Vasomotor symptoms and vaginal atrophy are both common menopausal symptoms. Hormone therapy is currently the only FDA-approved treatment for hot flashes. Current recommendations are to use the lowest dose of hormone therapy for the shortest period that will allow treatment goals to be met. Although the reanalysis of the WHI in 2007 by Roussow et al. provided evidence of coronary heart safety for users of hormone therapy under the age of 60 years and within 10 years of the onset of menopause, not all women desire or are candidates for hormone therapy. In this review we present an evidence-based discussion considering the effectiveness of hormonal and nonhormonal therapies for the relief of vasomotor symptoms and vaginal atrophy. Concern exists regarding systemic absorption of vaginal estrogen and possible adverse effects on the breast and uterus. Selective estrogen receptor modulators and estrogen agonists offer benefits through targeted estrogen agonist/antagonistic effects and are being evaluated with and without estrogen for symptomatic menopausal women. Centrally acting nonhormonal therapies that are effective for the relief of vasomotor symptoms include various antidepressants, gabapentin and clonidine. A limited number of clinical trials have been conducted with nonprescription remedies, including paced respiration, yoga, acupuncture, exercise, homeopathy and magnet therapy, and some, but not all of these, have been found to be more effective than placebo. Dietary herbal supplements, such as soy and black cohosh, have demonstrated mixed and inconclusive results in placebo-controlled trials. Potential therapies for vasomotor symptoms and vaginal atrophy require randomized, placebo-controlled trials of sufficient duration to establish efficacy and safety. Agents under investigation for vasomotor symptoms relief include neuroactive agents, such as gabapentin and desvenlafaxine; an estrogen receptor-beta-targeted herbal therapy, MF-101; and the selective estrogen receptor modulator, bazedoxifene, paired with estrogen.