Non-hormonal medications

Updated on 23 Jan 2024
2 Minutes to read

Article summary

Did you find this summary helpful?

Thank you for your feedback

The British Menopause Society (BMS) has produced a table with detailed information on non-hormonal prescribable alternatives to HRT. See factsheet. The following is a summary of some options. Most are off-license and have been evaluated for their impact on vasomotor symptoms. None are as effective as HRT.

Drug	Dose	Side effects	Notes
Clonidine	Commencing dose is 25mcg twice daily for 2 weeks, increased up to a maximum of 50mcg three times daily.	Side effects are dose related and can include dry mouth, nausea, fatigue, sleep disturbance.	The only non-hormonal medication with a licensed indication for vasomotor symptoms in the UK. It must be withdrawn gradually to avoid rebound hypertension. May not be suitable if baseline BP is low.
Selective serotonin reuptake inhibitors (SSRIs).	Paroxetine 10mg once daily. Fluoxetine 20mg once daily. Sertraline 25-50mg once daily. Citalopram 10-30mg once daily. Mirtazepine 15-30mg once daily.	Initial worsening anxiety, appetite increased, arthralgia, constipation, diarrhoea, dizziness, dry mouth, myalgia, nausea, sleep disorder, sexual dysfunction.	In general, baseline effectiveness for reducing vasomotor symptoms is 20-50%. Some SSRIs can decrease the efficacy of Tamoxifen and should not be used in women taking this treatment. These include Fluoxetine, Paroxetine and Sertraline. No one SSRI is better than another, and there is great individual variation in response. Paroxetine is licensed in the USA for vasomotor symptoms but not yet in the UK.
Selective serotonin and noradrenaline reuptake inhibitors (SNRIs).	Venlafaxine 37.5mcg once daily titrated up to 150mg per day.	There are often problems early on with dizziness and loss of sexual function.	Suitable to take if using Tamoxifen.
Gabapentin (gamma amino butyric acid agonist)	Commenced at 300mg daily. Can be increased in increments to 300mg three times daily.	Anxiety, altered appetite, weight gain, arthralgia, asthenia, confusion, constipation, cough, diarrhoea, dizziness, dry mouth, drowsiness. There is a very specific dose related component.	Reduces hot flushes at a dose of 900mg per day in about 50% of patients. Schedule 3 controlled medication.
Pregabalin (gamma amino butyric acid agonist).	50-300mg in divided doses.	Altered appetite, asthenia, concentration changes, confusion, constipation, dizziness, drowsiness, dry mouth, headache.	Baseline improvement is similar to gabapentin. Better tolerated than gabapentin. Schedule 3 controlled medication.
Oxybutynin (an antimuscarinic agent)	2.5mg taken each evening. It can be increased to 5mg taken up to twice daily.	Constipation, dizziness, drowsiness, dry mouth, dyspepsia, headache, flushing, urinary retention, agitation, blurred vision.	Can be limited by side effects. Contraindicated in patients with a history of angle closure glaucoma and myasthenia gravis.

Note:

For more information on non-hormonal alternatives to HRT, see management section.
Oxybutynin is an off-license option, however the dose of a transdermal patch for vasomotor symptoms is not established.
St John's Wort is available over the counter. NICE says there is some evidence that it may help relieve vasomotor symptoms. However there is some uncertainty about the appropriate dose and nature of preparations and it can also interact with other medications including Tamoxifen. For more information see management section.
Fezolinetant is a neurokinin 3 antagonist that was licensed for vasomotor symptoms on 14.12.2023. It is not yet available on the NHS but it is expected to be available on private prescription from mid January 2024. The recommended dose is one 45mg tablet taken daily. For more information click here.

References and Further Information:

Was this article helpful?

What's Next

HRT prescribing algorithm