Non-Hormonal and Plant-Based Menopause Options: What the Evidence Says

Not every woman wants HRT. Some can't take it. Some have been told they can't, which isn't always the same thing. And some just want to start with something gentler and see how far it gets them.

So they end up in the supplement aisle, or on a website, looking at a box with a flower on it that promises "menopause support". Black cohosh, red clover, sage, soy, magnesium, sometimes all 5 in one capsule. It's hard to know what helps, what does very little, and what can actually cause problems with medicines you already take.

So here's what the evidence says about the non-hormonal options, from the ones with the best research behind them to the ones that are mostly marketing. And who needs to ask before starting anything at all.

What counts as "non-hormonal"?

It covers 4 quite different things: talking therapies like CBT (cognitive behavioural therapy), changes to how you live, prescription medicines that aren't hormones, and plant-based products and supplements. They don't work in the same way and they don't have the same amount of evidence behind them.

It also helps to be clear about what each one is trying to help. Hot flushes and night sweats, sleep, mood, vaginal dryness and bone health are separate problems. Something that helps one might do nothing for the others. A lot of disappointment comes from expecting a sleep supplement to stop hot flushes.

CBT: the one with the strongest evidence

CBT for menopause symptoms is recommended in national guidance, either on its own or alongside other treatment. It's a short course, usually a few weeks, with a therapist, in a group or through a self-help programme.

What it does well is reduce how much hot flushes bother you and get in the way of your day, and help with sleep and low mood. What it doesn't reliably do is reduce how many flushes you have. That matters. Many women find that once a flush stops worrying them, they can carry on working, sleeping or talking through it.

CBT for insomnia (CBT-I) is a separate version, aimed only at sleep, and it's the recommended first treatment for long-term insomnia, ahead of sleeping tablets. It takes 4 to 6 weeks to build, and the effect tends to last after you stop. In England you can refer yourself to NHS Talking Therapies without going through anyone else, and there are good digital CBT-I programmes too.

The everyday changes, and where they stop

Some changes really do help. Cutting back on alcohol is a big one: it can make flushes worse, and it breaks up the second half of the night. Caffeine late in the day, spicy food and stress are common triggers too. Layers you can take off quickly, a cooler bedroom (around 18°C) and 2 thin covers instead of 1 heavy duvet all help with night sweats. And for women carrying extra weight, losing some weight may help flushes.

Exercise is a slightly different story. Trials haven't shown that it reliably reduces hot flushes. But it's one of the best things you can do for sleep, mood, muscle, bone and your heart, so it belongs in every plan, just not as the flush treatment.

And this part matters: if you're having 10 flushes a day and waking soaked every night, cotton sheets aren't going to fix that. If the changes above haven't helped enough after a few weeks, then it's time to look at the other options below.

Non-hormonal prescription options

A lot of women don't know these exist. There are prescription medicines for hot flushes that aren't hormones. One group is a newer type of tablet called neurokinin receptor blockers. They aren't hormones or antidepressants, and they work on the brain's temperature control rather than replacing oestrogen. A liver blood test is needed before starting, and one of them needs repeat liver tests over the first months. Others are medicines first used for other conditions, given at low doses, which can reduce flushes for some women.

They're a prescribing decision, they don't suit everyone, and some of them interact with other medicines, including some breast cancer treatments. But for women who can't or don't want to use HRT, including many women after breast cancer (with their breast team involved), they mean "you can't have HRT" is not the end of the conversation.

If you want to see your options side by side, they're all in my free Your Options guide, and the Symptom Tracker helps you see whether anything you try is actually making a difference.

Plant-based options: what the research shows

Soy and isoflavones. Isoflavones are plant compounds with a weak oestrogen-like effect. Soy as food, like tofu, edamame, soya milk and tempeh, is a perfectly good thing to eat, and there's some evidence that it may help flushes for some women when you eat a fair amount of it regularly. Isoflavone supplements are less clear: products vary a lot, many don't match what was used in the trials, and the results are mixed. If it helps, it tends to be modest and to take a few weeks.

Red clover. Another source of isoflavones. Trials are mixed, and where there's an effect it's small. It turns up in a lot of combination products.

Black cohosh. Probably the best known, and the trial results are inconsistent. UK packs carry a warning about rare but serious liver reactions. Stop it and get advice straight away if you notice yellowing of your skin or eyes, dark urine, unusual tiredness or pain under your right ribs. It isn't for anyone with liver disease.

Sage. Used for sweating for a long time, but the studies are small and not good enough to say it works. A cup of sage tea is food. Sage oil isn't recommended to take by mouth at all, and concentrated extracts aren't suitable if you have epilepsy, because they contain thujone, which can trigger seizures.

St John's wort. This is the one I'd be most careful with. It's sold for low mood without a prescription, and it interacts with a lot of medicines. It can make hormonal contraception less effective (so there's a real risk of pregnancy), and it can reduce how well HRT, blood thinners and some breast cancer treatments work. With some antidepressants and migraine medicines it can cause a dangerous reaction. Please don't take it alongside any of those without asking first.

The "menopause blends". Capsules with 6 or 8 ingredients usually contain small amounts of each, often including black cohosh or red clover. So you take on the cautions without a dose anyone has tested, and if it does help, you can't tell which part did it.

Magnesium

Magnesium is often suggested for sleep and stress, but the research in menopausal women is thin, and it isn't a proven sleep treatment. It's safe at sensible doses for most people. If your kidneys don't work normally, ask first. Leave at least 4 hours between magnesium and thyroid medicine, and if you're given an antibiotic, check how far apart to take them, because it differs between antibiotics. I wrote about which type of magnesium suits which job here.

If you'd like a magnesium supplement, the one I stock is Zooki Liposomal Magnesium. Magnesium contributes to the normal function of the nervous system and muscles, and to the reduction of tiredness and fatigue.

And before any supplement for tiredness, it needs checking whether something is actually low. Low iron, B12, vitamin D or an underactive thyroid can all feel like menopause, and they're all correctable. The clinic also has supplements and plant-based options through the supplier we work with, chosen for you once we know what's going on.

Who should ask before starting anything

Please ask first, before any herbal or plant-based product, if any of these apply to you:

• You've had breast cancer, or another hormone-sensitive cancer, or you're on treatment to lower your cancer risk. Isoflavones, red clover and black cohosh need your breast team's agreement.
• You take a blood thinner.
• You take an antidepressant, migraine medicine, epilepsy medicine or thyroid medicine.
• You rely on hormonal contraception.
• You're on HRT, because some herbal products change how well it works.
• You have liver or kidney disease.
• You're having surgery soon.

Bring the actual box with you, or a photo of the ingredients list. "A menopause supplement" isn't enough to check it.

If you'd like help with it

The clinic's Menopause service starts on Sunday 18 October, World Menopause Day, for perimenopause, menopause and early menopause, online, by video or voice call, anywhere in the UK. We go through your history, your symptoms, your cycle, your family history and everything you've already tried, including every supplement. Blood tests are arranged where they'll change the plan, and with around 40 clinics across the UK for the blood draw, most women can have it done near home. Then we look at the results together and talk through all your options, hormonal and non-hormonal, so you choose knowing every option. If a prescription is the right option for you, it goes through the doctor and pharmacy we work with, and I write to your GP where it's needed.

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Every Sunday morning I send out my newsletter, Beyond Prescriptions, with 1 women's health lesson and what to do with it. You can sign up here.

Debora Tentis, Women's Health Pharmacist.