This Way Up

Short answer: there isn’t a single “best” non‑hormonal option for everyone — evidence supports two kinds of approaches as most effective: (A) cognitive‑behavioral therapy or other structured mind‑behavior programs to reduce how much hot flashes bother you, and (B) non‑hormonal medications (SSRIs/SNRIs, gabapentin, clonidine) to reduce frequency and severity. Which is best depends on how bad your symptoms are, other health conditions and medications you take. What works (with specific examples and why) Cognitive‑behavioral therapy (CBT) — strongly evidence‑based for reducing the distress and interference from hot flashes even when frequency doesn’t change much. Available from trained therapists or online programs; examples of accessible services include This Way Up (online CBT courses) or local menopause clinics that offer CBT tailored to menopause. Good first‑line for mild–moderate bother and if you prefer non‑drug care. Paroxetine 7.5 mg (Brisdelle) — the only FDA‑approved non‑hormonal drug specifically for menopausal hot flashes. Reduces frequency/severity; useful if you want a prescription option. NOTE: avoid with tamoxifen (interacts). Venlafaxine (Effexor XR) or escitalopram (Lexapro) — antidepressants (SNRIs/SSRIs) with good trial evidence for reducing hot flashes; venlafaxine often works quickly. Preferred over paroxetine if you’re taking tamoxifen (less CYP2D6 interaction). Gabapentin (Neurontin) or pregabalin (Lyrica) — anticonvulsants useful for moderate–severe hot flashes, especially night sweats; often used at bedtime for sleep benefit. Side effects include dizziness and drowsiness. Clonidine (Catapres) — a blood pressure medicine that can reduce hot flashes in some people; modest benefit and side effects (dry mouth, low blood pressure). Device/behavioral aids — Embr Wave (wrist thermoregulatory device) has clinical studies showing symptom relief for some users; portable fans, cooling bedding, layering clothing, and avoiding triggers (alcohol, spicy food, hot rooms) also help. Acupuncture and herbal supplements (black cohosh, soy/isoflavones) — evidence is mixed and inconsistent; some people get benefit but results are variable and safety/quality concerns exist with supplements. How to choose Mild symptoms or preference to avoid drugs: start with CBT + behavioral measures (cooling strategies, fans, lifestyle). Moderate–severe symptoms: consider a non‑hormonal medication (Brisdelle/paroxetine if not on tamoxifen; venlafaxine or escitalopram if on tamoxifen or prefer an SNRI/SSRI; gabapentin if night sweats are prominent). If you want a non‑drug tech aid: try Embr Wave or practical cooling measures. Important safety notes If you’re taking tamoxifen for breast cancer, avoid paroxetine and fluoxetine (they interfere with tamoxifen). Venlafaxine or citalopram/escitalopram are safer choices for that situation. All prescription options have potential side effects—discuss risks, interactions and dosing with your clinician. Supplements are not always regulated; check with your provider before trying them. If you tell me how severe your hot flashes are, whether you’re on tamoxifen or other medicines, and whether you prefer drug vs non‑drug treatments, I can give a more personalized recommendation and suggested next steps.

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