Fezolinetant (Veozah) for Perimenopause: A Complete Guide to the First Non-Hormonal Hot Flash Drug

Why Fezolinetant Feels Like a Breakthrough

If you have been searching for a way to manage hot flashes without hormones, you have probably run into a short and not very satisfying list of options. Antidepressants, blood pressure medications, and supplements round out most of the conversation. That is why the 2023 FDA approval of fezolinetant, sold under the brand name Veozah, got so much attention in menopause medicine circles.

Fezolinetant is the first prescription drug in an entirely new category: a neurokinin B receptor antagonist designed specifically to reduce vasomotor symptoms. It does not act on hormones at all. Instead, it targets a specific signaling pathway in your brain that scientists now understand is directly responsible for triggering hot flashes. For women who cannot or do not want to use estrogen, this is a genuinely new option, not just a repurposed medication from another condition.

This guide walks you through how fezolinetant works, what the clinical trials showed, who the drug is approved for, what side effects look like, and how it compares to hormone therapy for hot flash relief. The goal is to give you the information you need to have a real conversation with your doctor.

The Neurokinin B Pathway: Why Your Brain Triggers Hot Flashes

To understand fezolinetant, it helps to understand why hot flashes happen in the first place. The short version is that your thermostat is broken, and estrogen is what normally keeps it calibrated.

Deep in the hypothalamus, a cluster of neurons called KNDy neurons (named for the three hormones they produce: kisspeptin, neurokinin B, and dynorphin) plays a central role in regulating body temperature and reproduction. Estrogen normally keeps these neurons quiet. When estrogen drops during perimenopause, the KNDy neurons become overactive. They start firing neurokinin B into a region of the hypothalamus called the thermoregulatory center. That flooding of neurokinin B signals is what appears to set off the cascade that ends with a hot flash: blood vessels dilating, skin flushing, sweat releasing.

Fezolinetant works by blocking the NK3 receptor, which is the specific receptor that neurokinin B binds to in the thermoregulatory area. By blocking that receptor, fezolinetant quiets the signal before it can trigger a hot flash. It does not change your estrogen levels. It does not act on any reproductive hormones. It simply interrupts the chain of events at a very targeted point in the brain.

What the Clinical Trials Found

Fezolinetant went through a large, well-designed clinical trial program called SKYLIGHT before it reached approval. The pivotal trials, SKYLIGHT 1 and SKYLIGHT 2, enrolled women who were experiencing at least seven moderate to severe hot flashes per day, which is a high bar. Participants received either 30 mg or 45 mg of fezolinetant daily or a placebo.

At 12 weeks, women taking the 45 mg dose saw their moderate-to-severe hot flash frequency drop by about 60 percent compared to roughly 45 percent in the placebo group. The severity score dropped significantly as well. The 30 mg dose also worked but showed slightly less benefit. Importantly, women started noticing a difference within the first week of treatment, which is faster than many alternatives.

A longer-term safety study called SKYLIGHT 4 followed women for 52 weeks. Hot flash reductions held up over time, and the safety profile remained consistent. About 2 percent of participants in the 45 mg group showed elevated liver enzymes, which is why the FDA requires liver function monitoring. No serious liver events occurred during the trial, but the label does include a warning to check liver function before starting and at 3, 6, and 9 months.

Who Fezolinetant Is Approved For

The FDA approved fezolinetant specifically for moderate to severe vasomotor symptoms due to menopause. The label does not carve out perimenopausal women separately, but women in perimenopause experiencing disruptive hot flashes are generally included in that population as long as vasomotor symptoms are the primary concern.

Fezolinetant is a particularly good fit if you have a history of hormone-sensitive cancer, have had blood clots, or have cardiovascular conditions that make estrogen therapy a complicated choice. It is also an option if you tried an SSRI or SNRI for hot flashes and did not get enough relief, or if the side effects from those medications did not work for your life.

You should not take fezolinetant if you have liver cirrhosis or severe liver impairment. It is also not recommended if you are taking certain medications that are processed by the same liver enzyme pathway (CYP1A2), including some antibiotics and the heartburn drug cimetidine, because those interactions can significantly raise fezolinetant levels in your blood. Your prescriber will review your full medication list before starting.

Side Effects and What to Watch For

In the clinical trials, fezolinetant was generally well tolerated. The most common side effects were abdominal pain, diarrhea, insomnia, and back pain. Most of these were mild and did not cause participants to stop the medication. Hot flashes themselves temporarily worsened in a small number of people when stopping the medication, though this was not a major pattern in the trials.

The most important monitoring concern is liver health. Elevated liver enzymes showed up in a small percentage of participants, and in most cases the levels returned to normal when the drug was stopped. The FDA requires liver function testing before you start, and at the three, six, and nine month marks. If you have any underlying liver condition, your doctor will need to weigh those risks carefully before prescribing.

Some women report mild insomnia, particularly in the first weeks. If sleep disruption is already a symptom you are dealing with in perimenopause, it is worth flagging that to your prescriber so they can help you manage it alongside the medication. Overall, the side effect profile is considerably different from hormones, which makes fezolinetant genuinely useful for women who have struggled to tolerate estrogen or progestogen.

Cost, Insurance, and Practical Access

Fezolinetant is a brand-name drug with no generic available, and the list price is around $550 to $600 per month. That price point puts it out of reach for many women without insurance coverage, and coverage has been inconsistent since launch. Some insurance plans cover it with a prior authorization process, while others have not yet added it to their formulary.

AstraZeneca, the manufacturer, offers a patient support program called Veozah Complete that can reduce out-of-pocket costs for eligible commercially insured patients. It is worth checking their website directly for current savings programs and eligibility requirements. If you are on Medicare or Medicaid, coverage rules differ, and the manufacturer program may not apply.

If cost is a barrier, it is worth having a frank conversation with your doctor about it. Some gynecologists and menopause specialists have samples, and others can help you navigate the prior authorization process with your insurer. Comparing the cost against other non-hormonal options like monthly SSRI prescriptions can also help put the numbers in perspective.

Fezolinetant vs. HRT: How Do They Compare for Hot Flashes?

Hormone therapy, particularly estrogen, remains the most effective treatment for vasomotor symptoms. Head-to-head comparisons between fezolinetant and estrogen-based HRT are limited because the trials did not pit them directly against each other. But based on available data, estrogen tends to reduce hot flash frequency by 75 to 90 percent in clinical trials, while fezolinetant lands around 60 percent reduction. That gap is real.

However, the comparison is not really apples to apples for most women who would consider fezolinetant. If estrogen were a completely comfortable and available choice, those women would likely already be taking it. Fezolinetant fills a specific gap: meaningful, clinically significant hot flash relief for women who cannot or should not use estrogen.

For women who are appropriate candidates for both, a discussion with your doctor should include not just hot flash relief but all the other effects of estrogen, including bone protection, cardiovascular considerations, and genitourinary symptoms. Fezolinetant only addresses vasomotor symptoms. It does not have evidence for protecting bone density or relieving vaginal dryness, so those needs would require separate management if you choose a non-hormonal path.

Finding a Provider Who Prescribes Veozah

Fezolinetant requires a prescription, and not all primary care providers are comfortable with it yet because it is still relatively new. Gynecologists and menopause specialists tend to be the most familiar with prescribing it. The Menopause Society (formerly NAMS) maintains a provider directory at menopause.org that lets you search for certified menopause practitioners in your area.

When you see your provider, it helps to come prepared with some specifics: how many hot flashes you are having per day, how they affect your sleep and daily functioning, and what you have already tried. Framing your symptoms in those concrete terms helps the provider understand why you want to explore this option and whether it fits your situation.

Some telehealth platforms that specialize in menopause care are also beginning to offer fezolinetant prescriptions. If in-person access is a challenge, that may be a route worth exploring. Regardless of how you access it, make sure whoever prescribes it has your full medication list, your liver function baseline, and a plan for the required follow-up monitoring.

Medical Disclaimer

This article is for informational purposes only and does not constitute medical advice. Fezolinetant (Veozah) is a prescription medication that requires evaluation by a qualified healthcare provider. Every person's health history is different, and only your doctor can determine whether fezolinetant is appropriate for you. Do not start, stop, or change any medication without speaking to your healthcare provider first.

The information in this article reflects research and prescribing information available as of early 2026 and may not reflect the most current clinical guidance.