Evidence review
Black Cohosh for Hot Flashes
Actaea racemosa
The short answer
Early or mixed evidencePossibly a little, but the evidence is mixed. Some trials of licensed European extracts, such as the one in Remifemin, and two recent meta-analyses found fewer or milder hot flashes than placebo, yet a Cochrane review of 16 trials and two independent year-long US trials found no clear benefit. Hormone therapy and approved nonhormonal medicines work far better, and because of rare but serious liver injury, stop at once for dark urine or yellowing skin.
7 key studies reviewed
Updated October 12, 2026
Key points
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01
The trials disagree
A 2012 Cochrane review of 16 trials (2,027 women) and two year-long NIH-funded trials found no clear benefit over placebo; meta-analyses from 2021 and 2023 were more positive.
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02
The product matters
Europe licenses three specific dry extracts at about 5 to 6.5 mg a day, roughly 40 mg of root. US supplements vary in extract and dose, and some have contained Asian Actaea species instead.
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03
Guidelines do not recommend it
The Menopause Society’s 2023 statement found insufficient evidence to recommend black cohosh for hot flashes and calls hormone therapy the most effective treatment.
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04
Rare but serious liver injury
Products labeled black cohosh have been linked to acute liver injury, rarely needing a transplant. Stop and see a doctor for dark urine, yellow skin or eyes, tiredness, or upper stomach pain.
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05
Cancer, pregnancy, and time limits
EMA advises against use after breast or other hormone-dependent cancers without medical advice, does not recommend it in pregnancy or breastfeeding, and sets a six-month limit without advice.
Black cohosh may ease hot flashes slightly for some women, but the evidence is mixed and any benefit is modest. Some randomized controlled trials (studies in which women are assigned by chance to the herb or a dummy pill) of specific European extracts, including the isopropanolic extract sold as Remifemin, reported fewer or milder hot flashes, and the European Medicines Agency (EMA) accepts three defined extracts as well-established medicines for hot flushes and profuse sweating. Yet a 2012 Cochrane review of 16 trials found no significant difference from placebo, and two independent, year-long trials funded by the US National Institutes of Health (NIH) found that black cohosh did no better than placebo while hormone therapy clearly did. The Menopause Society (formerly the North American Menopause Society) does not recommend it. Hormone therapy and approved nonhormonal medicines work far better, and black cohosh carries a rare risk of serious liver injury.
Hot flashes are sudden waves of heat, usually over the face, neck, and chest, often with sweating, flushing, and a racing heart, sometimes followed by chills. Night sweats are the same thing during sleep. They are the most common symptom of the menopause transition and often last for several years. Black cohosh (Actaea racemosa, long known as Cimicifuga racemosa) is a North American woodland plant whose root and rhizome (underground stem) were used by Native Americans and then adopted in Germany, where the first black cohosh medicine, Remifemin, went on sale in 1956. The Menopause Society calls it the most purchased botanical for menopause symptoms. In parts of Europe it is sold as a licensed medicine; in the United States it is a dietary supplement, which the Food and Drug Administration does not approve before sale.
This page goes through the main reviews and trials, including which product each tested and who paid for it; why regulators and guideline bodies reach different conclusions; what doses were studied; how black cohosh compares with sage; and the liver, breast cancer, and pregnancy cautions. Nothing here is medical advice. Hot flashes are usually menopausal, but sweating and flushing can also come from an overactive thyroid, infections, some cancers, and medicines, so new or unusual symptoms deserve a diagnosis before any remedy, and a clinician can explain treatments with much stronger evidence.
02 The trials
Key studies
The trials and reviews that carry the most weight for this question, with the product and dose each one tested. Results apply to the preparation studied.
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Leach and Moore, 2012 (Cochrane)
Cochrane systematic review of 16 randomized trials
- Who
- 2,027 perimenopausal or postmenopausal women
- What and how much
- Single-ingredient black cohosh by mouth, various extracts, median 40 mg a day
- How long
- Mean 23 weeks
No significant difference from placebo in hot flushes per day (0.07 a day; 95% CI −0.43 to 0.56; 3 trials, 393 women) or symptom scores (4 trials, 357 women). Hormone therapy did better. Trial quality mostly unclear; no author conflicts.
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Sadahiro et al., 2023
Updated pairwise meta-analysis of randomized trials
- Who
- 22 trials, 2,310 menopausal women
- What and how much
- Black cohosh extracts alone or combined with other active ingredients
- How long
- Varied by trial (not stated in the abstract)
Better than placebo for overall menopausal symptoms (Hedges’ g 0.575) and hot flashes (g 0.315; 95% CI 0.107 to 0.524), but not for anxiety or depression. Dropout rates were similar to placebo.
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Castelo-Branco et al., 2021
Review and meta-analysis; manufacturer co-authors
- Who
- 35 studies and 1 meta-analysis (43,759 women, 13,096 on iCR); 6 placebo-controlled trials pooled
- What and how much
- Isopropanolic extract (iCR, the Remifemin extract), alone or with St. John’s wort
- How long
- Studies published 1987 to 2019
Pooled standardized mean difference of −0.694 in favor of iCR for combined neurovegetative and psychological symptoms (p < 0.0001). Two authors worked for Schaper & Brümmer, Remifemin’s maker; EMA said it added no new trials.
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Newton et al., 2006 (HALT)
Randomized, double-blind, placebo-controlled; NIH-funded
- Who
- 351 women aged 45–55 with 2 or more hot flashes or night sweats a day
- What and how much
- Black cohosh 160 mg a day (70% ethanol extract, 2.5% triterpene glycosides); other arms tested multi-herb products and hormone therapy
- How long
- 12 months
No herbal regimen differed from placebo at 3, 6, or 12 months; differences were under 1 symptom a day. Hormone therapy cut 4.06 more symptoms a day than placebo (95% CI −5.93 to −2.19).
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Geller et al., 2009
Randomized, double-blind, placebo-controlled; NIH-funded
- Who
- 89 peri- or postmenopausal women with frequent hot flashes and night sweats
- What and how much
- Black cohosh 128 mg a day (ethanol extract with 7.27 mg triterpene glycosides); other arms tested red clover and hormone therapy
- How long
- 12 months
Hot flashes and night sweats fell 34% on black cohosh, 57% on red clover, 63% on placebo, and 94% on hormone therapy; only hormone therapy beat placebo. No sign of liver harm.
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Osmers et al., 2005
Randomized, double-blind, placebo-controlled, multicenter
- Who
- 304 women with menopausal complaints
- What and how much
- Isopropanolic extract (iCR) tablets equal to 40 mg of root a day
- How long
- 12 weeks
Menopause Rating Scale scores improved more than with placebo (P < .001), especially early in the menopause transition; the hot-flush subscore responded best. Funding is not stated in the abstract.
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Schellenberg et al., 2012
Randomized, double-blind, placebo-controlled; manufacturer-funded
- Who
- 180 women with menopausal complaints (166 in the efficacy analysis)
- What and how much
- Ze 450 extract (60% ethanol), 6.5 mg or 13.0 mg once a day
- How long
- 12 weeks
Kupperman Index scores fell 8.47 points (6.5 mg) and 17.0 points (13.0 mg) more than with placebo. Funded by the maker, Max Zeller Söhne, which employed three authors.
03 Evidence
What the research shows
Our rating for Black Cohosh for Hot Flashes, based on the studies below.
The most cited independent review is by Leach and Moore at the University of South Australia (Cochrane Database of Systematic Reviews 2012), whose authors declared no competing interests. It included 16 randomized trials with 2,027 perimenopausal or postmenopausal women, all using single-ingredient black cohosh by mouth at a median of 40 mg a day for an average of 23 weeks. In the three trials (393 women) that could be pooled for hot-flush frequency, black cohosh differed from placebo by just 0.07 flushes a day (95% confidence interval, the range in which the true effect probably lies, −0.43 to 0.56), and in four trials (357 women) menopausal symptom scores did not differ either. Hormone therapy reduced symptom scores more than black cohosh. Most trials reported their methods too poorly to judge their quality, and the authors concluded that there was insufficient evidence to support black cohosh for menopausal symptoms. The Menopause Society’s 2023 position statement cites this review.
The two largest independent trials were negative. In the Herbal Alternatives for Menopause (HALT) trial, Newton and colleagues (Annals of Internal Medicine 2006), funded by the National Institute on Aging, randomized 351 women aged 45 to 55 in Washington State to 160 mg a day of black cohosh, two multi-herb products, hormone therapy, or placebo for a year. No herbal regimen differed from placebo at 3, 6, or 12 months, the difference was always under one symptom a day, and women taking the multi-herb product with added soy had worse symptom intensity at 12 months. Hormone therapy cut 4.06 more symptoms a day than placebo. The authors noted that differences smaller than 1.5 symptoms a day could not be ruled out. Geller and colleagues (Menopause 2009), at the University of Illinois at Chicago’s NIH-funded botanical research center, randomized 89 women to a standardized black cohosh extract (128 mg a day), red clover, hormone therapy, or placebo for 12 months. Hot flashes and night sweats fell 34% with black cohosh, 57% with red clover, 63% with placebo, and 94% with hormone therapy; only hormone therapy beat placebo. A third trial, in 132 women with a history of breast cancer or a perceived high risk of it (Pockaj and colleagues, Journal of Clinical Oncology 2006), also found no benefit, with hot-flash scores falling 20% on black cohosh and 27% on placebo.
The positive trials mostly tested European licensed extracts, often with manufacturer involvement. Osmers and colleagues (Obstetrics and Gynecology 2005) randomized 304 women to isopropanolic extract tablets equal to 40 mg of root a day or placebo for 12 weeks. Menopause Rating Scale scores (a standard symptom questionnaire) improved more with black cohosh, the hot-flush subscore responded best, and women early in the menopause transition benefited most. The abstract does not state funding, but co-author Hans-Heinrich Henneicke-von Zepelin is listed as an employee of Schaper & Brümmer, Remifemin’s maker, in his later papers. Schellenberg and colleagues (Evidence-Based Complementary and Alternative Medicine 2012) randomized 180 women to 6.5 mg or 13.0 mg of the Ze 450 extract or placebo for 12 weeks; Kupperman Index scores (an older symptom scale) fell 8.47 and 17.0 points more than with placebo. That trial was funded by the maker, Max Zeller Söhne, which employed three of the authors. Not every licensed-extract trial succeeded: Frei-Kleiner and colleagues (Maturitas 2005) found no benefit over placebo in their main analysis of 122 women, only in a subgroup with more severe symptoms. EMA’s herbal committee based its approval on about 20 trials in which roughly 6,300 patients took black cohosh, but its assessment report concedes that none of the trials run to Good Clinical Practice standards showed unambiguous results on the validated symptom scales, and it summarizes a review pointing out that the products in the null US trials were not licensed medicines.
Newer pooled analyses lean positive, while guidelines remain skeptical. Sadahiro and colleagues (Menopause 2023) pooled 22 trials with 2,310 women and found improvements over placebo in overall menopausal symptoms and hot flashes (a standardized effect size of 0.315, which is small) but not in anxiety or depression; they included products that combined black cohosh with other ingredients. Castelo-Branco and colleagues (Climacteric 2021) reviewed 35 studies of the isopropanolic extract and pooled six placebo-controlled trials, reporting a standardized mean difference of −0.694 in favor of the extract; two of the authors worked for Schaper & Brümmer, and one pooled trial used a combination with St. John’s wort. A 2025 EMA review said this analysis contained no new trials. A systematic review commissioned to inform International Menopause Society recommendations (Maunder and colleagues, Climacteric 2026) rated evidence for black cohosh on hot flushes and menopausal scores as moderate certainty. In contrast, The Menopause Society’s 2023 statement concluded that there is insufficient evidence to support black cohosh for hot flashes and does not recommend it (Level I), and it recommends cognitive behavioral therapy, clinical hypnosis, SSRIs and SNRIs (antidepressants that also reduce hot flashes), gabapentin, and fezolinetant on its strongest level of evidence.
Several things may explain the disagreement. Trials tested different extracts at doses ranging from 8 to 160 mg a day, so a result for one product may not apply to another. Menopause trials show large placebo responses: in the Geller trial, placebo cut hot flashes and night sweats by 63%. Many positive trials used composite symptom scales rather than hot-flash diaries, lasted 12 weeks, and were run or funded by manufacturers, while the independent US trials lasted a year but used unlicensed supplements. Product identity is another problem: when Jiang and colleagues (Journal of Agricultural and Food Chemistry 2006) analyzed 11 US black cohosh products, three contained an Asian Actaea species instead of black cohosh and one contained a mixture. How black cohosh might work is unknown; EMA concludes it does not act as an estrogen through estrogen receptors. An independent trial of a licensed extract against placebo, using hot-flash diaries over at least six months, would help settle the question.
04 In practice
How it was taken in studies
The positive trials used small doses of specific dry extracts. EMA’s monograph covers three, all for adult women, by mouth, in tablets or capsules: an extract made with 58% ethanol (the one known in research as BNO 1055), 2.8 mg twice a day; one made with 60% ethanol (Ze 450), 6.5 mg once a day; and one made with 40% isopropanol (iCR, the Remifemin extract), 5.0 mg a day taken as one or two doses. These amounts correspond to roughly 40 mg of dried root a day. The NIH Office of Dietary Supplements (ODS) notes that Remifemin is standardized to the equivalent of 40 mg of root per daily dose of two tablets and has been reformulated over time. The independent US trials used different, unlicensed products: 160 mg a day of a 70% ethanol extract in HALT and 128 mg a day of an ethanol extract in the Geller trial. Milligram figures on different labels describe different extracts and are not comparable.
EMA says not to take black cohosh for more than six months without medical advice and to see a doctor or pharmacist if symptoms persist or get worse. The trials that reported a benefit measured it after 12 weeks, so that is a reasonable point to judge whether a product is helping, and a simple daily hot-flash diary started before treatment makes that judgment easier, given how much hot flashes fall on placebo alone. EMA sees no relevant use in men, children, or adolescents. More is not clearly better: EMA judged that trials comparing doses support about 40 mg of root a day, and in HALT 160 mg a day of a different extract did no better than placebo. In the Ze 450 trial only the double dose (13.0 mg, twice EMA’s dose for that extract) helped women with severe symptoms, but EMA notes the numbers were small.
Black cohosh tea, tinctures, and powdered root have not been tested for hot flashes in the trials described here. Supplements sold in the United States vary widely, and ODS notes that many are standardized only to provide at least 1 mg of triterpene glycosides a day. Choose a single-herb product that names Actaea racemosa or Cimicifuga racemosa, the root and rhizome, the extract, and the dose, ideally a licensed herbal medicine where one is available, and avoid multi-herb menopause blends: in HALT, the multi-herb product with soy made symptoms worse at 12 months. Black cohosh is unrelated to blue cohosh (Caulophyllum thalictroides), which NCCIH warns can raise blood pressure and blood sugar and cause chest pain, and neither should be used to start labor.
05 Caution
Before you try black cohosh
In clinical trials black cohosh is usually well tolerated. ODS reports mostly mild, short-lived digestive upset and rashes, and notes that breast pain, vaginal spotting, and other complaints occurred about as often on placebo. EMA lists allergic skin reactions, swelling of the face or limbs, indigestion, and diarrhea, with unknown frequency. The National Center for Complementary and Integrative Health (NCCIH) says it has been used safely in studies lasting up to a year, but ODS points out that most studies lasted six months or less, so long-term safety is not established.
Liver injury is the serious, if rare, risk. NIH’s LiverTox database says products labeled as black cohosh have been implicated in many instances of acute liver injury, some leading to emergency liver transplantation or death, and EMA’s monograph lists hepatitis, jaundice, and abnormal liver tests with unknown frequency. Causation is debated: a 2008 US Pharmacopeia (USP) review by Mahady and colleagues rated all 30 reports it examined as possibly, and none as probably, caused by black cohosh, but still recommended a label warning to stop and consult a practitioner with a liver disorder or symptoms such as abdominal pain, dark urine, or jaundice; the FDA does not require it. EMA’s assessment describes a 60-year-old woman who developed itching and dark urine after two weeks of use and later needed a liver transplant, and ODS notes that impurities or the wrong Actaea species might explain some cases. Liver monitoring in the year-long Geller trial found no problems, and an EU safety review reported in EMA’s 2025 update found the benefit–risk balance unchanged but asked for continued close monitoring of liver harm. Stop black cohosh and see a doctor at once for tiredness, loss of appetite, yellow skin or eyes, dark urine, or severe upper stomach pain with nausea or vomiting. People with liver disease should avoid it, as the USP advises, or use it only with medical advice.
EMA says anyone treated for breast cancer or another hormone-dependent tumor should not use black cohosh without medical advice. Black cohosh does not appear to act as an estrogen in people, and observational studies have not shown higher breast cancer risk: a systematic review by Fritz and colleagues (Integrative Cancer Therapies 2014) found no association with increased risk, and a German cohort study led by a Schaper & Brümmer employee reported no increase in recurrence. But in mice with breast tumors the extract increased lung metastases, and trials in breast cancer survivors did not show it relieves hot flashes better than placebo. In test tubes, an ethanol extract interfered with the activation of tamoxifen; human studies found only weak effects on the enzymes involved, so check with your oncology team first. EMA does not recommend black cohosh in pregnancy or while breastfeeding and advises effective contraception during use, since pregnancy is still possible in perimenopause. EMA lists no confirmed drug interactions but advises against combining black cohosh with estrogen unless a doctor recommends it, and its assessment report describes raised liver enzymes in a woman also taking the statin atorvastatin. Tell your doctor and pharmacist that you are taking it.
Some symptoms need a doctor rather than a herb. Any vaginal bleeding after menopause needs prompt investigation, and EMA advises seeing a doctor for vaginal bleeding during use. Hot flashes or night sweats with fever, unexplained weight loss, swollen glands, or drenching sweats can signal infection, lymphoma, or another illness. Flushing outside the usual menopausal pattern also needs checking: starting before 40, without any change in periods, returning years after menopause symptoms settled, in men not on hormone-lowering treatment, or with diarrhea, wheezing, palpitations, tremor, or heat intolerance, which can point to thyroid disease or rarer hormone-secreting tumors. When hot flashes disrupt sleep or work, see a clinician: hormone therapy, which The Menopause Society calls the most effective treatment, and nonhormonal options such as SSRIs, SNRIs, gabapentin, and fezolinetant have far stronger evidence than black cohosh.
06 Questions
Frequently Asked Questions
The evidence is mixed. Some trials of licensed European extracts, and meta-analyses from 2021 and 2023, found fewer or milder hot flashes than with placebo, but a 2012 Cochrane review of 16 trials found no significant difference, and two year-long NIH-funded trials found black cohosh no better than placebo while hormone therapy clearly worked. The Menopause Society does not recommend it. If it helps at all, the effect appears modest and may depend on the extract used.
Licensed European products use a few milligrams of specific dry extracts, such as 6.5 mg once a day or 2.8 mg twice a day, roughly equal to 40 mg of root. Remifemin is standardized to 40 mg of root per daily dose of two tablets. US supplements list milligrams of different extracts, which are not comparable. Positive trials judged results at 12 weeks, and Europe’s regulator advises not taking black cohosh for more than six months without medical advice.
Rarely, it may be. Products labeled black cohosh have been linked to acute liver injury, some cases needing a liver transplant, although a US Pharmacopeia review rated all 30 reports it examined as only possibly related, and contaminants or the wrong plant may explain some. Avoid it if you have liver disease. Stop at once and see a doctor for dark urine, yellow skin or eyes, unusual tiredness, loss of appetite, or upper stomach pain with nausea. Kava carries a similar warning.
Neither is proven. Black cohosh has far more trials, with mixed results. Sage has a few small, short trials of specific extracts and a 2023 meta-analysis with an imprecise result. One head-to-head trial, an eight-week Iranian study of 80 women, found sage reduced hot-flash frequency sooner, but the difference faded from the third week. The Menopause Society does not recommend herbal remedies. Our menopause guide compares the options.
Remifemin’s isopropanolic extract is the most studied black cohosh extract and one of the three licensed in Europe. Employees of its German maker, Schaper & Brümmer, co-authored several of its trials and reviews, and the Cochrane review, which included several of its trials, still found no clear benefit for hot-flush frequency. What is fairly clear is that products differ, so a negative result for one supplement does not settle every product, and vice versa.
Only with your oncology team’s agreement. Europe’s regulator advises people treated for breast cancer or other hormone-dependent tumors not to use black cohosh without medical advice. Observational studies have not shown higher cancer risk, but a mouse study found more lung metastases, and in a 132-patient trial in women with a history or high risk of breast cancer, hot-flash scores fell 20% on black cohosh and 27% on placebo. Nonhormonal prescription treatments have better evidence and are worth discussing first.
07 References
Sources
These references support the claims on this page. They are not an endorsement of any product. The black cohosh monograph carries its own full source list.
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Black cohosh (Cimicifuga spp.) for menopausal symptoms
Cochrane Database of Systematic Reviews (PubMed 22972105), 2012
Leach and Moore: 16 RCTs, 2,027 women, median 40 mg a day for a mean 23 weeks; hot flushes MD 0.07 a day (−0.43 to 0.56; 3 trials, 393 women); symptom scores SMD −0.10 (4 trials, 357 women); hormone therapy better; insufficient evidence; no competing interests.
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Black cohosh extracts in women with menopausal symptoms: an updated pairwise meta-analysis
Menopause (PubMed 37192826), 2023
Sadahiro et al.: 22 trials, 2,310 women, black cohosh alone or combined; overall symptoms g 0.575, hot flashes g 0.315 (0.107 to 0.524), somatic symptoms improved; anxiety and depression not significant; dropouts similar to placebo.
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Review & meta-analysis: isopropanolic black cohosh extract iCR for menopausal symptoms – an update on the evidence
Climacteric (PubMed 33021111), 2021
Castelo-Branco et al.: 35 studies and 1 meta-analysis, 43,759 women (13,096 on iCR); SMD −0.694 versus placebo; larger effects at higher doses or with St. John’s wort; two authors from Schaper & Brümmer.
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Complementary therapies for management of menopausal symptoms: a systematic review to inform the update of the International Menopause Society recommendations on women’s midlife health
Climacteric (PubMed 41498229), 2026
Maunder et al.: 158 studies from searches covering 2022–2024; moderate-certainty evidence supports black cohosh for vasomotor and menopausal symptoms; most complementary-therapy evidence low or very low certainty.
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Treatment of vasomotor symptoms of menopause with black cohosh, multibotanicals, soy, hormone therapy, or placebo: a randomized trial
Annals of Internal Medicine (PubMed 17179056), 2006
Newton et al. (HALT): 351 women aged 45–55, black cohosh 160 mg a day for 12 months; herbal arms under 1 symptom a day from placebo; hormone therapy −4.06 a day; multibotanical plus soy worse at 12 months; NIA grant.
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Safety and efficacy of black cohosh and red clover for the management of vasomotor symptoms: a randomized controlled trial
Menopause (PubMed 19609225), 2009
Geller et al.: 89 women for 12 months; black cohosh 128 mg a day (7.27 mg triterpene glycosides); reductions 34%, 57% red clover, 63% placebo, 94% hormone therapy; no liver signal; NIH-funded (full text).
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Phase III double-blind, randomized, placebo-controlled crossover trial of black cohosh in the management of hot flashes: NCCTG Trial N01CC1
Journal of Clinical Oncology (PubMed 16782922), 2006
Pockaj et al.: 132 women with a history or perceived high risk of breast cancer; crossover; black cohosh 20 mg twice daily; hot-flash scores fell 20% versus 27% on placebo (P = .53); NCI-funded.
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European Union herbal monograph on Cimicifuga racemosa (L.) Nutt., rhizoma (Revision 1)
European Medicines Agency (EMA/HMPC/48745/2017), 2018
Well-established use of three dry extracts for menopausal complaints such as hot flushes and profuse sweating; posology; six-month limit; liver warning signs; breast cancer, estrogen, pregnancy, lactation, and contraception advice; no interactions reported.
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Assessment report on Cimicifuga racemosa (L.) Nutt., rhizoma (Revision 1)
European Medicines Agency (EMA/HMPC/48744/2017), 2018
About 20 trials with roughly 6,300 patients; no unambiguous results on validated scales; HALT and Geller products unlicensed; Ze 450 dose trial; liver case reports including a transplant; breast cancer studies; tamoxifen and atorvastatin data.
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Addendum to assessment report on Cimicifuga racemosa (L.) Nutt., rhizoma
European Medicines Agency (EMA/HMPC/8411/2025), 2025
Adopted 19 November 2025: Castelo-Branco meta-analysis pooled six placebo-controlled RCTs and added no new trials; PRAC found the benefit–risk balance unchanged and asked for close monitoring of hepatotoxicity; no monograph revision.
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The 2023 nonhormone therapy position statement of The North American Menopause Society
Menopause (PubMed 37252752), 2023
Black cohosh is the most purchased menopause botanical; cites the Cochrane review and the USP liver warning; insufficient evidence for hot flashes (Level I, not recommended); recommends CBT, hypnosis, SSRIs/SNRIs, gabapentin, fezolinetant; hormone therapy most effective.
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Black Cohosh: Usefulness and Safety
National Center for Complementary and Integrative Health (NIH), 2024
Updated November 2024: 2023 review of 22 studies found improvement in hot flashes; uncertain for breast-cancer-related hot flashes; rare liver damage; wrong herbs in some products; blue cohosh risks; may not be safe in pregnancy or breastfeeding.
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Black Cohosh: Fact Sheet for Health Professionals
Office of Dietary Supplements, National Institutes of Health, 2020
Remifemin standardized to 40 mg root per two-tablet daily dose and reformulated over time; HALT and Geller details; mild side effects; at least 83 liver cases without proven causality; Australian and USP label warnings; no known clinically relevant interactions.
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Black Cohosh
LiverTox, National Institute of Diabetes and Digestive and Kidney Diseases (PubMed 31643322), 2025
Updated April 2025: products labeled black cohosh implicated in many instances of clinically apparent acute liver injury, some severe enough to lead to emergency liver transplantation or death.
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United States Pharmacopeia review of the black cohosh case reports of hepatotoxicity
Menopause (PubMed 18340277), 2008
Mahady et al.: 30 nonduplicate liver damage reports, all possible and none probable or certain causality; USP nonetheless recommended a cautionary label statement.
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Evaluation of the botanical authenticity and phytochemical profile of black cohosh products by high-performance liquid chromatography with selected ion monitoring liquid chromatography-mass spectrometry
Journal of Agricultural and Food Chemistry (PubMed 16637680), 2006
Jiang et al.: of 11 US black cohosh products, 3 contained Asian Actaea instead of black cohosh and 1 contained both; wide variation in constituents among authentic products.
Other herbs reviewed for menopause & hot flashes
- Sage for Hot Flashes Early or mixed evidence