OTC Options for Menopause: Product Selection and Counseling Strategies

This content was independently produced by Pharmacy Times in partnership with Bayer Healthcare.

Menopause is a natural transition marked by loss of ovarian function and menstruation. The median age of menopause onset in the US is 52 years, although approximately 5% to 10% of women experience early menopause by the time they are aged 45 years.¹

Menopause is often accompanied by vasomotor symptoms, mood changes, sleep disturbances, vaginal dryness, and weight fluctuations.¹ Perimenopause refers to the time when these signs are first observed and ends 1 year after the final menstrual period. Although prescription hormone replacement therapy (HRT) is the standard treatment for moderate to severe symptoms, many individuals seek out OTC solutions to manage milder discomfort. Pharmacists and health care providers play a key role in guiding safe product selection and counseling.

Common Symptoms and OTC Options

• Vasomotor symptoms: These symptoms occur due to changing hormone levels, most likely a decline in estrogen.^2,3 Herbal supplements such as black cohosh (Actaea racemosa), red clover (Trifolium pratense), soy isoflavones, and evening primrose (Oenothera biennis) oil are marketed for vasomotor symptoms. Although some women report modest symptom relief, clinical evidence remains mixed, and long-term safety data are limited. The primary treatment is usually prescription medications.
• Sleep and mood aids: Sleep disturbances during menopause are often caused by a combination of factors, including hormonal changes, vasomotor symptoms, and physiological changes.^4,5 They can also be attributed to a primary sleep disorder. A 2017 CDC report indicated that postmenopausal women were more likely to experience trouble falling asleep, staying asleep, and not waking up sufficiently rested compared with premenopausal women.⁴ Low-dose melatonin or magnesium glycinate may help with insomnia. St John’s wort (Hypericum perforatum) is sometimes used for mild mood disturbances, but it carries significant drug interaction risks.⁶
• Irritability and anxiety: These emotional symptoms happen because of declining estrogen and progesterone, which also decrease serotonin levels. They can also be secondary symptoms resulting from tiredness and poor-quality sleep. The evidence is mixed regarding OTC solutions or supplements, such as St John’s wort, kava (Piper methysticum), and omega-3 fatty acids. In general, if patients have feelings of irritability, anxiety, or depression, it is best to speak with their primary health care provider to explore lifestyle changes or prescription medication.
• Vaginal dryness: This happens due to lower levels of estrogen, which causes thinning, drying, and inflammation of vaginal walls.² Lubricants and moisturizers can be helpful. Choose products containing polycarbophil, hyaluronic acid, or water-based lubricants to provide temporary relief and improve comfort during intercourse.
• Bone and heart health support: Calcium and vitamin D supplements can help maintain bone density; omega-3 fatty acids may support cardiovascular health during and after menopause. Most women need at least 1200 mg/d of calcium, with levels higher than 2500 mg/d not recommended.⁷ To maintain adequate calcium absorption, a vitamin D dose of 400 to 600 international units is recommended either through sun exposure, diet, or supplementation.

Common Herbal Supplements

Black cohosh has been used in menopausal and perimenopausal patients to help manage vasomotor symptoms. However, it has mixed-to-negative evidence and was not superior to placebo in several large trials.³

Evening primrose oil has been studied for its potential benefits in alleviating vasomotor symptoms and psychological symptoms. The evidence is mixed, with some studies yielding positive findings and others showing little to no effect. It may help with the severity, but not the frequency, of vasomotor symptoms.⁸

Kava has been studied in conjunction with HRT and showed greater reduction in anxiety vs HRT alone. Additionally, when taken alone, 200 mg/d of kava has shown a decrease in anxiety when compared with a control group.⁹

Omega-3 Fatty acids have had favorable effects on depression and anxiety symptoms in menopausal women when combined with lifestyle factors like exercise, according to a systematic review.¹⁰

Red clover has been suggested to have a statistically moderate relationship with reduced frequency of vasomotor symptoms, according to a meta-analysis. However, the quality of the data was limited.¹¹

Soy isoflavones have shown small but statistically significant reductions in vasomotor symptom frequency, as well as more consistent benefits in trials with standardized isoflavone. It is considered one of the preferred nonhormonal therapies for these symptoms.¹²

St John’s wort has shown benefit in mild to moderate depression and/or improvements in irritability in perimenopausal and postmenopausal women in several clinical trials. However, there are many drug interactions, including antidepressants, hormone therapy, and oral contraceptives.^10,13,14

Vitamin E showed no difference in anxiety levels in a small study of postmenopausal women testing 400 μg per day for 8 weeks.¹⁴

Combination Products

There are many combination products on the market with blends of herbs, vitamins, minerals, and antioxidants that aim to relieve vasomotor symptoms and mood/sleep issues.¹⁴ When counseling patients, it is important to emphasize that there is a lot of variability in these products, and it is difficult to isolate which ingredient is causing the symptom relief.

OTC and Natural Options

Combining lifestyle strategies with supplements and prescription medications has been shown to increase symptoms.¹ Encourage patients to have regular exercise (aerobic and strength) for better mood and reduced anxiety. They can also incorporate stress management techniques, such as breathing exercises, yoga, and meditation. Continue to monitor sleep and practice good sleep hygiene, and evaluate patients' diets to make sure they include balanced meals and avoid blood glucose swings.¹⁰ Avoidance of triggers like alcohol, caffeine, and nicotine may also help.

Counseling Strategies

Effective counseling includes a thorough assessment of the patient’s symptoms, medical history, and current medications. An inventory of current herbal supplements should also be assessed, with a reminder to patients that these supplements are not subject to the same regulatory standards as prescription drugs.

Lifestyle strategies should also be emphasized, as balanced nutrition, regular exercise, stress management, and good sleep hygiene can all help alleviate symptoms and be highly effective when combined with other methods.

First, assess the severity of the patient’s symptoms. Ask how severe or frequently they are experiencing anxiety or irritability. Are they interfering with daily life and sleep? How many vasomotor symptoms do they experience a day?

Next, set realistic expectations. OTC supplements may yield small improvements, but they are not a cure. Importantly, it may take 8 to 12 weeks for some OTC products to work.

It is best to choose 1 supplement at a time when possible so that clinicians can isolate what works and better monitor adverse effects. Let the patient know that there is no standardization for many doses of herbal supplements and counsel them to use a reputable brand with third-party verification.

Check for contraindications and interactions by reviewing other medications and supplements the patient is taking. For example, St John’s wort interacts with several medications, kava can cause liver damage, and black cohosh is not recommended in certain populations. Ask about liver disease, cardiovascular disease, and psychiatric conditions.

Finally, give the patient support and resources for follow-up. If their symptoms persist or worsen, referral to a health care provider should be recommended. Many symptoms in menopause may require a prescription, and patients should be counseled about when to seek out medical care.

By setting realistic expectations and providing evidence-based guidance on OTC options for menopause, pharmacists can empower individuals to manage their symptoms safely and effectively.

REFERENCES

1. Menopause, women’s health, and work. CDC. November 14, 2024. Accessed October 13, 2025. https://www.cdc.gov/womens-health/features/menopause-womens-health-and-work.html

2. The menopause years. American College of Obstetricians & Gynecologists. Updated November 2023. Accessed October 13, 2025. https://www.acog.org/womens-health/faqs/the-menopause-years

3. Pockaj BA, Gallagher JG, Loprinzi CL, et al. Phase III double-blind, randomized, placebo-controlled crossover trial of black cohosh in the management of hot flashes: NCCTG trial N01CC1. J Clin Oncol. 2006;24(18):2836-2841. doi:10.1200/JCO.2005.05.4296

4. Vahratian A. Sleep duration and quality among women aged 40-59, by menopausal status. NCHS Data Brief. 2017:(286):1-8.

5. Maki PM, Panay N, Simon JA. Sleep disturbance associated with the menopause. Menopause. 2024;31(8):724-733. doi:10.1097/GME.0000000000002386

6. Al-Akoum M, Maunsell E, Verreault R, Provencher L, Otis H, Dodin S. Effects of Hypericum perforatum (St. John’s wort) on hot flashes and quality of life in perimenopausal women: a randomized pilot trial. Menopause. 2009;16(2):307-314. doi:10.1097/gme.0b013e31818572a0

7. North American Menopause Society. The role of calcium in peri- and postmenopausal women: consensus opinion of The North American Menopause Society. Menopause. 2001;8(2):84-95. doi:10.1097/00042192-200103000-00003

8. Farzaneh F, Fatehi S, Sohrabi MR, Alizadeh K. The effect of oral evening primrose oil on menopausal hot flashes: a randomized clinical trial. Arch Gynecol Obstet. 2013;288(5):1075-1079. doi:10.1007/s00404-013-2852-6

9. Sarris J, Stough C, Teschke R, et al. Kava for the treatment of generalized anxiety disorder RCT: analysis of adverse reactions, liver function, addiction, and sexual effects. Phytother Res. 2013;27(11):1723-1728. doi:10.1002/ptr.4916

10. Grigolon RB, Ceolin G, Deng Y. Effects of nutritional interventions on the severity of depressive and anxiety symptoms of women in the menopausal transition and menopause: a systematic review, meta-analysis, and meta-regression. Menopause. 2023;30(1):95-107. doi:10.1097/GME.0000000000002098

11. Kanadys W, Barańska A, Błaszczuk A, et al. Evaluation of clinical meaningfulness of red clover (Trifolium pratense L.) extract to relieve hot flushes and menopausal symptoms in peri- and post-menopausal women: a systematic review and meta-analysis of randomized controlled trials. Nutrients. 2021;13(4):1258. doi:10.3390/nu13041258

12. Tice JA, Ettinger B, Ensrud K, Wallace R, Blackwell T, Cummings SR. Phytoestrogen supplements for the treatment of hot flashes: the isoflavone clover extract (ICE) study: a randomized controlled trial. JAMA. 2003;290(2):207-214. doi:10.1001/jama.290.2.207

13. Liu YR, Jiang YL, Huang RQ, Yang JY, Xiao BK, Dong JX. Hypericum perforatum L. preparations for menopause: a meta-analysis of efficacy and safety. Climacteric. 2014;17(4):325-335. doi:10.3109/13697137.2013.861814

14. Mehrnoush V, Darsareh F, Roozbeh N, Ziraeie A. Efficacy of the complementary and alternative therapies for the management of psychological symptoms of menopause: a systematic review of randomized controlled trials. J Menopausal Med. 2021;27(3):115-131. doi:10.6118/jmm.21022