NMN Supplements for Perimenopause: Not Recommended
There is no evidence supporting the use of nicotinamide mononucleotide (NMN) supplements for perimenopausal symptoms, and established evidence-based treatments should be used instead. 1, 2, 3
Why NMN Is Not Appropriate for Perimenopause
NMN research has focused exclusively on general aging processes and NAD+ metabolism—not on hormonal symptoms of perimenopause. 4, 5, 6 The mechanism of action (boosting NAD+ levels to counter age-related cellular decline) does not address the underlying cause of perimenopausal symptoms, which is fluctuating and declining estrogen levels. 1
No clinical trials have evaluated NMN for hot flashes, night sweats, mood changes, or any other perimenopausal symptoms. 4, 5, 6 The existing human studies measured only NAD+ blood levels and general safety markers, not symptom relief. 7, 8
The high interindividual variability in NAD+ response to NMN (coefficient of variation 29-113%) makes it an unreliable intervention even for its intended anti-aging purposes. 8 This unpredictability would be even more problematic when attempting to treat specific symptoms like vasomotor dysfunction.
Evidence-Based Treatment Algorithm for Perimenopause
First-Line: Lifestyle Modifications
Weight loss of ≥10% body weight can eliminate hot flashes entirely in many women. 1, 2, 3, 9 This should be the primary recommendation for overweight or obese women experiencing vasomotor symptoms.
Smoking cessation significantly improves both frequency and severity of hot flashes. 1, 3, 9 Women who quit smoking show measurable improvements compared to those who continue.
Limit alcohol intake if it triggers hot flashes in the individual patient. 1, 2, 3, 9 Individual responses vary, so this requires patient-specific assessment.
Environmental modifications: dress in layers, maintain cool room temperatures, wear natural fibers, avoid spicy foods and caffeine. 2, 3, 9
Second-Line: Mind-Body Interventions
Acupuncture has demonstrated equivalence or superiority to venlafaxine and gabapentin in multiple studies. 1, 2, 3, 9 It is safe and effective for managing vasomotor symptoms.
Cognitive Behavioral Therapy (CBT) significantly reduces the perceived burden of hot flashes and improves hot flash problem ratings. 1, 2, 3, 9 This works even when symptom frequency remains unchanged.
Yoga may improve quality of life in the vasomotor symptom domain, though effects on frequency are inconsistent. 1, 3, 9
Third-Line: Non-Hormonal Pharmacologic Options
For moderate-to-severe symptoms not controlled by lifestyle and mind-body approaches:
Gabapentin 900 mg/day at bedtime reduces hot flash severity score by 46% versus 15% with placebo. 1, 2, 9 This is particularly effective when sleep is disrupted by night sweats, has no drug interactions, and no absolute contraindications. 2
Venlafaxine 37.5 mg daily (increase to 75 mg after 1 week) reduces hot flash scores by 37-61%. 2, 9 This is preferred when rapid onset is prioritized or gabapentin is ineffective. 2
Paroxetine 7.5 mg daily reduces frequency, severity, and nighttime awakenings by 62-65%. 2 However, paroxetine must be avoided in women taking tamoxifen due to CYP2D6 inhibition. 2
Review efficacy at 2-4 weeks for SSRIs/SNRIs and 4-6 weeks for gabapentin; switch to another agent if ineffective or poorly tolerated. 2
Fourth-Line: Hormonal Therapy (When Non-Hormonal Options Fail)
Menopausal hormone therapy (MHT) is the most effective treatment, reducing hot flashes by approximately 75% compared to placebo. 1, 2 However, it should only be used when non-hormonal options have failed due to increased risks.
Transdermal estrogen formulations are strongly preferred over oral preparations due to markedly lower rates of venous thromboembolism and stroke. 2
MHT is contraindicated in women with history of breast cancer, hormone-dependent malignancies, active or recent venous thromboembolism, prior stroke, active liver disease, or unexplained vaginal bleeding. 2
Common Pitfalls to Avoid
Do not recommend soy supplements or other herbal products (including black cohosh) as they lack evidence of clinically meaningful benefit beyond placebo. 1, 3 Black cohosh shows no benefit in randomized trials and has been linked to liver failure. 2
Vitamin E 800 IU daily has limited efficacy, and doses >400 IU/day are linked to increased all-cause mortality. 1, 2
Recognize the robust placebo response (up to 70% in some studies) when evaluating any treatment. 2 Many symptoms improve spontaneously over time. 2
Exercise does not have consistent evidence for hot flash reduction, though it should still be recommended for overall health benefits. 1