HRT or Non-Hormonal? Veozah, Lynkuet, and How an Arizona Telehealth Clinician Decides

By the Amsara Health team · Clinical review: Mia Chorney, DNP, MSCP · Updated October 2026

For a healthy woman under 60 with hot flashes, hormone therapy is almost always the first choice, because it works better than anything else and treats the rest of menopause too. For a woman who has had breast cancer, a blood clot, or a stroke, or who simply does not want estrogen, 2026 is the first year there have been two FDA-approved non-hormonal medications designed specifically for hot flashes. The decision between them is not a coin flip. It is a structured clinical judgment, and this article shows you how a menopause specialist makes it, including by telehealth in Arizona.

We will cover what the evidence says about hormone therapy, how Veozah and Lynkuet work and how they compare, the older non-hormonal options and the ones that do not work, who should not take estrogen, and the practical questions of monitoring and cost. If you want the mechanics of a telehealth hormone visit first, read our guide to HRT telehealth in Arizona.

Why is hormone therapy still the first-line treatment for hot flashes?

Because the effect size is unmatched. In the Cochrane review of 24 randomized trials with 3,329 women, estrogen therapy reduced hot-flash frequency by about 75% compared with placebo and cut severity by roughly 87%. The Menopause Society’s 2022 Hormone Therapy Position Statement calls hormone therapy the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause and notes that it prevents bone loss and fracture. For healthy women who start before 60 or within 10 years of their last period, the Society concludes benefits outweigh risks.

The regulatory environment now agrees. In February 2026 the FDA approved revised labels for menopausal hormone therapy without the boxed warnings on cardiovascular disease, breast cancer, and probable dementia, after HHS announced the change in November 2025. The warnings about blood clots, stroke, and unopposed estrogen remain, and they are the reason some women need an alternative. Our article Is HRT Safe? covers the risk evidence in detail.

Hormone therapy also does things no hot-flash drug can. It treats vaginal dryness and painful sex, protects bone, often improves sleep and joint pain, and in many women steadies mood. When a clinician recommends a non-hormonal drug instead, it is because estrogen is unsafe for that particular woman or because she has decided against it, not because the alternatives are equivalent.

Who should not take estrogen?

A telehealth intake is where these are caught, which is why a thorough history matters more than any lab. Based on current guidance summarized in a February 2026 American Family Physician editorial and The Menopause Society’s position statements, estrogen is generally contraindicated for women with:

• A personal history of breast cancer or another estrogen-sensitive cancer
• A prior venous blood clot (deep vein thrombosis or pulmonary embolism) or a known clotting disorder
• A prior stroke or heart attack, or established coronary artery disease
• Active liver disease
• Unexplained vaginal bleeding that has not been evaluated
• Uncontrolled high blood pressure (until it is controlled)

Relative cautions include migraine with aura, very high triglycerides, and elevated cardiovascular or clot risk; in some of these, a transdermal estradiol patch at a low dose remains an option, which is a judgment call for the clinician. Women on aromatase inhibitors or tamoxifen after breast cancer are a large and underserved group: their hot flashes are often severe, estrogen is off the table, and until recently the choices were limited. Lynkuet’s trial in exactly this population changed that.

How do Veozah and Lynkuet work?

Both drugs act on the same circuit in the hypothalamus. During menopause, falling estrogen removes the brake on a group of neurons that release neurokinin B; those neurons grow hyperactive and repeatedly trip the body’s thermostat, producing the sudden heat, flushing, and sweating of a hot flash. Veozah blocks the neurokinin 3 (NK3) receptor those signals use. Lynkuet blocks NK3 and also the neurokinin 1 (NK1) receptor, which is involved in sleep and mood regulation. Neither contains or affects hormones, which is why they are safe after breast cancer.

Veozah (fezolinetant)

The FDA approved Veozah on May 12, 2023 as the first neurokinin receptor antagonist for moderate to severe hot flashes. The dose is 45 mg once daily. In the two SKYLIGHT trials, which enrolled more than 1,000 women, the 45 mg dose reduced hot-flash frequency by about 2.1 to 2.6 more episodes per day than placebo at week 4 and about 2.5 to 2.6 at week 12, with significant reductions in severity, according to the current prescribing information.

In September 2024 the FDA added a warning about rare but serious liver injury, and in December 2024 it elevated that to a boxed warning. The FDA safety communication requires liver blood tests before starting, monthly for the first three months, and at months 6 and 9, and tells patients to stop and call their clinician for fatigue, nausea, itching, dark urine, or yellowing of the skin or eyes. The label revised in February 2026 keeps that schedule. Veozah should not be used with moderate or strong CYP1A2 inhibitors such as fluvoxamine or ciprofloxacin.

Lynkuet (elinzanetant)

The FDA approved Lynkuet on October 24, 2025. The dose is 120 mg (two 60 mg capsules) once daily at bedtime. In the OASIS 1 and 2 trials, published in JAMA in 2024, elinzanetant reduced hot-flash frequency by about 3.0 to 3.3 more episodes per day than placebo at week 4 and about 3.2 at week 12, and significantly improved sleep disturbance and quality of life. The 52-week OASIS 3 trial, published in JAMA Internal Medicine in September 2025, found a 73.8% reduction in hot-flash frequency at week 12 versus 47.0% with placebo, with sustained benefit over a year.

The OASIS 4 trial, published in the New England Journal of Medicine in June 2025, studied 474 women with hot flashes caused by endocrine therapy for breast cancer and found reductions of about 3.4 to 3.5 episodes per day versus placebo. On September 28, 2026, Bayer announced that the FDA had accepted its application for this indication with priority review. Lynkuet has no boxed warning. Its label does require liver enzyme and bilirubin tests before starting and again at 3 months, advises against starting if transaminases are already more than twice normal, and warns about drowsiness and next-day impairment, which is why it is taken at bedtime.

How do Veozah and Lynkuet compare?

	Veozah (fezolinetant)	Lynkuet (elinzanetant)
FDA approval	May 12, 2023	October 24, 2025
Mechanism	NK3 receptor antagonist	Dual NK1 and NK3 receptor antagonist
Dose	45 mg once daily, any time	120 mg once daily at bedtime
Hot-flash reduction vs. placebo (week 4)	about 2.1 to 2.6 fewer per day	about 3.0 to 3.3 fewer per day
Sleep effect	Not a primary endpoint	Significant improvement in sleep disturbance
Liver safety	Boxed warning; tests at baseline, months 1, 2, 3, 6, 9	No boxed warning; tests at baseline and month 3
Most common side effects	Abdominal pain, diarrhea, insomnia, back pain, hot flush, elevated liver enzymes	Headache, fatigue, drowsiness
Breast cancer population	Not studied for this indication	OASIS 4 positive; FDA priority review as of September 2026
Controlled substance?	No	No
Approximate cash price per month	about $566 list	about $618
Savings card (commercial insurance)	$0 first month, then as low as $30	As low as $25

Be careful with the numbers in the middle rows. The trials used similar designs but different populations, and no head-to-head study exists. The practical difference most clinicians weigh is this: Lynkuet’s lighter monitoring schedule and its sleep benefit make it attractive for a woman whose night sweats are wrecking her sleep, while Veozah has two more years of real-world safety data and a daytime dosing option for women who do not want a sedating medication. For a line-by-line cost comparison of hormonal and non-hormonal options, including visits and labs, see How Much Does HRT Cost in Arizona?.

What about the older non-hormonal options, and which ones do not work?

The Menopause Society’s 2023 Nonhormone Therapy Position Statement graded the evidence for every common alternative. Recommended, with Level I or II evidence: cognitive behavioral therapy, clinical hypnosis, weight loss, stellate ganglion block, SSRIs and SNRIs (low-dose paroxetine is the only one FDA-approved for hot flashes, as Brisdelle, since 2013), gabapentin, oxybutynin, and fezolinetant. Elinzanetant was approved after the statement was written.

Not recommended, because the evidence does not support them: paced respiration, cooling techniques, avoiding triggers, exercise and yoga (for hot flashes specifically; both are good for everything else), mindfulness and relaxation, dietary changes, soy and other supplements, cannabinoids, acupuncture, chiropractic, clonidine, pregabalin, and suvorexant. This list matters because the supplement aisle is where many women spend their first several hundred dollars.

The generic prescription options cost under $20 a month and are reasonable starting points for mild to moderate symptoms, but each has trade-offs: SSRIs and SNRIs can blunt libido and cause nausea; gabapentin is sedating; oxybutynin causes dry mouth and has anticholinergic concerns with long-term use. In practice, they reduce hot flashes by perhaps a third to a half, well short of estrogen or the neurokinin antagonists.

How does a clinician actually decide?

Here is the sequence a menopause specialist walks through, whether in an office or on a video visit.

1. Is estrogen safe for her? History of breast or estrogen-sensitive cancer, clot, stroke, heart attack, liver disease, or unevaluated bleeding moves her to the non-hormonal column. Everyone else stays in the hormone column by default.
2. Does she want estrogen? Some women decline it after a family history or a bad prior experience. That is a legitimate choice, and the clinician’s job is to make sure it is informed by current evidence, not 2002 headlines.
3. What are the symptoms, exactly? Hot flashes plus vaginal dryness, bone loss risk, or mood changes favor hormone therapy, which treats all of them. Isolated hot flashes and night sweats in a woman who cannot take estrogen favor a neurokinin antagonist.
4. Is sleep the main casualty? Night sweats that fragment sleep favor Lynkuet, taken at bedtime, or progesterone at bedtime within a hormone regimen.
5. What is her liver status and medication list? Baseline liver tests are required for both new drugs. Fluvoxamine or ciprofloxacin rules out Veozah. Sedating medications or a need to drive at night argue against Lynkuet.
6. What can she afford, and what will her plan cover? With commercial insurance and a savings card, both new drugs can cost $25 to $30 a month. Without it, generic estradiol or a generic SSRI may be the only realistic option, and the clinician should say so plainly.
7. Set a review date. Hot-flash medications are judged at 4 and 12 weeks. If a drug is not working by week 12, it is time to switch, not to wait.

A woman may also combine approaches: low-dose vaginal estrogen for genitourinary symptoms is considered safe for many breast cancer survivors in consultation with their oncologist, alongside a non-hormonal drug for hot flashes. Cognitive behavioral therapy for insomnia and hot flashes adds measurable benefit on top of any medication.

Can Veozah and Lynkuet be prescribed by telehealth in Arizona?

Yes. Neither drug is a controlled substance, so Arizona’s telehealth statute applies without restriction: under A.R.S. §36-3602, a clinician may prescribe after a video visit without an in-person examination. The required liver tests are routine blood draws at any Sonora Quest, Quest, or Labcorp patient service center, ordered electronically and reviewed at the follow-up visit, which is also how the monitoring schedule for Veozah is managed in practice. Amsara Health prescribes both Veozah and Lynkuet for Arizona patients when they are the right choice.

The telehealth model suits these medications well. The 4-week and 12-week check-ins that determine whether a drug is working are short conversations, and the liver-test reminders for Veozah are easier to track through a patient portal than through a paper calendar.

How much do hot flashes cost women if they go untreated?

More than the medication. A 2023 Mayo Clinic Proceedings study of 4,440 employed women aged 45 to 60 found that 13.4% reported an adverse work outcome tied to menopause symptoms and estimated $1.8 billion a year in lost productivity, or $26.6 billion when medical costs are added. Hot flashes last a mean of 7 to 9 years, and for about one in three women more than 10 years, according to The Menopause Society’s 2023 nonhormone therapy position statement. The question is not whether to treat them but which safe option fits the woman in front of you.

How does Amsara Health approach the HRT versus non-hormonal decision?

Amsara Health is an Arizona concierge telehealth practice led by Dr. Mia Chorney, DNP, a Menopause Society Certified Practitioner. The first visit is a full hour, which is what it takes to work through the history, the contraindications, the symptom pattern, and the budget honestly. Amsara prescribes FDA-approved hormone therapy and both Veozah and Lynkuet, orders labs through Sonora Quest and Quest, and schedules the 6- to 12-week follow-up before you leave the first visit. If you have been told you cannot take estrogen and left without a plan, that is exactly the conversation the free 15-minute discovery call is for.

Frequently asked questions

Sources

• The Menopause Society (NAMS). The 2022 Hormone Therapy Position Statement, press release. menopause.org, July 2022.
• The Menopause Society. The 2023 Nonhormone Therapy Position Statement, press release. menopause.org, June 2023.
• U.S. Food and Drug Administration. FDA Approves Novel Drug to Treat Moderate to Severe Hot Flashes Caused by Menopause (Veozah). fda.gov, May 12, 2023.
• U.S. Food and Drug Administration. FDA adds warning about rare occurrence of serious liver injury with use of Veozah (fezolinetant). fda.gov, 2024.
• Astellas Pharma. VEOZAH (fezolinetant) U.S. Prescribing Information, revised February 2026.
• U.S. Food and Drug Administration. LYNKUET (elinzanetant) Prescribing Information, NDA 219469. accessdata.fda.gov, October 2025.
• Pinkerton JV, et al. Elinzanetant for Vasomotor Symptoms (OASIS 1 and 2). JAMA, 2024 (PubMed).
• Pinkerton JV, et al. Elinzanetant over 52 weeks (OASIS 3). JAMA Internal Medicine, September 2025, summarized by Patient Care Online.
• Cardoso F, et al. Elinzanetant for vasomotor symptoms from endocrine therapy for breast cancer (OASIS 4). NEJM, June 2025, summarized by The ASCO Post.
• Bayer. Bayer’s Lynkuet (elinzanetant) granted Priority Review by US FDA for additional indication. bayer.com, September 28, 2026.
• U.S. Food and Drug Administration. FDA Approves Labeling Changes for Menopausal Hormone Therapy Products. fda.gov, February 12, 2026.
• American Academy of Family Physicians. Menopause management editorial, American Family Physician, February 2026.
• Cochrane. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes (CD002978). Foundational meta-analysis.
• Faubion SS, et al. Mayo Clinic study puts price tag on cost of menopause symptoms for women in the workplace. Mayo Clinic Proceedings / Mayo Clinic News Network, April 2023.
• The Menopause Society. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 2023;30(6):573-590.
• GoodRx. How much is Veozah without insurance? goodrx.com, updated April 2026.
• Drugs.com. Lynkuet prices, coupons and patient assistance programs. drugs.com, 2026.
• Arizona State Legislature. A.R.S. 36-3602: Delivery of health care through telehealth; requirements; exceptions. azleg.gov.

This article is for educational purposes and is not a substitute for individual medical advice. Talk with a licensed provider about your specific situation.

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