Black Cohosh: What Studies Show, What to Watch

Does black cohosh actually work?

Black cohosh is a plant extract widely sold for menopause symptoms, especially hot flashes and night sweats 1Ref 1Leach MJ, Moore V (2012).Black cohosh (Cimicifuga spp.) for menopausal symptoms.Cochrane systematic review of black cohosh for menopausal symptoms found insufficient, inconsistent evidence that it relieves hot flashes better than placebo, citing variation in extracts and trial quality.. A Cochrane systematic review pooled the available trials and found no consistent, convincing evidence that it relieves hot flashes better than a placebo 1Ref 1Leach MJ, Moore V (2012).Black cohosh (Cimicifuga spp.) for menopausal symptoms.Cochrane systematic review of black cohosh for menopausal symptoms found insufficient, inconsistent evidence that it relieves hot flashes better than placebo, citing variation in extracts and trial quality.. Some studies hint at benefit while others show none, and differences in extracts and study quality muddy the picture. The North American Menopause Society does not include black cohosh among its evidence-supported nonhormone options 2Ref 2The North American Menopause Society (Menopause Society) (2023).The 2023 nonhormone therapy position statement of The North American Menopause Society.The 2023 NAMS nonhormone position statement does not include black cohosh among its evidence-supported options and identifies antidepressants, gabapentin, and cognitive behavioral therapy as better-supported nonhormone choices.. That gap between how popular it is and how little proof supports it is the central issue for anyone considering it.

Why is the evidence so mixed?

Studies of black cohosh differ in the exact extract, dose, and duration, which makes their results hard to compare 1Ref 1Leach MJ, Moore V (2012).Black cohosh (Cimicifuga spp.) for menopausal symptoms.Cochrane systematic review of black cohosh for menopausal symptoms found insufficient, inconsistent evidence that it relieves hot flashes better than placebo, citing variation in extracts and trial quality.. Many were small, enrolling fewer than 100 women, and ran only 8 to 12 weeks using different symptom scales. The strong placebo effect in hot-flash research adds another layer, because a substantial share of women taking placebo report improvement 3Ref 3Grant MD, Marbella A, Wang AT, Pines E, Hoag J, Bonnell C, Ziegler KM, Aronson N (2015).Menopausal Symptoms: Comparative Effectiveness of Therapies (Comparative Effectiveness Review No. 147).AHRQ comparative-effectiveness review reached cautious conclusions about botanical remedies for menopause and documents the substantial placebo response in vasomotor-symptom trials.. A 2015 federal evidence review reached a similarly cautious conclusion about botanical remedies for menopause 3Ref 3Grant MD, Marbella A, Wang AT, Pines E, Hoag J, Bonnell C, Ziegler KM, Aronson N (2015).Menopausal Symptoms: Comparative Effectiveness of Therapies (Comparative Effectiveness Review No. 147).AHRQ comparative-effectiveness review reached cautious conclusions about botanical remedies for menopause and documents the substantial placebo response in vasomotor-symptom trials.. Related plant compounds called phytoestrogens, found in soy and red clover, show the same pattern of weak and inconsistent evidence 4Ref 4Lethaby A, Marjoribanks J, Kronenberg F, Roberts H, Eden J, Brown J (2013).Phytoestrogens for menopausal vasomotor symptoms.Cochrane review of phytoestrogens for menopausal vasomotor symptoms found weak and inconsistent evidence, paralleling the pattern seen with black cohosh..

Is black cohosh safe?

Black cohosh is usually well tolerated in studies, with mild stomach upset, headache, or rash as the typical complaints 1Ref 1Leach MJ, Moore V (2012).Black cohosh (Cimicifuga spp.) for menopausal symptoms.Cochrane systematic review of black cohosh for menopausal symptoms found insufficient, inconsistent evidence that it relieves hot flashes better than placebo, citing variation in extracts and trial quality.. The more serious concern is a small number of case reports that have linked it to liver injury. A clear cause has not been proven, and such reactions appear uncommon, but they are why new liver symptoms deserve prompt attention. Because supplements are not held to the same manufacturing standards as prescription medicines, the actual contents of a product can differ from its label. Interactions with other medicines are possible, so a clinician review makes sense before adding it.

How does it compare with other options?

Treatments with stronger evidence outperform black cohosh for bothersome hot flashes 2Ref 2The North American Menopause Society (Menopause Society) (2023).The 2023 nonhormone therapy position statement of The North American Menopause Society.The 2023 NAMS nonhormone position statement does not include black cohosh among its evidence-supported options and identifies antidepressants, gabapentin, and cognitive behavioral therapy as better-supported nonhormone choices.. Hormone therapy is the most effective option, and among nonhormone choices, certain antidepressants, gabapentin, and cognitive behavioral therapy have better trial support than herbal products 2Ref 2The North American Menopause Society (Menopause Society) (2023).The 2023 nonhormone therapy position statement of The North American Menopause Society.The 2023 NAMS nonhormone position statement does not include black cohosh among its evidence-supported options and identifies antidepressants, gabapentin, and cognitive behavioral therapy as better-supported nonhormone choices.. Symptoms also change across midlife: in perimenopause, when periods still occur, hot flashes may come and go, while afterward they can persist for a median of about 7.4 years, and longer than 10 years for some women 5Ref 5Avis NE, Crawford SL, Greendale G, et al. / Study of Women's Health Across the Nation (SWAN) (2015).Duration of menopausal vasomotor symptoms over the menopause transition.SWAN cohort study documents a median vasomotor-symptom duration of about 7.4 years, extending beyond 10 years for some women, so any remedy is judged over months..

Women weighing options can compare hormone therapy with practical ways to stop hot flashes.

When black cohosh questions need a clinician

A clinician can help you weigh black cohosh against options with stronger evidence and flag interactions with your other medicines. This matters especially if you have liver disease, take medicines processed by the liver, or have a history of hormone-sensitive conditions. A primary care clinician or menopause specialist can review the full picture with you.

A clinician can also explain how menopause symptoms tend to evolve and which night sweats deserve a workup beyond menopause. Gale can help you prepare for that conversation.