What is the best non hormonal treatment for hot flashes?

Short answer: there’s no one “best” non‑hormonal option for everyone, but the treatments with the strongest evidence are certain antidepressants (SSRIs/SNRIs), gabapentin, and cognitive behavioral therapy (CBT). Which is best for you depends on your medical history, other medications (especially tamoxifen), side‑effect tolerance, and whether hot flashes are mainly daytime or night‑time.

Options to discuss with your clinician

1. Paroxetine (Brisdelle / low‑dose paroxetine)

• Why: Brisdelle (paroxetine 7.5 mg) is the only nonhormonal FDA‑approved pill specifically for menopausal hot flashes and has good trial data.
• Caveat: paroxetine strongly inhibits CYP2D6 and can interfere with tamoxifen → avoid if you’re taking tamoxifen.

1. Venlafaxine (Effexor) or desvenlafaxine (Pristiq)

• Why: SNRIs have consistently reduced hot flash frequency/intensity in trials. Venlafaxine is often preferred for women on tamoxifen because it has less CYP2D6 inhibition than paroxetine.
• Side effects: nausea, headache, increased BP (venlafaxine), insomnia or sleepiness.

1. Gabapentin (Neurontin, Gralise)

• Why: Good evidence, especially helpful for nighttime hot flashes and sleep disturbances.
• Typical effect: useful when hot flashes interfere with sleep.
• Side effects: dizziness, drowsiness, peripheral edema.

1. Clonidine (Catapres)

• Why: modest benefit shown in some studies.
• Side effects: dry mouth, low blood pressure, dizziness — less effective than the options above for many women.

1. Oxybutynin (Ditropan)

• Why: some studies show reduced hot flashes; an option if you also have bladder symptoms.
• Caveat: anticholinergic side effects (dry mouth, constipation, blurred vision) — use with caution, especially in older adults.

1. Non‑drug therapies with good evidence

• Cognitive behavioral therapy (CBT): multiple randomized trials (including the MENOS studies) show CBT reduces hot‑flash bother and improves quality of life. Available as group therapy, guided self‑help, or internet programs.
• Clinical hypnosis: several randomized trials show clinically meaningful reductions in hot flashes for some women.
• Lifestyle measures and cooling strategies: avoid known triggers (alcohol, spicy foods, hot beverages), keep layers, use fans, paced breathing/relaxation techniques. These help many people but are usually less potent than medications.

How to choose

• If you want a pill: paroxetine (Brisdelle) or an SNRI (venlafaxine/desvenlafaxine) or gabapentin are the strongest evidence‑based choices. Pick based on side effects and interactions (e.g., venlafaxine preferred if on tamoxifen).
• If you prefer non‑drug care: CBT (in‑person or online programs used in trials) or clinical hypnosis are the best‑evidenced options.
• Always review your other meds and medical conditions with your clinician before starting a treatment.

If you want, tell me whether you’re on tamoxifen or other medications, whether your hot flashes are worse at night, and how you feel about medications vs non‑drug approaches — I can suggest a more tailored option and typical study doses to discuss with your clinician.