Best Herbal Supplements for Perimenopause Symptoms
A guide to the best herbal supplements for perimenopause, covering evidence, safety, and which symptoms each one addresses.
What to Know Before Taking Herbal Supplements
Herbal supplements are not a replacement for HRT in women who need hormonal support, but they can offer meaningful symptom relief for women who cannot or choose not to use HRT, or who want to complement their existing treatment. The evidence base varies considerably across different herbs. Some have robust clinical trial data; others have only traditional use or small studies. Interactions with medications are also possible, so always tell your GP or prescriber what you are taking. Quality matters significantly with supplements: look for products with standardised extracts and third-party testing, which gives you confidence that the active compound is present at the stated dose.
Black Cohosh
Black cohosh (Actaea racemosa) is one of the most studied herbal supplements for menopausal symptoms, particularly hot flashes and night sweats. It does not appear to act as a phytoestrogen, despite older theories, but may work through serotonin receptors to modulate temperature regulation. Clinical trials show mixed results: some find significant reduction in vasomotor symptoms, others show modest effect. A 2010 Cochrane review concluded it was modestly effective for hot flashes with a good safety profile when used for up to 12 months. It is not recommended for women with a history of hormone-sensitive breast cancer due to insufficient long-term safety data, and should not be used by those with liver conditions.
Red Clover
Red clover (Trifolium pratense) is rich in isoflavones, plant compounds that act as weak estrogen mimics. The main isoflavones in red clover, formononetin and biochanin A, are converted in the gut to compounds similar to those found in soy. Research on red clover isoflavones shows more consistent results than soy isoflavones for reducing hot flash frequency, with some trials finding a 40 to 50 percent reduction compared with placebo. Red clover also has emerging evidence for supporting bone density and cardiovascular markers. It is generally well tolerated, though women with hormone-sensitive conditions should discuss use with their doctor. Doses of 40 to 160mg of isoflavones daily are used in most studies.
Ashwagandha
Ashwagandha (Withania somnifera) is an adaptogenic herb with strong evidence for reducing cortisol, improving sleep quality, and lowering anxiety. In perimenopause, chronically elevated cortisol from hormonal disruption and life stress amplifies almost every symptom, from weight gain to brain fog to poor sleep. A 2021 randomised controlled trial specifically in perimenopausal women found that ashwagandha supplementation significantly improved quality of life scores, reduced hot flash severity, and improved sleep compared with placebo. Standard doses range from 300 to 600mg of root extract daily. It is generally well tolerated but should be avoided in pregnancy and used cautiously with thyroid medication.
Valerian Root
Valerian (Valeriana officinalis) is one of the most widely used herbal sleep aids and has specific relevance for perimenopausal insomnia. A 2011 study of menopausal women found that valerian reduced both sleep latency (time to fall asleep) and night waking compared with placebo. It appears to work by increasing GABA activity in the brain, promoting a calming effect without the dependency risk of pharmaceutical sleep aids. Doses of 300 to 600mg taken 30 to 60 minutes before bed are typical. Some people find it takes two to four weeks of consistent use before full benefit is felt. It can cause mild drowsiness and should not be combined with alcohol or sedative medications.
St John's Wort
St John's Wort (Hypericum perforatum) has good evidence for mild to moderate depression and has been studied in combination preparations for menopausal symptoms. A combination of St John's Wort and black cohosh has been tested in several clinical trials and found to reduce both hot flashes and mood disturbance more than either supplement alone. For women in perimenopause experiencing low mood, irritability, and anxiety alongside vasomotor symptoms, this pairing is worth discussing with a healthcare provider. The critical caveat: St John's Wort has significant interactions with many common medications including antidepressants, the contraceptive pill, blood thinners, and anticonvulsants. Never take it without checking interactions with your full medication list.
Sage
Sage (Salvia officinalis) has a long traditional history of use for excessive sweating and hot flashes, and is one of the few herbs with a plausible mechanism: it may inhibit the sweat gland receptors affected by cholinergic activity. A small but well-designed clinical trial found that a sage leaf extract significantly reduced the frequency of hot flashes and night sweats over 8 weeks, with good tolerability. It is available as a standardised extract tablet or as a herbal tea. The tea form, while pleasant, delivers less consistent dosing than an extract. Sage is generally very safe at food and supplement doses. Women with epilepsy should avoid high doses as thujone, a compound in sage, can lower seizure threshold at very high intakes.
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