Perimenopause Supplements: What Actually Works, What Doesn't, and What to Skip

Walk down any supplement aisle and you'll find dozens of products promising to fix hot flashes, mood swings, belly fat, and sleep. Searches for "perimenopause supplements" have grown about 75% recently, and the market has grown right along with them.

Here's the honest picture. In its 2023 position statement on non-hormone therapies, The Menopause Society did not recommend any dietary supplement for hot flashes, citing poor study quality and limited safety data. For hot flashes specifically, nothing on a shelf comes close to hormone therapy or the newer prescription non-hormonal options.

But hot flashes aren't the only problem. For mood, anxiety, stress, muscle, and energy, a few supplements do have solid randomized trials behind them. The key is knowing which ones, for which symptom, and in what form.

Here's how the research sorts out.

At a glance

The table is a starting point, not a prescription. What fits you depends on your symptoms, labs, medications, and health history.

The strongest evidence

Ashwagandha

Ashwagandha is an adaptogen that appears to work largely by calming the stress response. In a 2021 randomized, double-blind trial, 100 perimenopausal women took 300 mg of a standardized root extract twice daily or placebo for 8 weeks. The ashwagandha group had significantly lower total menopause symptom scores, with improvements in psychological, physical, and urogenital symptoms. The researchers also reported fewer hot flashes per week.

It seems to help most when stress and poor sleep are driving symptoms.

Who should be careful: Ashwagandha can raise thyroid hormone levels. Women with hyperthyroidism or Graves' disease should avoid it, and women on thyroid medication should have levels checked after starting.

Saffron

Saffron has a growing body of research for mood. In a 2021 trial of 86 perimenopausal women, 14 mg of a standardized saffron extract twice daily for 12 weeks cut anxiety scores by 33% and depression scores by 32%, beating placebo. It did not help hot flashes.

A follow-up 2026 trial in women aged 50 to 70 with low mood and poor sleep found the same extract improved mood, self-esteem, and sleep-related outcomes over 12 weeks.

Saffron is a reasonable option to discuss for women whose main struggles are anxiety, irritability, or low mood, especially those who prefer to start without medication. If anxiety is your main symptom, see Perimenopause Anxiety vs. Generalized Anxiety Disorder.

Creatine

Creatine isn't marketed as a menopause supplement, but the research is hard to ignore. Women naturally store less creatine than men, and estrogen changes affect how the body uses it. Combined with strength training, creatine reliably improves muscle strength and body composition, which matters as estrogen loss speeds muscle decline.

There are early signals for the brain, too. An 8-week trial of 36 peri- and postmenopausal women found faster reaction times and higher frontal brain creatine levels compared with placebo.

One honest caveat: despite the buzz, recent meta-analyses have found no effect on bone density. Creatine is a muscle and energy supplement, not a bone treatment. For what does protect bone, see Bone Loss Starts in Perimenopause.

Promising, with caveats

S-equol and soy isoflavones

Equol is a compound some people's gut bacteria make from soy. Only about half of Asian women and a quarter of non-Asian women have the bacteria to make it, which may explain why soy helps some women and not others.

S-equol supplements give it directly. In a 12-week Japanese trial of women who couldn't make their own, hot flash frequency dropped 58.7% on S-equol versus 34.5% on placebo, and neck and shoulder stiffness improved. But the trials are small, mostly in Japanese women, and the main U.S. trial had no placebo group.

For soy isoflavones in general, a pilot trial found that higher doses split into two or three daily servings worked best, especially for night sweats and in equol producers.

Important: S-equol and isoflavones act on estrogen receptors. They aren't a safe workaround for women avoiding estrogen because of breast cancer or other hormone-sensitive conditions. Eating soy foods is generally fine. Concentrated supplements are a different matter.

Fixing what's actually low

Some of the most effective supplements aren't menopause products at all. They correct deficiencies that look a lot like hormone symptoms. Low iron, vitamin D, B12, or magnesium can all cause fatigue, low mood, poor sleep, or brain fog. Testing first tells you whether these are worth taking, rather than guessing. See "Your Labs Are Normal" for why standard ranges can miss these.

Overhyped: weak or mixed evidence

These show up in many menopause blends, but the research doesn't back the marketing.

• Black cohosh. Probably the best-known menopause herb. A 2012 Cochrane review of 16 randomized trials found it worked no better than placebo for hot flashes, and The Menopause Society concluded the evidence is insufficient. It has also been linked to rare liver injury.
• Maca. Popular for energy and libido, but The Menopause Society does not recommend it for hot flashes.
• Ginseng. Not recommended for hot flashes.
• Chasteberry (vitex). Sometimes used for PMS, but not recommended for menopausal hot flashes.

None of this means these herbs never help anyone. Placebo responses in hot flash trials are high, and some women do feel better. But if you're spending money every month, it's worth putting it toward something with stronger evidence.

Safety: "natural" doesn't mean risk-free

Supplements aren't regulated like medications. Before you start anything, keep these in mind:

• Liver. Black cohosh has been tied to rare cases of liver injury. U.S. Pharmacopeia experts reviewed 30 possible cases and directed that products carry a liver warning. Stop it and get checked if you notice abdominal pain, dark urine, or yellowing skin.
• Thyroid. Ashwagandha can raise thyroid levels. Soy and other phytoestrogens can reduce absorption of thyroid medication, so space them apart.
• Hormone-sensitive conditions. Women with a history of breast cancer or other estrogen-sensitive conditions should avoid concentrated phytoestrogen supplements unless their oncology team approves.
• Medications. Herbs can interact with antidepressants, blood thinners, and sedatives. Bring your full supplement list to every appointment.
• Quality. Products vary widely. Choose standardized extracts at the doses used in research, from brands that use third-party testing, rather than proprietary blends that hide the amounts.

How to choose

1. Start with your main symptom. Anxiety and low mood point toward saffron. Stress-driven symptoms and poor sleep point toward ashwagandha. Muscle loss and fatigue with training point toward creatine.
2. Test before you guess. Iron, vitamin D, B12, thyroid, and blood sugar problems often mimic perimenopause.
3. Change one thing at a time. Give each supplement 8 to 12 weeks, the length of most trials, before judging it.
4. Skip the 12-ingredient blends. They often contain too little of each ingredient to match the research.
5. Don't let supplements delay real treatment. If symptoms are affecting your sleep, work, or relationships, a full evaluation, including a conversation about hormone therapy or prescription non-hormonal options, may help far more.

I keep professional-grade, third-party tested versions of the supplements in this article, in the forms used in the research, in my Fullscript dispensary. Please check with your own clinician before starting anything new, especially if you take thyroid medication, antidepressants, or blood thinners.

References

1. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023. Summary of supplement ratings in HealthEd. View source
2. Gopal S, et al. Effect of an ashwagandha (Withania somnifera) root extract on climacteric symptoms in women during perimenopause: a randomized, double-blind, placebo-controlled study. J Obstet Gynaecol Res. 2021;47(12):4414–4425. View source
3. Lopresti AL, Smith SJ. The effects of a saffron extract (affron) on menopausal symptoms in women during perimenopause: a randomised, double-blind, placebo-controlled study. J Menopausal Med. 2021;27(2):66–78. View source
4. Lopresti AL, Smith SJ. The effects of a saffron extract (Affron) on mood, sleep, self-esteem, and exploratory measures of physical appearance in women aged 50 to 70 years experiencing low mood and poor sleep. Front Nutr. 2026. Summary in Contemporary OB/GYN. View source
5. Creatine in women's health: bridging the gap from menstruation through pregnancy to menopause. J Int Soc Sports Nutr. 2025;22(1):2502094. View source
6. Creatine supplementation in women's health: a lifespan perspective. Nutrients. 2021. View source
7. Korovljev D, et al. Creatine hydrochloride in perimenopausal and postmenopausal women, 2025. Summary by Nia Health. View source
8. Creatine in women's health: where the research stands in 2026 (bone density meta-analyses). View source
9. S-equol: a potential nonhormonal agent for menopause-related symptom relief. J Womens Health. 2015;24(3):200–208. View source
10. S-equol in Japanese postmenopausal non-equol producers (12-week confirmation study). Summary in SupplySide. View source
11. Impact of dose, frequency of administration, and equol production on efficacy of isoflavones for menopausal hot flashes: a pilot randomized trial. Menopause. 2013;20(9):936–945. View source
12. For some women, hormone therapy isn't an option. Are menopause supplements any better? (expert interviews on black cohosh and phytoestrogens). View source
13. Parkview Health. A pharmacist's guide to menopause relief without hormones. View source
14. Exploding Topics. "Perimenopause supplement" search trend. View source