I had just turned 40 when it started. Suddenly, the ads on my social-media feeds changed. The algorithms decided I was now officially middle-aged and crumbling – by their metrics – and it was time for me to start buying hormone-supporting supplement blends, collagen powder, bum-sculpting leggings and anti- wrinkle creams.
In truth, the hormone supplements piqued my interest. I was sleeping badly, more anxious than ever, and low on energy after IVF and two pregnancies.
But could one product give me better sleep, focus, energy, clarity and libido, while ending bloating, weight gain, anxiety, mood swings, erratic menstrual cycles, heavy periods, muscle pain, headaches and indigestion, and lower my cholesterol, cortisol and blood sugar – all in a capsule or scoop of powder? Could a single supplement help with hormonal balance during perimenopause, menopause and beyond, each such hormonally different times of life? Has anyone tested what taking a large number of herbal and fungal extracts, plus vitamins and minerals, all at the same time, would do to a body? Why are they so expensive? And is there any evidence they work?
Middle-aged women make up a large, attractive market and we are all too often underserved by medicine (this is not a dig at overstretched GPs; women’s health is historically under-researched and, prior to 2021, was barely taught to trainee doctors). In the UK, about a third of all women are perimenopausal, menopausal or postmenopausal at any moment, many of whom worry about the risks posed by HRT (now shown to be mostly overstated). The global market for menopause products is worth $16.93bn, with the vast majority of spending being on dietary supplements. As one of my friends put it: “Middle-aged women take so many supplements that we rattle.” At least some of that is down to an industry capitalising on a healthcare void; “meno-washing” is hardly the first example of that happening.
That void leaves a lot of room for both bad actors and good, offering “natural” solutions, which we take without medical supervision, not knowing if a product is worth the money, or safe to take alongside existing prescriptions or health conditions. Taking supplements also feels very normal: just under 20 million British adults take them, according to Kantar (supplement use leapt up during the pandemic), despite new evidence from a study of 400,000 adults suggesting daily multivitamins don’t increase longevity.
Some women do report that they find hormone balancing supplements useful. But in both supplements and hormonal healthcare, the placebo effect is very powerful, especially when it comes to pain and mood: studies show that higher prices, fancier labels and apparently higher dosages, increase how well a placebo treatment of any kind works in trials, which could go some way to explaining why so many hormone-related supplements are pricey and come in pretty, limited-edition bottles, and why you’re often directed to take two or three pills at a time (this may also be because they contain so many ingredients that the dose won’t fit in a single capsule). But if a supplement seems to work, who cares whether it’s not working at a biological or clinical level? “Because at £100 a month, that’s money women could be spending on better food,” says Professor Susan Davis, a consultant endocrinologist, sex hormone clinical researcher and head of Monash University’s women’s health research programme. She advises the NHS on menopause and last year reviewed national and international menopause guidelines for the BMJ. “The only people who should be taking supplements are people with malabsorption or nutritional deficiencies.”
I wanted to know if I could trust the claims brands make, so I started digging into how supplements are regulated in the UK. The first baffling thing I discover is that there is an EU database, called the Article 13.1 On Hold Claims List – stay with me, I promise this does get interesting. It’s a list of health and wellbeing claims for botanical substances, such as ginseng or reishi, that back in 2006 the EU couldn’t agree how or whether to assess, but also didn’t want to reject. (Nearly 350 health claims for nutrients such as iron and vitamin D have since been assessed and allowed; thousands were rejected for lack of evidence.) These botanical claims were stuck on a spreadsheet and that’s where they remain today, all 2,078 of them. Supplement companies can use the claims (as long as they don’t conflict with other legislation) – such as that rue, sage or verbena can help women cope with menopause – but, crucially, most claims on the list haven’t yet been fully assessed. Nor do they look are they likely ever to be, because doing so would be wildly expensive.
“This is an unfortunate situation for consumers, because they may be buying products believing they have a particular health benefit, but this has yet to be assessed and approved, or not,” says Professor Susan Fairweather-Tait, who chairs the UK Nutrition and Health Claims Committee.
That doesn’t mean none of the ingredients listed have a biological effect, but we can’t really know which do.
To confuse things further, 26 menopause supplements have been granted traditional herbal registration (THR) status by the UK’s Medicines and Healthcare products Regulatory Agency (MHRA), based on them having been used safely in the EU for at least 30 years as menopause treatments: most are black cohosh extracts, a few include St John’s wort, sage, red peony or valerian. The THR mark also doesn’t necessarily mean they’ve been studied for effectiveness.
The UK’s written regulatory framework for food supplements is pretty robust. There are clear rules about what a brand is allowed to claim its product can do for our health. Unless a product is licensed by the MHRA as a medical product or device, or granted THR status, then technically it can’t claim to treat the symptoms of any health problem. Menopause and hormonal health are a bit of a grey area (menopause is not considered a disease), because you can say that certain ingredients support women through peri- or menopause. But no company should claim a product can treat specific symptoms of menopause, like hot flushes, anxiety, night sweats, muscle pain or insomnia. As the MHRA tells me, this, “would be regarded as medicinal and consequently bring the product into scope as a medicine”. And as the government’s labelling website says: “You cannot claim or imply that food can treat, prevent or cure any disease or medical condition.”
Nonetheless, there are companies, especially online only, which seem to do just that, either openly, or more subtly via branding or by spotlighting cherrypicked customer reviews. Industry insiders say sanction is rare, especially in a field like hormone health, where a product is more likely to be useless than toxic. Few consumers know how to report a product making unjustifiable health claims – and who has the time or energy?
Food supplements are regulated by the Food Standards Agency (FSA), but how many of us would attempt to find the trading address of the company and report a product to the local council’s trading standards team – and who knew they were the first responders overseeing food supplements, anyway? Some online-only companies don’t even have a UK address to visit. Add to that the fact that the number of trading standards officers employed by councils dropped by 30-50% across the UK between 2008 and 2020; that environmental health enforcement visits have halved; that the FSA describes the UK’s food testing system as in a state of “chronic decline” due to lack of funding; and that most prosecutions would have to be paid for out of the local council’s own budget, and you might start to wonder whether anyone really does have our backs.
I ask one scientist who formulates supplements – who did not want to be named, but who is thoroughly alarmed by the recent proliferation of supplement health claims – what is there to stop me from setting up a company selling cornflour capsules labelled as menopause supplements? “With a fair headwind, very little,” he says.
If I advertised online, I might get caught out by the Advertising Standards Authority (ASA), which hunts online for ads that break medical claims rules, particularly around menopause, using an AI tracker. In the last 18 months, the ASA has ruled against Happy Koala’s MenoDaily (sold on the Happy Mammoth site), Feel Menopause Support, FemTech’s Key for Peri + Menopause, Feminapause, Napiers the Herbalists’ Wild Yam Cream, Rejuvit, Ovira and Dirtea. The ASA only has the power to stop companies making claims in ads, though, meaning that the same words they rule against might still be used elsewhere.
As I researched this piece, targeted ads trailed me all over the internet and – honestly – I still wanted to believe them. But then one company “diagnosed” me with what it calls oestrogen overflow, after I filled out an online questionnaire. I actually do have a hormonal disorder for which I have only recently been medicated. The product I was recommended is supposed to remove excess oestrogen and increase progesterone, which, given that I’m progesterone sensitive, could be dangerous if it worked. When I emailed the “diagnosis” to my doctor, she sent back a face-palm emoji.
“I’ve done those surveys but made up the most pristine person,” says Davis. “I’ve said I’m 35, regular cycles, great sleep, great mood and at the end it still spat out ‘this product will help you optimise your quality of life’.”
Is the meno-pound just another wellness gold rush, like gut health, sleep tracking, detoxes, grounding blankets and superfoods, or is there a chance that some of them really do work? “Most of it is garbage,” she says. “For menopausal symptoms, the evidence is not there. All the stuff that’s being peddled has basically no evidence behind it. The only evidence for phytoestrogens in soy has been for possibly some cholesterol-lowering effects. The most evidence-based therapy is black cohosh and the evidence of it having any benefit is extremely poor quality and lacking in proper double-blind, randomised, placebo-controlled trials.”
What about wild yam extract? (The body-identical progesterone I take is made from yam) “None of us have the enzymes in our body to make progesterone out of yams,” she sighs, explaining the complex lab-based processes required to do so. What about “hormone-boosting” supplements made from cow or pig reproductive organs? “Your gastric acid probably destroys most of it. There’s a reason we give hormones in IVF by injection. But if growth hormones did get past your gastric acid – which I doubt – then there are dangers for adult growth hormone supplementation.”
Davis is not a fan of multi-extract, highly concentrated products. “Maybe boiling up sage leaves at home could help with menstrual cramps. But it’s bizarre to think you can take sage leaves, dry them out, extract them and mix them with five other things and that those things won’t oppose each other, are safe together and that you’ll know what quantity to take, when no one’s done studies of this.” For Davis, there are only two non-prescription treatments for midlife women struggling with hormonal symptoms for which there is good evidence: cognitive behavioural therapy and hypnosis for hot flushes.
“Most reputable products will have just one or two plant ingredients, like red clover or soy isoflavones, and possibly a vitamin or mineral included to enable a health claim to be made, like vitamin B6,” the scientist says. “Some companies do put serious scientific thought into their menopause products. But, when there are multiple plant ingredients in a product, efficacy might be called into doubt, as the amount of each individual extract is rarely going to be sufficient to have much effect.”
Other clinical professionals worry that women taking “natural” hormone treatments won’t look for the medical help they actually need. “One client I had was taking a whole load of different supplements for perimenopause, but it turned out that she had a clinical B12 deficiency,” says Laura Thomas, registered nutritionist and author of Can I have Another Snack? newsletter, which debunks nutritional pseudoscience. “There was a real medical explanation as to why she was feeling like shit that was not going to be corrected by an over-the-counter supplement.”
Supplements probably pose more of a risk to your wallet than your health, with many “hormone-balancing” products costing £50 to £100 a month. But in February this year, the Australian government issued a health advisory on ashwagandha (a commonly used ingredient in hormone-health supplements) due to the risk of liver damage. There are also reports of black cohosh causing liver injuries. The US-based Drug Induced Liver Injury Network says supplements now cause up to 20% of all cases, with 2017 data showing that multi-ingredient supplements are the most common cause of liver injuries.
No one I spoke to, which included the FSA, the Health Food Manufacturers Association, the MHRA, the ASA plus scientists and consultants from within the industry who didn’t want to be named, knew of any routine random testing of supplements after manufacture in the UK. Dr Pamela Mason from the Health and Food Supplements Information Service (HSIS) says: “Some supplements are clinically tested in trials before going to market, but that is voluntary.” Fairweather-Tait adds: “The government doesn’t have the resources, so it’s left to consumers to complain to trading standards.”
Studies that have been done on supplements are not reassuring. In a 2016 study of gingko biloba supplements bought in London, 33 out of 35 showed evidence of adulteration or extract levels which were too high or low; when a UCL and BBC team looked at 70 milk-thistle, evening primrose and gingko supplements, 36% of the milk thistle products contained no milk thistle and 27% of the gingko supplements contained no gingko.
“We get attacked as doctors for not believing in alternative treatments,” says Davis. “As a postmenopausal woman I would love it if there was something that was effective; I would love it if I didn’t have to take oestrogen for my own hot flushes. It’s not about us being in bed with the pharmaceutical industry. If I’m going to recommend something to my patients, I’ve got to have evidence of effectiveness and safety.” She sounds angry. “I have been sad and angry for quite some time – especially when women tell me how much time and money they have wasted. The most vulnerable seem to be the biggest losers.”
Be Bad, Better: How Not Trying So Hard Will Set You Free by Rebecca Seal is published by Souvenir Press at £10.99. Buy it for £8.99 at guardianbookshop.com
