Evidence-graded guideLast updated November 1, 2026

Best Supplements and Herbs for Perimenopause: 9 Ranked by What the Trials Found

The supplements with the best evidence for perimenopause are black cohosh for hot flashes and night sweats, ashwagandha for the mix of poor sleep, anxiety and flashes that defines the transition, and St John's wort for the low mood that often arrives with it, followed by magnesium for sleep, red clover isoflavones, and creatine with resistance training for the muscle and bone that start slipping in the mid-forties. None of these is as effective as hormone therapy, and we say so. But perimenopause lasts 4 to 8 years on average, many women cannot or prefer not to take hormones, and these are the options that have been put in front of a placebo and held up.

Perimenopause is the stretch from the first irregular cycles to a year after the last period, typically from the mid-forties, when oestrogen swings unpredictably rather than simply falling. That is why symptoms are so varied: hot flashes, heavy or erratic periods, insomnia, anxiety, brain fog, joint aches, migraine and a shift of fat to the middle. This page is for women in that window. See a doctor rather than a supplement shelf if you have bleeding between periods, periods heavier than before, bleeding after sex, any bleeding after 12 months without a period, new palpitations, or mood changes with thoughts of self-harm. Thyroid disease, iron deficiency and depression all mimic perimenopause and all need a blood test or a conversation, not black cohosh.

On belly fat, the most-searched perimenopause supplement question: no supplement has been shown to reduce the abdominal fat gain of the menopause transition. We explain what drives it and what actually moves it in the lifestyle section, because pretending a capsule does would be dishonest.

Quick answer

  • Black cohosh — reduced hot flashes and menopause symptom scores versus placebo in most trials; the best-tested non-hormonal herb
  • Ashwagandha — 600 mg/day cut total perimenopause symptom scores and hot flashes in an 8-week RCT
  • St John's wort — improves mild-to-moderate low mood, and with black cohosh reduced flashes and mood scores in a 16-week RCT
  • Magnesium — improves sleep onset and quality in older adults who are low; useful for the 3 a.m. waking of perimenopause
  • Red clover isoflavones — 80 mg/day modestly reduced hot flash frequency in a Cochrane analysis
  • Creatine plus resistance training — preserved hip bone density and built strength in a 12-month trial of postmenopausal women

The 9 best herbs and supplements for perimenopause

Ranked by the strength of human evidence. Strong = multiple trials or a meta-analysis. Moderate = a few small trials. Preliminary = early or animal data.

  1. Black cohosh

    Moderate evidenceActaea racemosa

    Black cohosh is the most-studied herb for the transition. A 2012 Cochrane review of 16 trials (2,027 women) found no significant advantage over placebo when all extracts were pooled, but the trials using the standardised isopropanolic extract (Remifemin, 40 mg/day) have been more consistently positive: a 12-week German trial of 304 women found Kupperman menopause scores fell by 7 points more than placebo, with the biggest effect in early perimenopause. Later meta-analyses restricted to this extract report hot flash reductions of roughly 25% beyond placebo. Not a huge effect, but real, and the safety record over 20 years is reassuring.

    Key evidence
    2012 Cochrane review of 16 RCTs (Leach) and the 2005 Osmers RCT of the isopropanolic extract, 304 women
    Studied dose
    20 mg twice daily of a standardised isopropanolic extract (Remifemin) or 40–80 mg/day of a root extract standardised to 2.5% triterpene glycosides, for 8–12 weeks
    Best for
    Hot flashes and night sweats in early perimenopause, in women who cannot or do not want to take hormones
    Cautions
    Rare case reports of liver injury: stop and get tested if you develop nausea, dark urine or jaundice, and avoid with existing liver disease. Not studied in women with a history of breast cancer; discuss with your oncologist. May add to the effect of blood-pressure drugs. Not for pregnancy.
    Full Black cohosh profile

  2. Ashwagandha

    Moderate evidenceWithania somnifera

    An 8-week placebo-controlled RCT of 91 perimenopausal women aged 45–55 found 300 mg twice daily of a root extract (KSM-66) reduced total Menopause Rating Scale scores significantly more than placebo, with improvements in hot flashes, sleep, anxiety and urogenital symptoms, and a rise in serum oestradiol alongside a fall in FSH and LH. Separate RCTs show it lowers cortisol by about 25%, improves sleep onset and quality, and reduces anxiety scores. That is a useful fit for perimenopause, where stress hormones and poor sleep amplify every other symptom. One trial is not a body of evidence, so it sits at Moderate.

    Key evidence
    2021 placebo-controlled RCT in perimenopausal women (Gopal), 91 participants
    Studied dose
    300 mg twice daily of a root extract standardised to withanolides (KSM-66 or Sensoril), for 8 weeks
    Best for
    Women whose worst symptoms are sleep, anxiety and feeling wired, with hot flashes on top
    Cautions
    Can raise thyroid hormone levels, so monitor if you take levothyroxine or have thyroid disease. Rare liver injury reports. Sedating and additive with sleeping tablets and alcohol. Avoid with hormone-sensitive breast cancer until more is known, and in pregnancy.
    Full Ashwagandha profile

  3. St John's wort

    Moderate evidenceHypericum perforatum

    Low mood and irritability are among the most common perimenopause complaints, and St John's wort has a large evidence base for mild-to-moderate depression: a 2008 Cochrane review of 29 trials (5,489 people) found it as effective as standard antidepressants with fewer side effects. For the transition specifically, a 16-week RCT of 301 women found a combination of St John's wort and black cohosh cut Menopause Rating Scale scores by 50% versus 20% on placebo and halved depression scores. A 12-week trial of St John's wort alone in 100 perimenopausal women found improved mood and fewer hot flashes. It is the strongest option here for the psychological side of perimenopause, but its drug interactions are serious.

    Key evidence
    2006 RCT of St John's wort plus black cohosh (Uebelhack), 301 women; 2008 Cochrane review for depression
    Studied dose
    900 mg/day of an extract standardised to 0.3% hypericin (300 mg three times daily), for 8–16 weeks
    Best for
    Perimenopause with low mood, tearfulness and irritability as the dominant symptoms, in women taking no interacting medication
    Cautions
    Induces liver enzymes that lower the levels of many drugs: hormonal contraception, HRT, SSRIs (serotonin syndrome risk), warfarin, digoxin, statins, some blood-pressure and migraine drugs, and many others. Never combine with an antidepressant. Causes photosensitivity. Not for pregnancy or bipolar disorder.
    Full St John's wort profile

  4. Magnesium

    Moderate evidence

    There is no perimenopause-specific magnesium trial, but the sleep and mood evidence transfers. An 8-week RCT of 46 older adults with insomnia found 500 mg/day improved sleep onset, sleep time and early-morning waking versus placebo, and a 2017 systematic review found reduced subjective anxiety in vulnerable groups. A small open study in breast cancer survivors reported 400–800 mg/day reduced hot flashes by about 40%, but the only placebo-controlled follow-up found no difference from placebo for flashes. So: take it for sleep, mood and the muscle aches of perimenopause, not for flashes.

    Key evidence
    2012 RCT in older adults with insomnia (Abbasi), 46 participants
    Studied dose
    300–400 mg elemental magnesium/day as glycinate, taken an hour before bed, for 6–8 weeks
    Best for
    Night waking, restless legs, muscle cramps, headaches and anxiety; a low-risk first step
    Cautions
    Loose stools are the limiting side effect; glycinate is gentlest. Separate from thyroid medication, tetracycline and quinolone antibiotics, and bisphosphonates by 4 hours. Avoid supplementing in kidney disease without advice.
    Full Magnesium profile

  5. Red clover isoflavones

    Moderate evidenceTrifolium pratense

    Red clover supplies the isoflavones formononetin and biochanin A, which act weakly on oestrogen receptors. The 2013 Cochrane review of phytoestrogens found that trials of a standardised red clover extract (Promensil, 80 mg isoflavones/day) showed a small reduction in hot flash frequency, while the large ISOFLAVONE trial of 252 women found no significant benefit at 12 weeks. A 2015 meta-analysis of 11 trials reported about 1 fewer flash per day versus placebo. The effect is modest, slower than black cohosh (allow 12 weeks), and more consistent in women with frequent flashes (more than 5 a day).

    Key evidence
    2013 Cochrane review of phytoestrogens for vasomotor symptoms (Lethaby), 43 RCTs
    Studied dose
    40–80 mg/day of red clover isoflavones from a standardised extract, for at least 12 weeks
    Best for
    Women with frequent hot flashes who want a mild, slow-acting option and have no history of hormone-sensitive cancer
    Cautions
    Acts on oestrogen receptors, so avoid with a history of breast, ovarian or uterine cancer, and with tamoxifen or aromatase inhibitors. Has coumarin-like compounds; discuss with your doctor if you take warfarin or antiplatelets and stop 2 weeks before surgery. Not for pregnancy.
    Full Red clover isoflavones profile

  6. Creatine monohydrate

    Moderate evidence

    Oestrogen loss accelerates muscle and bone loss from the mid-forties, and creatine with resistance training is the best-supported nutritional counter. A 12-month RCT of 47 postmenopausal women found 0.1 g/kg/day (about 7 g) of creatine with supervised training preserved femoral neck bone density (a 1.2% loss versus 3.9% with training alone) and increased bench-press strength more. A 2021 review of creatine across the female lifespan concluded it improves strength and lean mass in middle-aged and older women and may help mood and cognition during low-oestrogen phases. It does nothing for hot flashes; its role is protecting what the transition erodes.

    Key evidence
    2015 12-month RCT of creatine plus resistance training in postmenopausal women (Chilibeck)
    Studied dose
    3–5 g/day creatine monohydrate, daily, combined with resistance training at least twice a week
    Best for
    Women over 45 who are losing strength, noticing softer arms and legs, or have a family history of osteoporosis
    Cautions
    Mild water retention in the first weeks. Check kidney function first if you have kidney disease. Useless without training; it is a training amplifier, not a stand-alone treatment.
    Full Creatine monohydrate profile

  7. Vitamin D

    Moderate evidenceCholecalciferol (D3)

    Bone loss accelerates to 1–2% a year in late perimenopause, and vitamin D is needed to absorb the calcium that slows it. About 40% of women in their forties and fifties are deficient. A 2019 US Preventive Services Task Force review found vitamin D with calcium reduces fractures modestly in deficient and older adults but not in replete ones, and VITAL found no fracture benefit from 2,000 IU/day in a mostly replete population. Deficiency is also linked to low mood, muscle pain and fatigue, all of which are easy to misattribute to hormones. Test, then correct.

    Key evidence
    2022 VITAL fracture analysis (LeBoff) and 2019 USPSTF evidence review
    Studied dose
    1,000–2,000 IU (25–50 mcg) vitamin D3 daily with a meal; 4,000 IU/day for 3 months if 25(OH)D is under 30 nmol/L
    Best for
    Every perimenopausal woman with a 25(OH)D under 50 nmol/L, and anyone with joint pain, fatigue or low mood that has not been explained
    Cautions
    Doses above 4,000 IU/day long term can raise blood calcium, especially alongside calcium supplements or thiazide diuretics. Check levels with sarcoidosis, kidney stones or hyperparathyroidism.
    Full Vitamin D profile

  8. Omega-3 (EPA-rich fish oil)

    Preliminary evidence

    The hot flash trial was negative: a 12-week RCT of 355 women found 1.8 g/day omega-3 no better than placebo for flash frequency. The mood data are better. An 8-week RCT of 20 women with perimenopausal depression found 2 g/day of EPA-rich fish oil improved depression scores (with hot flashes also falling), and meta-analyses of EPA-predominant formulas show a modest antidepressant effect as an add-on. Omega-3 also lowers triglycerides, which rise after menopause, and may ease the joint aches many women report. Take it for mood and heart, not for flashes.

    Key evidence
    2014 MsFLASH RCT of omega-3 for hot flashes (Cohen), 355 women, negative; 2009 pilot RCT in perimenopausal depression (Freeman)
    Studied dose
    1–2 g/day of EPA+DHA with at least 60% EPA, with a meal, for 8 weeks
    Best for
    Low mood, joint stiffness and rising triglycerides in women who eat little oily fish
    Cautions
    Above 3 g/day increases bleeding time; discuss with your doctor if you take anticoagulants or have heavy perimenopausal periods. Choose a brand tested for oxidation and mercury.
    Full Omega-3 (EPA-rich fish oil) profile

  9. Sage (Salvia officinalis)

    Preliminary evidenceSalvia officinalis

    Sage is a traditional remedy for sweating, and the evidence is one 8-week open-label Swiss study of 71 menopausal women in which a fresh sage leaf tablet reduced mean hot flashes by 50% at 4 weeks and 64% at 8 weeks, with severe flashes falling by 79%. There was no placebo group, and placebo alone typically cuts flashes by 20–30%, so the true effect is unknown. A 2023 placebo-controlled Iranian trial of 60 women found 100 mg of sage extract daily reduced hot flash scores more than placebo, which is encouraging but small. Cheap, pleasant as tea, and worth a trial once the better-evidenced options have been tried.

    Key evidence
    2011 open-label study of fresh sage tablets (Bommer), 71 women
    Studied dose
    280 mg/day of a fresh sage leaf extract tablet, or 1–3 cups of sage tea daily, for 8 weeks
    Best for
    Night sweats and daytime flashes in women who want a food-level option alongside lifestyle changes
    Cautions
    Sage essential oil and high-dose extracts contain thujone, which is neurotoxic in excess: stick to leaf extracts and tea, and avoid concentrated oil. Not for pregnancy or breastfeeding. May lower blood glucose and interact with sedatives and anticonvulsants.
    Full Sage (Salvia officinalis) profile

How to choose

  • If hot flashes and night sweats are the main problem, start with black cohosh (isopropanolic extract, 40 mg/day) and give it 8 weeks; add red clover or sage if you need more and have no cancer history.
  • If the problem is sleep, anxiety and feeling wired, with flashes on top, ashwagandha 600 mg/day plus magnesium at bedtime is the better pairing.
  • If low mood and irritability dominate and you take no interacting medication, St John's wort 900 mg/day has the strongest evidence of anything here; if you take an antidepressant, the pill or HRT, it is off the table and you should talk to your doctor instead.
  • If you are losing strength or have a family history of osteoporosis, creatine with two resistance sessions a week, vitamin D and dietary calcium are the priorities; nothing else here protects bone.
  • If symptoms are severe (flashes hourly, no sleep, unable to work), ask about menopausal hormone therapy: for most healthy women under 60 it is safe, and it reduces flashes by 75–90% where the best herb manages 25–50%.
  • Run one new supplement at a time for 8–12 weeks and keep a simple symptom diary (flashes per day, nights with waking, a 1–10 mood score), because perimenopause symptoms fluctuate so much that memory alone will fool you.

What to skip

Anything sold for 'perimenopause belly fat'

No supplement has reduced abdominal fat gain in the menopause transition in a controlled trial. The shift of fat to the abdomen is driven by falling oestrogen, lower muscle mass and poorer sleep, and the only things shown to move it are resistance training, a calorie deficit, protein, sleep and, where appropriate, hormone therapy. Green tea extract, CLA, berberine and 'cortisol blockers' produce 1 kg or less in 12 weeks at best, and some stress the liver.

Bioidentical hormone creams from compounding pharmacies or online

Compounded progesterone and oestrogen creams are untested for dose, absorption and safety, and the Endocrine Society and NAMS both advise against them. If you want hormones, regulated body-identical oestradiol and micronised progesterone are available on prescription, with trial data.

Dong quai

The one placebo-controlled trial (71 women, 24 weeks) found no effect on hot flashes or vaginal cells, and dong quai contains coumarins that interact with warfarin and cause photosensitivity. Traditional use is in multi-herb formulas, not alone.

Evening primrose oil for hot flashes

A 6-month placebo-controlled trial found it no better than placebo for flashes, and a later small trial showed a benefit in severity but not frequency. It is more plausibly useful for cyclical breast pain than for the transition.

Safety and when to see a clinician

  • See a clinician if you have bleeding between periods, periods much heavier than before, bleeding after sex, any bleeding more than 12 months after your last period, new palpitations, or depression with thoughts of self-harm. The first four need an ultrasound or biopsy to rule out polyps, fibroids and endometrial changes.
  • Get thyroid function, ferritin and a full blood count checked before blaming symptoms on hormones: hypothyroidism and iron deficiency produce the same fatigue, brain fog, hair loss and mood changes and are easier to fix.
  • St John's wort interacts with more drugs than any other herb on this site, including antidepressants, hormonal contraception, HRT, warfarin, statins and migraine medication. Do not start it without checking every medication you take.
  • Phytoestrogens (red clover, soy isoflavones) and black cohosh have not been proven safe after hormone-sensitive breast cancer and may interact with tamoxifen; discuss with your oncologist first.
  • Liver: black cohosh and ashwagandha both have rare case reports of liver injury. Stop and get tested if you develop nausea, dark urine, pale stools or jaundice.
  • Contraception is still needed until 12 months after your last period (24 months if under 50). St John's wort reduces the reliability of hormonal contraception; perimenopausal pregnancy is rarer but not rare.

What matters as much as any herb

  • Resistance training two or three times a week is the single most effective intervention for the abdominal fat, muscle loss and bone loss of perimenopause, and the only one that reverses the first two.
  • Protein at 1.2–1.6 g/kg/day, spread across meals, preserves muscle and reduces the hunger that drives midlife weight gain; most women in their forties eat about half this.
  • Alcohol is the most reliable hot flash and night sweat trigger in diary studies, along with spicy food, hot drinks and warm rooms. A two-week alcohol break is a fair test before any supplement.
  • Cognitive behavioural therapy for menopause (CBT-Meno) reduced the impact of hot flashes and improved sleep and mood in several RCTs and is recommended by NICE and NAMS; it is available as self-help books and online programmes.
  • Sleep hygiene matters more now than at any earlier age: a cooler bedroom (18°C), fixed wake time, no alcohol within 3 hours of bed and daylight in the morning reduce night waking and the 3 a.m. anxiety that perimenopause brings.

Frequently asked questions

What is the best supplement for perimenopause?

For hot flashes, black cohosh (standardised isopropanolic extract, 40 mg/day) has the most trials. For the combination of poor sleep, anxiety and flashes, ashwagandha has the best single perimenopause-specific RCT. For low mood, St John's wort, if you take no interacting medication. None matches hormone therapy, which reduces flashes by 75–90%.

Do any supplements help perimenopause belly fat?

No. No supplement has reduced the abdominal fat gain of the menopause transition in a controlled trial, and the products sold for it (green tea extract, CLA, 'cortisol blockers') produce under 1 kg in 12 weeks at best. The fat shift is driven by falling oestrogen, lost muscle and poor sleep; resistance training, protein, a modest calorie deficit and sleep are what move it, and hormone therapy reduces central fat gain in trials.

Which herbs are good for perimenopause anxiety and mood?

St John's wort has the strongest evidence for low mood, with a Cochrane review of 29 trials and a perimenopause-specific RCT in combination with black cohosh. Ashwagandha reduced anxiety and sleep scores in perimenopausal women in an 8-week RCT. Magnesium helps sleep and mild anxiety in people who are low. Lavender oil (Silexan) has generalised anxiety trials but no perimenopause-specific data.

How long do perimenopause supplements take to work?

Black cohosh and ashwagandha showed differences from placebo by 4 weeks with full effect at 8–12 weeks. Red clover and other phytoestrogens need 12 weeks. St John's wort takes 2–4 weeks for mood. Magnesium can improve sleep within a week or two. If nothing has changed after 12 weeks at a studied dose, stop it.

Can I take black cohosh and St John's wort together?

Yes, and the combination has the best perimenopause trial of either herb: 301 women over 16 weeks had a 50% drop in menopause symptom scores versus 20% on placebo. The constraint is St John's wort's interactions, so the combination is only for women taking no antidepressant, hormonal contraception, HRT, warfarin, statin or other interacting drug.

Is it safe to take perimenopause supplements with HRT?

Magnesium, vitamin D, omega-3 and creatine are fine with HRT. St John's wort reduces HRT levels and must be avoided. Black cohosh and red clover are unnecessary once HRT controls flashes and have not been studied alongside it. Ashwagandha has no known HRT interaction but no data either; tell your prescriber.

Should I take collagen or biotin for perimenopause hair and skin changes?

Collagen peptides at 2.5–10 g/day have a dozen small RCTs showing improved skin elasticity and hydration, with the largest effect in women over 50, so it is a reasonable choice. Biotin only helps if you are deficient, and it interferes with thyroid and other blood tests. Hair thinning in perimenopause should prompt a ferritin and thyroid check before any supplement.

References

  1. Leach MJ, Moore V. Black cohosh (Cimicifuga spp.) for menopausal symptoms. Cochrane Database of Systematic Reviews (2012)View source
  2. Gopal S, Ajgaonkar A, Kanchi P, et al.. Effect of an ashwagandha (Withania somnifera) root extract on climacteric symptoms in women during perimenopause: a randomized, double-blind, placebo-controlled study. Journal of Obstetrics and Gynaecology Research (2021)View source
  3. Uebelhack R, Blohmer JU, Graubaum HJ, et al.. Black cohosh and St. John's wort for climacteric complaints: a randomized trial. Obstetrics and Gynecology (2006)View source
  4. Lethaby A, Marjoribanks J, Kronenberg F, et al.. Phytoestrogens for menopausal vasomotor symptoms. Cochrane Database of Systematic Reviews (2013)View source
  5. Bommer S, Klein P, Suter A. First time proof of sage's tolerability and efficacy in menopausal women with hot flushes. Advances in Therapy (2011)View source
  6. Cohen LS, Joffe H, Guthrie KA, et al.. Efficacy of omega-3 for vasomotor symptoms treatment: a randomized controlled trial. Menopause (2014)View source
  7. Chilibeck PD, Candow DG, Landeryou T, et al.. Effects of creatine and resistance training on bone health in postmenopausal women. Medicine and Science in Sports and Exercise (2015)View source
  8. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause (2023)View source
  9. Abbasi B, Kimiagar M, Sadeghniiat K, et al.. The effect of magnesium supplementation on primary insomnia in elderly: a double-blind placebo-controlled clinical trial. Journal of Research in Medical Sciences (2012)View source
  10. Davis SR, Castelo-Branco C, Chedraui P, et al.. Understanding weight gain at menopause. Climacteric (2012)View source
  11. LeBoff MS, Chou SH, Ratliff KA, et al.. Supplemental vitamin D and incident fractures in midlife and older adults. New England Journal of Medicine (2022)View source
  12. Black cohosh. National Center for Complementary and Integrative Health (2020)View source

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This guide is educational and is not medical advice. Herbs and supplements can interact with prescription medicines and are not regulated like drugs. Talk with a clinician or pharmacist before starting anything new, especially if you are pregnant, breastfeeding, have a chronic condition, or take medication.