You're in a meeting, or trying to sleep, or just standing in the grocery store — and then a wave of heat moves through your chest and face with no warning. Your skin flushes. You're soaked in seconds. And then it's over. For the women experiencing ten of these a day, the "dress in layers and carry a fan" advice can start to feel like a personal insult.
Hot flashes (also called vasomotor symptoms) are the most widely recognized sign of menopause, but the conversation about treating them has for years defaulted to two options: HRT or just endure. That's changed significantly in recent years, and most women haven't heard about what's now available.
Why do hot flashes happen at all?
The brain's thermoregulatory zone — the range of temperatures it's comfortable with — narrows dramatically when estrogen drops. A small rise in core temperature that the body previously tolerated silently now triggers a heat-dissipation response: blood vessels dilate, sweat glands activate, and you experience the flash.
The mechanism involves the hypothalamus and a specific neurotransmitter pathway: neurokinin B (NKB) and its receptor NK3. In the absence of estrogen, NKB neurons in the hypothalamus become hyperactive. This is now understood well enough that a drug was developed specifically to target it.
The SKYLIGHT 1 and SKYLIGHT 2 trials (2022–2023) tested fezolinetant — an NK3 receptor antagonist — in women with moderate-to-severe vasomotor symptoms. Across both trials, fezolinetant produced a 55–64% reduction in hot flash frequency versus placebo at 12 weeks. In women with the most severe baseline symptoms, reductions were above 70%. The FDA approved fezolinetant (sold as Veozah) in May 2023 — the first mechanism-specific non-hormonal treatment for hot flashes ever approved.
The full treatment menu
This is genuinely complicated territory, because the right treatment depends on how severe your symptoms are, what else is going on with your health, and how you personally feel about hormones. Here's the honest hierarchy.
Systemic HRT (estrogen alone or combined): The most effective treatment for vasomotor symptoms, reducing frequency by 75–90% in most trials. The FDA's 2026 removal of the black box warning from several HRT products reflects updated evidence that the cardiovascular and cancer risks were overstated in the original WHI interpretation for healthy women under 60. If you're under 60, within ten years of menopause, and without contraindications, HRT is worth a serious conversation with your doctor.
Fezolinetant (Veozah): The new option most women don't know exists. It directly targets the NK3 pathway driving the thermoregulatory problem. Works for women who can't take hormones, choose not to, or are in active cancer treatment. Requires a prescription. Not available for women with liver disease. Generally well tolerated.
SSRIs and SNRIs: Paroxetine at low dose is the only SSRI formally FDA-approved for hot flashes (sold as Brisdelle), but other SSRIs and SNRIs — particularly venlafaxine and desvenlafaxine — have strong trial evidence. Research shows these reduce hot flash frequency by around 50–60%. They also help with mood changes in perimenopause, which is a meaningful secondary benefit for many women.
Gabapentin: Off-label but well-evidenced, particularly for night sweats. Often used when sleep disruption is the primary complaint. Can cause drowsiness, which makes it more appropriate for evening use.
Cognitive Behavioral Therapy (CBT): A 2023 Cochrane review confirmed that CBT for menopausal symptoms reduces hot flash bother and impact by 40–50%. It doesn't reduce the number of flashes — but it changes how much they affect functioning and quality of life. For women who can access it, this is a meaningful, evidence-based option that complements other treatments.
Hypnotherapy: A handful of small RCTs show reduction in hot flash frequency. The evidence is weaker than CBT but notable. Likely works via relaxation and altered temperature perception. Worth trying if other options aren't accessible.
What to ask at your appointment
- "How many hot flashes per day would qualify as moderate or severe?" — getting your own symptoms categorized helps drive appropriate treatment
- "I'd like to know if I'm a candidate for fezolinetant" — many doctors are still unaware of it
- "What are my options if I can't take or don't want hormones?" — this should open a conversation about SSRIs, gabapentin, and fezolinetant
- "Is HRT actually off the table for me, given what the evidence now shows?" — the risk picture has changed significantly since 2002
A note from our medical advisors
Most doctors don't mention fezolinetant because it's new and many haven't incorporated it into their practice yet. That's genuinely worth knowing. Bring it up by name. Similarly, if you've been told HRT "isn't for you" without a detailed risk conversation, it's worth getting a second opinion from a menopause specialist — the NAMS practitioner finder is a useful starting point. You do not have to simply endure moderate-to-severe symptoms in 2026.
References
- Johnson KA, et al. Efficacy and Safety of Fezolinetant in Moderate-to-Severe Vasomotor Symptoms (SKYLIGHT 1). J Clin Endocrinol Metab. 2023;108(8):1981–1997. PubMed 36920788
- Lindh-Åstrand L, et al. Cognitive behavioral therapy for menopausal symptoms. Cochrane Database Syst Rev. 2023. Cochrane 2023
- NAMS 2023 Nonhormone Therapy Position Statement Advisory Panel. The 2023 nonhormone therapy position statement of The Menopause Society. Menopause. 2023;30(6):573–590. PubMed 37257146
- Avis NE, et al. Duration of Menopausal Vasomotor Symptoms Over the Menopause Transition. JAMA Intern Med. 2015;175(4):531–539. PubMed 25686030