Black Cohosh vs Red Clover vs Sage for Menopause Symptoms
Black cohosh, red clover and sage are studied for menopause hot flashes. Compare what reviews and regulators found, the liver warning for black cohosh, and who should ask first.
Content last updated . This page has not been medically reviewed.
Safety first. Supplements can cause side effects and interact with medicines. Read mushroom safety and interactions before you use any mushroom product.
Liver warning first. The US National Institute of Diabetes and Digestive and Kidney Diseases (LiverTox) says products labeled as black cohosh have been implicated in many instances of clinically apparent, acute liver injury, some of them severe and leading to emergency liver transplantation or death. [1] The National Center for Complementary and Integrative Health (NCCIH) says these problems are rare and that it is uncertain whether black cohosh was responsible. [2] The European Medicines Agency (EMA) says people should stop black cohosh medicines and see a doctor straight away if they develop signs such as tiredness, loss of appetite, yellowing of skin and eyes, severe upper stomach pain with nausea and vomiting, or dark urine. [3] See Liver Safety and Supplements.
Which plants are these?
GBIF accepts the names below. [5] Black cohosh and blue cohosh are different herbs. [2]| Common name | Scientific name | Part used in the sources we read |
|---|---|---|
| Black cohosh | Actaea racemosa (also written Cimicifuga racemosa) | Root or rhizome (underground stem) [2] |
| Red clover | Trifolium pratense | Sources we read describe extracts, and isoflavones that are structurally similar to estrogen [6] |
| Sage (common sage) | Salvia officinalis | Leaf (EU monograph "folium") [7] |
Traditional use (not proof)
Native Americans used black cohosh for kidney ailments, malaria, sore throat and menstrual cramps, and it has been used medicinally in Germany since the late 19th century. [2] Red clover is traditionally used for skin disorders, whooping cough and mastitis. [8] Sage was traditionally used for digestive, respiratory and skin problems. [9] The EU sage monograph lists traditional use for mild heartburn and bloating and for excessive sweating, among others. [7]What research shows
| Plant | What the sources found | Strength of evidence |
|---|---|---|
| Black cohosh | A 2023 review of 22 studies of black cohosh extracts, alone or with other herbs, found them potentially beneficial for overall menopause symptoms, with improvement in hot flashes but not anxiety or depressive symptoms. [2] EU regulators considered around 20 clinical studies in over 6,000 patients and granted "well-established use" for menopausal complaints, for dry extracts made with a solvent only. [3] | Promising but limited; regulator-recognized for one extract type |
| Red clover | NCCIH says studies on hot flashes have had inconsistent results and research has not shown conclusive evidence of benefit for any condition. [6] A 2016 meta-analysis found hot flash frequency lower with red clover, close to statistical significance, with very high variation between studies. [10] | Mixed |
| Sage | A 2023 meta-analysis of four studies in 310 postmenopausal women reported a significant effect on hot flash frequency versus placebo but not on severity, with high variation between studies. [11] One 4-week trial in 80 women used an extract of freshly harvested sage and was sponsored by its manufacturer. [12] NCCIH calls the research small. [9] | Promising but limited |
The North American Menopause Society's 2023 statement lists hormone therapy as the most effective treatment for hot flashes and night sweats, and lists supplements and herbal remedies among the options it does not recommend (levels I-II evidence). [13] The abstract we read does not break this down plant by plant, so ask a clinician about your situation. See Perimenopause and Menopause.
Where to read more
Single-plant pages: Black Cohosh, Red Clover, Sage. Overview: Herbs for Menopause Symptoms and Black Cohosh, Soy, Red Clover and "Hormone Balance" Claims. Medicines: How Interactions Work.Frequently asked questions
Which is best for hot flashes, black cohosh, red clover or sage?
No source we read ranks them, and trials comparing them head to head were not found in PubMed on 2026-10-23. Each has limited, product-specific evidence. [2] [6] [9]
Can black cohosh harm the liver?
Cases of liver injury, some very serious, have been reported in people taking products labeled as black cohosh, although NCCIH says it is uncertain black cohosh caused them. [2] [1]
Is red clover safe after breast cancer?
Talk to your healthcare provider first if you have a hormone-sensitive cancer; Memorial Sloan Kettering says red clover may worsen the condition. [8] NCCIH says red clover contains isoflavones structurally similar to estrogen. [6]
Is sage tea the same as the sage extract in trials?
Not necessarily. The 4-week trial used tablets of an ethanolic extract of freshly harvested sage. [12] The EU monograph lists sage tea and several extracts for its traditional uses, which do not name menopause. [7]
Should I stop my hormone or other prescribed medicine to try one?
Do not stop or change a prescribed medicine on your own. Ask the prescriber or a pharmacist, and ask before adding any herb. [4]
More details: evidence, limits and cautions
The details behind this page: cautions, limits of the evidence and where sources disagree. Open any note to read it.
Safety side by side
| Question | Black cohosh | Red clover | Sage |
|---|---|---|---|
| Pregnancy and breastfeeding | May not be safe [2] | May be unsafe; avoid [6] [8] | EU: safety not established; thujone may harm in pregnancy [7] [9] |
| Hormone-sensitive cancer | Uncertain whether safe [2] | Talk to your provider first [8] | Not described in the sources we read |
| Medicines and bleeding | Talk to your provider if you take any medicine [2] | May raise bleeding risk, for example with warfarin; lab studies suggest effects on enzymes that process many medicines [8] | EU: no interactions reported [7] |
| Children | EU: adult women only [3] | Not described in the sources we read | EU: under 18 not established [7] |
| Other | Wrong herb found in some products [2] | Used safely in studies up to 2 years [6] | Thujone can be toxic in large amounts [9] |
Tell the surgical team about any herb before an operation: Herbs Before and After Surgery. Check the plant name and part on the label: Quality Testing and Certifications.
References
- National Institute of Diabetes and Digestive and Kidney Diseases. Black Cohosh. LiverTox (PubMed record, updated 2025). Read 2026-10-23.
- National Center for Complementary and Integrative Health (US). Black Cohosh. Last updated November 2024. Read 2026-10-23.
- European Medicines Agency, Committee on Herbal Medicinal Products. Black cohosh: herbal medicinal product summary. Read 2026-10-23.
- NHS (UK). Menopause: treatment. Read 2026-10-23.
- GBIF Secretariat. GBIF Backbone Taxonomy species match, queried for Actaea racemosa, Trifolium pratense, Salvia officinalis, Melissa officinalis, Lavandula angustifolia and Passiflora incarnata. Read 2026-10-23.
- National Center for Complementary and Integrative Health (US). Red Clover. Read 2026-10-23.
- European Medicines Agency, HMPC. European Union herbal monograph on Salvia officinalis L., folium (EMA/HMPC/277152/2015, adopted 20 September 2016). Read 2026-10-23.
- Memorial Sloan Kettering Cancer Center. Red Clover: About Herbs. Read 2026-10-23.
- National Center for Complementary and Integrative Health (US). Sage. Read 2026-10-23.
- Ghazanfarpour M, et al. Red clover for treatment of hot flashes and menopausal symptoms: a systematic review and meta-analysis. J Obstet Gynaecol. 2016;36(3):301-311. Read 2026-10-23.
- Moradi M, et al. The Effect of Salvia Officinalis on Hot Flashes in Postmenopausal Women: A Systematic Review and Meta-Analysis. Int J Community Based Nurs Midwifery. 2023;11(3):169-178. Read 2026-10-23.
- Wilfried D, et al. Effectiveness of Salvia officinalis in the treatment of a wide spectrum of menopausal complaints: a double-blind, randomized, placebo-controlled trial. Heliyon. 2021;7(2):e05910. Read 2026-10-23.
- The North American Menopause Society. The 2023 nonhormone therapy position statement. Menopause. 2023;30(6):573-590. Read 2026-10-23.