Managing menopause symptoms involves a personalised approach that considers your medical history, the severity of your symptoms, and your personal preferences. The primary clinical treatment is Hormone Replacement Therapy (HRT), which is highly effective for most symptoms. For those who cannot or choose not to take hormones, there are several licensed and off label non hormonal medications, including new targeted brain therapies. Additionally, recent clinical updates have highlighted the significant role of talking therapies and targeted lifestyle adjustments in managing the transition.
What We Will Cover in This Article
- Hormone Replacement Therapy (HRT) types and delivery methods
- New non hormonal treatments for hot flushes (NK3 antagonists)
- 2024 NICE recommendations for Cognitive Behavioural Therapy (CBT)
- Localised treatments for vaginal and urinary symptoms
- Off label medical options for vasomotor symptoms
- The role of testosterone in managing low libido
Hormone Replacement Therapy (HRT)
HRT is the most effective treatment for managing the symptoms caused by the decline of oestrogen and progesterone. It works by replacing these hormones to stable levels, which protects bone density and heart health while relieving symptoms like hot flushes and mood swings.
HRT is categorised into oestrogen only treatment (for those who have had a hysterectomy) and combined HRT (for those with a womb). Combined HRT uses progestogen to protect the womb lining from thickening. Modern body identical HRT, such as 17\beta-oestradiol and micronised progesterone, is derived from plants and is chemically identical to human hormones. This form is often preferred as it carries a lower risk of blood clots and breast cancer compared to older synthetic versions.
- Delivery Methods: HRT can be taken as tablets, skin patches, gels, or sprays. Transdermal methods (patches and gels) are absorbed through the skin and do not increase the risk of blood clots.
- Cyclical vs Continuous: Perimenopausal women usually start with cyclical HRT to maintain a monthly bleed. Postmenopausal women typically move to continuous combined HRT, which is bleed free.
- Tibolone: A synthetic hormone that acts like oestrogen, progesterone, and testosterone. It is usually prescribed only for women who are fully postmenopausal.
Non Hormonal Medical Treatments
For women who have a history of certain cancers or who prefer to avoid hormones, there are several medical alternatives. Some of these are specifically licensed for menopause, while others are used off label by specialists.
A significant advancement in non hormonal treatment is the arrival of neurokinin 3 (NK3) receptor antagonists like fezolinetant (brand name Veoza). These drugs target the thermoregulatory centre in the brain to block hot flushes directly without using oestrogen. While currently available via private prescription in the UK, they are undergoing NICE appraisal for NHS use. Note that as of 2025, the MHRA recommends liver function monitoring for patients starting fezolinetant.
- Clonidine: A licensed non hormonal medication originally for blood pressure that can reduce the frequency of hot flushes.
- Antidepressants: Low doses of SSRIs or SNRIs (such as Venlafaxine) are often used off label to manage hot flushes and anxiety.
- Gabapentin and Pregabalin: These medications, typically for nerve pain, can be effective at reducing night sweats for some women.
- Oxybutynin: Usually for overactive bladder, this can also help control vasomotor symptoms when used off label.
Talking Therapies and Mental Health
The National Institute for Health and Care Excellence (NICE) updated its menopause guidelines in late 2024 to place a stronger emphasis on talking therapies.
Menopause specific Cognitive Behavioural Therapy (CBT) is now recommended as a first line option for managing hot flushes, night sweats, and sleep problems. CBT helps by changing how the brain perceives and reacts to symptoms, which reduces the distress associated with flushes. It can be used as a standalone treatment or alongside HRT to manage the psychological impacts of the transition.
- Anxiety and Low Mood: CBT is highly effective for the emotional changes triggered by hormonal fluctuations.
- Sleep Hygiene: Incorporating mindfulness and relaxation techniques can significantly improve sleep quality.
Localised and Genitourinary Treatments
Symptoms that affect the vagina and bladder, known as genitourinary syndrome of menopause (GSM), often require targeted treatment even if someone is already taking systemic HRT.
- Vaginal Oestrogen: Available as low dose pessaries, creams, or rings. These work locally on the tissues and carry almost no risk to the rest of the body.
- Vaginal Moisturisers: Non hormonal options that provide long term relief from dryness.
- Lubricants: Used during sexual activity to prevent discomfort and micro tears.
- Pelvic Floor Therapy: Exercises and specialist physiotherapy can help with urinary urgency and stress incontinence.
Testosterone for Libido
While not a standard part of HRT for everyone, testosterone can be a vital treatment for women experiencing persistent low libido (HSDD) after oestrogen levels have been stabilised.
- Eligibility: It is usually only considered if HRT alone has not restored sexual desire.
- Formulation: In the UK, it is often prescribed as a cream or gel.
- Monitoring: Blood tests are required before and during treatment to ensure levels remain within the female physiological range to avoid side effects like acne or excess hair growth.
To Summarise
There is no one size fits all treatment for menopause. HRT remains the gold standard for most, especially with the use of body identical hormones. However, the 2024 and 2025 clinical updates have expanded options for non hormonal care, particularly with the introduction of NK3 antagonists and the strong endorsement of menopause specific CBT. Choosing the right treatment involves a balance of symptom relief, risk assessment, and lifestyle goals.
If you experience sudden, severe chest pain, shortness of breath, or a sudden loss of coordination, call 999 immediately.
Can I take HRT if I have a history of breast cancer?
Standard HRT is usually not recommended after breast cancer, but non hormonal options like CBT, venlafaxine, or fezolinetant (depending on specific history) are effective alternatives.
How long does it take for treatments to work?
HRT often improves symptoms within a few weeks, though it can take up to three months to feel the full benefit. Non hormonal drugs like fezolinetant can work within a few days.
Is bioidentical HRT better than standard HRT?
Body identical HRT prescribed on the NHS (like Oestrogel and Utrogestan) is safe and regulated. Compounded bioidentical HRT from private clinics is not regulated and is not recommended by the British Menopause Society.
Can I stop HRT whenever I want?
Yes, but it is usually advised to taper the dose gradually with your doctor to prevent a sudden return of symptoms.
Does fezolinetant treat all menopause symptoms?
No, it specifically targets hot flushes and night sweats. It does not help with bone health, vaginal dryness, or mood in the same way that HRT does.
Are herbal remedies effective?
Some women find relief with Black Cohosh or St John’s Wort, but these can interact with other medications. They are generally less effective than clinical treatments in trials.
Authority Snapshot
This article was written by the MyPatientAdvice clinical team and reviewed by Dr. Stefan Petrov, a UK trained physician with an MBBS and postgraduate certifications including Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and the UK Medical Licensing Assessment (PLAB 1 & 2). Dr. Petrov has extensive experience in general medicine, surgery, and emergency care. He has worked in both hospital wards and intensive care units and contributes to medical education by creating patient focused health content. This information follows current clinical protocols (NICE NG23 updated 2024/2025) to ensure that readers receive accurate guidance on menopausal management.
