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Supplements for Perimenopause: Hot Flashes, Sleep, Mood and What the Trials Show

For perimenopause, supplements help a little at most, and prescription treatments work better. Black cohosh and soy isoflavones cut hot flashes slightly in some reviews but not in others (grade B), and the Menopause Society does not recommend them. Black cohosh has been linked to rare, sometimes serious liver injury. Melatonin, magnesium and fish oil did not ease hot flashes in trials. Ask a clinician about treatment.

Published How we grade evidenceEditorial policy

For hot flashes, night sweats and the sleep they wreck, supplements are a small part of the answer. Here is what the trials show for black cohosh, soy, red clover, melatonin, magnesium, ashwagandha and creatine, what the liver reports on black cohosh say, and what to ask a clinician about instead.

The short version

  • Prescription care works best. Hormone therapy relieves hot flashes best, and several non-hormone options are also recommended; supplements are not. Grade A (NAMS 2023).
  • Black cohosh: reviews disagree. A Cochrane review found no difference from placebo; two newer reviews found a modest benefit for hot flashes. Grade B, mixed (Leach 2012; Sadahiro 2023; Maunder 2026).
  • Black cohosh has been linked to rare, sometimes serious liver injury. Grade C (Mahady 2008; Brar 2021).
  • Soy isoflavones cut hot flashes by under 1 a day in one large pooled analysis, many of its trials at high risk of bias; Cochrane and a perimenopause-only analysis found no clear effect. Grade B (Franco 2016; Lethaby 2013).
  • Melatonin, magnesium and fish oil did not reduce hot flashes against placebo. Grade B (Yi 2021; Park 2015; Mohammady 2018).

What helps perimenopause symptoms most?

Grade A for prescription care, and it is a conversation for your clinician. The North American Menopause Society's 2023 review found that hormone therapy remains the most effective treatment for hot flashes, to be considered within 10 years of the final period. For people who can't or don't want to use hormones, it recommended cognitive behavioral therapy (CBT), clinical hypnosis, some antidepressants (SSRIs and SNRIs), gabapentin and fezolinetant. It advised against supplements and herbal remedies, and against soy foods, soy extracts and equol (NAMS 2023). Which option fits depends on your health history, so this guide gives no hormone or prescription doses.

Perimenopause usually begins in your mid- to late 40s and lasts about four years on average, and you can still get pregnant during it, even if you skip periods (Office on Women's Health). That matters for one herb below.

Does black cohosh work for hot flashes?

Grade B, mixed: the reviews disagree. Black cohosh is a North American root sold for hot flashes. A Cochrane review of 16 trials (2,027 women, with a median dose of 40 mg daily, for about 23 weeks on average) found no difference from placebo in the number of hot flashes in the 3 trials that could be pooled (393 women), or in symptom scores in 4 trials (357 women); hormone therapy worked better (Leach 2012). A 2023 analysis of 22 articles (2,310 women), including products that combined black cohosh with other ingredients, found that black cohosh extracts did better than placebo on overall symptoms and on hot flashes, though not on anxiety or low mood (Sadahiro 2023). Reviewers preparing the International Menopause Society's 2026 update judged the evidence for it moderate in certainty (Maunder 2026).

On our scale, B covers many controlled trials whose reviews disagree, and that is the case here: it is not a sign that black cohosh works, only that some reviews found a modest benefit and Cochrane found none. Our black cohosh page calls the menopause evidence strong; we don't, because the Cochrane review found no difference from placebo in its pooled trials.

Is black cohosh safe for your liver?

Liver injury is rare, but it is reported, and some cases were serious. NCCIH says cases of liver damage, some very serious, have been reported in people taking products labeled as black cohosh; it is uncertain whether black cohosh caused them, and some products contained the wrong herb (NCCIH). A US Pharmacopeia expert review of 30 reports judged each one a possible cause and asked for a caution on product labels (Mahady 2008). In a 2021 case report, a 50-year-old woman developed severe jaundice and itching after taking black cohosh for menopausal symptoms; her liver tests were normal again 6 months after she stopped (Brar 2021). Black cohosh is one of 6 botanicals most often reported for liver injury (Likhitsup 2024).

On the other side, pooled data from 5 trials (1,117 women) of one extract found no change in liver enzymes over 3 to 6 months (Naser 2011). Grade C for the liver risk: case reports, not trials. If dark urine, yellow skin or eyes, itching or unusual tiredness show up while you take it, stop it and get a liver blood test. Our guide to supplements and your liver lists the other herbs with the same warning.

Do soy isoflavones or red clover help hot flashes?

Grade B for a small drop. Isoflavones are plant compounds that act a little like estrogen. In a 2016 analysis of 62 trials (6,653 women), plant estrogens as a group were tied to about 1.3 fewer hot flashes a day, and soy isoflavones to about 0.8 fewer, but 3 in 4 of those trials (74%) were weak on 3 or more quality measures (Franco 2016). Cochrane reviewers, pooling what they could from 43 trials (4,364 women), saw no conclusive benefit. It noted a strong placebo effect, with hot flashes falling by 1% to 59% on placebo, and found that extracts with more than 30 mg a day of genistein (a soy isoflavone) consistently lowered hot flash frequency in 4 trials (Lethaby 2013). In perimenopausal women specifically, a 2025 analysis of 12 trials found no clear effect on hot flashes, though overall symptom scores, palpitations and low mood improved (Luan 2025).

Red clover is another isoflavone source. In 9 trials using 37.1 to 160 mg of isoflavones a day, it lowered hot flash frequency by a small to moderate amount (Jiang 2026). See our red clover page. Our database grades soy isoflavones C for menopause. We give B because there are many controlled trials, but they disagree: one large analysis found about 0.8 fewer hot flashes a day, while Cochrane and a perimenopause-only analysis found no clear effect.

What helps perimenopause sleep?

Grade B that melatonin did not improve sleep quality. In a 2021 analysis of 8 groups (812 women) taking 1 to 5 mg for 3 to 12 months, melatonin did not improve sleep quality in the 4 trials that measured it, nor hot flashes, mood or overall symptom scores; it eased physical symptoms a little (Yi 2021). For valerian, one trial in postmenopausal women found that 530 mg twice a day for a month improved sleep quality, and a review of herbs for menopausal sleep judged the evidence too thin for conclusions (Khadivzadeh 2018); grade C. We found no placebo-controlled trial of magnesium for sleep in perimenopause. Our sleep supplements guide compares the options for everyone else.

Can supplements help mood and anxiety in perimenopause?

Grade C for ashwagandha. In one 8-week trial in 100 perimenopausal women, 300 mg of a root extract twice a day lowered menopause symptom scores, including the psychological ones, more than placebo did (Gopal 2021). It is one trial, ashwagandha has caused liver injury in published cases (Björnsson 2020), and NCCIH says it is not recommended for people with autoimmune or thyroid disorders (NCCIH).

Across 32 placebo-controlled trials of diets and supplements in women around menopause, depressive and anxiety symptoms eased a little, but the trials differed so much that the effect of any single approach is unclear (Grigolon 2023). A 2025 analysis of 7 placebo-controlled trials found probiotics eased menopausal and hot flash scores; its conflict-of-interest statement says several of its authors work with, or for, a women's health company (Andrews 2025). Grade C. Our anxiety guide covers the rest.

What about joint aches, bones and muscle?

Grade C that calcium with vitamin D does not ease joint aches. In a Women's Health Initiative subgroup of 1,911 postmenopausal women, 1,000 mg of calcium with 400 IU of vitamin D a day did not change joint pain or swelling at 2 years (Chlebowski 2013). Our joint pain guide grades the other options. For bones, the 2026 review found moderate-certainty evidence that vitamin D lowers fracture risk, and high-certainty evidence that it is safe (Maunder 2026). Upper limit for adults: 4,000 IU of vitamin D a day, because more can raise blood calcium too high; take more only with blood tests or your clinician's advice (NIH ODS; check your stack).

Grade B for creatine with weight training, for muscle. Across 7 trials (608 postmenopausal women), creatine added about 0.37 kg of lean mass (5 trials) and 7.5 kg to leg-press strength (3 trials), mostly at 5 g a day or more with resistance training; bone density did not change (Naddafha 2026). In the largest trial, 237 women took creatine (0.14 g a day for each kg they weighed) or placebo while training for 2 years, and hip and spine bone density did not differ (Chilibeck 2023). These trials were after menopause, not during perimenopause. See our creatine page.

What we'd skip

  • Evening primrose oil for hot flashes. Hot flashes were no less frequent or shorter than on placebo, and the review called the evidence insufficient (Thevi 2024).
  • Fish oil for hot flashes. In 3 trials (483 women), hot flashes were no less frequent or severe than on placebo, though night sweats were a little less frequent (Mohammady 2018).
  • Magnesium for hot flashes. In 289 women with a history of breast cancer, 800 or 1,200 mg of magnesium oxide a day did no better than placebo and caused more diarrhea (Park 2015). Upper limit for adults: 350 mg a day of magnesium from supplements, because more causes diarrhea; take more only with blood tests or your clinician's advice (NIH ODS).
  • Melatonin for hot flashes. It did not ease vasomotor symptoms in pooled trials (Yi 2021).
  • Blue cohosh. It is a different herb from black cohosh, and NCCIH says it may cause high blood pressure, high blood sugar and chest pain (NCCIH).

Safety and interactions

When to see a doctor

  • Any bleeding or spotting after 12 months in a row without a period, even a small amount, or spotting between periods (MedlinePlus; Office on Women's Health).
  • Periods that stop before age 40: ask about testing (Office on Women's Health).
  • Hot flashes or lost sleep that disrupt your days. Prescription options with the strongest evidence exist (NAMS 2023).
  • Dark urine, yellow skin or eyes, or itching while taking black cohosh, ashwagandha or any herb.
  • Thoughts of harming yourself: call or text 988 in the US, now.
  • Don't stop a prescribed medicine on your own; ask the prescriber or pharmacist.

FAQ

What is the best supplement for perimenopause? None works as well as prescription treatment. Black cohosh and soy isoflavones cut hot flashes slightly in some reviews but not others (grade B), and the Menopause Society does not recommend supplements.

Does black cohosh really work for hot flashes? The reviews disagree (grade B, mixed). A Cochrane review found no difference from placebo in its pooled trials, while two newer reviews found a modest benefit for hot flashes.

Is black cohosh bad for your liver? Liver injury is rare, but some reported cases were serious (grade C). Stop it and get a liver blood test if dark urine, yellow skin or eyes, or itching appear.

Does magnesium help perimenopause? In a trial of 289 postmenopausal women with a history of breast cancer, magnesium oxide did not reduce hot flashes and caused more diarrhea. We found no placebo-controlled trial of magnesium for sleep in perimenopause.

Does ashwagandha help menopause symptoms? One 8-week trial in 100 perimenopausal women found lower symptom scores (grade C). It has caused liver injury in published cases and is not recommended for people with thyroid disorders.

Does creatine help women around menopause? With weight training, it added a little lean mass and strength in postmenopausal women, but did not change bone density (grade B).

Sources

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