Medicines for menopause: herbal, homeopathic, modern

The term "best" for menopause does not refer to a universal list, but rather to the optimal match of medication to specific symptoms, age, time since last menstruation, risk factors, and preferences. Hormone therapy remains the most effective method for reducing hot flashes, night sweats, and symptoms of genitourinary menopause syndrome, but it is not indicated for everyone and always requires an individual benefit-risk assessment. This is confirmed by international clinical guidelines and position statements from professional societies. [1]

The key concept in modern therapy is the "right window" for initiation. In women under 60 years of age or within the first 10 years of menopause, the benefit-risk ratio for appropriate low-dose therapy is usually most favorable. The route of administration, the type of hormone, and the need for endometrial protection are important. Transdermal forms and low doses are associated with a lower risk of thrombotic complications compared to oral forms, as reflected in position papers. [2]

Some patients are unable or unwilling to take hormones. Effective non-hormonal prescription options exist for them: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin, oxybutynin, and newer generation drugs that target neurokinin receptors in the thermoregulatory center. These approaches are officially recommended and have proven efficacy in randomized trials. [3]

Today, the term "new generation" primarily refers to neurokinin receptor antagonists. Fezolinetant was approved in 2023, and elizanetant joined it in 2025. These are non-hormonal agents that target the underlying cause of hot flashes, expanding the choice for women with contraindications to hormones or unwillingness to use them. [4]

Table 1. Quick Reference: Symptoms and Treatment Priorities

Dominant symptom	First line	Alternatives for stopping hormones	Important notes
Hot flashes and night sweats	Low-dose hormonal therapy	Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, gabapentin, oxybutynin, neurokinin receptor antagonists	Assessment of cardiovascular and thrombotic risk
Sleep disturbances associated with hot flashes	As above + sleep hygiene	Gabapentin, elinzanetant, or fezolinetant	Selection by portability
Dryness, pain during intercourse, recurrent urinary tract infections	Vaginal estrogens	Prasterone vaginally, ospemifene	Systemic absorption is minimal in topical forms.
Mood swings, anxiety	Assessment of depressive disorder	Selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors	Consider compatibility with tamoxifen

How to Systematically Choose Treatment: Steps for a Collaborative Decision

The first step is symptom mapping. The doctor and patient discuss the frequency and severity of hot flashes, sleep disturbances, urogenital complaints, and their impact on daily life. This helps determine the most important treatment goals and the appropriate initial dosage and form. Guidelines recommend categorizing targeted symptoms and monitoring their dynamics using hot flash diaries and quality of life scales. [5]

The second step is checking for contraindications. Before initiating hormonal therapy, breast and endometrial cancer, uncontrolled hypertension, and active thrombosis are excluded. When choosing non-hormonal therapy, drug interactions are considered, for example, the effect of certain antidepressants on tamoxifen metabolism in women after breast cancer treatment. [6]

The third step is choosing the route and composition. For vasomotor symptoms, oral and transdermal routes are possible; for genitourinary menopause syndrome, topical estrogens or prasterone are preferred; and for contraindications to hormones, proven non-hormonal options are recommended. It is important to discuss expectations regarding the duration of effect and a safety monitoring plan in advance. [7]

The fourth step is regular reassessment. Efficacy and tolerability monitoring is recommended after 6-12 weeks, followed by periodic dose revisions and the need for continuation. The decision on the duration of therapy is made individually, taking into account age, risk of osteoporotic fractures, and preferences. [8]

Table 2. Contraindications and precautions: what to check before starting

Group of drugs	Absolute contraindications	Special care is needed
Hormonal therapy	Active or previous hormone-dependent tumors, venous thromboembolism, stroke, severe liver disease	Migraine with aura, arterial hypertension, obesity - preference for transdermal forms and low doses
Antidepressants	Individual intolerance	When taking tamoxifen, avoid strong cytochrome P450 enzyme inhibitors; venlafaxine is preferred.
Gabapentin and oxybutynin	Hypersensitivity	Drowsiness, dry mouth - titrate, assess tolerance
Neurokinin receptor antagonists	Severe liver failure	Monitor liver enzymes according to the label in the instructions

Based on the positions of professional societies and drug labels. [9]

Hormone Therapy: When It's the Best Choice and How to Make It Safer

Hormone therapy is the most effective option for controlling hot flashes and night sweats, and is a first-line treatment for genitourinary syndrome of menopause. If a uterus is present, endometrial protection with a progestogen is mandatory; if a uterus is absent, estrogen alone can be used. Dose and route of administration are determined based on the principle of "minimum effective dose, taking into account preference and risk." [10]

The route of administration matters. Transdermal systems and gels demonstrate a more favorable risk profile for venous thromboembolism and possibly stroke compared to oral forms. This strategy is preferred in women with risk factors, including obesity and high blood pressure. Low-dose regimens reduce the risk and maintain efficacy against hot flashes. [11]

In genitourinary syndrome of menopause, local estrogens have a superior benefit-risk profile for vaginal symptoms compared to systemic estrogens, ensuring minimal systemic absorption. In recurrent urinary tract infections in postmenopausal women, vaginal estrogens reduce the frequency of episodes, as supported by clinical guidelines in urology. [12]

Monitoring during hormone therapy includes assessing efficacy and tolerability after 6-12 weeks, monitoring blood pressure, and, if necessary, laboratory testing as clinically indicated. Discontinuation does not require an "automatic" strict deadline: the duration is determined by the balance of benefits and risks, symptoms, and preferences. [13]

Table 3. Forms of hormonal therapy: pros, cons, for whom

Form	Pros	Cons	Who is it suitable for?
Transdermal patches and gels	Lower thrombogenic risk, flexible dosing	Skin reaction is possible	For risk factors for thrombosis and metabolic disorders
Oral tablets	Convenience, variety of combinations	More pronounced effect on coagulation and hepatic metabolism	In the absence of risk factors and a good metabolic profile
Vaginal estrogens	Maximum effect on local symptoms, minimal systemic exposure	Systemic tides do not resolve	For dryness, dyspareunia, recurrent urinary tract infections
Levonorgestrel-containing intrauterine systems in regimens	Reliable protection of the endometrium, contraception	Installation required	If endometrial protection and contraception are required

Clinical guidelines and position statements support differences in routes of administration and indications. [14]

Non-hormonal prescription options

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) reduce the frequency and severity of hot flashes, with paroxetine, citalopram, and venlafaxine having the best evidence base. The choice of drug depends on the accompanying symptoms, tolerability, and potential interactions, for example, with tamoxifen, where venlafaxine is generally preferred. [15]

Gabapentin helps with hot flashes and sleep disturbances, especially if night sweats are prominent. Oxybutynin in extended-release forms has been shown to reduce hot flashes in randomized trials, but is more likely to cause dry mouth and constipation, so titration and tolerability monitoring are necessary. [16]

Clonidine can reduce hot flashes, but tolerability often limits its use, and some professional societies no longer recommend it routinely due to its unfavorable side effect profile. Prescribing decisions are made individually, based on assessment of blood pressure, daytime sleepiness, and dry mouth. [17]

Neurokinin antagonists are a new class of non-hormonal agents that act on thermoregulatory neurons in the hypothalamus. These drugs relieve hot flashes without affecting estrogen receptors, making them an option for patients with contraindications to hormones or after breast cancer treatment. [18]

Table 4. Working doses and notes for non-hormonal drugs

Class	Example of starting dose	When it is especially useful	Common adverse events
Selective serotonin reuptake inhibitors	Paroxetine 10 mg in the evening	For hot flashes and anxiety, without tamoxifen	Nausea, decreased libido
Serotonin and norepinephrine reuptake inhibitors	Venlafaxine 37.5-75 mg	For hot flashes in patients on tamoxifen	Nausea, sweating
Gabapentin	300 mg at night with titration	For night sweats and sleep disorders	Drowsiness, dizziness
Oxybutynin prolonged release	2.5-5 mg once or twice a day	For hot flashes and hyperhidrosis	Dry mouth, constipation
Neurokinin receptor antagonists	Fezolinetant 45 mg once daily	Non-hormonal targeted option	Monitoring liver enzymes

Dosages and restrictions are based on position papers and instructions. [19]

"New generation": neurokinin receptor antagonists

Fezolinetant is the first approved class 3 neurokinin receptor antagonist indicated for the reduction of moderate to severe hot flashes. The drug acts on a key neuronal circuit in thermoregulation and is not a hormone. The package insert emphasizes the need for monitoring liver enzymes at baseline and over time. In Europe, fezolinetant has received a positive regulatory opinion, and an assessment report has been published. [20]

Elinzanetant is a class 1 and class 3 neurokinin receptor antagonist approved in 2025 for the treatment of hot flashes in postmenopausal women. The drug is taken once daily and has been shown in clinical trials to reduce the frequency and severity of hot flashes and improve sleep. Regulators have published the approval and labeling with detailed precautions and monitoring recommendations. [21]

Neurokinin antagonists are particularly valuable in women with contraindications to estrogen, as well as in those who cannot tolerate or do not want hormones. When choosing between drugs, interaction profiles, safety monitoring requirements, and individual tolerability are considered. The emergence of two independent molecules confirms the maturity of this approach and expands access to non-hormonal targeted therapy. [22]

A practical approach is to consider neurokinin receptor antagonists as an early non-hormonal option for severe hot flashes, especially if the patient has a history of cancer, a history of thrombosis, or a high cardiovascular risk. The decision should be made by the physician in consultation with the patient, weighing the benefits against potential risks. [23]

Table 5. Comparison of fezolinetant and elizanetant

Parameter	Fezolinetant	Elinzanetant
Target	Neurokinin receptor class 3	Neurokinin receptors class 1 and class 3
Reception mode	45 mg once daily	60 mg once daily
Regulatory status	Approved in 2023 in the US and Europe	Approved in 2025 in the US, positive decision in Europe
Key security features	Monitoring liver enzymes	Safety monitoring recommendations according to the label
For whom is it especially appropriate?	Hormonal withdrawal, moderate to severe hot flashes	Likewise, there are potential sleep benefits as per research.

Based on materials from regulators and reviews of the class mechanism. [24]

Genitourinary syndrome of menopause: local therapy and systemic alternatives

For dryness, burning, itching, dyspareunia, and frequent urinary tract infections, vaginal estrogens in the form of creams, tablets, or rings are the first-line treatment. They restore mucosal nutrition and microbiota and reduce the risk of recurrent infections in postmenopausal women. This is documented in current guidelines for urologic infections. [25]

If estrogens are contraindicated or undesirable, a non-hormonal alternative is available: prasterone for intravaginal administration. It is converted into active sex steroids within the mucosal cells and improves trophism without significant systemic effects. Its efficacy and safety have been confirmed by regulators in the US and Europe. [26]

Ospemifene is a selective estrogen receptor modulator for systemic use, indicated for dyspareunia and vaginal dryness in postmenopausal women. It acts as an agonist in vaginal tissue and as an antagonist in the endometrium, providing clinical benefit with a manageable risk profile. Indications and dosage are reflected in the updated label. [27]

The choice between topical estrogens, prasterone, and ospemifene is determined by the severity of symptoms, preferences, comorbidities, and tolerability. In cases of frequent urinary tract infections, topical forms are indicated as a prophylactic measure; if dyspareunia is predominant, ospemifene can be considered. [28]

Table 6. Variants in genitourinary syndrome of menopause

Preparation	Form	Pros	Restrictions
Estradiol topical	Cream, tablet, ring	High efficiency, minimal systemic exposure	Does not treat systemic hot flashes
Prasterone	Vaginal ovulation	Improving trophism and secretion	Use daily at first, then maintenance
Ospemifene	Tablet for oral administration	Benefits for dyspareunia and dryness	Systemic effects, risk factor assessment is mandatory

Data from instructions and regulator reviews. [29]

Herbal Remedies and Dietary Supplements: What the Evidence Says

Soy and isoflavones have long been considered a mild alternative. Recent systematic reviews indicate mixed results and a lack of consistent, clinically significant effects on hot flashes and quality of life, with studies often raising concerns about conflicts of interest. Therefore, isoflavones cannot be considered a reliable treatment for hot flashes. [30]

Red clover has mixed evidence: some studies show a modest reduction in hot flashes, while others show no effect. The quality of evidence varies, and the standardization of extracts varies, making it difficult to use as a regular treatment. In the absence of consistent results, the remedy is not considered a first-line treatment. [31]

Clary sage has been studied in small randomized trials and reviews, where it has been shown to reduce the frequency and severity of hot flashes. However, the quality of the evidence and effect size are limited, so sage should only be considered as an adjunctive option in motivated patients without the expectation of a significant effect. [32]

Black cohosh has conflicting data on its efficacy, and there are reports of possible liver damage regarding safety, although the cause-and-effect relationship is debatable and depends on the quality of the product. A European evaluation emphasizes the inconsistency of effect and the need for caution with supplements of unknown composition. Only standardized preparations should be used, but they are not considered first-line treatment. [33]

Table 7. Herbal remedies: brief assessment

Means	Effect on tides	Quality of evidence	Safety Notes
Soy isoflavones	From no effect to little effect	Moderate to low	Potential interactions with thyroid therapy
Red clover	Mixed results	Low	Interactions with anticoagulants are theoretically possible
Sage	Moderate reduction in small studies	Low	Bitterness in the mouth may occur, interactions are rare
Black cohosh	Inconsistent	Low	Rare reports of hepatotoxicity, problem of extract quality

Summary of systematic reviews and regulatory assessments. [34]

Homeopathy for Menopause: An Honest Look at the Evidence

Systematic evaluations of the effectiveness of homeopathy for hot flashes and other menopausal symptoms show a lack of high-quality evidence to support a clinical benefit beyond placebo. Individual observational studies and small randomized trials do not change the overall conclusion of insufficient evidence. [35]

National and international health organizations do not recommend homeopathy for the treatment of any disease as a method of proven effectiveness. Using such remedies instead of proven approaches may delay effective therapy. If a patient wishes to discuss homeopathic remedies, it is important to be honest about the weak evidence base. [36]

Even "harmless" products can interact or contain active ingredients in unpredictable concentrations. Therefore, any choice of alternative remedies should be discussed with a doctor to avoid risks and avoid missing out on more effective options. [37]

Bottom line: Homeopathy is not a recommended treatment for menopausal symptoms and should not be considered a replacement for hormonal or proven non-hormonal therapy.[38]

Table 8. If the patient has special conditions: how to narrow the choice

Situation	What to choose more often	What to avoid
Post-breast cancer	Non-hormonal options and neurokinin antagonists, local agents for genitourinary syndrome of menopause in consultation with an oncologist	Systemic estrogens without the oncologist's approval
Risk of thrombosis, obesity, high blood pressure	Low-dose transdermal estrogens unless contraindicated; or non-hormonal regimens	Oral high-dose estrogens
Vaginal symptoms predominate	Vaginal estrogens, prasterone, ospemifene	Expectation of effect from systemic non-hormonal drugs only on local symptoms
On tamoxifen	Venlafaxine among antidepressants	Paroxetine and fluoxetine due to effects on tamoxifen metabolism

Consolidated guidelines for the guidelines and positions of societies. [39]

Practical steps: how to start and monitor therapy

For vasomotor symptoms in women in the "right window," consider a low-dose transdermal regimen with mandatory endometrial protection while maintaining the uterus. When weaning off hormones, start with a low-dose selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor with titration; if the effect is insufficient or tolerability limits treatment, consider neurokinin receptor antagonists. [40]

When urogenital symptoms predominate, local estrogens or prasterone are preferred. For recurrent urinary tract infections in postmenopausal women, vaginal estrogens are prescribed prophylactically. In cases where a systemic alternative for dyspareunia is needed, ospemifene may be considered, taking risk factors into account. [41]

Schedule a follow-up visit or contact after 6-12 weeks to assess hot flashes, sleep, and vaginal symptoms, as well as tolerability. When using fezolinetant and elizanetant, monitor liver enzymes as recommended by the manufacturer. Further dose adjustments or strategy changes may be necessary if efficacy is insufficient. [42]

Do not rely on herbal and homeopathic remedies as the mainstay of treatment for severe symptoms. They should only be considered as adjuncts with informed consent and an understanding of the limitations, with safety and evidence-based approaches prioritized. [43]

Table 9. Frequently asked questions and short answers

Question	Short answer
How long does it take to see the effect?	Hormonal therapy and neurokinin antagonists - noticeable effect usually within 2-4 weeks
How long does it take to treat?	Individually; review every 6-12 months; long-term use is possible with local therapy
Is it possible to combine approaches?	Yes, for example, local estrogens for genitourinary menopause syndrome against the background of non-hormonal systemic therapy
What about liver safety in the "new generation"?	Follow the instructions: baseline and follow-up enzyme monitoring according to the schedule

Based on the instructions and positions of societies. [44]

Main

The best medications for menopause are those that match your predominant symptoms, medical indications, and personal preferences. Hormonal therapy remains the most effective for hot flashes and urogenital manifestations. If contraindicated, proven non-hormonal options are available, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin, oxybutynin, and a new class of drugs called neurokinin receptor antagonists. For genitourinary syndrome of menopause, topical estrogens are the first choice, while prasterone and ospemifene offer a wider range of options. Herbal remedies have a weak and inconsistent evidence base, and homeopathy is not recommended. The choice and monitoring of therapy is always based on a joint decision and regular reassessment. [45]