When we think about treating menopausal hot flushes and night sweats (vasomotor symptoms), menopausal hormone therapy (MHT) is usually the first treatment we think about. And for good reason. For most women, it's the most effective treatment available.
But medicine is never one-size-fits-all.
Some women can't take hormones because of their medical history. Others simply don't want to. Some have tried MHT and found it wasn't the right fit for them. Whatever the reason, it doesn't mean you have to simply put up with your symptoms.
One of the non-hormonal treatments I regularly discuss with patients is gabapentin.
Originally developed to treat epilepsy, gabapentin is now widely used for nerve pain, migraine and chronic pain. Over the past two decades, it has also been extensively studied as a treatment for menopausal hot flushes and night sweats.
In fact, the 2023 North American Menopause Society guidelines recommend gabapentin as one of the best-supported non-hormonal prescription treatments for vasomotor symptoms, with Level I evidence.
How effective is it?
The evidence is actually stronger than many people realise.
Across multiple randomised controlled trials, gabapentin reduces the frequency and severity of hot flushes by around 35–50%, with some studies reporting improvements of 60–80%, particularly at higher doses.
One landmark study of women with breast cancer found that 900 mg per day reduced hot flush frequency by 41% after just four weeks, compared with a 17% reduction in women taking placebo.
While MHT remains the most effective treatment overall, gabapentin is one of the most effective non-hormonal options we currently have.
Why I find it particularly useful
One of the reasons I like gabapentin is that it fits with how I think about the hormonal brain.
During perimenopause we often focus on falling oestrogen levels, but progesterone is changing too. Progesterone has calming effects within the brain, and as levels fluctuate and decline, many women become much more sensitive to poor sleep, anxiety and hot flushes.
Gabapentin doesn't replace progesterone or hormones. Instead, it works by calming overactive nerve signalling involved in the brain's temperature regulation pathways.
Perhaps more importantly, it often improves sleep at the same time.
For many women, particularly those waking multiple times each night drenched in sweat, improving sleep can have a huge impact on daytime energy, concentration, mood and overall quality of life.
How do I prescribe it?
Like many medications, I believe in starting low and going slow.
I usually recommend:
- 100 mg at night
- Increase by 100 mg every 3–7 days, depending on symptom control and side effects.
- Many women achieve good symptom control with 300–900 mg at night, particularly if symptoms are mainly overnight.
- If daytime hot flushes remain troublesome, doses can be divided through the day, with the strongest evidence being for 300 mg three times daily (900 mg/day).
- Higher doses have been studied, but in my experience they often add more side effects than additional benefit.
What about side effects?
The most common side effects are:
- Drowsiness
- Dizziness
- Feeling a little unsteady
These are usually most noticeable during the first week or two and often improve as the body adjusts.
Because it can cause sleepiness, many women actually find taking it at night works particularly well.
The bottom line
I love prescribing hormones when they're appropriate. They remain the most effective treatment for menopausal vasomotor symptoms.
But they aren't the only option.
One of the things I enjoy most about women's health is matching the treatment to the woman sitting in front of me - not the guideline.
If hormones aren't the right fit for you, there are still effective, evidence-based treatments available. Gabapentin is one of them.
The best treatment is always the one that fits your symptoms, your health, your preferences and your goals.
