Black cohosh for menopause: what the evidence shows and liver safety

Name: Black cohosh for menopause: what the evidence shows and liver safety
Creator: MenoWoman

Black cohosh is one of the most widely used herbal remedies for hot flashes, but good-quality trials have not shown it works better than a placebo. Rare cases of liver injury have been reported, so people with liver problems should be cautious.

Researched by the MenoWoman team. Edited by Marcela Sat. Updated 7 November 2026. We may earn from links.

Stop and see a doctor urgently if you develop yellow skin or eyes, dark urine, pale stools, belly pain or unusual tiredness while taking black cohosh.

What it is

Black cohosh is a plant native to North America. Supplements are made from its roots. Its scientific names are Actaea racemosa and Cimicifuga racemosa.¹

Products vary a lot in what they contain. Scientists do not know which compounds, if any, are active.¹

People take it mainly for hot flashes and night sweats. Some also use it for sleep problems, palpitations and irritability.¹

What the research shows

A Cochrane review in 2012 pooled 16 trials with 2,027 women. In 3 trials with 393 women, black cohosh made no difference to how often hot flashes happened compared with placebo.²

In the same review, hormone therapy reduced hot flashes and other symptoms more than black cohosh did. The authors said there was not enough evidence to support using it.²

Other trials agree. One trial of 351 women aged 45 to 55 found no difference from placebo. A 2016 analysis of 4 trials with 511 women also found no clear reduction in hot flashes.¹

The Menopause Society reviewed the evidence in 2023. It does not recommend black cohosh for hot flashes. More broadly, it does not recommend supplements or herbal remedies for hot flashes.^3,4

Safety and who should be careful

The main concern is the liver. Reports from around the world describe at least 83 cases of liver injury in people taking black cohosh. It has not been proven that black cohosh caused them.¹

Some cases may have involved impure or wrongly identified plants. In 2008, the US Pharmacopeia advised a warning label. It tells people with liver problems, or symptoms like dark urine or yellow skin, to stop and see a practitioner.^1,3

Australia has required a liver warning on black cohosh products since 2007. The FDA does not require one in the US.¹

Mild side effects include stomach upset and rashes. Experts advise against use in pregnancy without medical supervision.¹

Black cohosh has no known important drug interactions, but this has not been well studied.¹ If you have had breast cancer or another hormone-sensitive condition, ask your doctor first.

A doctor or pharmacist can check whether it interacts with any medicines or other supplements you take.

How it is available

Black cohosh is sold over the counter as a supplement in many countries. Rules on labeling and quality differ by country. In the US it is sold as a dietary supplement, without FDA approval for any use.¹

Because products vary, a label does not guarantee what is in the bottle. Some countries have stricter quality schemes for herbal products than others.

The bottom line

Black cohosh has been studied more than most herbs for menopause. Taken together, the trials do not show it works better than a placebo for hot flashes.^2,1

Placebo effects in hot flash trials can be large, so some women may feel better on any pill. That does not mean the herb itself is doing the work.

If you are bothered by hot flashes, a doctor can discuss options with stronger evidence. These include hormone therapy, non-hormonal prescription treatments and CBT.⁴

What it is used for: evidence rated

Option	Evidence	What the research shows
Hot flashes	Weak evidence	Many trials exist, but a Cochrane review of 16 trials found no difference from placebo in hot flash frequency.²
Night sweats	Weak evidence	A trial of 351 women found no improvement in hot flashes or night sweats compared with placebo.¹
Sleep problems and irritability	Weak evidence	People use it for these, but we found no good trials showing a benefit.¹

Ratings explained: how we rate. Always talk to a doctor or pharmacist before starting a medicine or supplement.