Last checked September 2026 against 10 sources · Editorial policy
Black cohosh for menopause
Black cohosh is the most studied herb for menopause, with mixed results. A 2012 Cochrane review of sixteen trials found no difference from placebo in hot flash frequency, while a 2023 review of 22 studies and a 2026 International Menopause Society review found possible benefit for hot flashes and overall symptoms. The usual dose studied is 40 mg a day. Rare but serious liver damage has been reported with black cohosh products.
Black cohosh for menopause: expectation vs reality
What people often expect
“Black cohosh is a natural form of estrogen that works like HRT”
What the evidence shows
Black cohosh is an herb, not a hormone, and in the Cochrane review HRT reduced hot flashes and menopause scores more than black cohosh did. It may help some women modestly, especially at 40 mg a day of a standardized extract, but the evidence is inconsistent, and products vary: some labeled black cohosh have contained a different herb.
Black cohosh for menopause: what studies show
What is black cohosh?
Black cohosh is a member of the buttercup family that grows in North America. Native Americans used it for kidney problems, sore throat and menstrual cramps, and it's been used medicinally in Germany since the late 19th century. Supplements use the root or rhizome. It's promoted for menopause symptoms, PMS and menstrual cramps. Black cohosh and blue cohosh are different herbs.
Does black cohosh work for hot flashes?
The evidence conflicts. The 2012 Cochrane review of 2,027 women found hot flash frequency differed from placebo by just 0.07 a day, not significant, and couldn't confirm safety because of poor reporting. A 2023 review of 22 studies found improvements in hot flashes and overall menopause symptoms, and the 2026 IMS review rated that evidence moderate certainty.
Black cohosh dose and extract
Most well-designed recent trials used an isopropanolic extract of black cohosh, and the most common dose is 40 mg a day, according to the Spanish Menopause Society, which considers it an effective and safe option for hot flashes. The Cochrane trials used a median of 40 mg a day for an average of 23 weeks.
Black cohosh for mood, sleep and anxiety
The Spanish Menopause Society reports improved mood alongside fewer hot flashes. But the 2023 review cited by NCCIH found improvements in hot flashes, not in anxiety or depressive symptoms. For low mood and sleep problems in menopause, CBT and HRT have stronger evidence.
Learn more →Black cohosh and liver safety
Black cohosh has been used safely in studies lasting up to a year and is generally well tolerated. But rare cases of liver damage, some very serious, have been reported with products labeled black cohosh; it's uncertain whether black cohosh caused them, and some products contained the wrong herb or unlisted herbs. Stop it if you notice dark urine, fatigue or yellowing skin.
Black cohosh after breast cancer
It's uncertain whether black cohosh is safe for women who've had hormone-sensitive conditions such as breast or uterine cancer, and whether it reduces hot flashes caused by breast cancer treatment. If you've had breast cancer, discuss it with your oncology team; non-hormonal medicines have better evidence in this group.
Learn more →Black cohosh vs HRT
In the Cochrane review, hormone therapy reduced daily hot flashes and menopause symptom scores significantly more than black cohosh. HRT also protects bones and treats vaginal dryness, which black cohosh hasn't been shown to do. If hot flashes seriously affect your life, HRT or prescription non-hormonal medicines are more reliable.
Learn more →Black cohosh in combination products
Black cohosh is often mixed with other herbs in menopause formulas. The 2023 review included products with black cohosh alone or in combination, and some commercial products contain herbs not listed on the label. Combination products make it harder to know what you're taking and what caused any side effect.
Learn more →Black cohosh by the numbers
40 mg
2,027
22
23 weeks
Reviews disagree partly because they used different trials, extracts and quality criteria.
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Black cohosh products and alternatives compared
Standardized black cohosh extract
Learn more →Good for
The form used in most recent trials, usually 40 mg a day.Watch
Benefit is modest and inconsistent; rare liver damage.Our pick: Remifemin. A standardized black cohosh extract that names its dose on the label.
Check price on Amazon →Multi-herb menopause formulas with black cohosh
Learn more →Good for
Convenient.Watch
Harder to know doses; some products contained unlisted herbs.Soy isoflavones
Learn more →Good for
About 20.6% fewer hot flashes in a meta-analysis.Watch
Not recommended by NAMS; may not suit women who shouldn't take estrogen.HRT
Learn more →Good for
Beat black cohosh for hot flashes and symptom scores in the Cochrane review.Watch
Needs a prescription; with a uterus, a progestogen too.
How to choose and use black cohosh
- Look for a product that names the extract and dose, such as 40 mg a day of a standardized extract.
- Avoid it if you have liver disease, and check with a doctor before starting.
- Don't confuse it with blue cohosh, a different herb with serious side effects.
- Avoid it in pregnancy or while breastfeeding.
When to stop black cohosh and see a doctor
Dark urine, jaundice or belly pain
Stop black cohosh and see a doctor; these can be signs of liver damage.
History of breast or uterine cancer
Talk to your oncology team before using it.
You have liver disease
Consult a doctor before taking black cohosh products.
Hot flashes still disrupting life
Ask about HRT or prescription non-hormonal medicines.
Black cohosh and menopause: questions women ask
Does black cohosh work for menopause?
For some women, modestly. A Cochrane review found no significant benefit over placebo for hot flashes, but newer reviews, including a 2026 International Menopause Society review, found moderate-certainty evidence of benefit.
How much black cohosh should I take for menopause?
Most trials used 40 mg a day of a standardized isopropanolic extract. Follow the product label and talk to your doctor, especially if you take other medicines.
Is black cohosh safe?
It's generally well tolerated and has been used safely in studies lasting up to a year. Rare but serious liver damage has been reported, so avoid it with liver disease and stop if you get dark urine or yellow skin.
Is black cohosh estrogen?
No. NCCIH lists black cohosh separately from phytoestrogens like soy and red clover. It's uncertain whether it's safe after hormone-sensitive cancers.
How long does black cohosh take to work?
Trials in the Cochrane review lasted an average of 23 weeks. Set a trial period and review it with your doctor if you notice no difference.
Can black cohosh help with mood?
One expert statement reports improved mood, but a 2023 review found benefit for hot flashes, not anxiety or depressive symptoms. CBT has better evidence for mood in menopause.
Can I take black cohosh with HRT?
There's little research on combining them. Tell your doctor about any supplement; HRT alone is more effective for hot flashes than black cohosh.
What is the difference between black cohosh and blue cohosh?
They're different herbs. Blue cohosh may cause high blood pressure, high blood sugar and chest pain, and has been linked to life-threatening complications in infants when used to induce labor.
Sources
- Leach MJ, Moore V. Black cohosh (Cimicifuga spp.) for menopausal symptoms. Cochrane Database Syst Rev. 2012;2012(9):CD007244.
- National Center for Complementary and Integrative Health. Black cohosh: usefulness and safety.
- Maunder A, Mardon AK, Rao V, et al. 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. 2026;29(2):165-209.
- Castelo-Branco C, Navarro C, Beltrán E, et al. Black cohosh efficacy and safety for menopausal symptoms. The Spanish Menopause Society statement. Gynecol Endocrinol. 2022;38(5):379-384.
- National Center for Complementary and Integrative Health. Menopausal symptoms: in depth.
- Ayers B, Smith M, Hellier J, et al. Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause. 2012;19(7):749-59.
- The North American Menopause Society. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573-590.
- NICE. Menopause: identification and management (NG23). Updated 2024.
- Taku K, Melby MK, Kronenberg F, et al. Extracted or synthesized soybean isoflavones reduce menopausal hot flash frequency and severity: systematic review and meta-analysis of randomized controlled trials. Menopause. 2012;19(7):776-90.
- NHS. Utrogestan (micronised progesterone): how and when to take.
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