Herbs for Menopause Symptoms: Black Cohosh, Red Clover, Sage and Others
What the North American Menopause Society, Cochrane, NIH and EU regulators say about black cohosh, red clover, sage and chasteberry for hot flashes, with liver and hormone cautions first.
Content last updated . This page has not been medically reviewed.
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The big picture
The 2023 position statement of the North American Menopause Society reviewed hot-flash (vasomotor) treatments. It did not recommend supplements or herbal remedies (evidence levels I-II) or soy foods and soy extracts (level II), and said hormone therapy remains the most effective treatment. [7] The NHS says there is very little evidence of how well red clover and black cohosh work or how safe they are, and some herbal remedies may cause serious side effects with other medicines. [8] MedlinePlus says research results are mixed and long-term safety information is limited. [9] Level I means good and consistent evidence; level II means limited or inconsistent evidence. [7] For a person's options, including hormone therapy, talk to a clinician. See perimenopause and menopause, hot flashes and black cohosh, soy, red clover and "hormone balance" claims.What research shows, by herb
Names follow GBIF. Black cohosh is Actaea racemosa (root or rhizome) [10][1]; red clover is Trifolium pratense [10][4]; sage is Salvia officinalis [10][11]; chasteberry is Vitex agnus-castus [10][3].| Herb | What the source found | Strength of evidence | Form and people studied |
|---|---|---|---|
| Black cohosh | A 2023 review of 22 studies found extracts, alone or with other herbs, potentially beneficial overall, with better hot flashes but no gain in anxiety or depressive symptoms. [1] Memorial Sloan Kettering calls the data conflicting. [12] The EU committee accepts specific dry extracts for hot flushes and sweating, citing about 20 studies and over 6,000 patients. [2] | Promising but limited, with mixed findings | Menopausal women; extracts, some in combinations |
| Red clover | NIH: inconsistent results for hot flashes. [4] A Cochrane review pooled five trials of one red clover extract and found no significant overall difference from placebo. [13] A 2021 meta-analysis of randomized trials found a statistically significant reduction in daily hot flushes, but said more well-designed studies are needed. [14] | Mixed | Menopausal women; isoflavone extracts |
| Sage | NIH: a few small studies suggest common sage might reduce hot flash frequency. [11] One 80-woman, placebo-controlled trial of an ethanol extract of fresh sage reported lower menopause symptom and hot flush scores after 4 weeks. [15] | Promising but limited | One small trial; ethanol extract tablets [15] |
| Chasteberry | NIH: a preliminary study suggested help with some menopausal symptoms, more research needed. [3] Memorial Sloan Kettering: studies suggest it helps PMS but not menopause symptoms, and one trial of chasteberry with St. John's wort did not help. [16] | Insufficient evidence | Preliminary |
| Phytoestrogen supplements overall | Cochrane (43 trials, 4,364 participants): no conclusive evidence of reducing hot flush frequency or severity; placebo reductions ranged from 1% to 59%. [13] | Insufficient or mixed | Foods and supplements with plant estrogens, 2013 review |
A result for one extract does not transfer to another product, tea or capsule. For a side-by-side view, see black cohosh vs red clover vs sage.
Traditional use
NIH says Native Americans used black cohosh for kidney ailments, malaria, sore throat and menstrual cramps, and that it has been used medicinally in Germany since the late 19th century. [1] Traditional use is not proof of benefit for menopause.Frequently asked questions
Does black cohosh help hot flashes?
A 2023 review summarized by NIH found improvement in hot flashes. [1] Memorial Sloan Kettering calls the data conflicting, and the NHS says evidence is very limited. [12][8]
Is red clover the same as hormone therapy?
No. It contains plant substances structurally similar to estrogen, but results for hot flashes are inconsistent. [4]
Which herb is recommended for menopause?
The North American Menopause Society did not recommend supplements or herbal remedies for hot flashes in 2023. [7]
Can I use these after breast cancer?
Safety is uncertain; ask your oncology team first. [1]
What else can I do?
Talk to a clinician about proven options, including hormone therapy and non-hormone medicines or therapy. [8]
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 first: liver, hormones and bleeding
Liver: cases of liver damage, some very serious, have been reported in people taking products labeled as black cohosh. NIH says these are rare and it is uncertain whether black cohosh caused them. [1] The EU herbal committee says to stop and see a doctor right away for tiredness, loss of appetite, yellow skin or eyes, severe upper stomach pain with nausea and vomiting, or dark urine. [2] Hormone-sensitive conditions: it is uncertain whether black cohosh is safe after breast or uterine cancer, [1] and chasteberry may not be safe for women with hormone-sensitive conditions. [3] Red clover contains plant substances structurally similar to estrogen, [4] and Memorial Sloan Kettering says to talk to your clinician if you have a hormone-sensitive cancer. [5] Bleeding: the NHS says to contact a doctor about any vaginal bleeding after 12 months without a period, or if your periods become heavier than before. [6] See herbs and hormone-sensitive conditions and herbs and liver injury.
Safety details
- Medicines: Memorial Sloan Kettering says black cohosh used with prescription medicines has been associated with adverse reactions, [12] and warns people on warfarin and other blood thinners about red clover and bleeding. [5] Ask a pharmacist; see medicine interactions.
- Pregnancy and breastfeeding: NIH says black cohosh and red clover may not be safe or may be unsafe, and sage may be unsafe in pregnancy because of thujone. [1][4][11]
- Sage: common sage contains thujone, which can be toxic in large amounts; larger amounts were used safely for up to 8 weeks in studies. [11]
- Duration: the EU committee says black cohosh is for adult women only and not longer than 6 months without consulting a doctor. [2] Memorial Sloan Kettering says long-term safety of red clover is not known. [5]
- Quality: some commercial black cohosh products contain the wrong herb. [1] See quality testing.
- Surgery, children, older adults, kidney: not described in the sources we read; tell the surgical team about every herb.
- Medicine decisions: never stop hormone therapy or any prescription on your own; ask the prescriber.
References
- NCCIH, NIH. Black Cohosh. Read 2026-10-23.
- EMA, HMPC. Black cohosh: summary for the public. Read 2026-10-23.
- NCCIH, NIH. Chasteberry. Last updated April 2025. Read 2026-10-23.
- NCCIH, NIH. Red Clover. Last updated April 2025. Read 2026-10-23.
- Memorial Sloan Kettering Cancer Center. Red Clover. Read 2026-10-23.
- NHS (UK). Symptoms of menopause and perimenopause. Read 2026-10-23.
- The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023. Read 2026-10-23.
- NHS (UK). Treatment for menopause and perimenopause. Page last reviewed 19 May 2026. Read 2026-10-23.
- MedlinePlus (U.S. National Library of Medicine). Menopause. Read 2026-10-23.
- GBIF Backbone Taxonomy, species match service (api.gbif.org/v1/species/match), queried for each scientific name used on this page. Read 2026-10-23.
- NCCIH, NIH. Sage. Last updated April 2025. Read 2026-10-23.
- Memorial Sloan Kettering Cancer Center. Black Cohosh. Read 2026-10-23.
- Lethaby A, et al. Phytoestrogens for menopausal vasomotor symptoms. Cochrane Database of Systematic Reviews. 2013. Read 2026-10-23.
- Evaluation of clinical meaningfulness of red clover extract to relieve hot flushes and menopausal symptoms: a systematic review and meta-analysis of randomized controlled trials. Nutrients. 2021. Read 2026-10-23.
- Randomized, double-blind, placebo-controlled trial of a Salvia officinalis extract tablet in menopausal complaints. Heliyon. 2021. Read 2026-10-23.
- Memorial Sloan Kettering Cancer Center. Chasteberry. Read 2026-10-23.
Education, not medical advice. This page is for general information. It does not diagnose or treat any condition and is not a substitute for care from a qualified health professional. Natural does not automatically mean safe. Ask a clinician or pharmacist before changing your care, especially if you take medication, are pregnant or breastfeeding, or have a health condition.