For most women, hormone replacement therapy (HRT) is the most effective treatment for hot flashes and night sweats — and it also helps protect bone and ease vaginal dryness. Fezolinetant (brand name Veozah) is a newer non-hormonal option that can meaningfully reduce hot flashes, especially when hormones aren't suitable, but it treats only vasomotor symptoms and requires liver-blood-test monitoring. Here's how the two compare so you can have a more informed conversation with your clinician.
How each one works
HRT (menopausal hormone therapy)
HRT replaces some of the estrogen your ovaries make less of during menopause. Estrogen helps steady the brain's temperature-control center, which is what settles hot flashes and night sweats. If you still have a uterus, a progestogen is added to protect the uterine lining. Estrogen can be delivered as a pill, patch, gel, or spray. For the bigger picture, see our overview of hormone replacement therapy.
Fezolinetant (Veozah)
Fezolinetant is the first neurokinin-3 (NK3) receptor antagonist approved for menopausal hot flashes. Instead of adding hormones, it blocks a brain signal (neurokinin B) that becomes overactive as estrogen falls, helping to reset the same temperature-control center from a different angle. Because it contains no hormones, it is often considered when estrogen isn't an option. See our deep dive on Veozah (fezolinetant) and other non-hormonal menopause treatments.
| Treatment | How it works | Best suited for | Key cautions or monitoring | Other menopause symptoms addressed |
|---|---|---|---|---|
| HRT | Replaces estrogen (plus a progestogen if you have a uterus) to steady the brain's temperature control. | Many women in early menopause without contraindications who want the most effective hot-flash relief. | Small increases in blood-clot, stroke, and (with combined, longer-term use) breast-cancer risk; not for some cancer or clotting histories. Individualized review. | Vaginal dryness, night sweats, and bone-loss protection; may also help sleep and mood. |
| Fezolinetant (Veozah) | Non-hormonal NK3-receptor blocker that calms an overactive brain signal driving hot flashes. | Women who can't or prefer not to use estrogen, or who want a hormone-free option. | Liver blood tests before and during treatment; FDA boxed warning for rare but serious liver injury; some drug interactions. | Hot flashes and night sweats only — does not treat vaginal symptoms or protect bone. |
Which works better for hot flashes?
Major medical groups — including ACOG and The Menopause Society — describe systemic estrogen therapy as the most effective treatment for moderate-to-severe hot flashes and night sweats. Fezolinetant also reduces the frequency and severity of hot flashes in clinical trials and is a genuine option, but it is generally positioned as an alternative rather than a replacement for HRT when hormones can be used safely. For many women the "best" choice depends less on a head-to-head winner and more on personal health history and preferences.
Who each option may suit
HRT may be a strong fit for women in early menopause (often under 60 or within about 10 years of their last period) who also want bone protection or relief from vaginal dryness, and who don't have specific contraindications. Fezolinetant may suit women who can't or prefer not to use estrogen — for example, some women with a history of hormone-sensitive cancer, blood clots, or certain cardiovascular concerns — though the right choice always depends on your full medical picture and your clinician's assessment. Some women also weigh HRT against antidepressants and other non-hormonal medicines.
Beyond hot flashes: what each does — and doesn't — address
This is a key difference. HRT eases a broad range of menopause symptoms: hot flashes, night sweats, vaginal dryness and painful sex, and it helps slow the bone loss that raises fracture risk. Fezolinetant, by contrast, targets only hot flashes and night sweats. It does not treat vaginal or urinary symptoms and is not a bone-protective treatment. If those issues matter to you, factor that into the conversation. Not sure where you are in the transition? Our menopause stage quiz can help frame the discussion.
Safety and monitoring at a glance
Every option has trade-offs. HRT carries small, well-studied risks that vary by type, dose, timing, and personal history — these can include a small increase in the risk of blood clots or stroke, and combined therapy has been linked to a small increase in breast-cancer risk with longer use. Fezolinetant's most notable requirement is liver monitoring: the U.S. Food and Drug Administration advises liver blood tests before starting and at intervals during treatment, and has added a boxed warning about rare but serious liver injury. People are told to stop the medicine and seek care if signs of liver problems appear, such as yellowing of the skin or eyes, dark urine, or unusual nausea. Neither medication should be started or stopped on your own.
The bottom line
HRT remains the most effective treatment for vasomotor symptoms and does the most across menopause symptoms, while fezolinetant offers a hormone-free way to calm hot flashes and night sweats — with liver monitoring as the main caveat. The right pick is individual. Talk to your clinician or a menopause specialist about your symptoms, health history, and goals before starting or changing any treatment.