Non Hormonal Treatments

Who Are Non-Hormonal Treatments For?

Non-hormonal treatments are relevant for women who cannot take systemic HRT due to medical contraindications (such as certain hormone-sensitive cancers, active liver disease, or uncontrolled cardiovascular conditions), women who choose not to take hormones for personal reasons, or women whose symptoms are mild enough to be managed effectively with lifestyle and targeted interventions. For most women with troublesome menopausal symptoms, non-hormonal options are less effective than HRT overall — but they are meaningful, evidence-based alternatives that can substantially improve quality of life. Many are also used alongside HRT to address specific symptoms.

The foundation for all women — whether or not they use HRT. Lifestyle changes address multiple symptoms simultaneously and have no side effects.

Regular Exercise (Aerobic + Resistance)

Pros

Reduces hot flush severity and frequency
Protects bone density — critical post-menopause
Improves sleep architecture
Significant mood and anxiety benefits
Reduces cardiovascular and metabolic risk
Supports healthy body composition

Cons

Requires consistent effort and habit formation
Benefits accumulate gradually — not immediate relief
Access to gym or safe outdoor space may be a barrier for some

Cost: R0–R700/month · Home bodyweight training is free; gym membership R300–R700/month · Combines with: Almost always combined with other interventions. Works synergistically with CBT, dietary changes and — if applicable — HRT.

Dietary Optimisation

Pros

High-protein diet preserves muscle mass post-menopause
Calcium & vitamin D from food protects bone
Reducing alcohol markedly decreases hot flush frequency
Anti-inflammatory diet supports mood and joint health
Phytoestrogens from soy and flaxseed may modestly reduce flushes

Cons

Dietary change is difficult to sustain long-term
Phytoestrogen evidence is modest, not dramatic
No single diet eliminates menopause symptoms

Cost: R0 (dietary shifts, no extra cost) · Whole-food, plant-inclusive diet may slightly reduce grocery spend · Combines with: Exercise, magnesium supplementation, and sleep hygiene — all work better together.

Sleep Hygiene & Stress Management

Pros

Improves sleep onset and continuity
Cool bedroom environment significantly reduces night sweats' impact
Mindfulness and yoga have measurable hot flush and mood benefits
No cost, no side effects

Cons

Requires discipline and habit change
Not sufficient alone for severe vasomotor symptoms
Results vary between individuals

Cost: R0–R300/month · Free apps (Insight Timer, YouTube yoga) or paid mindfulness programmes · Combines with: CBT for insomnia (CBT-I), magnesium glycinate at night, and melatonin where sleep onset is the primary issue.

The most effective non-hormonal pharmacological options, with robust clinical trial data. All require a prescription from an HPCSA-registered practitioner.

SSRIs — Escitalopram, Paroxetine — SSRIs (Selective Serotonin Reuptake Inhibitors) are a class of antidepressants that increase serotonin availability in the brain. In menopause they are used off-label at lower doses than for depression, primarily to reduce hot flush frequency and treat co-existing anxiety or low mood.

SSRIs — Escitalopram, Paroxetine

Pros

Reduce hot flush frequency by 50–60%
Also treat co-existing anxiety and depression
Widely prescribed, familiar to GPs
Evidence from multiple RCTs

Cons

Sexual side effects (reduced libido, delayed orgasm) common
Nausea on initiation
Paroxetine interacts with tamoxifen — cannot be used in breast cancer patients on tamoxifen
Takes 2–4 weeks to reach full effect
Withdrawal symptoms if stopped abruptly

Cost: R80–R300/month · Generics widely available and affordable in SA (escitalopram generics ~R80–R150/month) · Combines with: CBT for menopause, sleep hygiene, exercise. Often used alongside vaginal oestrogen for genitourinary symptoms.

SNRIs — Venlafaxine, Desvenlafaxine — SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) are similar to SSRIs but also act on norepinephrine pathways. Effective for hot flushes and mood, and importantly, some SNRIs (venlafaxine) are safe for breast cancer survivors taking tamoxifen — unlike paroxetine.

SNRIs — Venlafaxine, Desvenlafaxine

Pros

Reduce hot flushes by 50–60%
Effective for anxiety and depression
Venlafaxine safe for breast cancer survivors on tamoxifen (unlike paroxetine)
Desvenlafaxine has good trial data specifically for menopause

Cons

Blood pressure elevation at higher doses
Nausea and insomnia on initiation
Discontinuation syndrome if stopped abruptly
Requires dose tapering

Cost: R150–R500/month · Venlafaxine generics available; Pristiq (desvenlafaxine) is brand-only and higher cost · Combines with: CBT, exercise, vaginal oestrogen for GSM. First-line non-hormonal pharmacological choice for breast cancer survivors with hot flushes.

Gabapentin / Pregabalin — Originally developed as anticonvulsants, these drugs calm overactive nerve signalling. In menopause they reduce vasomotor symptoms — particularly night sweats — and meaningfully improve sleep quality. They are not antidepressants and work via a different mechanism to SSRIs/SNRIs.

Gabapentin / Pregabalin

Pros

Reduces hot flushes, particularly night sweats
Significantly improves sleep
Useful when SSRIs/SNRIs not tolerated or contraindicated

Cons

Sedation and dizziness — especially at initiation
Weight gain
Potential for dependence with long-term use
Not as effective as SSRIs for mood symptoms

Cost: R150–R400/month · Gabapentin generics available; pregabalin slightly higher · Combines with: Often used at night specifically for sleep and night sweats, combined with an SSRI/SNRI for daytime hot flush management.

Fezolinetant (Veoza) — A newer, purpose-built non-hormonal menopause drug. It works by blocking neurokinin B (NKB) receptors in the hypothalamus — the specific pathway that drives hot flushes when oestrogen declines. Unlike SSRIs, it has no antidepressant effect but is highly targeted for vasomotor symptoms with no sexual side effects.

Fezolinetant (Veoza)

Pros

Specifically targets the neurokinin 3 pathway driving hot flushes
Reduces hot flush frequency by ~60% in trials
Non-hormonal, non-antidepressant mechanism
No sexual side effects
Suitable for breast cancer survivors

Cons

Newer agent — less long-term safety data than SSRIs
Higher cost — currently limited availability in SA
Liver enzyme monitoring required
Not suitable for women with liver disease

Cost: R1,200–R2,500/month · Currently limited SA availability; may require import or private pharmacy — costs vary · Combines with: Vaginal oestrogen for GSM, lifestyle interventions, and CBT for mood and sleep.

Clonidine — An alpha-2 adrenergic agonist originally used for high blood pressure. It reduces hot flushes by dampening the nervous system's vasomotor response. Less effective than SSRIs/SNRIs and carries more side effects, so it is generally a second-line option.

Clonidine

Pros

Has modest evidence for hot flush reduction
Long-used, well-understood drug
Affordable

Cons

Less effective than SSRIs/SNRIs for hot flushes (20–30% reduction)
Side effects include dry mouth, dizziness, fatigue, low blood pressure
Not first-line per modern menopause guidelines

Cost: R80–R200/month · Inexpensive generic; available at most pharmacies · Combines with: Lifestyle interventions. Generally a second-line option when other treatments are not tolerated.

Evidence varies widely. Those listed here have the best available data — always discuss with your healthcare provider, especially regarding interactions with medications.

Magnesium Glycinate

Pros

Improves sleep onset and quality
Reduces anxiety and irritability
Supports bone density
May modestly reduce hot flush severity
Well-tolerated, inexpensive

Cons

Evidence for hot flushes is limited and indirect
High doses cause loose stools
Not a standalone treatment for significant symptoms

Cost: R100–R250/month · Quality magnesium glycinate supplements widely available in SA pharmacies · Combines with: Sleep hygiene, CBT-I, vitamin D. A low-risk addition to almost any menopause management plan.

Isoflavones (Soy / Red Clover Phytoestrogens)

Pros

Modest reduction in hot flush frequency (20–30%)
Generally safe
Some cardiovascular and bone health benefits in observational studies

Cons

Effect size is substantially smaller than HRT or SSRIs
Inconsistent results across trials — bioavailability varies between individuals
Concerns (unproven) about use in hormone-sensitive cancers — discuss with oncologist

Cost: R200–R400/month · Menophase, Promensil (red clover) and soy isoflavone supplements vary in price · Combines with: Dietary phytoestrogens (flaxseed, soy foods), magnesium, lifestyle interventions. Not a replacement for prescription options in moderate-severe symptoms.

Black Cohosh (Cimicifuga racemosa)

Pros

Some evidence for modest hot flush reduction
Long history of use for menopause
Does not appear to have oestrogenic activity — may be safe for breast cancer survivors (discuss with oncologist)

Cons

Evidence is inconsistent across trials
Rare but serious hepatotoxicity (liver damage) reported
Not recommended alongside hepatotoxic medications
Quality control of herbal products varies

Cost: R150–R350/month · Remifemin is a standardised extract; generic brands widely available · Combines with: Lifestyle interventions. Should not be used alongside hepatotoxic drugs or without informing your doctor.

Vitamin D3 + Calcium

Pros

Essential for bone health post-menopause
Vitamin D deficiency is extremely common in SA (despite sun exposure)
Reduces fracture risk combined with weight-bearing exercise
Supports immune function and mood

Cons

Does not address hot flushes or mood symptoms
High-dose calcium supplements may carry cardiovascular risk — dietary calcium preferred
Regular vitamin D blood level monitoring recommended

Cost: R100–R250/month · Vitamin D3 + K2 combination supplements widely available; calcium from diet preferred over supplements · Combines with: Weight-bearing exercise, magnesium. Considered essential in all postmenopausal women regardless of other treatment choices.

Acupuncture

Pros

Some evidence for modest hot flush reduction
Addresses stress, anxiety and sleep as secondary benefits
No drug interactions
Well-tolerated

Cons

Evidence quality is limited — many trials not well-controlled
Effect is modest and variable
Cost of ongoing sessions
Access to qualified practitioners may be limited in SA

Cost: R400–R1,200/month · Typically 2–4 sessions/month at R200–R400/session; sessions may reduce over time · Combines with: Mindfulness, exercise, dietary changes. Best as a complement to evidence-based interventions rather than a primary treatment.

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