When it comes to perimenopause, the biggest hormonal change that anyone with ovaries will go through, we’re left in the dark, or worse, brushed off, symptoms dismissed (this is especially true for African American and Latina women, who, on average, go through menopause earlier than white women, and also experience worse symptoms).^{1 2} When I asked my gynecologist about my cluster of symptoms, she seemed to only hear my complaint of weight gain, told me to eat less, and welcomed me to middle age. I left the appointment so disheartened, but I can’t blame her: A 2023 survey published in the journal Menopause found that nearly 70 percent of OB/GYN residency programs in the U.S. lacked curriculums dedicated to menopause, and a 2019 Mayo Clinic survey of medical residents (specializing in family medicine and obstetrics and gynecology) found that only 6.8 percent reported feeling “adequately prepared to manage women experiencing menopause.”^{3 4}

Rather than being taken seriously, “the Change,” as it’s been coined, became a joke, a trope of women gone mad with rage and hot flashes, that no one really seemed to want to talk about. But the tide is changing. Women are talking about their symptoms, we’re connecting the dots, and we are seeking out ways to manage those symptoms.

What is perimenopause?

I’d never given much thought to perimenopause, and only vaguely thought of menopause as something that was very far in my future. Little did I know that perimenopause would knock me off my feet, at a time when I still felt so young. So what is it exactly? Perimenopause is the transition period leading up to menopause (menopause is when the ovaries completely stop producing estrogen and you haven’t had a period for a full year; fun fact: menopause is exactly one day—the day you haven’t had a period for 12 months, after that, you are considered post-menopausal). Perimenopause starts in your early to mid-40s on average, but it can start as early as your 30s and it can last between four and 10 years.⁵ It is a time of wild hormonal fluctuations, with extreme ups and downs, but with a general pattern of declining estrogen (and progesterone) production. It’s a time in which your monthly period can become unpredictable, sometimes not happening at all, and other times coming like a 100-year flood. Every woman’s perimenopausal experience is as unique as she is, and symptoms are far-ranging and some are even surprising. Here is a (non-exhaustive) list, in no particular order: heart palpitations, itchy, crawling skin, insomnia, anxiety, depression, joint pain, vaginal dryness, urinary incontinence, weight gain, especially in the belly, mood swings, loss of libido, brain fog, hair loss/hair thinning, memory loss, vertigo, night sweats, hot flashes, dry mouth, and bleeding gums. As you can see, it’s not just hot flashes; in fact, a survey of perimenopausal women found that the top three symptom complaints were mood swings, brain fog, and fatigue.⁶

It turns out that estrogen affects nearly every part of our bodies, and with its decline, we start experiencing (sometimes weird) symptoms. In addition to the more acute symptoms, long-term effects of estrogen loss—especially if there is no management of symptoms—include muscle loss, bone loss, and a higher risk for insulin resistance and other metabolic dysfunction, dementia, and cardiovascular disease. But there are ways to counteract this, and the perimenopausal years are the perfect window of opportunity for healthy interventions.

Shifting how you eat must become a priority

When it comes to diet, one thing becomes crystal clear during perimenopause: what may have worked for years just doesn’t anymore. Sixty to 70 percent of women report gaining weight during the menopausal transition, particularly in the belly, and this weight gain can be a risk factor for cardiovascular disease.⁷ Perimenopause leads to reduced metabolic flexibility, or the ability to switch between burning carbs and fat for fuel, changes our body composition, with a significant increase in fat mass and a reduction in lean muscle mass, and changes where fat is distributed in our bodies (looking at you, belly fat), making it imperative to adjust how we eat.^{8 9}

Lean into a low-inflammatory diet.

Estrogen plays an important role in modulating inflammation in our bodies, so as estrogen decreases, inflammation increases. Inflammation can increase the severity of menopausal symptoms and the risk of a number of degenerative diseases.^{10 11 12} Now is the time to lean into a low-inflammatory diet. What does that look like? The main things to avoid (or at least strictly limit) include sugars, refined carbohydrates and processed grains, fried foods, high omega-6 vegetable oils, and alcohol, as they are all drivers of inflammation. Instead, fill your plate with quality protein, healthy fats, and loads of fiber-rich vegetables. Take inspiration from the Mediterranean diet, which comes out on top in research for promoting health through perimenopause and beyond, including reducing cardiovascular risk, maintaining bone mineral density and a healthy weight, preventing cognitive decline, improving mood, decreasing hot flashes, and reducing the risk of all-cause mortality.^{13 14 15} This way of eating is based on a foundation of anti-inflammatory and antioxidant-rich foods: seafood, olive oil, pastured dairy and meat, nuts and legumes, vegetables, and an array of spices. 

Learn to prioritize protein.

During the menopausal transition, protein breakdown increases and protein synthesis declines.¹⁶ To counteract the loss of lean muscle mass, it is imperative to eat enough protein. Experts recommend 1.2 grams of protein per kilogram of body weight for perimenopausal women; converted to pounds, that would be 81.6 grams of protein per day for a 150-pound person. If you are very physically active, especially if you are strength training (a must for peri- and post-menopausal women!), those requirements can increase to 2 grams per kilogram of body weight daily.¹⁷ One study found that post-menopausal women who consumed at least 1.1 g/kg body weight daily had lower fat mass and better upper and lower body strength compared to those in the low protein group (less than .8g/kg/body weight/day).¹⁸ Good protein sources include grassfed or regeneratively raised beef, bison, pork, chicken, and eggs; seafood; pasture-based Greek yogurt, cottage cheese, whey protein; and tofu.

It's also important to fill in nutritional gaps with key supplements, including a multivitamin (a multi will cover your bases, including the B-complex vitamins; however, if you opt out of a multi, take a B-complex supplement); vitamin D to keep your bones, immunity, and cardiovascular system in tip-top shape; and magnesium and vitamin K2 to provide cardiovascular support and protect from osteoporosis. A quality omega-3 fish oil is also a must for managing inflammation.

Supplements for your symptoms

Indole-3-carbinol (I3C)

According to Lorna Vanderhaeghe, a women’s health expert and author of Sexy Hormones, perimenopause is a time in which your hormones can fluctuate wildly, with dramatic spikes and drops in estrogen levels, which lead to heavy and/or long periods, mood swings, fatigue, night sweats, uterine fibroids, weight gain, sleep disturbances, and low libido. So, while estrogen levels generally decline throughout perimenopause, they do so in an irregular manner, which can lead to estrogen imbalances. I3C is a compound found in cruciferous vegetables like broccoli and kale and research has shown that it maintains a healthy balance of estrogen by metabolizing more potent, cancer-causing estrogens into non-toxic forms. It also helps eliminate xenoestrogens, estrogen mimickers found in certain plastics, pesticides, conventional cleaning products, cosmetics, etc.

Try: 150-300 mg daily.¹⁹

Progesterone cream

While we often think of estrogen as the only hormone that dramatically decreases during menopause, progesterone levels decline more quickly than estrogen during the perimenopausal years. Progesterone naturally counterbalances estrogen, so this can cause some unwanted symptoms, especially in women who are estrogen dominant. There are progesterone receptors throughout the body—in the brain, the bones, the thyroid, and the breasts—and symptoms of low progesterone can include anxiety, irritability, elevated cortisol (the stress hormone), headaches, heavy and/or prolonged periods, weight gain, breast tenderness, and low bone density. Using a natural progesterone cream can improve these symptoms. On the flip side, progesterone is also important for a woman who has low estrogen levels, because the body converts progesterone into estrogen when levels get too low.^{20 21 22} Because progesterone directly affects hormone levels, and is a precursor to other hormones, it is important to follow the directions on the label and start at the lower dose to find the amount that works well for you.

Black cohosh

The herb black cohosh is one of the most studied—and most widely used—natural treatments for menopausal symptoms and other female hormonal imbalances. It has been shown to be especially effective for reducing the severity and frequency of hot flashes, in addition to reducing other symptoms such as mild anxiety and depression, vaginal dryness, decreased libido, and sleep disturbances. Most research has found that women begin to see relief of symptoms between four and eight weeks of supplementing.

Try: 40-80 mg, twice daily.^{23 24 25 26}

Dong quai

This uterine tonic enhances metabolism, improves liver function (which improves the excretion of hormones), aids in the utilization of vitamin E, and has a mild sedative activity.²⁷ Traditionally, dong quai is believed to have a balancing or “adaptogenic” effect on the female hormonal system. In Traditional Chinese Medicine, dong quai is rarely used alone and is typically used in combination with other herbs.^{28 29} 

Try: 500-750 mg, one to two times per day.

Rhodiola

Recent research has found that black cohosh is even more effective when paired with the adaptogenic herb rhodiola. Rhodiola supports the body during mental and physical stress and has been studied for its ability to reduce anxiety, mental fatigue, stress, and depression. A study published in 2020 showed that a combination of black cohosh and rhodiola was “significantly superior” to black cohosh alone in reducing a number of menopausal symptoms, including hot flashes and sweating, sleep problems, depressed mood, irritability, anxiety, and both physical and mental exhaustion.

Try: 400 mg daily.^{31 32}

Sage

This herb may aid mood swings and hot flashes as well as reduce excessive perspiration due to menopausal hot flashes during the day or at night.³³

Try: 500 mg, one to three times a day.³⁴

Shatavari

A supplement that Kathy Millington, RD, Nutritional Health Coach at Natural Grocers in Lincoln, Nebraska, likes to recommend for healthy sexual function in menopausal women is shatavari. “It's traditionally used in Ayurveda as the main tonic for the female reproductive system. It supports healthy libido and vaginal moisture, and I've had women report back to me that it worked well for them,” she says. Shatavari has hormonal balancing properties, and in Ayurvedic practice, it is said to balance excess pitta, or heat, in the body. Animal research has also found that shatavari has an anti-anxiety effect, similar to a common prescription anti-anxiety medication.³⁵

Try: Doses start at 500 mg daily.³⁶

Resveratrol Through Menopause and Beyond

When hormone levels decrease during menopause, the effects are widely felt throughout the body. In addition to affecting the sex organs, hormones, and estrogen specifically, decreasing hormone levels affect bone development and strength, heart and blood vessel health, brain function, and mood balance. Resveratrol is a polyphenolic free radical scavenger found in many darkly colored foods, most famously wine. But resveratrol also has a lesser-known side, as a phytoestrogen capable of supporting healthy blood vessel function and maintaining optimal circulation. Through these actions resveratrol is a powerful ally for women as they go through the menopause transition and beyond. In one study resveratrol reduced the number and intensity of hot flashes.⁴⁹ The largest, and longest-running study to date on resveratrol and women’s health, the Resveratrol Supporting Healthy Aging in Women (RESHAW) study, found that 75 mg of resveratrol twice daily for 12 months reduced overall pain scores, improved menopausal symptoms, and improved general wellbeing; it improved insulin sensitivity, cerebrovascular health, and cognitive function to ward off cognitive decline; and it improved bone mineral density, leading to a significant improvement in T-scores, which is associated with a reduced risk of major or hip fracture.^{50 51 52}

Vitex (Chaste Tree)

Vitex supports healthy estrogen-to-progesterone balance in the body through several different mechanism of action.³⁷ Although commonly used for PMS and concerns during the childbearing years, vitex also has a strong history of relieving symptoms associated with menopause. In studies, it seems to be particularly effective at reducing vasomotor symptoms (think hot flashes and night sweats).^{38 39}

Try: 500-1000 mg, one to three times a day for three to six months.⁴⁰

Folic acid

This B vitamin may not be the first supplement that comes to mind when building your menopausal supplement kit, but research has shown that it is effective at reducing both the frequency and severity of hot flashes in menopausal women. Hot flashes are the number one reason a woman seeks medical treatment during menopause; not only are they extremely unpleasant, but they can lead to insomnia and fatigue, behavioral changes, including depression and anxiety, memory and concentration problems, and decreased libido. They can decrease a woman’s quality of mental, physical, and social life. A placebo-controlled study conducted in Iran that included 70 menopausal women found that daily supplementation with 1 gram of folic acid significantly reduced the severity, duration, and frequency of hot flashes after four weeks, with no side effects. 

Try: 1 mg daily for at least four weeks.⁴¹

Herbal phytoestrogens

Phytoestrogens in herbs are capable of exerting estrogenic effects, although their activity compared with estrogen is only 2% as strong.⁴² This low activity produces a balancing action of estrogen effects. If estrogen levels are low, the phytoestrogens will exert a slight estrogenic effect. If estrogen levels are high, the phytoestrogens compete with estrogen for absorption at the binding sites and there will be a decrease in estrogen effects.⁴³ A variety of herbs with weak estrogen-like actions, such as licorice, alfalfa, and red clover have traditionally been used for menopausal symptoms.⁴⁴

Proanthocyanidins

These compounds naturally occur in the fruit, bark, leaves and seeds of many plants. Sometimes called OPCs (oligomeric proanthocyanidins) or PCOs (proanthocyanidin oligomers), these compounds are polyphenols that offer significant health benefits. Proanthocyanidins are best known for helping the body fight free radicals and in particular for protecting the integrity of the blood vessels. However, in a lesser known role, they may also improve physical and psychological symptoms of menopause.^{45 46 47} It is somewhat of a mystery how proanthocyanidins impart their benefits because they don’t appear to alter hormone levels directly.⁴⁸ The most concentrated forms of proanthocyandins are grape seed extract and a patented extract of maritime pinebark called Pycnogenol^®.

The importance of slashing stress and supporting the adrenals

“Healthy adrenals are the key to an effortless menopause” according to Lorna Vanderhaeghe, author of Sexy Hormones. Natural practitioners agree that low adrenal function is one of the most common underlying causes of menopausal symptoms. This is why: The adrenals are an important part of the endocrine system, and though they are best known for producing the stress hormones cortisol and adrenaline, as the ovaries stop producing sex hormones the adrenals pick up the slack and start producing estrogen’s precursor hormones DHEA and androstenedione, as well as progesterone. But often, by the time a woman reaches the perimenopausal and menopausal years, her adrenal glands are so depleted that they are unable to produce adequate amounts of the sex hormones, and will instead prioritize production of cortisol. This can worsen menopausal symptoms and increase symptoms related to adrenal deficiency like fatigue and insomnia. Chronic stress depletes the adrenals, so it is critical to focus on reducing stress as much as possible. Also consider supporting adrenal health with supplements such as vitamin C, a B complex, and the adaptogenic herbs panax ginseng, shatavari, holy basil (tulsi), rhodiola. While a B complex and vitamin C are helpful for anyone to support adrenal function, you will likely have to try different adaptogenic herbs to see what works best for you.

A woman’s menopause experience is as unique as she is, but how healthy you are overall as you move into these years plays a huge role in how well your body adapts to the changes. Take care of your general health first, and then focus on lifestyle habits and specific herbs and nutrients to treat symptoms such as hot flashes, night sweats, insomnia, and anxiety. If one product or lifestyle change doesn’t work for you, experiment with others until you find the right combination, so you will not just survive, but thrive, through this time of life! Also consider visiting your local Nutritional Health Coach (NHC) to help you navigate these transformative years.

References

1. Harlow Sioban, Prof Emeritus Epidemiology. “25 years of research shows insidious effect of racism on Black women’s menopausal transition, health,” University of Michigan School of Public Health, Feb 23, 2022. https://sph.umich.edu/news/2022posts/insidious-effect-of-racism-on-blac…
2. Gupta AH. “How Menopause Affects Women of Color,” The New York Times, Aug. 23, 2023 https://www.nytimes.com/2023/08/23/well/live/menopause-symptoms-women-o…
3. Welsh Erin T, MA. “Most OB/GYN residency programs in US lack dedicated menopause curriculum.” Healio, August 10, 2023. https://www.healio.com/news/womens-health-ob-gyn/20230810/most-obgyn-re…
4. Kling JM, MacLaughlin KL, Schnatz PF, Crandall CJ, Skinner LJ, Stuenkel CA, Kaunitz AM, Bitner DL, Mara K, Fohmader Hilsaca KS, Faubion SS. Menopause Management Knowledge in Postgraduate Family Medicine, Internal Medicine, and Obstetrics and Gynecology Residents: A Cross-Sectional Survey. Mayo Clin Proc. 2019 Feb;94(2):242-253. doi: 10.1016/j.mayocp.2018.08.033.
5. Haver, Mary Claire, MD. “What Is Perimenopause?” The ‘Pause Life, https://thepauselife.com/blogs/the-pause-blog/what-is-perimenopause
6. Harper JC, Phillips S, Biswakarma R, Yasmin E, Saridogan E, Radhakrishnan S, C Davies M, Talaulikar V. An online survey of perimenopausal women to determine their attitudes and knowledge of the menopause. Womens Health (Lond). 2022 Jan-Dec;18:17455057221106890. doi: 10.1177/17455057221106890. 
7. Kodoth V, Scaccia S, Aggarwal B. Adverse Changes in Body Composition During the Menopausal Transition and Relation to Cardiovascular Risk: A Contemporary Review. Womens Health Rep (New Rochelle). 2022 Jun 13;3(1):573-581. doi: 10.1089/whr.2021.0119.
8. Eaton SA, Sethi JK. Immunometabolic Links between Estrogen, Adipose Tissue and Female Reproductive Metabolism. Biology (Basel). 2019 Feb 7;8(1):8. doi: 10.3390/biology8010008.
9. Simpson SJ, Raubenheimer D, Black KI, Conigrave AD. Weight gain during the menopause transition: Evidence for a mechanism dependent on protein leverage. BJOG. 2023; 130(1): 4–10. https://doi.org/10.1111/1471-0528.17290
10. McCarthy, M., Raval, A.P. The peri-menopause in a woman’s life: a systemic inflammatory phase that enables later neurodegenerative disease. J Neuroinflammation 17, 317 (2020). https://doi.org/10.1186/s12974-020-01998-9
11. Vegeto E, Benedusi V, Maggi A. Estrogen anti-inflammatory activity in brain: a therapeutic opportunity for menopause and neurodegenerative diseases. Front Neuroendocrinol. 2008 Oct;29(4):507-19. doi: 10.1016/j.yfrne.2008.04.001.
12. Harding AT, Heaton NS. The Impact of Estrogens and Their Receptors on Immunity and Inflammation during Infection. Cancers (Basel). 2022 Feb 12;14(4):909. doi: 10.3390/cancers14040909.
13. Vetrani C, Barrea L, Rispoli R, Verde L, De Alteriis G, Docimo A, Auriemma RS, Colao A, Savastano S, Muscogiuri G. Mediterranean Diet: What Are the Consequences for Menopause? Front Endocrinol (Lausanne). 2022 Apr 25;13:886824. doi: 10.3389/fendo.2022.886824. 
14. Cano A, Marshall S, Zolfaroli I, et al. “The Mediterranean diet and menopausal health: An EMAS position statement.” Maturitas, Vol 139, September 2020. https://doi.org/10.1016/j.maturitas.2020.07.001
15. Carla Gonçalves, Helena Moreira, Ricardo Santos. Systematic review of mediterranean diet interventions in menopausal women[J]. AIMS Public Health, 2024, 11(1): 110-129. doi: 10.3934/publichealth.2024005
16. Simpson SJ, Raubenheimer D, Black KI, Conigrave AD. Weight gain during the menopause transition: Evidence for a mechanism dependent on protein leverage. BJOG. 2023; 130(1): 4–10. https://doi.org/10.1111/1471-0528.17290
17. Simpson SJ, Raubenheimer D, Black KI, Conigrave AD. Weight gain during the menopause transition: Evidence for a mechanism dependent on protein leverage. BJOG. 2023; 130(1): 4–10. https://doi.org/10.1111/1471-0528.17290
18. Gregorio L, Brindisi J, Kleppinger A, Sullivan R, Mangano KM, Bihuniak JD, Kenny AM, Kerstetter JE, Insogna KL. Adequate dietary protein is associated with better physical performance among post-menopausal women 60-90 years. J Nutr Health Aging. 2014;18(2):155-60. doi: 10.1007/s12603-013-0391-2. 
19. Vanderhaeghe L, MS and Pettle A, MD. Sexy Hormones: Unlocking the Secrets to Vibrant Sexual Health;Chapter 5. Basic Health Publications, Inc., 2010
20. Catenaccio E, Mu W, and Lipton M. “Estrogen- and progesterone-meidated structural neuroplasticity in women: evidence from neuroimaging.” Brain Struct Funct. 2016 Nov; 221(8): 3845-3867 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679703/
21. Vanderhaeghe L, MS and Pettle A, MD. Sexy Hormones: Unlocking the Secrets to Vibrant Sexual Health;Chapters 2 and 3. Basic Health Publications, Inc., 2010
22. Prior, JC. “Progesterone for Symptomatic Perimenopause Treatment—Progesterone politics, physiology and potential for perimenopause.” Facts Views Vis Obgyn. 2011;3(2): 109-120. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987489/#!po=75.0000
23. Mehrpooya M, Rabiee S, Larki-Harchegani A, et al. “A comparative study on the effect of “black cohosh” and “evening primrose oil” on menopausal hot flashes.” J Edu and Health Promot2018; 7:36. http://www.jehp.net/temp/JEduHealthPromot7136-5643627_154036.pdf
24. Mohammad-Alizadeh-Charandabi S, Shahnazi M, Bayatipayan S. “Efficacy of black cohosh (Cimicifuga racemose L.) in treating early symptoms of menopause: a randomized clinical trial.” Chin Med. 2013;8:20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4029542/
25. Jiang K, Jin Y, Huang L, et al. “Black Cohosh Improves Objective Sleep in Postmenopausal Women with Sleep Disturbance.” Climacteric. 2015;18:4 https://www.tandfonline.com/doi/full/10.3109/13697137.2015.1042450
26. Northrup C, MD. Women’s Bodies, Women’s Wisdom; Chapter 14: Menopause. Bantam Dell, 2006. 
27. Lee J. What Your Doctor May Not Tell You About Menopause. New York, NY: Warner Books; 1996.
28. Qi-bing M, Jing-yi T, Bo C. Advance in the pharmacological studies of radix Angelica sinensis(Oliv) Diels (Chinese danggui). Chin Med J1991;104:776–81.
29. McCaleb, Robert, Leigh Eveyln. The Encyclopedia of Popular Herbs. Prima Health. 2000.
30. Collins J. What’s Your Menopause Type. Roseville, CA: Prima Publishing; 2000.
31. Pkhaladze L, Davidova N, Khomasuridze A, et al. “Actaea racemose L. Is More Effective in Combination with Rhodiola rosea L. for Relief of Menopausal Symptoms: A Randomized, Double-Blind, Placebo-Controlled Study.” Pharmaceuticals. May 2020; 13(5): 102 doi: 10.3390/ph13050102
32. Edwards D, Heufelder A, Zimmerman A. “Therapeutic effects and safety of Rhodiola rosea extract WS 1375 in subjects with life-stress symptoms—results of an open-label study.” Phytother Res. Aug 2012; 26(8): 1220-5 doi: 10.1002/ptr.3712
33. Collins J. What’s Your Menopause Type. Roseville, CA: Prima Publishing; 2000.
34. Collins J. What’s Your Menopause Type. Roseville, CA: Prima Publishing; 2000.
35. Garabadu D and Krishnamurthy S. “Asparagus racemosus Attenuates Anxiety-Like Behavior in Experimental Animal Models.” Cellular and Molecular Neurobiology. Feb 2014;34, 511-521. https://link.springer.com/article/10.1007/s10571-014-0035-z
36. Lall A. “This Ayurvedic Supplement Reduces Anxiety and Fights Menopause Symptoms.” First for Women, Nov 2, 2019. https://www.firstforwomen.com/posts/health/shatavari-for-menopause-anxi…
37. van Die, M. D., Burger, H. G., Teede, H. J., & Bone, K. M. (2009). Vitex agnus-castus (Chaste-Tree/Berry) in the treatment of menopause-related complaints. Journal of alternative and complementary medicine (New York, N.Y.), 15(8), 853–862. https://doi.org/10.1089/acm.2008.0447
38. Naseri, R., Farnia, V., Yazdchi, K., Alikhani, M., Basanj, B., Salemi, S. (2019). Comparison of Vitex agnus-castusextracts with placebo in reducing menopausal symptoms: a randomized double-blind study.Korean J Fam Med, 40(6), 362-367. doi: 10.4082/kjfm.18.0067
39. Abbasporr, Z., Hajikhani, N.A., Afshari, P. (2011). Effect of Vitex agnus-castus on menopausal early symptoms in postmenopausal women: a randomized, double-blind, placebo-controlled study. Journal of Advances in Medicine and Medical Research, 1(3), 132-140. DOI: 10.9734/BJMMR/2011/163 
40. Collins J. What’s Your Menopause Type. Roseville, CA: Prima Publishing; 2000.
41. Bani S, Hasanpour S, et al. “The Effect of Folic Acid on Menopausal Hot Flashes: A Randomized Clinical Trial.” J Caring Sci. 2013 Jun;2(2): 131-140. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4161099/
42. Elghamry MI, Shihata IM, Biological activity of phytoestrogens. Planta Medica. 1965; 13: 352-357.
43. Pizzorno, Joseph, and Murray, Michael, N.D. Textbook of Natural Medicine2^nd Ed. Churchill Livingstone. 1999
44. Crawford AM. The Herbal Menopause Book. Freedom, CA: Crossing Press, 1996.
45. Yang HM, Liao MF, Zhu SY, Liao MN, Rohdewald P. A randomized, double-blind, placebo-controlled trial on the effect of Pycnogenol on the climacteric syndrome in peri-menopause women. Acta Obstet Gynecol Scand. 2007;86(8):978-85.
46. Schor J. Grape Seed Extract Effective for Menopausal Symptom Relief. Denver Naturopathic Clinic website. April 2009. Available at: http://denvernaturopathic.com/grapeseedestractforhotflashes.html 
47. Terauchi M, Horiguchi N, Kajiyama A, Akiyoshi M, Owa Y, Kato K, Kubota T. Effects of grape seed proanthocyanidiin extract on menopausal symptoms, body composition, and cardiovascular parameters in middle-aged women: a randomized, double-blind, placebo-controlled pilot study. Menopause. 2014;10 [Epub ahead of print]
48. Wahner-Roedler DL, Bauer BA, Loehrer LL, Cha SS, Hoskin TL, Olson JE. The effect of grape seed extract on estrogen levels in postmenopausal women: a pilot study. Journal of Dietary Supplements. 2014;11(2):184-197. 
49. Leo, L., Surico, D., Deambrogio, F., Scatuzzi, A., Marzullo, P., Tinelli, R., Molinari, C., & Surico, N. (2015). Dati preliminari sull'efficacia del resveratrolo in una nuova formulazione nel trattamento delle hot flushes [Preliminary data on the effectiveness of resveratrol in a new formulation in treatment of hot flushes]. Minerva ginecologica, 67(5), 475–483.
50. Thaung Zaw, Jay Jay MBBS1; Howe, Peter R.C. PhD1,2,3; Wong, Rachel H.X. PhD1,2 Long-term resveratrol supplementation improves pain perception, menopausal symptoms, and overall well-being in postmenopausal women: findings from a 24-month randomized, controlled, crossover trial, Menopause: January 2021 - Volume 28 - Issue 1 - p 40-49 doi: 10.1097/GME.0000000000001643
51. Thaung Zaw JJ, Howe PR, Wong RH. Long-term effects of resveratrol on cognition, cerebrovascular function and cardio-metabolic markers in postmenopausal women: A 24-month randomised, double-blind, placebo-controlled, crossover study. Clin Nutr. 2021;40(3):820-829. doi:10.1016/j.clnu.2020.08.025
52. Wong, R. H., Thaung Zaw, J. J., Xian, C. J., & Howe, P. R. (2020). Regular Supplementation With Resveratrol Improves Bone Mineral Density in Postmenopausal Women: A Randomized, Placebo-Controlled Trial. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research, 35(11), 2121–2131. https://doi.org/10.1002/jbmr.4115