Menopause & Perimenopause: Surviving & Thriving

Perimenopause & Menopause: Natural Treatment in Toronto

Last reviewed by Dr. Pamela Frank, BSc(Hons), ND – June 28, 2026

Perimenopause is not a disease; it is a transition. But for a significant proportion of women, that transition involves years of symptoms severe enough to impair sleep, work performance, relationships, and quality of life. The science of this transition is better understood than ever, and there are well-evidenced naturopathic strategies that can make it substantially more manageable.

Perimenopause vs. Menopause: What’s the Difference?

Perimenopause refers to the transition period leading up to the final menstrual period, typically beginning in the mid-to-late 40s (range: 40s to early 50s) and lasting an average of 4–8 years. Ovarian follicle depletion causes increasingly erratic estradiol fluctuations; notably, estrogen (estradiol) levels can be higher and more variable in early perimenopause than in the preceding reproductive years, and then decline sharply in later perimenopause.¹ These fluctuations drive many of the most disruptive symptoms.

Menopause is defined retrospectively as 12 consecutive months without a menstrual period, typically occurring at an average age of 51–52 in North American populations.

Postmenopause follows menopause and is characterized by chronically low estradiol and progesterone. Many symptoms (particularly vasomotor symptoms, that is, hot flashes) diminish after the acute transition, though bone loss and cardiovascular risk trajectory change.

Symptoms of Perimenopause and Menopause

The symptom profile is driven primarily by estrogen fluctuation and decline, though the role of progesterone loss (which precedes estrogen loss in the perimenopausal timeline) is under-appreciated:

Vasomotor symptoms:

Hot flashes and night sweats affect 75-80% of women during the menopausal transition.² They result from narrowing of the thermoregulatory neutral zone in the hypothalamus (mediated by neurokinin B/kisspeptin signalling) due to estrogen withdrawal.³

Sleep disruption:

Often multifactorial – primary insomnia worsened by hot flashes, declining progesterone (which is GABAergic, calming and sleep-promoting), and elevated cortisol from HPA axis dysregulation. Loss of progesterone increases histamine release. This means higher blood histamine levels. Nighttime increases in histamine interfere with normal melatonin function.

Mood changes:

Anxiety, irritability, low mood. Estrogen modulates serotonin and dopamine receptor sensitivity; the perimenopausal decline in estradiol can unmask vulnerability to mood disorders.⁴

Cognitive symptoms (brain fog):

Difficulty with verbal memory, word retrieval, and processing speed during perimenopause. MRI evidence shows altered brain glucose metabolism during this window.⁵ For most women, cognitive symptoms improve after the transition; persistent impairment warrants formal assessment.

Irregular periods and heavy bleeding:

In perimenopause, anovulatory cycles are common, leading to irregular period timing and, in anovulatory cycles, unopposed estrogen, causing heavier bleeding.

Genitourinary syndrome of menopause (GSM):

Vaginal dryness, dyspareunia, urinary urgency, and recurrent UTIs are driven by urogenital tissue atrophy from declining estradiol.

Bone loss:

Estrogen maintains bone density by inhibiting osteoclast activity. Bone loss accelerates sharply in the 5–7 years around menopause.⁶

Cardiovascular risk:

The cardioprotective effect of estrogen declines with menopause; the incidence of cardiovascular disease in women rises significantly in the decade post-menopause.⁷

What Drives Perimenopausal Symptoms?

The key hormonal changes:

Progesterone Declines First

Anovulatory cycles reduce luteal phase progesterone output before estradiol meaningfully declines. This progesterone-deficient state, with still-present estrogen, produces a relative estrogen excess that contributes to sleep disruption, anxiety, uterine fibroids, and heavy bleeding in early perimenopause.

Estradiol Becomes Erratic, Then Declines

Variable, often elevated estradiol in early perimenopause gradually gives way to sustained low estradiol. Both the fluctuation and the eventual decline drive symptoms.

FSH rises

As ovarian follicle numbers decline, FSH rises to stimulate remaining follicles. FSH >25 IU/L with irregular cycles suggests perimenopause, though FSH alone is not diagnostic.

Natural Treatment Options for Perimenopause and Menopause

1. Phytoestrogens

Isoflavones (soy-derived genistein and daidzein, or red clover-derived biochanin A and formononetin) are the best-studied dietary phytoestrogens for vasomotor symptom management. They bind estrogen receptors with selective agonist/antagonist activity (ERβ preference).

A 2021 systematic review and meta-analysis found that dietary phytoestrogens, particularly isoflavone supplementation, produced a statistically significant reduction in hot flash frequency (approximately 20.6%) and severity compared to placebo, though effect sizes were modest compared to HRT.⁸ Soy foods are preferred over concentrated isoflavone supplements for women with a personal or family history of hormone-sensitive breast cancer, and this clinical decision requires individualized assessment. Naturopathic care does not replace oncology guidance.

2. Black Cohosh (Actaea racemosa)

Black cohosh is the most studied phytotherapeutic for menopausal symptoms. Multiple RCTs show reductions in hot flash frequency, severity, and associated sleep disruption. The German Commission E and ESCOP recognize it for climacteric complaints. Its mechanism is not primarily estrogenic (despite historical assumption); it appears to act through serotonergic and dopaminergic pathways.⁹

A 2012 systematic review found that standardized black cohosh extract reduced composite Kupperman Menopause Index scores compared to placebo in most trials.¹⁰ Duration of use: evidence generally supports 6-12 months of continuous use; longer durations require monitoring. Rare cases of hepatotoxicity have been reported; these are idiosyncratic and uncommon but warrant monitoring in longer-term use. Black cohosh should be avoided in women with existing liver disease.

Until more is known, patients with hormone-sensitive conditions should avoid black cohosh. Some of these conditions include uterine cancer, ovarian cancer, endometriosis, and uterine fibroids.

3. Pycnogenol (French Maritime Pine Bark Extract)

A 2007 RCT found that Pycnogenol (100 mg/day) significantly reduced perimenopausal symptom scores (Menopause Rating Scale) compared with placebo, with notable reductions in hot flashes, fluid retention, and libido complaints.¹¹ Anti-inflammatory and antioxidant mechanisms are proposed.

4. Dietary Intervention for Menopause & Perimenopause

• Mediterranean diet pattern: Associated with reduced vasomotor symptom severity in prospective cohort data.¹²
• Reducing dietary triggers: Alcohol, caffeine, spicy foods, and refined carbohydrates can precipitate or worsen hot flashes.
• Blood sugar regulation: Glycemic instability worsens HPA axis reactivity and can amplify vasomotor symptoms and mood instability. A low-GI/GL dietary pattern is foundational.
• Calcium and magnesium: Adequate dietary calcium supports bone health during accelerated peri/post-menopausal bone loss. Magnesium glycinate supports sleep quality and reduces HPA axis reactivity.

5. Progesterone Support (Early Perimenopause)

The loss of luteal progesterone in anovulatory perimenopausal cycles is clinically significant and under-addressed. Progesterone is GABAergic (its metabolite allopregnanolone is a positive GABA-A modulator), sleep-promoting, anxiolytic, and counter-regulatory to estrogen’s proliferative effects on uterine and breast tissue. Chaste tree berry (Vitex agnus-castus) has dopaminergic properties that support LH pulsatility and may improve luteal phase progesterone output, but only in someone who is still ovulating. Therefore, it is most appropriate in early perimenopause when ovulatory cycles are still occurring intermittently.¹³

6. HPA Axis (Adrenal) Support

Post-menopausally, the adrenal glands become a primary source of estrogen precursors (via DHEA-to-estrone conversion). Supporting adrenal function with vitamins, minerals, adaptogens (Rhodiola rosea, Withania somnifera, Schisandra chinensis), adequate sleep, blood sugar regulation, and stress management is a relevant long-term strategy. Elevated cortisol compounds sleep disruption, weight gain, bone loss, and mood symptoms. Addressing it directly is not optional in perimenopausal management. A morning cortisol blood test is highly recommended, rather than assuming high cortisol.

Adrenal gland support is, in my view, the most important strategy for smoothing the perimenopause transition and supporting long-term health.

7. Bone Health

Calcium (1000 mg/day from combined food and supplemental sources), vitamin D3 (maintaining serum 25-OH >75 nmol/L), magnesium, vitamin K2 (MK-7 form), and weight-bearing exercise form the evidence base for peri/post-menopausal bone health support. Supplemental calcium carbonate is less bioavailable than calcium citrate, particularly in women with lower gastric acid production. DEXA scan at menopause, and follow-up imaging informs risk stratification.

Lab Testing for Perimenopause

These tests can be done by a medical doctor and are mostly covered by OHIP. They can also be ordered by a naturopathic doctor in Ontario, in which case, none of them would be covered by OHIP.

Relevant baseline investigations: FSH, LH, estradiol (ideally cycle day 2-3 if still cycling), progesterone (cycle day 21 or 7 days post-ovulation if cycling), AMH, SHBG, total and free testosterone, DHEA-S, 7-9 a.m. cortisol, thyroid panel (TSH, free T4, free T3, TPO and thyroglobulin antibodies, thyroid disorders are highly prevalent in perimenopausal women and produce overlapping symptoms), CBC, ferritin (heavy perimenopausal bleeding commonly causes iron deficiency), fasting glucose, fasting insulin, lipid panel (cardiovascular risk trajectory changes post-menopause), 25-OH vitamin D, and DEXA scan (bone mineral density test) if indicated.

This article is just a sampling of the strategies that I can help you with to ease menopause and perimenopause symptoms, restore your energy, help you feel like yourself again, sleep better, and reduce hot flashes and night sweats using natural medicine. For individual help with perimenopause, menopause or any other health problem, book an appointment here or call the office for more information at 416-481-0222.

by Dr. Pamela Frank, BSc(Hons), ND, updated June 28, 2026

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References for Menopause & Perimenopause

1. Hale GE, Robertson DM, Burger HG. The perimenopausal woman: endocrinology and management. J Steroid Biochem Mol Biol. 2014 Jul;142:121-31. doi: 10.1016/j.jsbmb.2013.08.015. Epub 2013 Oct 14. PMID: 24134950.
2. Masoumi, Maryam & Azizi, Marzieh & Atarod, Zoleikha & Gartoulla, Pragya & Abdollahi, Fatemeh & Fooladi, Ensieh. (2017). A Systematic Review of Prevalence of Vasomotor and Sexual Symptoms Among Iranian Middle-Aged Women. Iranian Red Crescent Medical Journal. 19. e43952. 10.5812/ircmj.43952.
3. Padilla SL, Johnson CW, Barker FD, Patterson MA, Palmiter RD. A Neural Circuit Underlying the Generation of Hot Flushes. Cell Rep. 2018 Jul 10;24(2):271-277. doi: 10.1016/j.celrep.2018.06.037. PMID: 29996088; PMCID: PMC6094949.
4. Schmidt PJ, Rubinow DR. Sex hormones and mood in the perimenopause. Ann N Y Acad Sci. 2009 Oct;1179:70-85. doi: 10.1111/j.1749-6632.2009.04982.x. PMID: 19906233; PMCID: PMC2891531.
5. Maki PM, Henderson VW. Cognition and the menopause transition. Menopause. 2016 Jul;23(7):803-5. doi: 10.1097/GME.0000000000000681. PMID: 27272226.
6. Eastell R. Treatment of postmenopausal osteoporosis. N Engl J Med. 1998 Mar 12;338(11):736-46. doi: 10.1056/NEJM199803123381107. PMID: 9494151.
7. Mosca L, Barrett-Connor E, Wenger NK. Sex/gender differences in cardiovascular disease prevention: what a difference a decade makes. Circulation. 2011 Nov 8;124(19):2145-54. doi: 10.1161/CIRCULATIONAHA.110.968792. PMID: 22064958; PMCID: PMC3362050.
8. Levis S, Griebeler ML. The role of soy foods in the treatment of menopausal symptoms. J Nutr. 2010 Dec;140(12):2318S-2321S. doi: 10.3945/jn.110.124388. Epub 2010 Nov 3. PMID: 21047930; PMCID: PMC2981010.
9. Burdette JE, Liu J, Chen SN, Fabricant DS, Piersen CE, Barker EL, Pezzuto JM, Mesecar A, Van Breemen RB, Farnsworth NR, Bolton JL. Black cohosh acts as a mixed competitive ligand and partial agonist of the serotonin receptor. J Agric Food Chem. 2003 Sep 10;51(19):5661-70. doi: 10.1021/jf034264r. PMID: 12952416.
10. Shams T, Setia MS, Hemmings R, McCusker J, Sewitch M, Ciampi A. Efficacy of black cohosh-containing preparations on menopausal symptoms: a meta-analysis. Altern Ther Health Med. 2010 Jan-Feb;16(1):36-44. PMID: 20085176.
11. Yang HM, Liao MF, Zhu SY, Liao MN, Rohdewald P. A randomised, double-blind, placebo-controlled trial on the effect of Pycnogenol on the climacteric syndrome in peri-menopausal women. Acta Obstet Gynecol Scand. 2007;86(8):978-85. doi: 10.1080/00016340701446108. PMID: 17653885.
12. Barnard ND, Kahleova H, Holtz DN, Znayenko-Miller T, Sutton M, Holubkov R, Zhao X, Galandi S, Setchell KDR. A dietary intervention for vasomotor symptoms of menopause: a randomized, controlled trial. Menopause. 2023 Jan 1;30(1):80-87. doi: 10.1097/GME.0000000000002080. Epub 2022 Oct 16. PMID: 36253903; PMCID: PMC9812421.
13. Loch EG, Selle H, Boblitz N. Treatment of premenstrual syndrome with a phytopharmaceutical formulation containing Vitex agnus castus. J Womens Health Gend Based Med. 2000 Apr;9(3):315-20. doi: 10.1089/152460900318515. PMID: 10787228.
14. Valerieva E, Vasileva M, Baynova K, Krusheva B, Petkova E, Nenova M, Novakova P, Staevska M, Cimbollek S, Valerieva A. Women’s hormones and hypersensitivity: allergic diseases in menopause. Front Allergy. 2026 Apr 8;7:1777688. doi: 10.3389/falgy.2026.1777688. PMID: 42027630; PMCID: PMC13099772.
15. Pham L, Baiocchi L, Kennedy L, Sato K, Meadows V, Meng F, Huang CK, Kundu D, Zhou T, Chen L, Alpini G, Francis H. The interplay between mast cells, pineal gland, and circadian rhythm: Links between histamine, melatonin, and inflammatory mediators. J Pineal Res. 2021 Mar;70(2):e12699. doi: 10.1111/jpi.12699. Epub 2020 Nov 29. PMID: 33020940; PMCID: PMC9275476.
16. Acupuncture: Avis NE, Coeytaux RR, Isom S, Prevette K, Morgan T. Acupuncture in Menopause (AIM) study: a pragmatic, randomized controlled trial. Menopause. 2016; 23(6):626-37. ● Two groups: (1) individualized treatment for the first 6 months then they received the usual care for the second 6 months (acupuncture group), (2) vice versa (control group) ● Acupuncture group significantly reduced vasomotor symptoms by up to 36.7% and improved sleep QOL measures (hot flash interference, sleep quality, physical symptoms, memory symptoms, anxiety); all benefits persisted at least 6 months after the end of the treatment, with benefits noticed after 3 treatments and max clinical benefit noticed at 8 treatments (avg). Abdominal acupuncture is an effective and safe method for menopause depressive disorder, it improves the menopause depressive symptoms with persistent action, fewer symptoms of relapse, and adverse reactions. Source: Zhongguo Zhen Jiu. 2010 Nov;30(11):913-7
17. Vitamin D: Cangussu L, Nahas-Neto J, Orsatti C, Poloni P, Schmitt E, Almeida-Filho B, Nahas E. Effect of isolated vitamin D supplementation on the rate of falls and postural balance in postmenopausal women fallers: a randomized, double-blind, placebo-controlled trial. Menopause. 2016; 23(3):267-74.
18. Blueberries: Johnson SA, Figueroa A, Navaei N, Wong A, Kalfon R, Ormsbee LT, Feresin RG, Elam ML, Hooshmand S, Payton ME, Arjmandi BH. Daily blueberry consumption improves blood pressure and arterial stiffness in postmenopausal women with pre-hypertension and stage 1-hypertension: a randomized, double-blind, placebo-controlled clinical trial. J Acad Nutr Diet. 2015; 115(3): 369-77.
19. Schisandra Chinensis: Park JY, Kim KH. A randomized, double-blind, placebo-controlled trial of Schisandra Chinensis for menopausal symptoms. Climacteric. 2016; 19(6):574-580.
    ● Kupperman Index score (menopausal symptoms) were significantly lower in the Schisandra group compared to placebo – effective in hot flushes, sweating, and heart palpitations
20. Fenugreek husk: Shamshad BS, Jayalakshmi HK, Vidyavathi HG, et al. A novel extract of fenugreek husk alleviates postmenopausal symptoms and helps to establish the hormonal balance: a randomized, double-blind, placebo-controlled study. Phytother Res. 2016; 30(11):1755-1784.
    ● Fenugreek extract (Trigonella foenum-graecum husk) 250 mg each capsule, 500 mg twice daily after meals for 90 days. After 90 days, menopausal symptom severity (GCS) scores decreased significantly, especially in the subsections of the questionnaire involving anxiety, depression, vasomotor symptoms, mood swings, insomnia, headaches, vaginal dryness. The mean quality of life score (SF-36) improved in 73% of participants compared with 32.5% of those in the placebo group. In the placebo group, there was a significant increase in general well-being and mental health compared to baseline.
21. Maca: Stojanovska L, Law C, Lai B, Chung T, Nelson K, Day S, Apostolopoulos V, Haines C. Maca reduces blood pressure and depression, in a pilot study in postmenopausal women. Climacteric. 2015; 18(1):69-78. ● Over the 12 week period, maca appeared to significantly reduce diastolic blood pressure and depression in postmenopausal Chinese women.
22. S-(-)equol: Natural S-(-)equol, a product of the bacterial transformation of the soybean compound daidzein, reduces the severity of hot flashes and other menopausal symptoms. Source: J Womens Health (Larchmt). 2011 Oct 12. S-equol supplementation may alleviate certain menopausal symptoms in women who are equol nonproducers (women who do not produce the daidzein-metabolite equol after eating soy). Source: Menopause, 2009; 16(1): 141-8.
23. Red Clover Isoflavone: Supplementation with red clover isoflavones was found to be associated with a considerable decrease in overall menopausal symptom intensity including hot flashes. Source: Gynecological Endocrinology, posted online August 26, 2011.
    Supplementation with red clover isoflavones was found to be associated with a considerable decrease in overall menopausal symptom intensity including hot flashes.  Source: Gynecological Endocrinology, posted online August 26, 2011.
24. Black Cohosh: Supplementation with black cohosh in early menopausal women was found to show significantly more improvement than the control group in vasomotor, psychiatric, physical, and sexual symptoms.  Source: Chinese Medicine 2013, 8:20
25. Vitamin E: A lower vitamin E:lipid ratio was found to be associated with osteoporosis. These findings suggest that vitamin E may increase bone mineral density in healthy postmenopausal women.  Source: J Bone Miner Metab, 2013 March 28
26. Pycnogenol & Skin: Daily supplementation with pycnogenol in postmenopausal women improved skin hydration by 8% and skin elasticity by 25%.  Source: Skin Pharmacol Physiol. 2012; 25(2):86-92. Epub 2012 Jan 21.
27. Omega-3s: Supplementation with 1.05 g/d ethyl-eicosapentaenoic acid (E-EPA) plus 0.15 g/d ethyl-docosahexaenoic acid for 8 weeks was found to improve depressive symptoms and psychological distress in menopausal women.
    Source: Am J Clin Nutr, 2008 Dec 20; [Epub ahead of print]. 
28. Phytoestrogens and Menopause: Plant-based therapies such as phytoestrogen supplementation were shown to significantly reduce some menopausal symptoms including hot flashes. Source: Use of Plant-Based Therapies and Menopausal Symptoms: A Systematic Review and Meta-analysis.JAMA. 2016 Jun 21;315(23):2554-63.
29. Fennel: In a blinded, placebo-controlled trial, 90 postmenopausal women (ages 45-60 years) were treated with fennel or a placebo. The fennel group had a significant decrease in a range of menopausal symptoms. It was concluded that fennel is an effective and safe treatment in reducing menopausal symptoms without adverse effects.
    Source: Effect of Foeniculum vulgare Mill. (fennel) on menopausal symptoms in postmenopausal women: a randomized, triple-blind, placebo-controlled trial.Menopause. 2017 Sep;24(9):1017-1021.
30. Acupuncture: A systematic review was conducted, finding that the use of acupuncture, both as an adjunctive treatment or alone, was effective at improving the health-related quality of life and vasomotor symptoms of menopause with no negative side effects.
    Source: Management of Menopause Symptoms with Acupuncture: An Umbrella Systematic Review and Meta-Analysis. The Journal of Alternative and Complementary Medicine. 2018, Jan 3.
31. Diet and Age of Menopause Onset: A study found a link between the type of food that women regularly ate, and the age they went through menopause. Those who had higher amounts of refined pasta and rice went through the change earlier, while women whose diets focused more on fish, beans, and other legumes started menopause at a later age.
    Source: Dietary intake and age at natural menopause: results from the UK Women’s Cohort Study. 2018. J Epidemiol Community Health, jech-2017.
32. Green Tea to Reduce Cholesterol/Triglycerides: In a randomized control trial, green tea extract was found to significantly reduce triglyceride and cholesterol levels compared to placebo. Therefore, green tea extract may be a more cost-effective way to improve lipid profiles in postmenopausal women without major side effects. Source: Impact of green tea extract on serum lipid of postmenopausal women: A randomized controlled trial. 2017. Journal of Traditional and Complementary Medicine.

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Dr. Pamela Frank has been in practice as a naturopathic doctor for over 26 years. Since 1999, she has earned acclaim as a leading naturopath in Toronto, amassing multiple awards.

Dr. Pamela has a special interest in addressing hormone-related complexities, including but not limited to PCOS, endometriosis, acne, hair loss, weight management, thyroid issues, and fertility.

Residing in Toronto with her family and loyal companion, Dolly the rescue dog, Dr. Pamela seamlessly combines her professional commitment with a diverse range of interests.

Beyond her clinical endeavours, she actively engages in kickboxing, leadership roles within Scout Groups, yoga practice, podcasting, and outdoor pursuits such as backcountry camping.

Dr. Pamela’s comprehensive approach reflects not only her dedication to optimal health but also her passion for continual personal and professional growth.

DISCLAIMER: The information provided here may not apply precisely to your individual situation. Diagnostic and therapeutic choices must always be tailored to the individual patient’s circumstances, and consultation with a licensed naturopathic physician should be undertaken before following any of the treatment strategies suggested on this website.