Natural health products (NHPs)—including herbal medicines, vitamins, and mineral supplements—are known by various names worldwide, such as dietary supplements in the United States, complementary medicines in Australia, and botanicals and/or nutraceuticals among naturopaths. The term encompasses a wide range of products marketed as “supplements” to enhance health and/or as “medicines” to treat illnesses, but remains largely outside conventional medical practice (1–3). This variability reflects how different jurisdictions around the world regulate and classify NHPs. Some jurisdictions treat them under food-related guidelines, while others regulate them as medicines (1). For example, the Australian health authority recognizes natural and complementary medicines as substances with therapeutic effects rather than merely supplements (1, 4).

Over the past two decades, global consumption of NHPs has steadily increased, with unprecedented growth in market size and product diversity (1, 3). The increased relevance of NHPs is also reflected in Australia’s contemporary health and wellness landscape, with nearly half of Australians (49.4%) reporting the use of NHPs in 2022 (3, 5). Growth in consumer demand for NHPs has been driven by expectations of their benefits, dissatisfaction with conventional medical options, greater perceived safety of “natural” options, and the desire for greater control over healthcare choices (6, 7). This shift is particularly notable among middle-aged and older adults, individuals with chronic conditions, and women (5, 7, 8).

For many women, midlife represents a challenging period, marked by significant physiological transitions, such as menopause, and the onset of diseases that profoundly impact health and quality of life (QoL) (9–12). For example, the onset of vasomotor symptoms (VMS), such as hot flushes (flashes) and night sweats, can severely reduce QoL by causing sleep disturbances, fatigue, and mood swings (11, 13–15). During midlife, many women also experience changes in body composition, including increased visceral adiposity and a shift in fat distribution toward the middle section of the body (16, 17). Changes in sex hormones, body fat distribution, and lipid profiles, as well as sleep disturbances, can increase the risk of conditions like obesity, sarcopenia, osteoporosis, and cardiovascular disease (CVD) (17–21). Chronic pain is another significant issue, and studies indicate that women experiencing a higher burden of menopause symptoms are nearly twice as likely to suffer from chronic pain than those with fewer or no symptoms (22). Mobility issues and an increased prevalence of disabilities also become more common during midlife, often linked to obesity, arthritis, and other chronic conditions (20). Mental health is another important area, as perimenopausal and postmenopausal women are at higher risk for developing depressive symptoms and major depressive disorder compared with premenopausal women (23–25). Moreover, cognitive complaints, such as memory problems, are more common among midlife women, potentially attributable to hormonal fluctuations observed during this period, compounded by age-related decline in cognitive performance (26, 27).

Conventionally, management of women’s health in midlife has focused on Menopausal Hormone Therapy (MHT), also known as Hormone Replacement Therapy (HRT) (15, 28). This approach, which is based on estrogen, progesterone, or their combinations, is an effective way to control menopausal symptoms while also providing other health benefits (15, 28). Other issues with broad health implications, such as sleep or pain, are often addressed symptomatically and in isolation, rather than holistically through combined medical, behavioral, environmental, and motivational approaches (15, 29, 30). Misconceptions about MHT use, such as those related to outdated evidence from a 2002 study suggesting that MHT use increases the risk of breast cancer, may lead many midlife women to seek alternative approaches for their menopausal symptoms (31). Placing greater value on personal agency and self-care, many women actively seek natural approaches to broaden their toolkit and repertoire of methods and medicines to address their diverse health needs. NHPs play an important role in this context, with 51% of menopausal women globally using them (32).

Integrating NHPs with conventional medical practice can offer women more holistic and personalized care options, especially where conventional options may be limited or have undesirable side effects (33). However, most commonly, self-prescribed medications are not always the most effective and/or best indicated. In Australia, a study of 2,020 women, over half of whom were postmenopausal, identified phytoestrogens (e.g., red clover and soy supplements), evening primrose oil, ginseng, and black cohosh as the most commonly used NHPs for hot flushes, whereas omega-3 supplements and glucosamine were most frequently used for other symptoms (e.g., CVD, joint pain). A majority of Australian women are thus using NHPs that are either known to be ineffective for their intended indication or whose efficacy and long-term safety have not yet been established (34). Therefore, the effective and safe use of NHPs alongside conventional options requires systematic frameworks that can generate robust scientific evidence on NHPs. Such evidence should encompass the pharmacological and biochemical actions of NHPs, including their biological targets and mechanisms. While some NHPs have been studied in clinical trials, many have not been evaluated with the same rigor as conventional medicines. Communication of the scientific foundations and validation of NHP use must also be enhanced.

In response to these needs and to inform a more systematic approach to the development and integration of NHPs into clinical practice, a multidisciplinary expert group of clinician-scientists, researchers, a pharmacist, and naturopaths gathered in Australia in February 2024. During this meeting, experts exchanged views and discussed their experience with natural treatments and relevant clinical evidence. The group, whose members are also authors of this paper, focused on the complementary use of NHPs to support women’s health in midlife. Discussions were guided by a semi-structured agenda and informed by pre-circulated background materials. While no formal consensus-building steps were undertaken, the dialogue surfaced key knowledge gaps and areas of shared concern that warrant further attention.

This narrative review draws from the group’s discussions, supplemented by a content-led literature search (PubMed; includes publications available up to 9 December 2024) to outline key considerations requiring further exploration. No restrictions were placed on publication date or study type.

This article provides a structured overview of the practical, clinical, and regulatory considerations surrounding NHP use, from the authors’ perspective, and should not be perceived as professional guidance. To this end, we sought to identify key challenges and propose high-level strategies for future work. The intention is to encourage informed discussion among stakeholders and promote the responsible integration of NHPs into care pathways. We believe that this can be achieved by seeking the best available scientific evidence and linking these insights with traditional knowledge in a way that is meaningful to both scientific/medical and traditional systems of health knowledge.

In reframing these broader insights as practical considerations for action, we identified several notable barriers to the safe and effective integration of NHPs into clinical practice, informed by the group’s diverse perspectives and illustrated with examples from the literature. Depending on the specific jurisdiction or setting, the challenges may be related to regulatory systems, scientific evidence, preparedness of health professionals, and/or consumer behavior. To guide the discussion in the following sections, Table 1 presents a summary of the key barriers identified, their implications, and potential strategies to help address them.

Although knowledge of NHPs as used in traditional medicine can inform attempts to study and integrate them into conventional care, a fundamentally evidence-based approach is critical. Despite their popularity and potential benefits based on accounts from traditional practice, the scientific evidence supporting the efficacy and safety of NHPs is often inconsistent or of suboptimal quality (34–36). This can lead to hesitancy and skepticism among health professionals regarding using NHPs, even where reasonable evidence may be available.

A significant obstacle at the systems level is the lack of standardized mechanisms and policy frameworks for regulating, overseeing, and ensuring the safety, quality, and effectiveness of traditional medicine practices, practitioners, and products (1, 33). The last extensive global guidance from the World Health Organization (WHO) on research and evaluation concerning the safety, efficacy, and quality of NHPs was issued more than two decades ago in 2000 (37). Updated research guidelines are urgently needed. Regulation of NHPs is far less stringent than that of conventional medicines. Globally, there is no consensus on the definitions, terminologies, and classifications of NHPs, leading to variations in how they are regulated (1). Systematic frameworks that effectively link traditional knowledge with scientific insights are needed if we are to better integrate the use of NHPs with conventional care to support women’s health in midlife. Rigorous evaluation of NHPs, mirroring the approach taken with conventional medicines, is crucial for establishing safety and efficacy. This will pave the way for the responsible integration of NHPs into patient care, wherever they are adequately supported by evidence.

Unlike synthetic drugs with a single, well-defined active ingredient, NHPs, such as ashwagandha and curcumin, are typically complex mixtures of multiple bioactive compounds with diverse bodily targets and actions (38, 39). This complexity can lead to challenges in standardizing efficacy and safety assessments, and thus, not all the regulatory standards required for conventional drugs may apply to NHPs. However, we propose adopting several key elements of Health Technology Assessment (HTA) frameworks (40), with appropriate modifications that consider the complexity of NHPs to systematically identify, assess, and evaluate products with promising therapeutic potential.

As highlighted by the WHO, “fundamental to implementing an integrated health system is acknowledging and bringing together different ways of knowing and/or different forms of evidence” (33). The development and integration of NHPs within healthcare should be grounded in systematic methods, particularly measurement of valid clinical outcomes, but can certainly be informed by known traditional uses. This knowledge generation and synthesis process should be accompanied by the creation/optimization of robust databases to catalog NHPs and systematically document their therapeutic effects. These databases would support further annotation through comprehensive literature reviews and/or insights from experts who regularly use them (including, but not necessarily limited to, naturopaths). Systematic evaluation of all the existing evidence is essential to reach evidence-based conclusions regarding the efficacy and safety of any NHP. Ideally, such resources would facilitate identifying active compounds, elucidating their mechanisms of action at the molecular level, and validating their efficacy and safety through controlled clinical studies. The databases should be updated regularly to incorporate new findings and ensure their ongoing relevance in the field (41).

In implementing frameworks to enhance the systematic identification, assessment, and evaluation of NHPs, we identified three key considerations: (1) Differences in the activity spectrum of extracts (e.g., whole-plant extracts vs. different plant parts), (2) bioavailability of active compounds, and (3) the chemical form(s) of the product. Each of these may significantly influence the therapeutic and/or safety profile of an NHP, including how its components work together and interact with other substances. We discuss these considerations using examples of NHPs that have gained interest from consumers and health professionals for reasons such as suitability for a range of health needs, coupled with a relatively safe profile and few significant drug interactions.

It is essential for health professionals and consumers to be well-informed about the safe and effective use of NHPs alone or in conjunction with conventional medicines to maximize therapeutic benefits and minimize potential risks. For example, reports indicate that consumers continue to use certain NHPs, like black cohosh (Actaea racemosa), to alleviate menopausal symptoms without professional guidance, despite inconsistent evidence regarding their safety, including potential hepatotoxic effects (34, 66–68). A significant number of individuals reportedly do not disclose NHP use to their doctors, which is a concern, as not all health professionals may initiate discussions about NHP usage during consultations (8). Common reasons for nondisclosure include the belief that NHPs are inherently safe because they are “natural” and the perception that such use is irrelevant to their conventional treatment (8).

Additionally, many people use NHPs alongside over-the-counter and/or prescription medicines. Over half of Australian adults who use NHPs report concurrent use with other medications on the same day. This practice is five times more common among individuals over 65 years old compared with young adults (18–24 years old) (5). This potentially leads to herb-drug interactions that can compromise the efficacy and safety of conventional treatments (38, 69). One emerging example is berberine, a naturally occurring alkaloid utilized in traditional Chinese and Ayurvedic medicine for over 3,000 years. Potential health benefits attributed to berberine include blood sugar control, cholesterol management, cardiovascular support, weight loss promotion, and inflammation reduction (70, 71). Standard doses of berberine are usually well-tolerated (72); however, berberine can affect the metabolism of certain common drugs, including cyclosporine, anticoagulants, diabetes and blood pressure drugs, and sedatives (70, 72). Berberine interacts with cytochrome CYP3A4 and intestinal P-glycoprotein, significantly affecting the bioavailability of orally administered medications (72). Given the growing interest in berberine as a potentially beneficial NHP, due to its hypoglycemic and anti-inflammatory effects (73–76), optimizing patient safety necessitates ensuring its well-informed co-administration with conventional treatments.

NHPs have potential as complementary or adjunctive therapies alongside conventional medicines in a variety of settings. For instance, palmitoylethanolamide (PEA) is an NHP with promising potential as a complementary option for pain management. As a member of the N-acyl-ethanolamine family, PEA is a bioactive lipid synthesized in response to cellular injury and is found in all body tissues, including the brain (77). PEA has anti-inflammatory, analgesic, anticonvulsant, and neuroprotective effects (77). In managing chronic pain—a common issue among midlife women—PEA is well-suited to be used adjunctively as it promotes endogenous cannabinoid system activity through its ability to augment the activity of cannabinoid receptors CB1 and CB2. These receptors are expressed in nerve tissue and immune cells and help modulate the inflammatory response by suppressing immune cell activation, which can reduce pain perception (78). PEA has consistently shown activity in placebo- or active-controlled studies (79–82). In a double-blind, placebo-controlled trial involving 636 sciatic pain patients, those receiving PEA treatment (600 mg/day) reported a reduction in subjective pain scores from 7.1/10 to 2.1/10 compared to the placebo group (83). Moreover, numerous studies also associate PEA with enhanced well-being and functional ability, noting minimal reported side effects (79–82).

Other NHPs have also shown promise as complementary treatments for managing milder symptoms alongside conventional medicines (52–55, 84, 85). Systematic analyses indicate that curcumin has effects on arthritis pain and function comparable to non-steroidal anti-inflammatory drugs (NSAIDs), modulating the NF-κB immune response similarly and without significant adverse events (52–55). Oleoresins from Boswellia serrata and other species have long been used in traditional medicine, and the major active components, the boswellic acids, have been shown to have anti-inflammatory properties (86, 87). Boswellia is marketed for various purposes, including managing mild pain and other symptoms in people with conditions such as osteoarthritis. Similar to curcumin, systematic analyses indicate that Boswellia is more effective than placebo in providing pain relief and improving functional outcomes in people with osteoarthritis while maintaining a favorable safety profile (55, 84, 85). Current evidence suggests that formulations containing curcumin and Boswellia extracts could be beneficial for mild pain and inflammation-related symptoms.

For many NHPs, no definitive conclusions are available regarding their efficacy or effectiveness due to the paucity and/or low quality of available evidence (44, 55, 80, 84, 88–91). While considering the unique features and complexity of NHPs, as outlined above, future studies should implement rigorous methodologies to reduce bias. These include randomization, allocation concealment, managing dropouts, and avoidance of selective reporting. Adequate attention must also be given to studying side effects as well as benefits. Such investment in systematic evidence generation will support safer and more effective use of NHPs.

The use of NHPs should be guided by health professionals. However, professionals often struggle to keep up with new evidence that may be equivocal or of uncertain quality; regulatory standards are of limited use in terms of practical guidance (92). Consumers are faced with vast amounts of conflicting or inaccurate information online and on social media, leading to confusion and potential misuse of NHPs, as these platforms are often unregulated in many countries, lacking oversight such as expert review or fact-checking (93–95). Enhanced educational resources and improved communication strategies for professionals and consumers are essential to promoting the safe and informed use of NHPs. While robust evidence is essential for credibility, accurate and effective communication of this information to both professionals and consumers will help build trust and confidence in integrating NHPs in areas such as menopausal health.

A comprehensive training curriculum for health professionals that provides a balanced view of safety, benefits, and appropriate applications of NHPs would support informed discussions during health consultations. A cross-sectional online survey of 2,341 pharmacists from nine countries highlighted the urgent need to incorporate NHP education into undergraduate curricula and emphasized the importance of continuing education courses and workshops for trainees and practicing professionals to stay updated on the latest research and practice trends (96). Making educational materials and resources accessible to people with different general and health literacy levels is another priority (41). Enhancing health literacy can empower individuals to make informed choices and engage in self-care practices involving NHPs. For instance, although graphical presentations of a systematic analysis of dietary supplements for osteoarthritis exist, these are primarily intended for health professionals (97). The information could be adapted into a more consumer-friendly infographic to better communicate these important findings to a broad audience. A good example is the Australasian Menopause Society’s (AMS) guide on NHPs for managing menopausal symptoms. The guide uses an intuitive traffic light system to present current evidence-based recommendations, making the information easy to interpret. For instance, AMS highlights that some products, like red clover, evening primrose oil, black cohosh, and omega-3 supplements, require more research. This approach makes it easier for consumers to understand their options and encourages a cautious yet open-minded approach to their use in clinical practice (66).

This article is a narrative review informed by multidisciplinary expert discussions and supplemented by a thematic literature search. As such, we acknowledge inherent limitations in the scope and completeness of the selection of sources. While we aimed to provide a balanced overview of key considerations on the integration of NHPs into clinical practice, not all recommendations may be generalizable across regulatory or cultural settings due to variations in healthcare systems, practice norms, and product availability. These limitations underscore the need for further region-specific and systematic investigations to complement the perspectives offered in this review.

While NHPs are increasingly considered relevant by midlife women and other consumers due to their perceived benefits based on traditional use, many NHPs lack rigorous scientific validation. With rising global consumption and the increasingly common use of NHPs alongside conventional healthcare, appropriate systematic evaluation frameworks are urgently needed. To integrate NHPs effectively and safely within our care systems, we need to draw upon evidence generation and dissemination methodologies parallel to those used for conventional medicines but tailored to address the unique complexities of NHPs. Safe, responsible, and informed use of NHPs will also require enhanced continuing education for health professionals and improved consumer communication strategies. Future work should support these efforts by building the evidence base and aligning practice, education, and policy. To enhance patient health outcomes and realize the potential of NHPs, we must have the evidence we need and ensure that all stakeholders understand how best to use it.