvements in overall quality of life. A second drug in this class, elinzanetant, was approved in 2025 and works on a similar principle, targeting two receptors instead of one. Its key trials showed significant reductions in moderate to severe hot flashes at both 4 and 12 weeks.
Certain antidepressants also reduce hot flashes, even in women who aren’t depressed. Low-dose paroxetine is actually FDA-approved specifically for this purpose. In trials, it reduced hot flashes by about 41% at 10 mg and 52% at 20 mg compared to placebo. Venlafaxine, escitalopram, and citalopram have also shown meaningful effects, though they’re used off-label for menopause. These can be a practical choice if you’re also dealing with the mood changes or sleep problems that often accompany the transition.
Treatments for Vaginal Dryness and Painful Sex
Hot flashes get the most attention, but vaginal dryness, irritation, and painful intercourse affect many women during and after menopause, and unlike hot flashes, these symptoms tend to get worse over time rather than better. The good news: treatments for these symptoms are distinct from systemic hormone therapy and carry fewer risks.
Topical estrogen, applied directly to vaginal tissues as a cream, ring, or tablet, works at much lower doses than systemic hormone therapy. Very little reaches the bloodstream, which means it provides targeted relief with minimal whole-body estrogen exposure. It’s the most common first-line approach for these symptoms.
Prasterone is a vaginal insert that delivers DHEA, a precursor hormone that the body converts locally into estrogen and other hormones. Used nightly, it’s designed for moderate to severe vaginal dryness. Ospemifene takes a different approach entirely: it’s an oral pill taken daily that acts on estrogen receptors in vaginal tissue without being estrogen itself, making it an option even for some women with a history of estrogen-sensitive breast cancer.
What About Supplements?
Many women try supplements before or instead of prescription options. The evidence is mixed, and generally weaker than for prescription treatments.
Black cohosh is the most widely used herbal remedy for hot flashes. A large review of 47 trials involving over 8,300 women found it was more effective than placebo at reducing hot flashes. However, an earlier review concluded there’s no high-quality, consistent evidence that it works better than placebo. The contradiction likely reflects wide variation in formulations, doses, and study quality. If you try it, give it at least 8 to 12 weeks, but keep your expectations realistic.
Soy isoflavones, which contain plant-based compounds that weakly mimic estrogen, have shown modest reductions in hot flash frequency and vaginal dryness in a review of 62 studies. However, they didn’t significantly reduce night sweats. Soy is generally safe in dietary amounts (tofu, edamame, soy milk), though concentrated supplements are a different question for women with estrogen-sensitive conditions.
A Note on Compounded “Bioidentical” Hormones
Compounded bioidentical hormones are custom-mixed by specialty pharmacies and often marketed as more natural or safer than standard prescriptions. The National Academies of Sciences reviewed the evidence and found a lack of rigorous clinical data supporting those claims. Most of the safety and effectiveness information came from low-quality sources like anecdotal reports and patient testimonials. These products also face limited federal and state oversight for quality control, which led the review panel to conclude that their widespread use poses a public health concern.
This is different from FDA-approved bioidentical hormones, which use the same molecular forms of estrogen and progesterone but go through standardized manufacturing, testing, and regulatory review. If you want bioidentical hormones, FDA-approved versions are available and offer more predictable dosing and safety data.
Protecting Your Bones After Menopause
Estrogen plays a major role in maintaining bone density, so the drop during menopause accelerates bone loss. This isn’t something you’ll feel, which makes it easy to overlook. After menopause, you should aim for 1,200 mg of calcium per day, up from the 1,000 mg recommended for younger adults. Dairy products, fortified foods, and leafy greens can get you there, with a supplement filling any gap. For vitamin D, the recommendation is 600 IU daily until age 70, then 800 IU after that. Vitamin D helps your body absorb calcium and is difficult to get from food alone, so a supplement is practical for most people.
Weight-bearing exercise (walking, jogging, strength training) directly stimulates bone maintenance and also helps with the sleep disruption, mood changes, and weight gain that often accompany menopause. Regular physical activity won’t eliminate hot flashes, but it addresses many of the secondary symptoms that erode quality of life during this transition.