A Holistic Approach to Supporting Perimenopause
Perimenopause is the transitional phase before menopause, and is known as a ‘second puberty’ due to the dramatic hormonal shifts that occur during this time. Perimenopause typically beings in your 40s (but can start much earlier!) and lasts until menopause, the average age of which is 51 years in Australia. Fluctuating oestrogen and declining progesterone can lead to symptoms that make you feel not quite like yourself. These can include hot flushes, insomnia, mood swings, heavy periods, brain fog, vaginal dryness, weight gain, low libido, fatigue, and joint pain.
If you are over 35, this is the next phase in your life to start thinking about and preparing for! The dietary and lifestyle interventions will be beneficial for you to start putting into practice.
If you are in your perimenopausal transition, all information here will be relevant to you! You will likely benefit from utilising the therapeutic nutrient and herbal interventions, as well as implementing dietary and lifestyle recommendations.
From a Naturopathic perspective, this phase offers a chance to nurture the body, restore energy levels, and prepare for a smoother menopause utilising evidence-based nutrients, herbs, dietary modifications, and lifestyle practices
Symptoms Naturopathic Care Can Support
Hot Flushes/Night Sweats - Rapid oestrogen drops cause heat surges and sleep disruptions
Insomnia - Hormonal shifts and anxiety hinder falling or staying asleep
Mood Swings/Anxiety - Oestrogen fluctuations disrupt serotonin, sparking irritability or low mood
Heavy/Irregular Periods - Oestrogen dominance leads to flooding or erratic cycles
Brain Fog - Hormonal and stress changes cloud cognitive clarity
Vaginal Dryness - Low oestrogen reduces lubrication, affecting comfort and intimacy
Weight Gain - Metabolic shifts and insulin resistance can add unwanted weight
Low Libido - Hormonal imbalances and fatigue dampen desire
Fatigue - Stress and poor sleep zap energy levels
Joint Pain - Bone density and muscle loss can increase discomfort
Nutrients
Magnesium
It feels like I have been discussing magnesium for years at this point in my career - and with good reason! It’s an incredible nutrient for women during all life stages, and perimenopause is no different. Magnesium activates GABA receptors in the brain, promoting relaxation and reducing neuronal excitability, which calms the nervous system. It also relaxes smooth muscle tissue, easing vasomotor symptoms such as hot flushes. By supporting HPA axis regulation, it lowers cortisol, mitigating stress-driven oestrogen spikes. Stress and poor diet deplete magnesium, making supplementation vital in perimenopause.
Try 300mg magnesium glycinate at night to promote healthy sleep. You may need to titrate up from here pending on how you respond. There are some beautiful sleep magnesium blends worth considering that contain additional nutrients and herbals if you are struggling with insomnia.
Magnesium glycinate - a beautiful mineral that works wonders during this life phase.
Omega-3 Fatty Acids
Omega-3s (EPA/DHA) reduce inflammation by inhibiting pro-inflammatory cytokines (e.g., IL-6, TNF-α), which can exacerbate mood swings and joint pain. They also enhance serotonin receptor sensitivity, stabilising mood, and support brain health by maintaining neuronal membrane fluidity, reducing the classic perimenopausal brain fog. By improving insulin sensitivity, omega 3s can also aid oestrogen clearance, easing vasomotor symptoms.
Aim to consume seafood (salmon, sardines, mackerel, and rainbow trout are highest in omega 3s) 2 - 3 times weekly. Additionally, for most perimenopausal women I suggest 1 - 2 grams of EPA/DHA daily, choosing a reputable brand that has been third-party tested.
Vitamin D
Healthy Vitamin D levels are crucial for our mood, immunity, and bone health. Vitamin D upregulates serotonin synthesis in the brain which can stabilise moods, and reduces parathyroid hormone to maintain bone density, both critical functions as oestrogen declines. It also modulates immune responses, lowering inflammation that drives hot flushes. Deficiency, more common than you would expect in Australia - I see it weekly - worsens perimenopause symptoms.
The top source of Vitamin D is sunlight. Healthy sun exposure is key - aim for 20 minutes daily at 10am or 3pm in summer, or 11am or 2pm in winter, ensuring that you are not getting burnt. Note that sunscreen and clothing blocks your synthesis of Vitamin D.
I suggest testing your Vitamin D levels and aiming for around 100 nmol/L. Supplementation from 1,000-2,000IU is quite safe without knowing your levels, however I always suggest testing as opposed to guessing!
Calcium
Calcium stabilises bone matrix by supporting the activity of osteoblasts (bone-building cells), reducing osteoporosis risk as oestrogen-driven bone formation slows. It also regulates muscle contraction by balancing calcium ion channels, which can ease cramps and tension.
Calcium through food is ideal if you can, and if you choose to supplement please be very conscious about what form you are taking. High-calcium foods include dairy (milk, yogurt, cheese), dark leafy greens, soy products such as tofu, tempeh and edamame, almonds and Brazil nuts, fortified milks, sardines, and dried figs.
Supplementation doses will depend on your diet - 500 - 600mg of calcium citrate daily in split doses is the researched amount and form.
I couldn’t speak about calcium without an honourable mention to cottage cheese. 1/2 cup provides 100mg calcium and 12g of protein!
Creatine
Creatine enhances ATP production in mitochondria, boosting cellular energy for brain and muscle function, which can counter fatigue and brain fog - both very common symptoms during perimenopause. It supports muscle protein synthesis, preserving lean mass as oestrogen declines, and may enhance dopamine signalling, improving mood. There is some excellent emerging research on the cognitive and physical benefits for it in women!
Take 5g daily with water or in a smoothie.
Herbal Medicine
Black Cohosh
Black cohosh is the most studied herbal medicine for perimenopause and menopause. I love this therapeutic and use it often for women of all different ages for different reasons! Black cohosh binds to serotonin receptors (5-HT1A) in the hypothalamus, stabilising thermoregulation to reduce hot flushes and night sweats. It can also modulate oestrogen receptors weakly, supporting oestrogen clearance without stimulating breast tissue, making it a non-hormonal option for symptom relief.
Sage
Sage contains compounds such as rosmarinic acid that modulate hypothalamic thermoregulatory centres, reducing vasomotor symptoms like hot flushes and night sweats. Its mild sedative properties enhance GABA activity, promoting sleep, while antioxidants support oestrogen clearance by reducing oxidative stress.
This works beautifully in tea or a herbal tincture. I recommend 1-2 teaspoons of dried sage/cup, brew for 10 minutes, then drink hot or cold. Aim for 3 cups daily.
Withania (Ashwagandha)
Withania, a well-known and loved adaptogen, lowers cortisol by regulating the HPA axis, reducing stress-driven oestrogen spikes. It enhances GABA receptor activity, promoting sleep, and stabilises mood by supporting serotonin and dopamine balance, easing perimenopause’s emotional rollercoaster. This herb is beautiful for those who are particularly stressed or anxious, or are struggling with insomnia. Pair with magnesium at nighttime if sleep support is needed.
Withania glycetract (alcohol-free) tincture
St John’s Wort
A well studied herbal medicine, St. John’s wort inhibits serotonin reuptake, boosting synaptic serotonin levels to reduce anxiety and depression. It also modulates dopamine and norepinephrine, stabilising mood. Its anti-inflammatory properties may support oestrogen clearance, easing vasomotor symptoms.
Drug interactions can occur with this herb so please check it is safe for you to take with your healthcare provider.
Chaste tree (Vitex agnus-castus)
A beautiful herb to modulate and support progesterone levels as your naturally progesterone levels decline. Vitex binds to dopamine D2 receptors, reducing prolactin secretion, which supports progesterone production by enhancing luteinising hormone release. This counters oestrogen dominance, stabilising cycles and reducing PMS-like symptoms such as breast tenderness and irritability.
A note on fertility - be mindful and use your chosen method of contraception during perimenopause if you don’t want to conceive. Erratic ovulation can make it tricky to predict your cycle and fertile windows, but you are absolutely still fertile!
Bioidentical Progesterone
Clearly not a herbal medicine! However, it is a very important therapy to consider. Bioidentical progesterone (called Prometrium in Australia) is identical to our endogenous progesterone. It binds to progesterone receptors, supporting progesterone production to counter oestrogen dominance. It converts to allopregnanolone, a neurosteroid that enhances GABA activity, calming the nervous system, reducing anxiety, and promoting sleep. It also inhibits endometrial proliferation, so can ease heavy periods.
This will need to be prescribed to you by your GP or specialist.
Dietary Interventions
Phyto-oestrogens
Phyto-oestrogens are compounds that exist in foods, such as isoflavones and lignans, that bind weakly to oestrogen receptors, acting as selective oestrogen receptor modulators (SERMs). They support oestrogen clearance by competing with stronger endogenous oestrogens, reducing oestrogen-driven symptoms like hot flushes and vaginal dryness, while supporting bone health. Avoid excess consumption in oestrogen-dependent cancers.
The top 10 foods high in phytoestrogens are flaxseeds/linseeds, edamame, tofu, tempeh, sesame seeds, mung beans, alfalfa sprouts, oats, lentils, and the herb red clover.
1 - 2 tablespoons of flaxseed in your smoothie or sprinkled over yoghurt is a nice place to start.
From Advanced Clinical Naturopathic Medicine by Leah Hechtman, 2020
Fibre and Cruciferous Vegetables
Fibre binds excess oestrogen in the gut, promoting its excretion via the bowels, while cruciferous vegetables (containing indole-3-carbinol and sulforaphane) enhance phase II liver detoxification (glucuronidation, sulphation), supporting oestrogen clearance. This can reduce bloating, heavy periods, and reduce hormonally driven mood swings.
The fibre RDI for women in Australia under 50 is 25g. Aim for 25g minimum daily - some people will benefit from more than this. Fibre-rich foods include chia seeds, flaxseeds, oats, lentils, chickpeas, avocado, almonds, pears, raspberries, brussels sprouts, and carrots.
Cruciferous vegetables include broccoli, kale, brussels sprouts, cauliflower, cabbage, bok choy, watercress, radish, and turnips. Aim for 1-2 cups cooked daily. Read more about fibre in this blog.
Lifestyle
Exercise
Exercise, specifically lifting weights, enhances insulin sensitivity and upregulates liver enzymes (e.g., CYP450) to support oestrogen clearance, reducing hot flushes. It boosts endorphins and serotonin, stabilising mood, and increases osteoblast activity via mechanical stress, strengthening bones and muscles to counter osteoporosis risk as oestrogen declines.
Aim for at least 150 minutes of exercise weekly, with an emphasis on lifting weights, 2 - 3 times weekly.
Alcohol and Caffeine
Alcohol and caffeine inhibit liver detoxification enzymes (e.g., CYP1A2), impairing oestrogen clearance and increasing hot flushes. They also raise cortisol, disrupting sleep and adrenal health. Being mindful and conscious about of your intake of both of these compounds can support oestrogen metabolism and stabilises your HPA axis, reducing vasomotor symptoms.
Some women notice drastic changes when they eliminate alcohol or coffee - so it is worth trialling this one by one to see how they affect you. The most common feedback I hear is reduced or no more hot flushes, improved sleep, and healthier moods.
Try my hot choccy recipe as an substitute for that extra coffee that never tastes as good as the first!
Stress Management
Stress management such as mindfulness, meditation, and yoga lowers cortisol by downregulating the HPA axis, reducing oestrogen spikes and anxiety. It enhances GABA and serotonin activity, promoting sleep and mood stability, countering perimenopause’s emotional volatility.
Aim for 10 - 15 minutes a day of a stress management technique that appeals to you. Try using an app like Calm or Open so you can stay accountable.
Acupuncture
Acupuncture stimulates specific points in the body to modulate the autonomic nervous system, reducing sympathetic activity (which are linked to hot flushes) and enhancing parasympathetic tone, improving mood and sleep. It can also reduce vasomotor symptoms by improving blood flow and reducing inflammation.
Try 1 session weekly for 6 weeks and assess how you feel.
Perimenopause can be a beautifully transformative phase navigated with resilience using some of the Naturopathic tools we’ve discussed - magnesium, Black cohosh, phytoestrogens, lifting weights, and more. I hope these evidence-based strategies empower you to thrive during this transition.
Please leave any questions on perimenopause below, or reach out if you would like my support during this transitional phase of your life.
Author
Jaclyn Cave
BHSc (Nat), BComm (Soc)
Masters Women’s Health Medicine (UNSW - completing)
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