In part 1 of this article, we discussed the physiological and hormonal changes during perimenopause, and reviewed nutrition and lifestyle habits that can help to reduce symptoms associated with perimenopause. Part 2 focuses on supplemental support, herbs and hormone therapy for perimenopause.
Hormone-Supportive Nutrients & Considerations
Certain vitamins and minerals play a crucial role in maintaining hormonal balance and overall well-being during perimenopause. Magnesium—particularly in the forms of glycinate, L-threonate, or citrate—can help alleviate stress, support progesterone production, and enhance sleep quality. However, it’s important to consider individual tolerance, as certain forms may cause gastrointestinal discomfort, such as diarrhea, and high doses can interact with blood pressure medications. Individuals with kidney disease should consult a nephrologist before supplementing.
Vitamin D and K2 are vital for bone health, but supplementation requires caution in those with kidney disease and those with elevated blood calcium levels. Furthermore, those on warfarin and those with a rare condition, G6PD deficiency, should not take vitamin K. Regular monitoring of vitamin D levels is recommended to ensure safe and effective use. B vitamins, especially B6 and B12, play a key role in neurotransmitter synthesis and hormone metabolism. However, prolonged excessive intake of B6 may lead to peripheral neuropathy, underscoring the importance of appropriate dosing and monitoring of levels. Consulting with a knowledgeable healthcare provider helps tailor these nutrients to individual needs and health conditions.1
Integrative and Evidence-Informed Interventions for Perimenopause
Supplements & Herbal Support
The market is flooded with supplements and herbal remedies promising relief from perimenopausal symptoms like hot flashes, mood swings, and fatigue. Supplements are generally under-regulated, under-studied and often over-promise, which is why it is important to work with a knowledgeable physician or healthcare provider, who can provide guidance on safe, effective and high quality supplements to support specific symptoms and be part of a personalized care protocol. While some of these interventions have research to support their use, others lack evidence, making it essential to distinguish between effective or promising options requiring further study and ineffective modalities. Among the better-supported supplements, fish oil (omega-3 fatty acids, especially EPA and DHA) have evidence for cardiovascular and brain health and may help with reduce inflammation and mood regulation. 2
Flaxseed and soy-derived isoflavones have been investigated for their phytoestrogen content, yet their efficacy in managing perimenopausal symptoms remains inconsistent. Isoflavones, particularly genistein and daidzein—abundant in soybeans, chickpeas, and lentils—are among the most biologically active plant-based estrogens, although their estrogenic potency is substantially weaker than endogenous estrogens. Some meta-analyses suggest that dietary or supplemental soy isoflavones may confer a modest reduction in vasomotor symptoms, particularly hot flashes, but findings across clinical trials remain mixed, with many failing to demonstrate a statistically significant benefit over placebo..3 Similarly, flaxseed, a rich source of lignans that are metabolized into estrogen-like compounds, has yielded limited evidence for improving vasomotor symptoms, however this improvement hasn’t been found to be statistically significant compared to placebo.4,5 Phytoestrogens may offer potential benefits in hormonal modulation and metabolic health, making them a consideration for women seeking non-hormonal alternatives to manage menopausal symptoms, particularly those who cannot or prefer not to use hormone replacement therapy (HRT). We need larger studies to understand the impact of flaxseed on breast cancer and the endometrium (lining of the uterus).
For women experiencing estrogen dominance symptoms—such as heavy periods, breast tenderness, or fibroids—Calcium-D-Glucarate (CDG) and Diindolylmethane (DIM) are sometimes used to support estrogen metabolism, though their effects can be varied and should be monitored by a healthcare provider. These compounds may aid in the metabolism and detoxification of estrogen, potentially alleviating symptoms associated with excess estrogen. Specifically, calcium D-glucarate has been suggested to support estrogen clearance by inhibiting the reabsorption of estrogen in the intestines, while DIM may promote estrogen metabolism in the liver.6 7 NAC, a precursor to glutathione, can shift the estrogen metabolism towards protective pathways and inhibit estrogen-dependent cancer causing DNA damage.8 More studies are needed to confirm this effect in the clinical setting and determine the optimal dose.
Berberine, known for its insulin-sensitizing properties and its impact on the gut microbiome, may be beneficial for those facing perimenopausal weight gain linked to insulin resistance but should be used cautiously, especially alongside diabetes medications.9 Some herbs, while widely marketed, require more research to confirm their effectiveness. Maca has gained popularity for improving energy and libido, with some preliminary evidence suggesting it may support hormone balance, though its exact mechanisms remain unclear. However, the clinical efficacy of maca root remains under debate, as much of its traditional use has been taken out of cultural and historical context. 10 Additionally, the rising global demand for maca has led to concerns over the quality and sustainability of mass-produced products, further emphasizing the need for cautious and informed use. Women with hormone-sensitive conditions such as breast cancer, endometrial cancer or endometriosis should discuss its use with their qualified healthcare provider.11
Ashwagandha, an adaptogen known for lowering cortisol and promoting relaxation, may help with stress and sleep. Those with low blood pressure, thyroid conditions, or diabetes should monitor their use, as it can affect the cardiovascular and endocrine systems. In a small study, Ashwagandha improved symptoms of menopause and menopause-related quality of life. 12
Vitex (Chastetree berry/Chasteberry) is sometimes used to support progesterone levels and regulate menstrual cycles, making it supportive for those with PMS symptoms related to estrogen dominance. Those on medications for certain mood disorders should check with their doctor before use. Anyone with a hormone-sensitive cancer, should also discuss use with their qualified healthcare provider.13
While certain supplements offer clear benefits, many require more research to fully understand their long-term effects and appropriate use in perimenopause. Individual responses can vary significantly, making personalized guidance essential. Consulting a healthcare provider can help determine which supplements, if any, align with a woman’s specific needs. By staying informed and cautious, women can take a science-based approach to perimenopausal health while staying informed about ongoing research with their healthcare providers in this evolving field. Always work with a qualified healthcare provider to make informed decisions about your health and wellness.
Hormone Therapy for Perimenopause
For some women, hormone therapy can provide significant relief from perimenopausal symptoms. We know that initiating menopausal hormone therapy to treat symptoms, especially at the onset of menopause, offers benefits when used appropriately. What about perimenopausal use of hormones? Oral micronized progesterone, particularly when taken at night in a cyclical fashion, has been shown to improve sleep quality, reduce anxiety, alleviate cyclical night sweats, and help regulate menstrual cycles.14 This approach may be particularly beneficial for women experiencing significant sleep disturbances, anxiety and mood fluctuations related to perimenopausal hormonal shifts. In early perimenopause, when estrogen levels are typically elevated relative to progesterone, adding progesterone therapy for such symptoms is typically sufficient. In the later stages of perimenopause, when estrogen levels start to decline, systemic estrogen therapy can be started (e.g., in the form of a patch or oral). Symptoms, goals of therapy, risks vs benefits should be discussed with a healthcare provider to determine the therapeutic modality that would be most appropriate.
For those seeking both symptom relief and contraception, combined oral contraceptives (COCPs) can be a helpful option. COCPs provide stable hormone levels, which can help regulate cycles, reduce heavy or irregular bleeding, and alleviate vasomotor symptoms such as hot flashes. Additionally, they offer bone-protective benefits and reduce the risk of ovarian and endometrial cancers.15 However, COCPs may not be suitable for women with certain cardiovascular risk factors, history of hormone-sensitive cancers, migraines with aura, emphasizing the need for individualized care when considering hormonal options. Some also argue that COCPs should not be prescribed in perimenopause given safety and efficacy profile.16 Some women, with contraindications to estrogen therapy, benefit from a progestin only pill, or an IUD, especially if seeking contraception and/or to control menstrual bleeding. We believe that there is no one size fits all, and that this decision should be discussed between the patient and the clinician, in order to come up with an informed and personalized plan, based on the patient, their symptoms, goals and response to treatment modalities.
For women experiencing the genitourinary symptoms associated with declining hormone levels (e.g., vaginal dryness, painful intercourse, vaginal irritation), after evaluation and ruling out other conditions, there are many vaginal estrogen options available.
A Brief Word About Menopause
Around the onset of menopause, 12 months after the cessation of the menstrual cycle, vasomotor symptoms often become more prominent and constant. Menopausal hormone therapy vs non-hormonal therapy, should be discussed, if it hasn’t already been initiated. Estradiol is available as oral, transdermal (patch, gel or spray), or vaginal. Systemic estrogen (estrogen that, when delivered, has effects throughout the body), can alleviate hot flashes and night sweats, vaginal dryness and can support bone density. Many women report (and some studies show) that estrogen therapy can improve brain fog, mood and joint aches. Vaginal estrogen can help reduce genitourinary symptoms of menopause. Systemic estrogen is used in conjunction with oral progesterone therapy (or a progestin IUD or a patch containing both hormones) in women with a uterus. Menopausal hormone therapy is typically recommended no longer than 10 years after menopause and not past the age of 60, given increased risks of use later in life. Again, there is no one size fits all, and the approach should be individualized. While management of menopause is outside of the scope of the current article, this is a topic we will cover in the future.17 18 19
Conclusion: A Proactive Approach to Perimenopause
Perimenopause is not just an inevitable struggle—it is an opportunity for women to take control of their health during what can be quite a vulnerable time in a woman’s life. At our practice, we are dedicated to empowering women through this journey by providing personalized care plans tailored to the unique needs of perimenopausal women. We understand that this transition isn’t just about managing symptoms – it’s about taking steps toward improving your quality of life, enhancing your health span, and maintaining vitality for years to come. Our integrative, evidence-based approach focuses on treating the root causes of symptoms while offering holistic support to help women feel balanced and rejuvenated. From tailored nutrition advice and lifestyle changes to advanced therapeutic options, we support women in making informed choices that allow them to flourish.
We also provide targeted treatments that support cognitive function and cardiovascular health, reducing the risk of chronic conditions such as heart disease and osteoporosis. The benefits of integrating mindfulness, physical activity, and balanced nutrition are profound, and they form the foundation of how we help women improve their lives during perimenopause.
We encourage any woman experiencing perimenopause symptoms to speak to their doctor about the possibility of perimenopause and available treatment options.
Our team is here to guide and support you every step of the way. We’re committed to providing the personalized care you deserve, helping you move forward with confidence and strength. You have the power to take charge of your health during perimenopause – and we’re here to help you do just that. To learn more about our support services, contact us at 646.627.8000, fill out this form for a complimentary discovery call, or email Bridget@drbojana.com.
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