Is there a natural alternative to HRT?
Yes, and it isn’t a herb. NICE suggests a talking therapy, menopause CBT, for hot flushes. Herbs have only some evidence. And if HRT isn’t suitable, a hormone-free tablet now has NICE’s backing.
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Is there a natural alternative to HRT?
Yes. The best-backed one is a therapy, not a pill. NICE suggests menopause-specific CBT, a talking therapy, for hot flushes and night sweats.
You can have it alongside HRT. Or instead, if HRT isn’t safe for you or you’d rather not take it. For most people HRT is still the first thing NICE offers for hot flushes, and the NHS says its benefits usually outweigh the risks.
Herbs have less behind them. NICE says there’s only some evidence for isoflavones or black cohosh, and their safety is uncertain.
| Option | What NICE says | Good to know |
|---|---|---|
| Menopause CBT (a talking therapy) | Consider it for hot flushes and night sweats, and for sleep problems or low mood linked to them. | Group, one to one, remote or self-help. |
| Fezolinetant (a hormone-free prescription tablet) | Recommended for moderate to severe hot flushes when HRT is unsuitable. | Needs liver blood tests. |
| Antidepressants or clonidine (a blood pressure medicine that can also ease hot flushes) | Not routinely a first choice for hot flushes alone. | A doctor may suggest one if CBT doesn’t help. |
| Vaginal moisturisers and lubricants | Consider them if you can’t or would rather not use vaginal oestrogen. | Sold at pharmacies, no prescription needed. |
| Isoflavones or black cohosh | Some evidence they may ease hot flushes. Safety is uncertain. | Products vary. Problems when mixed with other medicines have been reported. |
| Unregulated hormone products | How well they work and how safe they are is unknown. | Talk to a doctor first. |
Sources: NICE NG23; NICE TA1143; NHS; NHS
Under 40? This NICE advice is for people aged 40 or over. See your GP, and read about early menopause tests.
Pick the row that fits your main symptom, and take it to your GP.
Does CBT really help hot flushes?
It did in a UK trial. In MENOS 2, 140 women had group CBT, self-help CBT or no treatment. Each had at least 10 bothersome flushes or night sweats a week, for at least a month.
They scored how much their flushes bothered them, from 1 to 10. On average, they started at about 6.
| Type of CBT | Points better than no treatment at 6 weeks | Points better at 26 weeks |
|---|---|---|
| Group CBT | 2.1 | 1.3 |
| Guided self-help CBT | 2.1 | 1.2 |
Source: Ayers 2012, Menopause
The main score was bother, not how many flushes came.
Night sweats also came less often with both types. Mood and quality of life improved at 6 weeks too.
NICE says CBT can be face to face or remote, in a group or one to one, or self-help. Ask your GP what’s on offer near you.
For sleep problems in general, see CBT for insomnia.
What if I can’t take HRT?
That hormone-free tablet is fezolinetant. NICE recommends it for moderate to severe hot flushes and night sweats when HRT is unsuitable.
In England, the NHS must fund it for these people if it’s the most suitable option. It hasn’t been tested head to head with other hormone-free treatments. NICE says it may work about as well, but this is uncertain.
Liver checks on fezolinetant
- 1
Before you start
A blood test to check your liver.
- 2
First 3 months
The test is repeated every month.
- 3
After that
Tests when your doctor thinks they’re needed.
- 4
Warning signs
Tiredness, itching, yellow skin or eyes, dark pee, pale poo, feeling or being sick, loss of appetite or tummy pain: get medical help straight away.
Source: MHRA
The MHRA says to avoid it if you have liver disease or a higher risk of it. More on liver function tests.
Antidepressants or clonidine? NICE says not routinely as a first choice for hot flushes alone. The NHS says a doctor may suggest one if CBT doesn’t help.
Never stop or change a prescribed medicine without your prescriber.
Is there natural HRT or a natural oestrogen supplement?
Not one with known safety. NICE says how well unregulated hormone products work, and how safe they are, is unknown.
An unregulated product is like a jar whose label nobody has checked. It might be fine, but no one can tell you what’s inside, how strong it is or whether it’s safe.
So if it’s sold as natural or bioidentical HRT, ask a pharmacist if it’s a licensed medicine.
Plant compounds called isoflavones, and the herb black cohosh, have some evidence for hot flushes. But NICE warns that products vary, safety is uncertain and problems when mixed with other medicines have been reported.
The NHS says there’s very little evidence on how well herbal remedies work or how safe they are. Had breast cancer, or at high risk? NICE flags serious interactions between St John’s wort and medicines including the breast cancer medicine tamoxifen.
Talk to a doctor before taking any herbal supplement, as the NHS advises. For the evidence on each herb, see menopause supplements.
What can I do myself for perimenopause symptoms?
Six NHS self-help steps for hot flushes and sleep
- Wear light clothing and keep your bedroom cool at night.
- Try a fan, a cool shower or a cold drink.
- Cut back on triggers such as spicy food, caffeine, hot drinks, smoking and alcohol.
- Exercise regularly and keep to a healthy weight.
- Find ways to bring your stress down, such as yoga, tai chi or meditation.
- Keep regular sleep routines and get plenty of rest.
Source: NHS: things you can do
Vaginal dryness? Moisturisers and lubricants are sold at pharmacies without a prescription. NICE says to offer them to people who’ve had breast cancer.
Using condoms? Pick a water-based lubricant, as oil-based ones can damage condoms.
Feeling dizzy? The NHS says a hot flush can make you feel dizzy or cause palpitations. A fast or pounding heartbeat is worth a GP visit, the NHS says.
More on hot flushes and other perimenopause symptoms.
When to speak to a GP
Book an appointment if:
- You think you have menopause symptoms and want to know your options.
- You get a fast or pounding heartbeat (palpitations).
- You still have periods and you’re bleeding more, not less, than before.
- You haven’t had a period for 12 months or more and you have any vaginal bleeding, even once or a small amount.
- You take other medicines and want to try a herbal remedy. NICE says problems when mixed with other medicines have been reported.
On fezolinetant? Get medical help straight away for signs of liver trouble, such as yellow skin or eyes, dark pee or pale poo.