If for whatever reason the hormonal route isn’t right for you, you may be interested in exploring nonhormonal prescription medications, botanicals and other supplements that may help alleviate or reduce menopausal symptoms.

What’s more, women are living longer now than ever before, and this new reality raises concerns around the ramifications of low hormone levels during and after the menopausal transition. In other words, because the average age of menopause is 51, the average woman now needs to consider the effects of low hormone levels for a third to half of her life. It’s ultimately a good problem to have, but it only underscores the importance of maintaining our health and exploring all our options for support long-term.

It's essential to assess the effectiveness of the therapeutic(s) you've chosen, just as you would if you chose to pursue hormone therapy. If your primary goal is to alleviate menopausal symptoms, you'll know within a few weeks to months whether the strategy you’ve chosen is working for you. Generally, herbal remedies take longer than prescription medications.

If your goals are to alleviate menopausal symptoms AND to protect your brain, bones, blood vessels, and rest of your body, then it's smart to track bone changes, cardiovascular and metabolic health measurements, and vaginal changes over time as well. This information will give you important feedback to inform your decisions.

Women usually cannot feel bone changes or cardiovascular and metabolic changes, so it’s a good idea to work with your medical provider to monitor your bone density and other long-term health markers. For most women, a heart attack is often the first sign that the blood vessels are diseased, and a fall that results in a broken bone is often the first sign that they have significant bone loss. However, vaginal changes are easier to feel, and may come with an increased frequency of vaginal pain or dryness, urinary tract infections, or pain/discomfort with sex.

Your medical provider may recommend prescription medications that are not hormone-based if you cannot or choose not to use hormone therapy. This is a decision for you and your provider to make together, but it can be helpful to know what options exist as you go in to this discussion. You may want to ask if any of the following could be useful for you:

• Paroxetine (Brisdelle®, Paxil®) - The only antidepressant that is FDA-approved specifically for treating hot flashes. Other antidepressants that are often prescribed but not specifically approved for hot flashes include Venlafaxine (Effexor®), escitalopram (Lexapro®), citalopram (Celexa®), fluoxetine (Prozac®), and sertraline (Zoloft®). Note that even though these medications are antidepressants, they also specifically treat hot flashes, not just mood symptoms.
• Gabapentin (Neurontin®) is a drug primarily used to treat seizures and nerve pain but has been found to relieve/reduce hot flashes in some women. It is more often considered when used with migraine and sleep disorders.
• Oxybutynin is a drug that is typically used to treat overactive bladder and urinary incontinence. It has also been shown to reduce hot flashes (vasomotor symptoms) in some women.
• Fezolinetant (Veozah®) was just recently FDA-approved in May 2023 for treating hot flashes. It works by blocking NKB in the temperature control portion of the brain.

If you’re interested in using supplements or botanicals, keep in mind that it may take longer to see results than it would for prescription drugs. A study comparing the use of soy isoflavones to estrogen therapy for the treatment of hot flashes found that it took approximately three weeks for estrogen therapy to reach its maximum effect, whereas it took the soy isoflavones 48 weeks to reach its maximum effect. Patience is key, and it's important to be realistic in your expectations.

There’s reasonable scientific data supporting the role of some botanicals and supplements in alleviating symptoms of perimenopause and menopause as well as benefiting long term health. However, it can be difficult to draw absolute conclusions as these studies are often not consistent on dosing and can include combinations of remedies. Additionally, head-to-head studies comparing hormone therapy to non-hormonal remedies are lacking.

Below, we’ll review some commonly used supplements.

The following is for educational purposes and not meant to be construed as complete information nor medical advice. Always discuss supplement use with your healthcare provider as some can interact with other medications you may be using.

Basic nutrients

The North American Menopause Society provides guidance on the following basic nutrients:

Calcium is the most abundant mineral in the human body and many bodily processes rely on this element. It is very important in establishing and maintaining bone health throughout a person’s life. It is recommended that calcium be obtained mostly from the diet (1000 mg/day for women 19-50 and 1200 mg/day for women >51) and supplementation is recommended when adequate amounts are not present in the diet.

Vitamin D has many functions in the human body including aiding in the absorption of calcium in the intestines and therefore is important to bone health. Several studies have shown that calcium and Vitamin D supplementation can reduce bone loss and risk of fracture in postmenopausal women. There is debate about the optimal dose of Vitamin D as well as the optimal Vitamin D level in the body.

Omega-3 fatty acids

Omega-3 fatty acids must be consumed in the diet as they cannot be made by the body. Dietary consumption is best, but supplementation has been shown to be beneficial in several conditions such as cardiovascular disease, cognitive function and mood. Preliminary research has shown benefit to hot flashes and mood disorders during the menopause transition, but more studies are needed.

Phytoestrogens

Phytoestrogens ****are plant compounds with estrogenic properties that can act like estrogen in the body. Phytoestrogens have a weaker estrogenic effect compared to the estrogen made in the body.

• Isoflavones are a type of phytoestrogen found in the soy plant. Systematic reviews of the research have shown that supplementation with soy isoflavones may have a positive impact on hot flashes, vaginal dryness, cardiovascular markers, blood pressure, and bone health.
• Red clover contains an isoflavone that may improve hot flashes in postmenopausal women, according to several clinical studies. A small randomized controlled trial found that red clover may improve bone health in healthy post-menopausal women.
• Flaxseed In addition to phytoestrogenic properties, ground flaxseeds are fiber rich and also contain omega-3s and lignans which have many theoretical health benefits including lowering cholesterol and reducing risk of osteoporosis and breast cancer. However, the research is mixed on whether flax improves hot flashes.

St. John's Wort

St. John’s Wort (hypericum perforatum) is widely used to support mood but may also benefit menopause-specific symptoms. In one study, St. John's Wort (270-330 mg three times daily) improved both hot flashes and depression scores in a small group of menopausal women. St. John’s wort is known to interact with many medications, so be sure to discuss it with your healthcare provider.

Black cohosh

Black cohosh (cimicifuga racemosa) is a plant in the buttercup family and its extract has been widely used to remedy menopausal symptoms, especially in Europe. The exact mechanism of action by which black cohosh works is not fully understood. Older studies suggest that black cohosh may have an estrogenic effect on the body, but newer research suggests that it may act on serotonin receptors instead, which can be helpful for hot flashes and mood improvement. Overall, there is not enough high-quality evidence to determine definitively if black cohosh is effective. There are some promising studies, however. Black cohosh combined with St. John's Wort improved menopause symptoms in two small clinical trials. One analysis of studies to date suggests a small benefit to overall menopausal symptom burden and another review found a small benefit to mood and vasomotor symptoms.

L-Theanine

L-theanine is an amino acid that is found naturally in green and black tea and mushrooms. A review of existing studies suggest it may reduce anxiety and stress and promote relaxation and sleep when taken as a supplement. One randomized controlled trial also found a benefit to cognitive function.

Rhubarb

Some research suggests that rhubarb may help ease menopausal night sweats and hot flashes, though more high-quality studies are needed. One small study found that rhubarb may also help to lower cholesterol and improve blood vessel function.

Fenugreek

Fenugreek (Trigonella foenum-graecum) is a clover-like herb that is used in cooking as well as in alternative and Chinese medicine. Randomized controlled trials have shown a significant reduction in hot flashes, and improved mood and sexual function, with fenugreek supplementation.

Maca root

Maca root is a cruciferous vegetable often used as a supplement to promote sexual health and vitality. A preliminary study has shown a reduction in menopause symptoms such as hot flashes, heart palpitations, and sleep disturbances with maca supplementation. Some studies have also shown improvement in male and female sexual function but this data is limited and more research is needed.

Pine Bark

Pycnogenol® (French maritime pine bark) has been shown in clinical trials to reduce perimenopausal and menopausal symptoms and to have antioxidant and anti-inflammatory properties. Overall, small sample sizes, limited numbers of studies per condition, and variation in outcome measures make it difficult to draw definitive conclusions about the efficacy or safety of other pine bark extract supplements.

Adaptogenic herbs

Adaptogens are a class of herbs and plants used for centuries in traditional medicine systems, such as Ayurveda and traditional Chinese medicine. They are prized for their unique ability to help the body adapt to and manage stress. Some adaptogens are thought to help regulate hormone levels, improve energy, and improve mental clarity. Different adaptogens have different benefits.

• Ginseng improved sexual function and relieved menopause symptoms in a small clinical trial.
• Rhodiola may modulate estrogen receptors and could potentially improve mood, cognitive function, and memory, though more clinical research is needed.
• Ashwaganda (Withania somnifera) is an adaptogenic herb believed in Ayurvedic medicine to be neuroprotective, anti-inflammatory, and supportive of a healthy stress and hormonal response. Several small clinical studies suggest that ashwagandha may help balance hormones and reduce specific menopausal symptoms as well as improve sexual function.

There are very few studies comparing acupuncture against hormone therapy. That said, it’s a low-risk intervention with a long history of use in Chinese medicine. Here are a few things the research tells us:

• Acupuncture has been shown in a meta-analysis to improve sleep in perimenopausal women across several studies when compared to or combined with medications.
• Another meta-analysis published found acupuncture to be more effective than antidepressants for mood issues and had significantly fewer side effects than antidepressants.

The bottom line: you live in your body, meaning you get to decide how to support your body during perimenopause, menopause, and beyond. Other options exist if hormone therapy is not the right remedy for you. And if you decide later down the line that nonhormonal remedies aren't providing the results you need, you can always revisit the idea of hormone therapy.