“Wow, you could open a health-food store with all this,” my friend says as she closes the cupboard door in my kitchen. She is not wrong, I realise, as I gaze at the boxes, bottles and pouches of supplements I’ve accumulated since being told by my GP, two years ago, at the age of 43, that I was, officially, perimenopausal.
At a glance, there’s the vitamin D supplement I bought after reading that our natural supply diminishes at this stage of life; rhodiola, which is meant to help with anxiety and reduce cortisol levels; agnus castus for PMT symptoms; and magnesium to help with my midlife insomnia. I have one friend who swears by wild yam to help stomach cramps and another who uses ginkgo biloba to help overcome brain fog.
Over the years, I have collected quite an array of herbal supplements for my intermittent insomnia, and after hearing from the GP that I was menopausal, and starting HRT in 2021, I also began looking into holistic HRT remedies, too.
Dr Louise Newson, a GP and menopause specialist who runs a clinic in Stratford-upon-Avon, says she has seen a big surge in demand for HRT alternatives in recent years. “There is an absolutely huge market nowadays for menopause-related supplements,” she says. “And while it’s understandable that women are looking for a way to relieve symptoms, I would always urge caution in seeing herbal medicines as a cure-all for menopause symptoms.”
The fact is that menopause is big business. According to a 2021 report by American firm Grand View Research, the menopause supplement industry is predicted to reach a whopping US$22.7 billion (NZ$37.9b) by 2028.
This is partly a byproduct of celebrities being more vocal about going through perimenopause. British TV personality Davina McCall has led the way: her programme Sex, Myths and the Menopause, which aired in 2021, helped show women they didn’t have to suffer in silence.
Dr Juliet Balfour, a GP and menopause specialist on the British Menopause Society Medical Advisory Council, says increasing numbers of women are looking to take control of their menopause. “It’s easier for women to source supplements themselves, rather than navigating our overstretched and under-resourced NHS, so supplements are often the first option women will try,” she says.
The issue with the alternative health sector, says Dr Balfour, is that it is largely unregulated and that there is very little in the way of scientific research to indicate that some of the most popular holistic alternatives actually work. Some, she warns, could even have health risks attached if taken in conjunction with HRT. “In my opinion, it is a myth that natural is better,” she says.
“Some supplements, such as black cohosh, St John’s wort and some Chinese herbal medicines, which have proved popular as alternative HRT supplements, can interact with other prescribed and non-prescribed medication, so caution is needed.” For example, NHS guidelines state that it’s not safe to take St John’s wort as well as clinical HRT, as it could mitigate the effect of the HRT and even exacerbate anxiety.
Dr Balfour, who also runs a menopause clinic in Wells, Somerset, thinks that women like me could be being exploited. “Companies are making money out of women who are desperate to find ways to cope with their symptoms and the stresses of midlife. Supplements can be very expensive and are being marketed specifically for midlife women.”
There also seems to be a persistent hangover from one highly publicised yet misleading study in 2002, which linked HRT to an increased risk of breast cancer. Dr Shahzadi Harper, who runs a women’s health clinic in London and specialises in perimenopause, says the 2002 Women’s Health Initiative (WHI) study caused significant concern. “I had just qualified as a GP at the time, and didn’t really receive any training around the menopause and HRT,” she says. “Women and doctors alike panicked after that study; women stopped taking it and doctors stopped prescribing it.”
Subsequent research provided more nuanced findings, Dr Harper says. “The women recruited in that study were more than 10 years postmenopause, and had a median age of 63 years and a BMI of 28, meaning that their baseline risk for breast cancer and cardiovascular disease was already higher than average.”
While the risks associated with HRT vary depending on a number of factors such as age, BMI, and the type of hormones used, it’s also worth noting that newer, body-identical hormones have less risk attached to them.
Twenty-one years on from that study, the demand for herbal HRT alternatives is higher than ever. Emma Bardwell, a qualified nutritionist who specialises in menopause, believes that so-called “meno-washing” is also a side effect of the burgeoning menopause market. “Essentially, brands are sticking the word ‘meno’ on supplements, skincare and food labels, and tripling the price,” Bardwell says. And although we need to normalise menopause as much as possible, celebrities haven’t necessarily helped when it comes to providing the right sort of guidance.
“You know we’ve reached peak menopause when Oprah gets involved,” Bardwell says. Influencers have also been quick to get on the menopause bandwagon. The problem is that many aren’t qualified to talk about health, diet, HRT or supplements. “The content they’re putting out has the potential to be confusing at best and damaging at worst, and the public are buying into it without a second thought, simply because the person has a large Instagram platform.”
Marketing v evidence
Dr Newson points out, however, that some supplements can have benefits for women during perimenopause. “There are two that I take – magnesium and vitamin D. Studies show that magnesium is beneficial for sleep, anxiety, headaches and bone strength, all issues that women should be mindful of during the perimenopause and menopause. I have also found that taking magnesium reduces the frequency of my migraines,” she says.
I have to say I’ve also found magnesium good for helping to ease my insomnia and relax me at night. And it’s good to hear that vitamin D has bona fide benefits, too. “Bone health is so important, as the risk of osteoporosis rises sharply for women postmenopause, so guidelines recommend taking vitamin D to help your body absorb calcium, which in turn supports healthy bones,” Dr Newson says. She also points out that there’s evidence the supplements isoflavones and black cohosh may help relieve hot flushes and night sweats.
“Women ask me a lot about plant phytoestrogens, which are plant-derived compounds that have a similar structure to human oestrogen. You can look to increase the amount of phytoestrogens in your diet by increasing the amount of fruit [plums, pears, apples, grapes and berries] and vegetables [including beans, sprouts, cabbage, spinach, soya beans, grains, onions and garlic] you eat, but it is worth pointing out that they do not have the same potency as the oestrogen produced by your body, so will not have a very significant effect,” she says.
“Plus, there is no evidence that phytoestrogens are beneficial for menopause symptoms or future health in the way that oestrogen in HRT has been shown to be.”
Dr Newson is also asked frequently about the benefits of taking St John’s wort. “While there is some evidence that St John’s wort may be of benefit in the relief of symptoms such as hot flushes, there’s uncertainty about appropriate doses, persistence of effect, variation in potency and potential serious interactions with other drugs, such as tamoxifen.”
Sandra Ishkanes, a functional medicine practitioner at Gynelogic, an alternative health clinic, says that there are some holistic alternatives that have proven benefits, such as the protein supplement N-acetyl cysteine, which was found in a 2019 study to help prevent the development of osteoarthritis. “It’s my go-to supplement for joint pain in menopause,” she says. Ishkanes also believes that vitamin C and collagen can boost skin health and radiance. “Both are integral for collagen production, ensuring that the skin retains its radiance and elasticity during menopause.”
However, as Dr Newson points out, although some supplements may help improve symptoms, they will not improve future health in the way HRT can: “Women who take HRT have a lower future risk of developing diseases including heart disease, osteoporosis, Type 2 diabetes, clinical depression, colon cancer and dementia.”
When HRT isn’t an option
Some women, however, are not able to take combined HRT for medical reasons. Lisa Talbot, a 54-year-old personal stylist from Maidenhead, couldn’t take HRT due to a family history of breast cancer, but says holistic supplements have been a “game-changer” for her. “Women like me who can’t take HRT are out on a limb, feeling helpless,” she says. “They need to know there really are alternatives out there that can help them.”
Talbot has been taking a menopause supplement which includes vitamin B12, sage and red clover extracts for about a year and saw a difference in her symptoms within the first month, mainly in the reduction of hot flushes. “I wasn’t sleeping well at night prior to taking it, but, dramatic as it sounds, it has given me my life back. No more sleepless nights, no hot flushes and generally a much better mood.”
Some studies have shown sage to be effective in easing menopause symptoms. In 2011, for example, Swiss researchers discovered that women taking a daily tablet of fresh sage experienced a reduction in hot flushes of 50 per cent in four weeks. After continuing to take sage, hot flushes among the participants in the study were reduced by 64 per cent within eight weeks.
However, Bardwell points out that the research backing up how effective herbal remedies are is often scant. “Anecdotally, some women will find that alternative therapies and treatments help. The placebo effect is powerful, as is state of mind,” she says.
What actually works
Dr Newson observes that women’s health has been under-researched and underfunded for too long. “If we are to help women now and in the future, we need more long-term research into the impact of hormones throughout a woman’s life, particularly during perimenopause and menopause, but also the long-term impact of the benefits of HRT, not just for symptom relief but on overall health.”
Dr Balfour says that, as a menopause specialist, she would rather women didn’t spend money on unproven supplements and home-testing kits for hormone levels: “Women need easier access to support and evidence-based advice on the options that can really help with their symptoms and their long-term health.” These include lifestyle changes, cognitive-behavioural therapy, local oestrogen and HRT. “If you’re eating a healthy and unrestricted diet, most people won’t need to take supplements unless they have particular medical conditions,” Dr Balfour adds.
Dr Newson agrees that a healthy diet is paramount. “Start from there, rather than relying on a bathroom cabinet full of supplements,” she advises.
So, perhaps it’s time I stopped stocking my apothecary cupboard full of supplements and focused more on getting my five a day. I just need to get through the supplements I’ve got first and remember to put through another prescription for my HRT.