Supplements for perimenopause

The perimenopause stack — by symptom cluster

Vasomotor (hot flashes, night sweats)

MHT is the most effective intervention; non-hormonal trial-evidenced options include SSRIs/SNRIs (paroxetine, venlafaxine), gabapentin, and the newer NK3R antagonists (fezolinetant). Supplements with the cleanest signal: saffron 30 mg/day (Kashani 2018 trial showed reduction in vasomotor symptoms), and (with caveats) black cohosh — the 2012 Cochrane was inconclusive, but some standardised extracts have positive RCTs. Discuss black cohosh use with prescriber given rare hepatotoxicity reports.

Sleep and night-time symptoms

Sleep disruption in perimenopause has multiple drivers: vasomotor wake-ups, anxiety, restless legs. Magnesium glycinate 300–400 mg elemental in the evening is the core supplement. L-theanine 200 mg as needed for sleep-onset difficulty. Low-dose melatonin (0.3–0.5 mg) for sleep-phase shifts; not a primary insomnia treatment but useful adjunct. Saffron has signal for sleep-quality improvement in this cohort. If sleep is severely impaired by hot flashes, MHT or non-hormonal alternatives (fezolinetant) outperform supplements substantially.

Mood — anxiety, irritability, depressive symptoms

Saffron 30 mg/day has the cleanest single-supplement signal in perimenopausal mood symptoms — non-inferior to SSRIs in some trials, fewer side effects. Omega-3 (DHA-emphasised) at 2 g/day for depressive symptoms. Ashwagandha (KSM-66) 300–600 mg/day for anxiety component (avoid in thyroid disease). For clinical depression, this is a primary-care or psychiatry conversation — not a supplement-only approach.

Bone health — start prevention now, not later

Perimenopause is the inflection point for accelerated bone loss; bone density should be assessed if risk factors warrant (FRAX, DXA). Vitamin D3 1000–2000 IU/day to target 30–50 ng/mL. Calcium 1000–1200 mg/day total intake — diet-first, supplement only the gap, take with food. Vitamin K2 (MK-7) 100–180 mcg/day modulates calcium handling. Weight-bearing and resistance exercise outweighs all supplements for bone density.

Cardiovascular shift

Perimenopause is when LDL, blood pressure, and lipid trajectories often worsen. Omega-3 EPA/DHA 1–2 g/day for cardiovascular substrate. Mediterranean-pattern eating and exercise dominate; check BP and lipid panel at this transition.

Heavy or irregular periods

Iron status frequently drops with heavy menstrual bleeding — test ferritin and supplement if low. Don't supplement iron empirically. This is also a moment to evaluate uterine pathology (fibroids, polyps, hyperplasia) — heavy or prolonged bleeding warrants GYN evaluation.

Brain fog

Often improves with treatment of underlying sleep disruption, MHT (if appropriate), and mood. Supplement-aisle effects are modest. Omega-3 DHA, magnesium L-threonate if available, and addressing reversible deficiencies (B12, thyroid, vitamin D) are the high-utility moves. Don't chase "cognitive enhancer" products — the levers are sleep + hormones + cardiovascular health.