_ RCGP Learning

Written by Dr Toni Hazell

Menopause and hormone replacement therapy (HRT) has become a hot topic in the last few years, with celebrity endorsement for various treatments (some evidence based, others not so much!) and a greater understanding of the multiple ways in which the menopause and perimenopause can present. As well as hot flushes and night sweats (vasomotor symptoms/VMS), symptoms can include insomnia, reduction in energy levels, cognitive dysfunction or ‘brain fog’, low mood, headaches and genitourinary symptoms¹. 

Many women will benefit from the use of HRT, but it is unsuitable for some (for example due to a history of breast cancer), and others prefer not to use it. Alternative options may be bought over the counter or prescribed and as of March 2026 there is one more non-HRT possibility available on the NHS, with the NICE approval of fezolinetant. 

Women who would rather use a herbal option will find plenty to choose from on their local high street or online - isoflavones, soya products, black cohosh, St. John’s wort and red clover are all marketed to treat the menopause. There is some evidence for black cohosh (though use is often limited by adverse effects including constipation and weight gain); there are only poor-quality studies available for other herbal options. Many herbal options have natural oestrogenic activity, and the British Menopause Society (BMS) therefore cautions against their use in women who have had breast cancer. This is not the case for St. John’s wort, which is mentioned in the NICE guidance on menopause as something that may relieve VMS in women who have had breast cancer³. As an enzyme inducer, it does however have many interactions with other drugs that we prescribe, including some such as warfarin for which change in drug levels can have serious implications. Most herbal preparations are not regulated in the same way as prescribed medication, meaning that the amount of active ingredient can vary between products. Women who wish to use herbal treatments for their menopause could be usefully signposted to information from the Women’s Health Concern⁴ and advised to look for preparations which carry the Traditional Herbal Registration (THR) mark⁵. This indicates that the product has been registered with the Medicines and Healthcare Regulatory Agency (MHRA) and meets MHRA standards for quality and safety. A list of preparations with a THR mark is available on the MHRA website⁶ and includes several products used for symptoms of the menopause. 

Menopause-specific cognitive behavioural therapy (CBT) is another hormone-free option, although access on the NHS may vary. It can be delivered face to face or remotely and to an individual or in group sessions³ and has evidence for reduction in VMS severity, stress and insomnia, as well as being particularly useful for those women who have diagnosed anxiety or depression related to their menopause. 

Prescribable options include selective serotonin re-uptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), clonidine, drugs which affect the gamma-amino butyric acid (GABA) receptors, fezolinetant and oxybutynin. More information on these is given in the table below^2,3,7,8. We should also remember that all women (whether or not they take HRT) can benefit from lifestyle advice in the (peri)menopause – weight-bearing exercise will reduce osteoporosis risk, exercise in general can improve mood and there is some evidence for the benefits of a Mediterranean diet to improve VMS⁹. 

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References:

1. BMS. What is the menopause? January 2026. [Accessed May 2026].
2. BMS. Non-hormonal-based treatments for menopausal symptoms. November 2025. [Accessed May 2026].
3. NICE. NG23. Menopause: identification and management. April 2026. [Accessed May 2026].
4. WHC. Complementary and alternative therapies. November 2025. [Accessed May 2026].
5. MHRA. The Traditional Herbal Registration (THR) Certification Mark: Guidance for Business. [Accessed May 2026].
6. MHRA. Herbal medicines granted a traditional herbal registration (THR). October 2025. [Accessed May 2026].
7. NICE. TA1143. Fezolinetant for treating moderate to severe vasomotor symptoms associated with menopause. March 2026. [Accessed May 2026].
8. MHRA. Fezolinetant▼(Veoza): risk of liver injury; new recommendations to minimise risk. April 2025. [Accessed May 2026].
9. Kennard A, Lindo FM, Ring M et al. Lifestyle Medicine and Vasomotor Symptoms: An Analytic Review. Am J Lifestyle Med. 2024 Feb 27:15598276241232359.