Perimenopause can be challenging, for several different reasons. Thankfully, recent research has better highlighted the role and importance of estrogen replacement in brain, heart, and bone health as women age. However, there are some circumstances in which estrogen replacement therapy may still not be appropriate. In those cases, there are some alternatives in which could be considered.

Specific selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) medications are often considered the most effective alternatives to estrogen replacement. These options include venlafaxine, desvenlafaxine, citalopram, escitalopram, or paroxetine. Sertraline and fluoxetine are not commonly used in perimenopausal symptom management because neither has shown a clinically significant effect on hot flashes (Handley & Williams, 2015). The clinical response to these medications for perimenopausal symptoms has shown to be more rapid (within days) than the typical response to SSRIs and SNRIs for treatment of depression (within weeks) (Handley & Williams, 2015). Generally speaking, literature recommends typically starting with either citalopram or escitalopram as first-line SSRIs for perimenopausal symptom management. Paroxetine is often avoided due to the frequent and significant side effect potential. Venlafaxine is generally recommended as the first-line SNRI for perimenopausal symptom management.

There are also non-prescription supplements that can be helpful for some individuals as well. Studies have shown that omega-3 polyunsaturated fatty acids (fish oil) are helpful in reducing hot flashes, improving mood, and supporting cardiovascular health (Minihane, 2025). Studies have also shown that black cohosh, a perennial plant, can be helpful in managing hot flashes, night sweats, mood changes, and joint pain associated with perimenopause (Hedaoo, Badge, Tiwade, Bankar, & Mishra, 2024). However, liver damage has been associated with the use of black cohosh, so it is very important to check labels and follow posted recommendations. I recommend seeking supplements with “USP” or “NSF” labels, which indicates the supplement has been tested by one of these third-party organizations to confirm that it meets science-based, high-quality standards. Naturopathic doctors (NDs) are also excellent resources in managing perimenopausal symptoms, especially when avoiding estrogen replacement therapies. We highly recommend a collaborative approach with NDs for anyone pursuing perimenopausal symptom management.

There seems to be an awesome movement in mainstream media to break the stigma surrounding menopause through discussion, advocacy, education, and empowerment, and we absolutely love to see it! At Pacific Endometriosis and Pelvic Surgery, we are passionate about creating a space where conversations about perimenopause feel informed, supportive, and approachable. Our hope is that continued education and open dialogue help patients feel empowered to better understand their symptoms and all the options available to them.

References

Charafi, L., Bolling, K., Schroader, B. K., & Halvorson, L. (2025). Characterization and treatment patterns of peri/menopausal and postmenopausal women with and without vasomotor symptoms in a retrospective database study. Women’s Health Reports (New Rochelle, N.Y.), 6(1), 742–751. https://doi.org/10.1177/26884844251366113

Handley, A. P., & Williams, M. (2015). The efficacy and tolerability of SSRI/SNRIs in the treatment of vasomotor symptoms in menopausal women: A systematic review. Journal of the American Association of Nurse Practitioners, 27(1), 54–61. https://doi.org/10.1002/2327-6924.12137

Hedaoo, K., Badge, A. K., Tiwade, Y. R., Bankar, N. J., & Mishra, V. H. (2024). Exploring the efficacy and safety of black cohosh (cimicifuga racemosa) in menopausal symptom management. Journal of Mid-Life Health, 15(1), 5–11. https://doi.org/10.4103/jmh.jmh_242_23

Minihane, A. M. (2025). Omega-3 fatty acids, brain health and the menopause. Post Reproductive Health, 31(2), 97–104. https://doi.org/10.1177/20533691251341701

Stubbs, C., Mattingly, L., Crawford, S. A., Wickersham, E. A., Brockhaus, J. L., & McCarthy, L. H. (2017). Do SSRIs and SNRIs reduce the frequency and/or severity of hot flashes in menopausal women. The Journal of the Oklahoma State Medical Association, 110(5), 272–274. https://pmc.ncbi.nlm.nih.gov/articles/PMC5482277/