Ashwagandha in perimenopause

Ashwagandha has early, small-trial evidence for lowering perceived stress and modestly improving sleep, and one 100-woman trial suggests it may ease perimenopausal symptom scores. The evidence is thin, the extracts studied differ from one another, safety data stop at about three months, and rare liver injury and thyroid effects are real enough to plan around.

What it is

Ashwagandha (Withania somnifera) is an evergreen shrub whose root has been used in Ayurvedic medicine as an adaptogen, a loose term for something thought to improve resilience to stress. The species name, somnifera, means sleep-inducing. Most US supplements contain root extract; some add leaf, which has a different chemistry. The best-known constituents are withanolides, a group of steroidal lactones, though NIH notes other compounds may also contribute.

Why women in midlife take it

Perimenopause often brings a lower tolerance for stress, anxiety that seems to come from nowhere, and sleep that breaks in the early hours; see why perimenopause wakes you at 3 a.m.. Ashwagandha is marketed squarely at that cluster, usually with a cortisol story attached, and has become one of the most talked-about supplements for women in their 40s.

What the evidence shows

Perimenopausal symptoms. The one directly relevant trial randomized 100 women with climacteric symptoms to 300 mg of ashwagandha root extract twice daily or placebo for 8 weeks; 91 finished. The ashwagandha group had significantly lower total Menopause Rating Scale scores, with improvements in the psychological, somato-vegetative and urogenital domains, and better menopause-specific quality of life. Serum estradiol rose and FSH and LH fell relative to placebo. This is a single, short trial from one research group, and hormonal shifts of that size have not been confirmed elsewhere. Read it as a hypothesis worth testing, not a settled result.

Stress and anxiety. A 60-day trial in 60 stressed but healthy adults compared 240 mg per day of a standardized extract with placebo. Anxiety scores on the Hamilton scale fell more with ashwagandha (P = .04), a broader depression, anxiety and stress scale showed only a near-significant change, and morning cortisol fell. No adverse events were reported. The authors called for larger and more diverse trials. The Office of Dietary Supplements summarizes the field as suggesting lower stress, anxiety and cortisol, and notes that a psychiatric task force provisionally recommends specific root-extract doses for generalized anxiety disorder while saying it cannot make a stronger recommendation without more data.

Sleep. In a 10-week trial of 60 people with insomnia and anxiety, 300 mg of root extract twice daily shortened sleep onset latency (29.0 versus 33.9 minutes at 10 weeks) and raised sleep efficiency from about 76 to 83 percent, compared with 75 to 80 percent on placebo. Sleep quality and anxiety scores also improved. NIH’s assessment is that a small number of studies suggest better sleep quality, efficiency, total sleep time and time to fall asleep, more so in people with insomnia.

Overall. NCCIH’s verdict is that some ashwagandha preparations may be effective for insomnia and stress, with the caveat that trials are small and use different formulations, and that the evidence for anxiety is unclear. There is not enough evidence for cognition, athletic performance or other uses.

Dose and form used in studies

Trials used root extracts at 240 to 600 mg per day, most often 300 mg twice daily, for 8 to 10 weeks. Extracts are standardized to different withanolide percentages, so a milligram of one product is not equivalent to a milligram of another. The ODS fact sheet states plainly that this variation makes dosing recommendations hard to develop.

Safety, interactions and who should avoid it

Common effects. Loose stools, nausea and drowsiness, usually mild. Ashwagandha appears well tolerated for up to about 3 months; long-term safety is unknown.

Liver. A 2020 case series described five people in Iceland and the US Drug-Induced Liver Injury Network who developed jaundice, nausea, itching and abdominal discomfort 2 to 12 weeks after starting ashwagandha-containing supplements. The injury was cholestatic or mixed, no one developed liver failure, and liver tests returned to normal within 1 to 5 months in the four people with follow-up. Chemical analysis confirmed ashwagandha in the products and found no other toxic compounds. NCCIH and ODS both list liver injury as a rare but documented risk.

Thyroid. In a trial of 50 adults with subclinical hypothyroidism, 600 mg per day for 8 weeks lowered TSH and raised T3 and T4 compared with placebo. For someone on levothyroxine, that is a plausible route to over-replacement. NCCIH advises people with thyroid disorders to avoid ashwagandha and lists thyroid medication as an interaction.

Other interactions. NCCIH lists sedatives, anticonvulsants, diabetes medications, blood pressure medications and immunosuppressants. Nothing has been studied alongside SSRIs or hormone therapy; given the sedative effect and the estradiol finding above, disclose it to your prescriber. No interaction with blood thinners has been reported, but no data exist either.

Who should avoid it. Pregnant or breastfeeding women; people with autoimmune or thyroid disorders; anyone with liver disease; and anyone preparing for surgery.

How to choose a product

Buy a single-ingredient root extract and check the Supplement Facts panel for the extract amount and the withanolide standardization, since that is what links a product to a specific trial. Avoid “stress blends” that hide the dose inside a proprietary total. Prefer a product with a third-party certification mark such as USP Verified or NSF, which confirms the label matches the contents but does not speak to effectiveness. If sleep is the main complaint, magnesium glycinate is a lower-risk first step to discuss with your clinician.

Bottom line

Ashwagandha is a reasonable short-term experiment for stress or sleep if you have no thyroid or liver condition, are not pregnant, and tell your prescriber. Give it 8 to 12 weeks, track results with the symptom check, and stop at the first sign of liver trouble. If anxiety, low mood or insomnia are the real problem, they respond to treatments with much stronger evidence, and a menopause-informed clinician can help separate cause from symptom. See how to find a menopause specialist or the clinician finder.