Supplements are often recommended for symptoms. Be wary. Most have little data on safety and whether they work.
It’s important to discuss any supplement you are considering with your health care provider in case its contraindicated with something else you are taking.
And please check out Supplements: Before you Buy for a quick overview on what can be mixed in with supplements and how the various forms differ. A quick guide to becoming a wise shopper!
WHAT IT DOES
Vitamin D is not a direct fix for a specific symptom, but keeping vitamin D at adequate levels is important to many aspects of women’s health, so we cover it here.
Vitamin D is made by your body after exposure to sunlight. Vitamin D supports immune function and nerve and muscle health.
Bone health: Vitamin D is also essential for calcium absorption, which is critical for building bone. Here is where it ties into forty-ish women — until approximately age 30, a woman normally builds more bone than she loses. But after age 35, bone breakdown overtakes bone buildup, which causes a gradual loss of bone mass. Estrogen helps preserve calcium in the body and prevent bone breakdown. As a result, the declining levels of estrogen after the final menstrual period (i.e. menopause) contribute to bone loss. A 2010 study suggests that low progesterone levels, common in early perimenopause, also affect cells’ ability to repair bone.1 As part of the Study of Women Across the Nation (SWAN), researchers found that women with lower than 20 ng/mL of Vitamin D had a higher rate of nontraumatic fracture.2 An August 2019 study reported that subjects given high doses of Vitamin D (4000 IU per day or 10 000 IU) versus 400 IU/day over 3 years had lower bone mineral density so it could be that too much Vitamin D isn’t good.
Cardiovascular Disease: It was thought that Vitamin D played a possible role in preventing cardiovascular disease, which is known to increase in menopausal women.3 However the 2018 VITAL study — a study that looked at the effects of 2,000 IU)/day vitamin D3 supplements with or without 1,000 mg/day marine omega-3 fatty acids or a placebo in 25,000 adults, ages 50 and over for 5.3 years — did not prove this out.
Cancer: Low vitamin D levels are seen in many autoimmune diseases, some cancers, and other chronic diseases, although the research has yet to be done on whether there is a causative effect. The VITAL study (detailed above) looked at cancer occurrence and did not see a reduction in developing cancer in the overall study population. However, in the African American subjects that took vitamin D, there was a 23% reduction in cancer risk. The summary of findings notes that further research is needed to confirm this finding.
Cognition: And another study found that women (ages 55-67) who had Vitamin D levels, greater than 25 nmol/L, had better executive function when tested 10 years later than those with levels below that.4
New research is coming out all the time. For now, it seems like a good idea to keep vitamin D levels between 30 – 50 nanograms per milliliter (ng/mL). This is a test you can ask your healthcare provider to run with your regular blood work. Keep in mind some labs report nmol/L and others ng/mL.
SOURCES
The sun is your best source, since your body makes vitamin D after exposure to sunlight — experts suggest 10 minutes per day. Careful sun protection is essential to prevent skin damage and cancer. Our bodies can absorb vitamin D from egg yolks, salmon, saltwater fish, and liver. Meanwhile, some foods are fortified with vitamin D (such as milk and some breakfast cereals), but it’s actually difficult to get adequate vitamin D only through diet, so here a supplement is a good option.
NOTES
Take Vitamin D with a meal tto maximize absorption.
SAFETY AND DOSAGE
Vitamin D toxicity is very rare. Most people supplement with 1,000 or 2,000 IU per day, and in this range vitamin D is safe. Toxicity actually comes from too much calcium because, as noted above, vitamin D increases calcium uptake, which in large amounts can lead to nausea or vomiting. This FAQ on vitamin D toxicity from the Mayo Clinic puts it into perspective: taking 50,000 international units (IU) a day of vitamin D for several months has been shown to cause toxicity. This level is many times higher than the Recommended Dietary Allowance for most adults of 600 IU of vitamin D a day. Sometimes physicians prescribe 50,000 IU tablets of Vitamin D to be taken weekly, but usually only for up to 3 months and only for people with significant vitamin D deficiency (levels under 20 ng/mL, for example).11
EXPERTS, RESOURCES AND THINGS TO EXPLORE
The NIH Office of Dietary Supplements: Vitamin D
The Vitamin D Council, a nonprofit dedicated to education on Vitamin D
Medline Plus on Vitamin D
Dr. Low Dog’s Vitamin D Primer, (requires opt-in)
Dr. Reihhold Veith, a world expert on vitamin D from Mt. Sinai Hospital, has an eight-minute video for those who want a deep dive on D
Dr. Michael Holick, another vitamin D expert from Boston University
WHAT THEY DO
B vitamins as a group (B1, B2, B3, B5, B6, and B12) are often dubbed “the anti-stress vitamins” for their ability to combat anxiety, irritability, and poor memory. B vitamins are a major contributor to brain and cellular health, emotional well-being, conversion of food to energy, neurotransmitter production, and memory.5
B vitamins are necessary for the conversion of tryptophan to melatonin, which is used to treat sleep disruption. They also help your adrenal glands produce hormones after your ovaries have stopped producing them.
Specifically, vitamin B6 (pyridoxine) is known to have positive effects on PMS.6 It helps make serotonin, a chemical responsible for transmitting brain signals. As we age, our serotonin levels decrease. These fluctuating serotonin levels may be a contributing factor in the mood swings and depression common in perimenopause and menopause.
Vitamin B12 is found in many foods and is an important component for bone and neurologic health. As we age, we lose some of our ability to absorb vitamin B12.
Since some of the most common perimenopausal symptoms include anxiety, irritability, and increased stress, it’s not surprising that we continue to see the recommendation for perimenopausal women to take a B complex supplement. A B complex usually includes the key B vitamins — B1 (thiamine), B2 (riboflavin), B3 (niacin), B5 (pantothenic acid), B6 (pyridoxine), B12 (cobalamin).
However, B vitamins are also readily available in food — see Sources section below.
SOURCES
Generally, the following foods are good sources for B vitamins: beef, seafood, eggs, poultry, peas, asparagus, nuts, spinach, and sunflower seeds. This article does such a great job of detailing how to get specific B vitamins from food.
SAFETY AND DOSAGE
Vitamins are separated into two categories based on how they are absorbed and whether or not they are stored in the body. Along with vitamin C, the B vitamins are water-soluble. Water-soluble vitamins dissolve in water upon entering the body, but your body cannot store excess amounts of water-soluble vitamins for later use. This is both good and bad — good because you are not at risk of toxicity from these vitamins, but bad because you need to be sure you are getting enough through food and supplements.
EXPERTS, RESOURCES AND THINGS TO EXPLORE
Dr. Andrew Weil: Can any B vitamins be harmful?
Medline Plus on B vitamins
NIH Office of Dietary Supplements on vitamin B6
WHAT IT DOES
Magnesium is a mineral that enables cells to make energy, stabilizes cell membranes, and causes muscles to relax. It is responsible for over 600 enzymatic reactions throughout the body, primarily in bones, muscles, and the brain. Among many other things, magnesium helps bones remain strong, helps regulate blood glucose levels, and aids in the production of energy and protein.7
Government studies indicate that half the US adult population is deficient in magnesium. Magnesium deficiency can lead to insomnia, heart palpitations, leg cramps.
Magnesium has been shown to help with the perimenopausal symptoms of migraines and PMS. When the body responds to stress, adrenaline is released, and its job is to move magnesium into the bloodstream to calm things down. If you are low in magnesium, the calm doesn’t come. So for people in chronic stress, it’s possible that magnesium is low.
SOURCES
Cooked spinach, black beans, pumpkin seeds, many nuts, avocados, salmon, and brown rice are all good sources of magnesium. You will often see dark chocolate as listed as a source for magnesium, though we appreciated this article that put that recommendation into perspective. And try an Epsom salt bath. It’s a great non-food source of magnesium — and is relaxing and soothing for sore muscles to boot!
SAFETY AND DOSAGE
The RDA of magnesium for women is 320 milligrams (mg), while the daily value is 400 mg. There is an upper limit of 350 mg, but that is for the supplement portion of magnesium intake. Too much magnesium from food does not pose a health risk in healthy individuals, because the kidneys eliminate excess amounts in the urine.8,9
NOTES
There are many formulations of magnesium. Magnesium oxide is the least expensive form but can have a laxative effect in some people. For some people, this is a benefit of magnesium! However, for those not in need of a laxative, magnesium chelate, magnesium malate, and magnesium glycinate are all formulated to avoid loose stools. Because magnesium can have a muscle-relaxing and calming effect, it’s a good supplement to take at bedtime.
EXPERTS, RESOURCES, AND THINGS TO EXPLORE
NIH Office of Dietary Supplements on magnesium
For those really interested in the role of magnesium, this paper from the University of Adelaide includes leading research from all over the world about the new understandings of the role of magnesium. Dr. Carolyn Dean MD, ND who has a website on magnesium) once suggested everyone dump a copy of this on their doctor’s desk. She believes doctors are undereducated on the role of magnesium since the research is new and minerals, in general, aren’t covered in medical school.
WHAT IT DOES
As with vitamin D, probiotics don’t fix a specific perimenopausal symptom, but increasingly research is linking gut health to other aspect of health. Probiotics are strains of live bacteria and yeast that can help keep your gut microbiome healthy.
Recent research has shown that many of the mood-related neurotransmitters we used to think of as sourced from the brain are actually synthesized in our gut. Following on that, research is looking at the impact of gut health on mood.10
SOURCES
Any fermented food is a probiotic: yogurt, sauerkraut, pickled vegetable, and kimchi are some examples. Kombucha, a popular beverage made from fermented tea, is also a probiotic. This article from Science-Based Medicine, a site written by MDs, takes on the question we’ve all been wondering about: can you get adequate amounts of probiotics from food or do you need a supplement?
NOTES
There are many opinions about how many and which probiotic strains are important, or the number of active live cultures. Many experts suggest that rotating brands of probiotics is important to keep introducing new strains to your system.
SAFETY AND DOSAGE
Unless you have a compromised immune system, probiotics are generally considered safe for the general population. This link to Consumer Lab answers the question: how many CFUs should you look for in a probiotic? There has been a recent explosion in the number of probiotic products marketed to consumers as having health benefits. And while there are demonstrated health benefits of some strains, particularly with respect to the effects of antibiotics, there are no studies supporting the use of many of the strains used. A recent article in JAMA outlines some of the potential risks and suggests more FDA involvement in manufacturing regulation and labeling.10
EXPERTS, RESOURCES AND THINGS TO EXPLORE
The National Center for Complementary and Integrative Health on probiotics
If you didn’t catch it above, we thought this article about getting probiotics from food was well-researched and worth reading
“Gut-Check.” an article from Science-Based Medicine, calls into question the hypothesis that probiotics work
WHAT IT DOES
What’s the deal with omega-3s and omega-6s? They are called the essential fatty acids. They are essential because we don’t make them in our bodies, but have to get them through food.
Isn’t one good and one bad? Which is which? It really confused us, too. So here is the deal … we need both omega-3s and omega-6s in about equal amounts. However, the American diet tends to have too much omega-6 and is lacking in omega-3, which is why we hear the advice to supplement with omega-3 and to stay away from omega-6.
Omega-6s stimulate inflammation and are found in vegetable oils and other processed foods. Omega-3s reduce inflammation and are found mostly in deep water fatty fish. Our bodies need to be able to stimulate and reduce inflammation to work properly, so it’s important to get some omega-6, but it’s likely you are getting enough (and possibly too much) from your current diet. As such, we focus here on how to get more omega-3s. Within the omegas-3s, there are three types: EPA, DHA, and ALA (see sources for each below).
There has been attention paid to omega-3s and heart health benefits, but both this article from NIH Office for Complementary Medicines and this one from Nutritionfacts.org suggest that studies don’t bear out heart benefits for omega-3 supplementation. In terms of perimenopausal relevance, however, this small study did see a benefit for omega-3s on hot flashes.
SOURCES
We assume you already get enough omega-6s. Here are foods to boost your omega-3s: for EPA and DHA, eat 4 ounces of cold-water, fatty fish like herring, sardines, mackerel, salmon, halibut, tuna, or swordfish twice a week. Use this calculator to find fish lowest in mercury but high in omega-3s. For ALA, try more flax seed, hemp oil, and walnuts.
NOTES
Make sure to choose a product made with small fish (like sardines and anchovies) to avoid the toxin accumulation that happens with bigger fish. Also, be sure to get the triglyceride form — many products use the ester ethyl form, which is like a concentrate and should be avoided. The product should have both EPA and DHA. As with all supplements, choose a product that has been third-party tested and uses non-GMO ingredients.
SAFETY AND DOSAGE
Omega-3s can reduce blood clotting, so you should let your doctor know if you are taking them, particularly if you are also taking a blood-thinning medication (this article from an MD sheds light on the risk). Similarly, if you are scheduled for surgery, be very sure to let your doctor know how much you are taking.
The FDA recommends not exceeding 3,000 mg/day of EPA and DHA combined, with up to 2,000 mg/day of that coming from dietary supplements.
EXPERTS, RESOURCES, AND THINGS TO EXPLORE
From the Harvard School of Public Health: Omega-3 Fatty Acids: An Essential Contribution
NIH National Center for Complementary and Integrative Health on omega-3s, and a fact sheet for health professionals
Dr. Weil on balancing omega-3s and omega-6s
Women’s Health Network article on omega-3s
Recent (October 2019) research study: Omega 3s from marine sources reduce the risk of death from heart disease.
WHAT IT DOES
Most of us think of sleep support when we hear melatonin. Yet while melatonin, a hormone produced by both the pineal gland (in our brains) and our gut, is best known for sleep, it also plays a role in bone formation12 and acts as an antioxidant, anti-inflammatory, pain reliever, and antidepressant. It has even been shown to help with heartburn.
When it gets dark, the pineal gland secretes melatonin. As melatonin levels rise, our body temperature falls, causing us to feel sleepy. When it becomes light again, the blue light from the sun suppresses melatonin production. However, there is also blue light in our television, computer, and phone screens. So if we work inside and in front of screens and continue to use our screens up until bedtime, we are interfering with our natural sleep-wake cycles by suppressing the production of melatonin.
In addition, melatonin levels decline as we age.13, 14
SOURCES
There are a few foods that boost melatonin directly: bananas, sweet corn, ginger, tart cherries, figs, tomatoes, and oats.11 Other foods work on the melatonin pathway. Tryptophan, an essential amino acid, is a precursor to melatonin, and vitamin B6 helps convert tryptophan to melatonin. As a result, foods that are good sources of tryptophan (e.g. pumpkin seeds, roasted soybeans, many cheeses) and vitamin B6 (e.g. chickpeas, tuna, salmon) can help boost melatonin. There are also many melatonin supplements. Advisor to Women Living Better, Dr. Paula Witt-Enderby, who does research on melatonin and bone formation, recommends a close look before you buy — find a pure melatonin supplement rather than one combined with other nutrients.
SAFETY AND DOSAGE
While there are many supplements for melatonin, expert Dr. Paula-Witt Enderby (mentioned above in “Sources”) suggests working first to support the natural production of your own melatonin cycles. Here is how: Prioritize sleep. Work with your natural melatonin cycles by going to bed earlier. Try to be in bed around 10pm and if this is not achievable, then try to make incremental steps towards this goal over time. Any movement towards 10pm will be of benefit. Prepare for sleep. Establish a routine to settle the mind and body: (a) turn off extra lights around the house starting around 8pm; (b) minimize things that stimulate the mind like video games, television, talk radio, loud music; (c) turn on soft music or lessen the household “noise”; (d) try stretching poses to release endorphins in the body to begin to relax the body naturally; (e) Try just laying on the floor for 10 minutes – for many people this helps to settle the body. Manage light. Minimize light exposure during the night if there is ambient light in your bedroom by wearing an eye mask; minimize use of electronic devices at night; increase natural light exposure during the day by getting outside as much as you can. Food – what to eat. Add foods rich in melatonin like ginger, tart cherries, walnuts, bananas, sweet corn, figs, tomatoes, and oats. Food – when to eat. Aim to finish eating by 8pm. Drink. Minimize alcohol consumption as this can suppress melatonin levels and aggravate the nervous system.
If you are not feeling any benefit within a few weeks of trying the strategies listed above, you may want to incorporate a melatonin supplement into your daily nighttime routine. As with any supplement you should consult your physician first to see if there are any conditions or drugs that contraindicate its use for you. It’s always best to start low (~0.5-1mg melatonin) and then increase as needed. Studies have shown that melatonin gets taken up by the body in different amounts by different people. The key thing to remember is to take your melatonin supplement right before bed since you are trying to enhance your nighttime melatonin levels. Keep in mind three main possible side effects: vivid dreaming, daytime grogginess, and sedation. If you’re still experiencing any of those after two weeks, cut your dose in half. On the other hand, if you are not experiencing side effects and not seeing sleep benefits, you can slowly start increasing your dose.
EXPERTS, RESOURCES AND THINGS TO EXPLORE
The National Center former Complementary and Integrative Health on melatonin
Dr. Paula Witt-Enderby writes about the potential of melatonin to manage a broader range of symptoms.
REFERENCES
1. Vanadin Seifert-Klauss and Jerilynn C Prior, Progesterone and Bone: Actions Promoting Bone Health in Women. Osteoporos. 2010; 2010: 845180.
2. Cauley JA, Greendale GA, Ruppert K, et al. Serum 25 hydroxyvitamin D, bone mineral density and fracture risk across the menopause. J Clin Endocrinol Metab. 2015;100(5):2046-2054. doi:10.1210/jc.2014-4367
3. Gouni-Berthold I, Krone W, Berthold HK. Vitamin D and cardiovascular disease. Curr Vasc Pharmacol. 2009 Jul;7(3):414-22.
4. Goodwill AM, Campbell S, Simpson S Jr, Bisignano M, Chiang C, Dennerstein L, Szoeke C. Vitamin D status is associated with executive function a decade later: Data from the Women’s Healthy Ageing Project. Maturitas. 2018 Jan;107:56-62. doi: 10.1016/j.maturitas.2017.10.005. Epub 2017 Oct 4.
5. David O Kennedy. B Vitamins and the Brain: Mechanisms, Dose and Efficacy—A Review. Nutrients. 2016 Feb; 8(2): 68.
6. Shiva Khayati Motlagh, Sima Nemati, and Zohreh Tavakoli. Effects of Magnesium and Vitamin B6 on the Severity of Premenstrual Syndrome Symptoms. Elham Ebrahimi. J Caring Sci. 2012 Dec; 1(4): 183–189.
7. de Baaij JH, Hoenderop JG, Bindels RJ. Magnesium in man: implications for health and disease. Physiol Rev. 2015 Jan;95(1):1-46.
8. Musso CG. Magnesium metabolism in health and disease. Int Urol Nephrol 2009; 41:357-62.
9. Institute of Medicine (IOM). Food and Nutrition Board. Dietary Reference Intakes: Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride
. Washington, DC: National Academy Press, 1997.
10. Steenbergen L, Sellaro R, van Hemert S, Bosch JA, Colzato LS. A randomized controlled trial to test the effect of multispecies probiotics on cognitive reactivity to sad mood. Brain Behav Immun. 2015 Aug;48:258-64.
11. Cohen PA. Probiotic Safety—No Guarantees. JAMA Intern Med. 2018;178(12):1577–1578. doi:10.1001/jamainternmed.2018.5403
12. Holly Lassila, Nutjaree Pratheepawanit Johns, Christine K O’Neil, Jeffrey R Johns, Judith L Balk and Paula A Witt-Enderby. Alternative Options to Manage Menopausal Symptoms with a Focus on Melatonin and Osteoporosis. Clinic Pharmacol Biopharmaceut 2014, 3:1
13. Maria, S and Witt-Enderby, PA. Melatonin Effects on Bone: Potential Use for the Prevention and Treatment of Osteopenia, Osteoporosis and Periodontal Disease and for Use in Bone Grafting Procedures. Journal of Pineal Research, 56(2): 115-125, 2014.
14. Witt-Enderby, PA. Healthy tips about Light Exposure at Night.