There are a number of non hormonal options shown to be effective by the British Menopause Society for the very small minority of women for whom systemic HRT is not recommended first line.
SSRI's like Paroxetine, Fluoxetine and Citalopram and SNRI's like Venlafaxine are recognised for their positive effects on depression and anxiety. They also can improve hot flushes in some women. However an unfortunate side effect of this group of medicines is a loss of libido.
Paroxetine 10mg seems to be the most effective and is now licensed in the USA for menopausal hot flushes. Others that might be helpful are citalopram and fluoxetine. In breast cancer survivors taking Tamoxifen, Venlafaxine 75mg can reduce hot flushes and shows some improvement in fatigue, mental health and sleep disturbance. Unfortunately SSRI's and SNRI's are associated with side effects such as a dry mouth, nausea, constipation, appetite problems and a reduction in libido, a very unwanted side effect for many menopausal women. SSRI's should not be offered for vasomotor symptoms unless HRT cannot be given. Women on Tamoxifen should not take fluoxetine or paroxetine as it will make tamoxifen ineffective.
Gabapentin can improve flushes and sweats but needs high doses. Side effects include sleepiness, dizziness, palpitations, weight gain and dry mouth. The dose of Gabapentin needs to be changed gradually according to response and side effects. Some women benefit from this medication as it improves sleep, others find it very sedating, especially during the day.
Clonidine is the only non hormonal drug licensed for hot flushes in the UK. Effectiveness studies are contradictory, although some women show significant benefits. It must be stopped gradually as sudden withdrawal can cause rebound hypertension and as it is an anti-hypertensive medication it may not be suitable for patients with low blood pressure.