In the online perimenopausal community, there appear to be some battle lines drawn. If you thought these virtual watering holes were full of women supporting one another with no judgement or disagreement, then you would be mistaken. Just as in real life, factions are present, and strong opinions drive polarities that sometimes erupt in typed jabs and laughing, angry and crying emojis.

One of the more obvious and ever-present ones is the pharmaceutical vs. natural camp.

Simply put, one group of women is more open and receptive to prescribed medications that have been battle-tested in clinical trials, and this includes FDA-approved hormone therapy (estradiol and progesterone) that is produced by major pharmaceutical companies and available in generic and name brand formulations (vs. hormones made by compounding pharmacies). This group of women may include those who tried natural remedies that proved inadequate, harmful or ineffective as well as those who trust conventional medicine because it has been trialed, tested, in many cases with proven efficacy, and is produced according to regulations, with known and documented side effects.

The other group of women trends toward the “natural at all costs” philosophy. This is the group that may discourage going to conventional doctors and favors naturopathic and functional medicine practitioners instead. They are also the ones likely to caution against using prescribed medications, such as antidepressants (including but not limited to other drugs prescribed off label to help with perimenopausal hot flashes, night sweats, anxiety and more), as well as pharma-grade HRT. Their rationale may be that Big Pharma drugs have harmed them personally or those they know, that there is an unsavory profit motive involved in the practice of medicine that doesn’t put people first and that natural alternatives can’t harm you.

Naturally (pun not intended), there is a deep affinity among women thrust into perimenopause to try what’s close at hand, readily available and perceived as harmless. So many of us had no warning and little or no education about what would happen to our bodies and minds in midlife. We just knew that when we hit our late 30s to mid 40s, we started feeling different, off-kilter and a bit abnormal. Thus, we are fending for ourselves – at least those of us with the grit and resilience to even try to address the panoply of hormonal change symptoms. And that self-advocacy often starts with over-the-counter supplements and various concoctions, potions and pills recommended by word of mouth and easily obtained.

The problem is that just because something is natural, doesn’t mean it’s good for you, beneficial to your individual biochemistry or without side effects. Here are some commonly suggested natural remedies, bandied about through the grapevine among communities of women, or offered to us by supplement companies and holistic non-MD providers whose biggest competitors are, in fact, the commercial pharmaceutical industry and the very few mainstream physicians skilled in caring for midlife women (oh, those precious few!).

5-HTP:

• A nervous system and brain neurochemical used to boost serotonin, a mood regulator, in the body with the goal of reducing depression.
• Sometimes used to help treat insomnia and anxiety.
• Possible risks include heartburn, nausea, diarrhea, stomach pain, drowsiness, muscle spasms. Avoid use if taking antidepressants.
• May be safe if taken for up to one year.

Black Cohosh:

• An herb original to North America commonly deployed as an estrogen booster, even casually called “herbal estrogen.”
• Often sought to help with hot flashes and commonly included in so-called menopause supplements.
• Potential side effects are upset stomach, rashes, headaches, weight gain, bloating and liver damage.

Chasteberry / Vitex:

• Also known as Vitex agnus-castus, chasteberry and monk’s pepper, an herb used to help with infertility, PMS (migraines, depressed mood and breast pain in particular), menopause (specifically mood and sleep improvement), acne, breastfeeding, inflammation, bone repair, headaches and epileptic seizures.
• Potential risks: nausea and upset stomach, skin rashes, acne, headaches, heavy menstruation and should not be taken with antipsychotic medications, birth control pills and HRT.

Evening Primrose Oil:

• Comes from a plant and used historically to treats skin problems, wounds and hemorrhoids; also contained omega-6 fatty acids.
• Often used for breasts pain, PMS, arthritis, asthma and eczema.
• Possible side effects: upset stomach, dizziness, nausea, headaches, rashes and not recommended for those taking anticoagulant, antiplatelet, blood pressure, antidepressant and phenothiazine medications.

Inositol:

• Also known as myo-inositol, a type of sugar involved in bodily insulin response and hormones linked to mood and cognition, also called vitamin B8.
• Has antioxidant features that may counteract free radicals in the brain and circulatory system and naturally occurring in fiber-dense foods, such as beans, brown rice and wheat bran.
• Used to treat high cholesterol, insulin regulation, anxiety and panic, depression and polycystic ovarian syndrome (PCOS).
• Potential side effects: stomach pain, headaches, nausea and dizziness.

Kava Kava:

• Sourced from the pipe methysticum plant, often purported to help with anxiety, drug withdrawal, insomnia and stress due to impact on the brain and central nervous system.
• May be safe to use for up to six months, but is linked to liver damage and should be avoided by breastfeeding women, those with Parkinson’s disease and at least two weeks prior to surgery.

Maca:

• A root vegetable known to be used for at least 3,000 years, sourced from the Andes Mountains.
• Used to help male infertility, decrease depression, aid hair growth, stimulate libido and address menopausal symptoms (hot flashes).
• Side effects could include unpredictable impact on hormone levels and should not be taken by those with fibroids, thyroid issues, breast cancer, uterine cancer, ovarian cancer or endometriosis.

Red Clover:

• A plant used in traditional medicine to treat osteoporosis, heart disease, arthritis, cancer, menstrual symptoms and menopausal issues.
• Contains isoflavones, a variety of phytoestrogen, that weakly mimics estrogen in the body, with most research inferring benefits for menopause produced by supplement manufacturers. 
• Also claimed to help with anxiety, depression and even vaginal dryness.
• Possible side effects: vaginal bleeding, skin irritation, headaches, nausea and potential contraindications with various medications.

Tryptophan:

• Also known as L-Tryptophan, an amino acid needed for protein production, naturally occurring in protein-rich foods such as poultry, eggs and red meat.
• A precursor to 5-HTP, which converts to serotonin, a mood-balancing brain neurotransmitter that is also responsible for a host of other bodily functions, and used to help with PMS, depression and insomnia.
• Possible side effects: drowsiness, stomach pain, vomiting, blurry vision, diarrhea and, potentially, a neurological disorder called eosinophilia-myalgia syndrome (EMS) [possibly connected to contaminated products].

Valerian Root:

• Commonly used for insomnia, believed to affect GABA receptors in the brain responsible for controlling fear and anxiety.
• Also used to address headaches, anxiety, digestive problems, menopause symptoms (hot flashes), pain and fatigue.
• Possible side effects: headache, dizziness, itchiness, upset stomach, dry mouth, vivid dreams, daytime drowsiness and liver damage.
• Probably should not be combined with over-the-counter cold and flu medicines, antidepressants, sleeping pills or alcohol.

As you can see, there are side effects and risks associated with “natural” agents as well as pharmaceutical prescriptions – the most commonly cited and warned against in perimenopause being antidepressants and HRT. Coincidentally, many of the side effects of these supplements mirror some of the side effects associated with certain medications.

Many supplements have not been thoroughly tested through randomized, double-blind clinical trials, and many reports of potential benefit for the symptoms they are said to address are limited at best. In perimenopause and menopause, women ultimately must decide which options work best for them. For some, it will mean medications of any type are off limits. For others, they will embrace FDA-approved medicines. And many, many more will adopt an integrative approach, blending options from both worlds.

When a woman is hit like a deer in headlights by perimenopausal or menopausal symptoms, she often is at her most vulnerable. With almost no warning or often without any foreboding sharing of information from elder women or healthcare providers, women find themselves sweaty and sleepless, anxious and depressed, dried out and all cried out – with virtually no answers or informed, trusted sources to help them.

Women in this position, at least for the few among us who find the strength to advocate for themselves and seek help, are willing to try almost anything. This often means a succession of visits to conventional medicine practitioners – a tour with stops to the internal medicine doctor, an OB/GYN, maybe second opinions of the former . . . and then this is where most women stop. They frequently give up because these doctors have no real solutions or real education on this critical juncture that all midlife women – basically half of the world’s population – will one day face. All too often, physicians tell these women to exercise more, dress in layers, reduce stress or even grin and bear it until it passes.

For the women who give up on mainstream doctors, they may turn to over-the-counter offerings, like various supplements, teas and other untested and unregulated concoctions, seeking relief from evening primrose oil, “menopause vitamins,” black cohosh and other oils, tinctures, herbs and pills.

Still finding little to no relief, said women then may turn to what may be her final frontier: functional medicine doctors and naturopaths.
Sadly, these practitioners often take advantage of perimenopausal and menopausal women by offering hyperbolic hopes, grandiose promises and incredible cures, usually under the umbrella of “natural,” “customized” or “personalized” care. And it doesn’t come cheap, with repeated rounds of testing, reports, office visits and so much more.

So, are naturopaths and functional medicine doctors the equivalent of healthcare quacks? Are they selling snake oil and preying on legions of vulnerable, desperate midlife women?

What are their credentials?

Naturopathic doctors are not necessarily trained or credentialed. Going into the pool of naturopathic medicine providers is like jumping into a hurricane; one may need to survive the harsh, whipping winds before reaching the more tranquil eye of the storm. There is no universal standard for licensing naturopathic practitioners. Some states require that they attend a four-year program, study basic sciences similar to those taught in medical school and pass a state licensing exam. But others have no training at all, being unskilled, unlicensed and with no education whatsoever.

Functional medicine doctors, on the other hand, have usually completed medical school and then earned additional credentials from functional or alternative medicine organizations, such as The Institute for Functional Medicine.

How do they approach perimenopause or menopause?

If menopause and perimenopause communities on Facebook or Reddit are any indication, functional medicine doctors and naturopaths have an interesting approach to managing midlife hormonal symptoms. Their approach often involves repeated, rigorous testing of hormone levels and other metrics, such as vitamin levels, thyroid counts and much more. Women have left untold numbers of remarks about paying $600-$1,000 for a single office visit. They are frequently “prescribed” expensive vitamins and supplements (some of which they later find could have been purchased online for much less), and they may get compounded hormone treatments (available through compounding pharmacies with which these naturopaths have established agreements or relationships). The compounded hormones are not the same as FDA-approved and regulated hormone replacement therapy (HRT) in the form of pharmaceutical grade gels, patches or sprays, and oral micronized progesterone (or Prometrium).

Naturopaths and functional medicine doctors are said to habitually link perimenopause symptoms with other alleged and unproven conditions, like thyroid issues, gut health and adrenal fatigue.

Science-Based Medicine writes: “The problem with ‘functional medicine’ is that at its core it is close to being as nonsensical as the more ‘obvious’ forms of quackery. It just hides it better, given the number of fancy-sounding laboratory tests.”

Is functional or naturopathic medicine evidence-based?

Conventional medicine is based on years of data and research, including clinical trials, empirical case studies, lab experiments and more. That’s how medicine arrives at standards of care for various conditions, and that’s also how prescribed medicines finally reach the level of consumer access, after efficacy and relative safety are vetted. This is not to say there aren’t problems with “Big Pharma” and that all too many physicians reach for the prescription pad and lowest common denominator too readily before actually listening to and looking at the woman before them in the examination room.

But is functional medicine or naturopathic medicine actually based on proven science? Well, both purport to be more “integrative” and “holistic” than their competition. This is described as “addressing the web-like interconnections of internal physiological factors,” and “seeking a dynamic balance among the internal and external factors in a patient’s body, mind and spirit.”

But this is tantamount to a “get out of jail free” card “for basically anything practitioners want to do,” according to Science-Based Medicine.

Insurance usually doesn’t cover naturopathic or functional medicine.

Going to a naturopath or functional medicine doctor is expensive – and generally not covered by health insurance. Most practitioners don’t (or don’t have the authority to) order conventional blood testing, so they use other means, like saliva testing, in an attempt to build out the spider web of imagined conditions their “patients” are suffering from. Plus, lab tests are not necessary to diagnose perimenopause.
“The reason insurance doesn’t cover most of these tests and that conventional physicians won’t order them is because they are unhelpful, useless and / or not based in science and evidence.”

Some of the tests often recommended or ordered include those for heavy metals, micronutrients, methylation, inflammation, gut permeability, adrenal stress and metabolism. These tests are sometimes followed by the caveat that they are not intended to diagnose or treat a disease or to substitute for a physician’s expertise.

Why don’t they just prescribe regular hormone replacement therapy?

Many women are still afraid to take standard HRT, largely based on the continued reputational damage done from the now-misguided 2002 WHI study, which caused millions of women to abandon hormonal treatment almost overnight. Oncologists like Avrum Bluming are now going ultra-public about the safety and benefits of HRT for the symptoms of perimenopause and menopause, including longer-term brain, heart and bone health, as are many gynecologists, women’s health specialists and even psychiatrists. In fact, HRT is now known as the “gold standard” for addressing perimenopause and menopause difficulties, many of which can be life-altering and debilitating.

But naturopaths and functional medicine doctors continue to corral mistruths about HRT’s safety and effectiveness, preying on women’s fears and desire to be “as natural as possible.” Dr. Jen Gunter blows up the confusion they add about “body identical” vs. “bioidentical” hormones in “Stop Using ‘Body Identical’ and ‘Bioidentical’ to Refer to Menopausal Hormone Therapy” in this piece.

One such practice in Metro Atlanta proclaims: “We offer complete counseling and diagnostic testing to help you determine which treatments are right for you. We always prefer to treat patients with the most natural, least invasive therapy possible. Dietary supplements such as Estrovera are effective at relieving the symptoms of menopause. Other therapies such as acupuncture, biofeedback and dietary changes can also have a profound impact on patients’ symptoms.”

This same practice requires a log-in to view the prices of the dozens of supplements they “prescribe.” But a quick online search of Estrovera reveals it costs about $123.00 for 90 pills – about the same or more than what a typical HRT prescription of bioidentical estradiol and progesterone cost without insurance. This product does seem to have mostly positive reviews, but many of the reviews are tainted by women’s expressed fears of going on HRT, trying to stay away from HRT as long as possible, or seeking relief of hot flashes only (when there are 100+ known symptoms of perimenopause that HRT mostly can address, including vasomotor symptoms).

So is a naturopath or functional medicine doctor right for you?

Only you can decide if seeing a naturopath or functional medicine doctor is right for you. In this case, as with all things that are potentially expensive in both time, energy, emotional labor and monetary cost, buyer beware.

Given the increasing amount of evidence about the tried-and-true solutions for perimenopausal symptoms, those with the greatest amount of efficacy remain FDA-approved HRT and low-dose antidepressants (for those who can’t or won’t use HRT, or for those who still have breakthrough anxiety, depression or insomnia).

Supplements, vitamins, exercise and nutrition have their place in the total continuum of well-being, whether you’re perimenopausal or not. These can be adjuncts to HRT, or in the case of exercise and nutrition as the foundation of health, serve as building blocks.

But there is little defensible grounds for paying hundreds or thousands of dollars on minimally proven – or even outright disproven – homeopathic “prescriptions” to treat menopause and perimenopause.

In a previous post, I covered the main components of a total healthcare team that midlife women need begin building as they get serious about their long-term well-being. Just a few of those slots should be devoted to providers such as a primary care physician, a dentist, a gynecologist familiar treating women beyond the realm of fertility and pregnancy, and a dermatologist, among others.

These core practitioners should be able to fulfill and treat the most pressing and common healthcare needs we face going into middle age and beyond. These are the type of providers who are usually covered by your insurance within your networks, with the only payments rendered being whatever it takes to meet your deductibles and contribute your co-pays.

But what else is out there? What other tools should middle-aged women have in their well-being grab bag?

Well, there is more. This could be looked at negatively or positively, depending on your viewpoint. You may be thinking, “Great! At least there are all sorts of trained people out there to meet my needs.” Or you may instead be saying to yourself, “What kind of BS is this, and how expensive is this going to be.”

No matter your paradigm, the truth is that our holistic mind-body needs can be vast. And conventional doctors, even specialists, are not always the best, most comprehensive resources for information when it comes to things that cannot be prescribed and picked up at the pharmacy, or that are not necessarily part of a diagnosable condition, illness, disease or pathology.

Other types of wellness providers that may be discretionary (depending on your situation) and “nice to have” include:

Acupuncturist. Acupuncture has been indicated as being helpful for menopause symptoms. Some research has linked improvement in sleep problems, vasomotor symptoms and overall mood with acupuncture. For those who don’t know, acupuncture is a form of alternative medicine rooted in Chinese medicine. It involves superficially inserting small needs in the body. Ranges for the cost of acupuncture vary, often between $50-$95 per session.

Dietician. Despite their name, dieticians do much more than just put clients on diet. Dieticians are experts in nutrition who usually have an undergraduate degree from an accredited university or college with coursework that has been vetted by the Accreditation Council for Education in Nutrition and the Academy of Nutrition and Dietetics. Many dieticians have master’s degrees, have completed industry internships, have passed national examinations and are required to complete continuing education requirements. A dietician helps people focus on healthy eating habits and sound nutrition practices. These specialists can help women struggling with midlife weight loss or medical conditions that make weight loss or weight maintenance challenging.

Massage Therapist. Massage therapists are trained to understand bodily mechanics as they use touch to manipulate the muscles and soft tissues of the body. Massage therapy has been associated with stress reduction, circulation improvement, lymphatic system stimulation, recovery from injury and a general feeling of well-being. Medically, massage can help with nerve pain, fibromyalgia, anxiety and other physical pain syndromes or symptoms. According to national averages, the typical cost for a massage session is $50-$150.

Personal Trainer. Personal trainers are credentialed to provide custom workout plans and supervised exercise sessions for clients. They often serve individuals interested in specific goals, usually weight loss, muscle gain, injury recovery and foundational bodily function. Based on their training, the not only provide motivation, accountability and support, but they also know how to prevent injury during training and to develop modifications based on a client’s limitations. Personal trainers are usually certified by one of the prevailing industry bodies – NASM, ACE or ISSA.

Therapist. Therapists are not psychiatrists – they cannot prescribe medications. Sometimes a therapist may also be classified as a psychologist or social worker, but not always. Therapists help people deal with particular issues, such as addiction or marital challenges, but they also provide overall support for a variety of emotional, mental or physical health problems.

* Some insurance carriers will cover the cost of dieticians or nutritionists.