Black cohosh passes the evidence test for hot flushes; most menopause remedies don't

Hormone therapy is the standard treatment for menopausal symptoms, yet many women either cannot take it or prefer not to, and turn instead to herbs, supplements, acupuncture and mind-body practices. That market is vast and the research behind it is famously patchy, which leaves both women and their clinicians guessing about what actually helps. The International Menopause Society is updating its recommendations on women's midlife health, and this review was carried out to establish which complementary therapies have credible support, for which symptoms, and whether they are safe.

Researchers searched six databases for randomised controlled trials and systematic reviews on complementary therapies for menopause published between January 2022 and December 2024. From 3187 citations they included 158 studies: one overview, 36 meta-analyses, seven systematic reviews and 114 randomised trials. Outcomes covered menopausal, vasomotor, genitourinary, cardiometabolic and sleep symptoms, plus bone health and safety. Study quality and the certainty of the evidence were graded using established tools, including Cochrane's risk of bias assessment and the GRADE system.

Most of the promising results, spanning acupuncture, Chinese herbal medicine, individual herbs, nutrients and mind-body or touch therapies, rested on low or very low certainty evidence. A smaller set reached moderate certainty: black cohosh for hot flushes and overall menopausal symptoms, Chinese herbal medicine for menopausal symptoms, sleep and blood pressure, acupuncture combined with Chinese herbal medicine for sleep, and vitamin D for fracture risk. High-certainty evidence supported the safety of vitamin D. Most complementary therapies appeared safe overall, with few serious side effects reported.

Because this review was built to inform the International Menopause Society's updated recommendations, it carries more weight than a standalone paper. It confirms a long-standing pattern in this field: plenty of small positive trials, very few rigorous enough to settle anything. It also sharpens the picture by separating the handful of therapies with moderate-certainty support from the crowd trading on weaker evidence. The open question is whether black cohosh, Chinese herbal medicine and the acupuncture combination would hold up in larger, better-designed trials, which the authors explicitly call for.

If you are weighing up remedies for hot flushes, poor sleep or other menopausal symptoms, this is a reason to treat most product claims with caution, because the bulk of the evidence behind them is weak. It is also a reason to take black cohosh, Chinese herbal medicine and vitamin D more seriously than the average supplement, since these reached moderate-certainty support for specific outcomes. The reassuring note is safety, with few serious side effects reported across most therapies studied. Hormone therapy remains the standard treatment, and nothing here displaces it.