Perimenopause and menopause are natural phases in a person’s life marked by fluctuating and eventually declining estrogen levels. Common symptoms include hot flashes, night sweats, mood changes, sleep disruption, vaginal dryness, and bone density loss. While menopause hormone therapy (MHT) remains the most effective medical treatment for many symptoms, many individuals seek over-the-counter supplements and products for relief due to cost, accessibility, fear of hormones, or preference for “natural” treatments. Yet, the evidence for their effectiveness varies widely — ranging from modest to minimal — and scientific and lay perspectives often conflict.
There are many things to consider before taking a supplement. Are supplements more natural for our bodies than medication that may be paid for by our insurance? Are supplements more effective to help with sleep, body aches, mood changes, and hot flashes? Are there any dangers to using supplements?
What does “natural” really mean?
The major sex hormones in a woman’s body are estradiol (an estrogen), progesterone (a progestogen), and testosterone (an androgen). These are the body’s natural substances. Although one may use other estrogens, progestogens, or androgens, most women on MHT choose FDA-approved products that contain these pure substances, often called “bio-identical” or “body-identical” hormones. These hormones are synthesized in a lab from wild yams or soybeans and are available by prescription in commercial pharmacies.
Some herbal products contain molecular precursors to the body’s natural hormones. For example, wild yam cream contains diosgenin. But unlike a laboratory, our body cannot convert diosgenin into estrogen or progesterone. Others likely exert any purported effects through other receptor pathways. But no herbal products, even though they may seem more natural, provide the natural hormonal molecules made by our bodies.
Are herbal products effective to treat my symptoms?
For an excellent synopsis on the evidence of various herbs and supplements, see the publicly-available 2023 review of non-hormonal menopause therapies by The Menopause Society. [1] The article includes information on soy isoflavones, S-equal, ammonium succinate (Amberan), lactobacillus, rhubarb, black cohosh, wild yam, dong quai, evening primrose, maca, ginseng, labisia pumila/eurycoma longifolia, chasteberry, milk thistle, omega-3 fatty acids, vitamin E and cannabanoids. None are recommended to treat menopausal symptoms.
Another review, written by an integrative medicine physician with a background in herbal medicine, also found a lack of strong evidence for many popular herbal products. [2]
While studies have not shown consistent effectiveness of supplements or herbal products, many women do find some relief with herbal products. The most likely explanation lies with the placebo effect. Placebo interventions, a “sugar pill,” will improve everything from cancer pain to depression to sleep. For menopause symptoms, placebo effect has been shown to be as high as 50% effective. Unfortunately, placebo does not last indefinitely. After days or weeks, the symptoms will slowly return.
Menopause hormone therapy is the most effective treatment for the symptoms of menopause. For women with a uterus, estrogen is combined with a progestogen. Women without a uterus may use only an estrogen. For women who cannot or choose not to use hormones, there are non-hormonal medications as well as non-medication options that treat various symptoms. Unfortunately, none are as effective and address such a wide range of symptoms as MHT.
The quality of unregulated supplement products vary far more than FDA-approved medications.
As an example, one study of 31 melatonin products found that the actual melatonin content of a tablet ranged from -83% to 478% of the stated amount. [3] Additionally, batch-to-batch variations among individual products showed amounts varied by over 450%. Even more concerning, 26% of the products contained serotonin, a substance not listed on the label.
One of the few herbal products with better evidence of effectiveness is black cohosh. The effect is likely through the serotonergic pathway, similar to how SSRI antidepressants can relieve hot flashes. Unfortunately, multiple reports of serious liver toxicity have been associated with its use. Contaminates are blamed.
Although FDA products are not immune to dose variation and contaminants, the issue is vastly less common. [4] [5]
[1] North American Menopause Society (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 30(6), 573–590. https://doi.org/10.1097/GME.0000000000002200
[2] Low Dog T (2005). Menopause: a review of botanical dietary supplements. The American journal of medicine, 118 Suppl 12B, 98–108. https://doi.org/10.1016/j.amjmed.2005.09.044
[3] Erland, L. A., & Saxena, P. K. (2017). Melatonin Natural Health Products and Supplements: Presence of Serotonin and Significant Variability of Melatonin Content. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 13(2), 275–281. https://doi.org/10.5664/jcsm.6462
[4] Dabestani, A. et al. (2023) A data-driven quality-score system for rating drug products and its implications for the health care industry. Journal of the American Pharmacists Association, 63(2), 501-506 https://pubmed.ncbi.nlm.nih.gov/36336583/
[5] Valisure detects NDMA in Metformin (2020) https://www.valisure.com/valisure-newsroom/valisure-detects-high-levels-of-ndma-in-metformin
