Natural and lifestyle alternatives to HRT

The non-hormone options with the strongest evidence for hot flashes are not the ones most often sold as "natural." Cognitive behavioral therapy (CBT), clinical hypnosis and a handful of prescription non-hormone medicines have trial support, while The Menopause Society does not recommend over-the-counter supplements or herbs for hot flashes.¹ Hormone therapy remains the most effective treatment for hot flashes and night sweats, but some women choose not to use it and some cannot.¹

The gap between what is marketed and what has been tested is the real story here. The wellness aisle and the research literature point in different directions. The approaches with the best trial evidence tend to be talk-based or prescription. The approaches with the loudest marketing, such as herbs, adaptogens and medicinal mushrooms, tend to have fewer, smaller trials, and often not in women going through perimenopause. This guide goes through the natural options women ask about most and says plainly what each one has behind it.

Which non-hormone options have the best evidence for hot flashes?

The Menopause Society's 2023 position statement reviewed the evidence for hot flashes and night sweats, which doctors call vasomotor symptoms. It gave its strongest recommendation (Level I) to CBT, clinical hypnosis, SSRIs and SNRIs (medicines also used for mood), gabapentin and fezolinetant. Oxybutynin was also recommended.¹

Two of these involve no medicine at all. The statement found that CBT can ease how bothersome hot flashes are, and that clinical hypnosis has been shown to reduce how often they happen and how severe they are.¹ The National Center for Complementary and Integrative Health (NCCIH) notes that hypnosis is generally safe when practiced by trained, licensed providers.³

Fezolinetant is a prescription medicine that blocks a brain receptor called neurokinin B receptor 3. It is approved by the FDA for hot flashes and night sweats. In the trials the statement reviewed, raised liver enzymes were rare and resolved.¹ Whether any prescription option suits you is a conversation for your doctor. So is the bigger question of how these compare with hormone therapy, which our HRT guide covers.

What does not have good evidence for hot flashes?

The same statement did not recommend exercise, yoga, mindfulness-based interventions, relaxation, cooling techniques, avoiding triggers, acupuncture, soy foods and soy extracts, or over-the-counter supplements and herbs for hot flashes. The evidence was weak, mixed or negative.¹

That wording matters. "Not recommended for hot flashes" is not the same as "not worth doing." The statement itself notes that exercise and yoga have other health benefits.¹ NCCIH reports that in one funded study mindfulness meditation reduced how bothersome hot flashes were without changing their intensity, and that tai chi and meditation-based programs may help with sleep, mood and stress.³,⁴ Treat these as ways to feel better in your day, not as treatments for hot flashes.

Do black cohosh, soy and red clover work?

Black cohosh is the most studied herb for menopause, and the evidence is conflicting. The Menopause Society found insufficient evidence to support it for hot flashes, noting that a 2012 Cochrane review found no significant difference from placebo.¹ NCCIH points to a 2023 review of 22 studies that found black cohosh products potentially beneficial for overall menopause symptoms and hot flashes, but not for anxiety or depression.⁵

The safety question is separate. Rare cases of liver injury have been reported with black cohosh products. NCCIH says it is uncertain whether black cohosh caused them, and that some products have contained the wrong herb. If you take it and notice dark urine or unusual fatigue, check in with a health care provider.⁵

For soy and red clover supplements, a Cochrane review of 43 trials found no conclusive evidence that phytoestrogen supplements reduce hot flashes. Placebo pills reduced hot flashes by between 1% and 59% in most trials, which shows how strongly expectation can shape this symptom. A few trials of extracts high in a soy compound called genistein did find consistent reductions, and the authors called for more research. No harm to the uterine lining or other adverse effects were seen with use up to two years.⁶ Soy as food is a different question, covered in our perimenopause diet guide.

Vitex (also called agnus castus) is often listed alongside these. We did not find evidence in the authoritative reviews we checked that it helps with perimenopausal symptoms, so we cannot say that it does.

Do adaptogens work in perimenopause?

"Adaptogen" is a term used for herbs and roots traditionally said to help the body cope with stress. It is not a medical classification, and the stress-related claims made for them often go further than the trials do. A frequent example is that they "balance" or "regulate" cortisol. Some trials have measured a small fall in cortisol, but that is not the same as restoring balance, and none of the evidence below was gathered specifically in perimenopause. For background on the hormone itself, see cortisol.

Ashwagandha. NCCIH says some preparations may be effective for insomnia and stress, while the evidence on anxiety is unclear.⁷ A 2024 meta-analysis of nine randomized trials with 558 participants found lower perceived stress, anxiety scores and blood cortisol than placebo, with mild to moderate side effects in four studies and little known about long-term safety.⁸ NCCIH notes that it may be safe up to three months, that rare cases of liver injury have been linked to it, and that it is not recommended for people with autoimmune or thyroid disorders. It may interact with thyroid hormone, diabetes, blood pressure and sedative medicines, and it should be avoided in pregnancy.⁷

Maca. A systematic review found four small trials in perimenopausal and postmenopausal women that all reported favorable effects on symptom scores. The authors still judged the evidence limited, because the trials were few and small, and said safety has not been established.⁹

Ginseng. NCCIH describes the research as limited, with possible small benefits for fatigue, and says insomnia is its most common side effect. It may affect blood clotting and blood sugar.¹⁰

Licorice root. NCCIH says there is not enough high-quality evidence to support it for any health condition. Its compound glycyrrhizin can cause serious effects such as irregular heartbeat, especially with large or long-term use, and even small amounts have been linked to severe effects in people with high blood pressure. Interactions with corticosteroids have been reported.¹¹ One correction: "adrenal fatigue" is sometimes used to market licorice and other adaptogens, and we found no authoritative source supporting it as a medical diagnosis, so we have left it out.

Rhodiola, holy basil and schisandra. The Menopause Society's review does not support herbs and supplements for hot flashes, and we did not find menopause-specific trial evidence for these three in the reviews we checked.¹ That is not proof they do nothing. It means nobody can tell you with confidence that they help.

Do medicinal mushrooms help?

Reishi, lion's mane, cordyceps, maitake and turkey tail are the mushrooms most often marketed for midlife. A 2021 review of the human trials found a field with "numerous shortcomings and gaps." Reishi results were mixed. Lion's mane trials were small and short, mostly in people with mild cognitive impairment. Maitake and turkey tail were studied mostly in cancer patients, often in very small groups, and cordyceps had little separate human evidence.¹² Claims about nerve growth factor, cellular energy or immune activity come largely from lab work, which does not tell you what a capsule does for brain fog or fatigue in perimenopause. We found no trials in perimenopausal women among the sources we reviewed.

How do you use supplements more safely?

The reasons matter more than the rules, so here they are.

• Supplements are not reviewed for safety or effectiveness before they are sold. The FDA is not authorized to review them first and can act only after a problem product reaches the market. NCCIH also warns that what is on the label may not be what is in the product.²

• "Natural" does not always mean safe. Herbs act on the body, which is why several above can interact with medicines, including thyroid, diabetes, blood pressure and blood-clotting treatments. NCCIH gives St. John's wort, which can make many medicines less effective, as the standard example.² See thyroid if you take thyroid medication.

• Tell your doctor and pharmacist about everything you take, including before surgery.²

• Pregnancy is still possible in perimenopause. Ashwagandha should be avoided in pregnancy and large amounts of licorice are unsafe.⁷,¹¹ Our guide to pregnancy and contraception explains why.

What else is worth trying, and when should you see a doctor?

If your goal is to feel better rather than to buy a product, the evidence points to CBT, clinical hypnosis, and approaches that help sleep and stress, such as tai chi or meditation. Regular movement has health benefits beyond hot flashes.¹,³,⁴ If sleep is the main problem, start with our sleep and stress guide.

See a healthcare provider if symptoms are affecting your quality of life or your mental health, if natural approaches are not giving enough relief, or if you are not sure whether what you feel is hormone-related. Mention any supplement you take, and stop black cohosh and call promptly if you notice signs of liver trouble such as dark urine and fatigue.⁵

Read next: HRT and hormone testing in perimenopause, Perimenopause diet and gut health