The risk-benefit evaluation for managing vasomotor symptoms and other menopause-related health issues should be tailored to each individual woman, taking into account her own assessment of the most bothersome symptom(s) and her personal weighting of risks versus quality of life. For most symptomatic menopausal women, hormone therapy (HT) remains the best treatment, but various nonhormonal options are available for treating menopausal symptoms and bone loss in women who are unable or unwilling to take HT. Low doses of local vaginal estrogen remain an option for treatment of vaginal atrophy in these women. This article reviews alternatives to systemic HT for treating menopausal symptoms and related health issues.