Herbs for Menopause and Hot Flashes: 10 Ranked by Evidence, With Honest Caveats
The herbs with the best evidence for menopause symptoms are black cohosh, red clover isoflavones and sage, with St John's wort for the mood component and magnesium and vitamin D for sleep and bone. Before any of them, one fact: menopausal hormone therapy (HT) reduces hot flashes by 75–90 percent in trials and is the most effective treatment that exists. For most healthy women under 60 or within 10 years of their last period, the benefits outweigh the risks, and the 2022 and 2023 position statements of the North American Menopause Society say so plainly. Herbs are for women who cannot take HT (hormone-sensitive cancers, clotting history), who have tried it and stopped, or who prefer not to, and the honest expectation is a 30–50 percent reduction in hot flashes at best, against a placebo response that is itself around 25–30 percent.
This guide is for women in perimenopause and early postmenopause with hot flashes, night sweats, broken sleep, low mood and irritability who want to know which supplements have trial support and at what dose. It is not for women with unexplained bleeding after menopause, bleeding between periods or after sex, a breast lump, or pelvic pain, all of which need a doctor first. Women with a history of breast cancer, liver disease or blood clots should discuss any herbal option with their specialist, because several on this list have oestrogenic activity or liver signals.
Each pick is graded by the quality of human evidence for menopause symptoms specifically. Most are Moderate. The black cohosh entry covers the liver injury reports in detail. A section on what not to bother with follows, and the lifestyle section covers the non-herb levers (CBT, paced breathing, weight, alcohol) that have trial evidence as good as or better than most of the herbs.
Quick answer
- Black cohosh — reduced hot flashes by about 25 percent more than placebo in a 2021 meta-analysis of 22 RCTs; rare liver injury reports
- Red clover isoflavones — modest reduction in hot flash frequency (about 1–2 fewer per day) with 40–80 mg/day
- Sage — a single RCT found a 64 percent drop in hot flash intensity over 8 weeks; promising but one trial
- St John's wort — improves menopausal mood and, in combination with black cohosh, hot flashes; many drug interactions
- Magnesium glycinate — improves sleep quality in older adults; weak direct hot flash data
- Vitamin D with calcium — does not treat hot flashes but reduces fracture risk, the main long-term issue after menopause
The 10 best herbs and supplements for menopause
Ranked by the strength of human evidence. Strong = multiple trials or a meta-analysis. Moderate = a few small trials. Preliminary = early or animal data.
Black cohosh is the most-studied menopause herb and the results are genuinely mixed. A 2021 meta-analysis of 22 RCTs (2,310 women) found it reduced hot flash frequency and overall menopause scores significantly more than placebo, with the strongest results for the standardised isopropanolic extract (Remifemin) at 40 mg/day over 8–12 weeks. The 2012 Cochrane review of 16 trials, however, found no significant benefit, and the large 2006 HALT trial found it no better than placebo. It is not oestrogenic, which makes it a reasonable option after breast cancer with oncologist agreement.
- Key evidence
- 2021 meta-analysis of 22 RCTs, 2,310 women (Castelo-Branco et al.); contrasts with 2012 Cochrane review
- Studied dose
- 20 mg of a standardised isopropanolic extract (2.5% triterpene glycosides) twice daily, for a 12-week trial
- Best for
- Hot flashes and night sweats in women who cannot or prefer not to use hormone therapy
- Cautions
- About 80 case reports of liver injury worldwide, some needing transplant; causality is debated and many involved adulterated products, but the US Pharmacopeia and EMA require a liver warning. Stop immediately and get tested if fatigue, dark urine, pale stools, abdominal pain or jaundice appear. Avoid with existing liver disease, in pregnancy, and alongside tamoxifen without oncologist agreement.
Red clover supplies the isoflavones formononetin, biochanin A, genistein and daidzein, which act as weak selective oestrogen receptor modulators. A 2021 meta-analysis of 11 RCTs found red clover reduced daily hot flash frequency by about 1.7 compared with placebo, with the clearest benefit in women having five or more a day, while the 2013 Cochrane review of phytoestrogens found inconsistent results across trials. The 80 mg/day Promensil trials were more consistently positive than lower doses.
- Key evidence
- 2021 meta-analysis of 11 RCTs on red clover and vasomotor symptoms (Kanadys et al.)
- Studied dose
- 40–80 mg/day of red clover isoflavones from a standardised extract, for 12 weeks
- Best for
- Women with frequent (5+ per day) hot flashes who want a plant-oestrogen approach
- Cautions
- Oestrogenic: avoid with a history of breast, ovarian or endometrial cancer, and with tamoxifen or aromatase inhibitors. Contains coumarins, so caution with warfarin and before surgery. Not for pregnancy.
Sage has a long traditional reputation for sweating and one good modern trial. A 2011 Swiss open-label study of 71 women found a fresh sage leaf tablet reduced hot flash frequency by 50 percent at four weeks and 64 percent at eight weeks, with the intensity score falling by a similar amount. A 2019 RCT of 94 Iranian women found a 100 mg sage extract three times daily reduced hot flashes, night sweats and overall symptom scores more than placebo over eight weeks. Small trials, but consistent and the herb is cheap.
- Key evidence
- 2019 placebo-controlled RCT of 94 women on sage extract (Zeidabadi et al.) plus 2011 open-label study
- Studied dose
- 280 mg/day of a fresh sage leaf extract tablet, or 100 mg dried extract 3 times daily, for 8 weeks
- Best for
- Hot flashes with heavy sweating; a low-risk first try
- Cautions
- Sage essential oil and high-dose extracts contain thujone, which is neurotoxic and can trigger seizures; stick to standardised tablets or tea, not the oil. Avoid in epilepsy and pregnancy. May lower blood sugar additively with diabetes drugs.
St John's wort treats the mood side of menopause, where it is as effective as SSRIs for mild to moderate depression in a 2008 Cochrane review of 29 trials. For menopause specifically, a 2010 RCT of 100 perimenopausal women found 900 mg/day reduced hot flash frequency and severity over 8 weeks, and a 2006 German RCT of 301 women found a fixed black cohosh plus St John's wort combination reduced menopause scores by 50 percent versus 20 percent on placebo and improved mood. The interaction list is the problem.
- Key evidence
- 2006 RCT of 301 women on black cohosh + St John's wort combination (Uebelhack et al.)
- Studied dose
- 900 mg/day of an extract standardised to 0.3% hypericin (300 mg 3 times daily), for 8–12 weeks
- Best for
- Menopausal low mood, irritability and anxiety alongside hot flashes
- Cautions
- Induces CYP3A4 and P-glycoprotein and reduces levels of many drugs: the contraceptive pill, warfarin, digoxin, statins, HIV drugs, cyclosporine, some chemotherapy and tamoxifen's active metabolite. Serotonin syndrome risk with SSRIs, SNRIs, tramadol and triptans. Causes photosensitivity. Do not combine with any antidepressant.
Vitamin D does not reduce hot flashes; a 2020 analysis of the Women's Health Initiative trial found no effect on vasomotor symptoms. It is on this list because the most important long-term consequence of menopause is bone loss, with women losing up to 20 percent of bone density in the five to seven years after their last period. Combined vitamin D (800 IU) and calcium (1,000–1,200 mg) reduce hip fracture by about 15–30 percent in older women in meta-analyses, and vitamin D deficiency is also associated with worse mood and muscle weakness.
- Key evidence
- WHI calcium + vitamin D trial (36,282 women) and subsequent meta-analyses on fracture
- Studied dose
- 800–2,000 IU vitamin D3 daily plus 1,000–1,200 mg calcium from diet and supplement combined
- Best for
- Every postmenopausal woman, for bone; not for hot flashes
- Cautions
- Calcium supplements above dietary needs may slightly raise kidney stone risk and have a debated link to cardiovascular events; prioritise food calcium. Avoid high-dose vitamin D with sarcoidosis or hyperparathyroidism. Separate calcium from thyroid medication and iron by 4 hours.
Magnesium glycinate
Preliminary evidenceMagnesium is widely sold for menopause sleep and mood but the direct evidence is weak. A 2011 pilot in 29 breast cancer survivors found 400–800 mg/day cut hot flashes by 41 percent, but the follow-up 2015 RCT of 289 women found magnesium oxide no better than placebo. Where it does have data is sleep: a 2012 RCT in 46 older adults found 500 mg/day improved sleep onset, duration and early-morning waking, and a 2023 systematic review found consistent small benefits on subjective sleep. Glycinate is better tolerated than oxide.
- Key evidence
- 2012 RCT of magnesium on insomnia in older adults (Abbasi et al.); 2015 negative RCT for hot flashes
- Studied dose
- 300–400 mg elemental magnesium as glycinate in the evening, for 8 weeks
- Best for
- Menopausal insomnia, night-time restlessness and muscle cramps; not for hot flashes
- Cautions
- Reduce dose if stools loosen. Avoid high doses in kidney impairment. Separate from thyroid medication, quinolone and tetracycline antibiotics and bisphosphonates by 2–4 hours.
Ashwagandha's evidence is for stress, anxiety and sleep, where several RCTs show cortisol reductions of 20–30 percent and improved sleep scores. For menopause there is one dedicated trial: a 2021 RCT of 91 perimenopausal women found 300 mg of a root extract twice daily for 8 weeks reduced total menopause rating scale scores significantly more than placebo, including hot flashes, and modestly raised oestradiol. Promising, but one trial and an industry-funded one.
- Key evidence
- 2021 RCT of 91 perimenopausal women on 600 mg/day ashwagandha root extract (Gopal et al.)
- Studied dose
- 300 mg of a standardised root extract (e.g. KSM-66 or Sensoril) twice daily, for 8 weeks
- Best for
- Perimenopausal women whose main complaints are anxiety, poor sleep and feeling wired
- Cautions
- Case reports of liver injury, mostly with high doses or combination products. Can raise thyroid hormone levels, so monitor if on levothyroxine or with hyperthyroidism. Additive sedation with sedatives and alcohol. Avoid in pregnancy. Some evidence it can trigger emotional blunting in a minority.
Omega-3 (EPA/DHA)
Preliminary evidenceOmega-3s are often recommended for menopausal mood and hot flashes, and the evidence is split by symptom. For hot flashes, the 2014 MsFLASH trial of 355 women found 1.8 g/day of EPA+DHA no better than placebo over 12 weeks. For mood, a 2009 Canadian RCT of 120 women found 1 g/day of EPA-rich omega-3 reduced depressive symptoms and hot flash frequency in women with mild depression, and omega-3 has broader antidepressant evidence at EPA-dominant doses. It also supports cardiovascular risk, which rises after menopause.
- Key evidence
- 2014 MsFLASH RCT of 355 women (negative for hot flashes); 2009 RCT of 120 women (positive for mood)
- Studied dose
- 1–2 g/day of combined EPA+DHA with EPA higher than DHA, for 8–12 weeks
- Best for
- Menopausal low mood, dry eyes and joint stiffness; not hot flashes
- Cautions
- Mild antiplatelet effect; caution above 3 g/day with warfarin and before surgery. Can raise LDL slightly in some people. Fishy burps are common; freezing capsules helps.
Evening primrose oil
Preliminary evidenceEvening primrose oil is one of the best-selling menopause supplements and one of the least supported. A 1994 BMJ RCT of 56 women found 4 g/day no better than placebo for hot flashes over 6 months. A 2013 Iranian RCT of 56 women found 1,000 mg/day reduced hot flash severity but not frequency over 6 weeks, and a 2021 RCT found some benefit on overall quality of life. The gamma-linolenic acid in it has slightly better data for cyclical breast pain than for anything menopausal.
- Key evidence
- 1994 BMJ RCT of 56 women (negative); 2013 RCT of 56 women (modest benefit on severity)
- Studied dose
- 1–2 g/day of oil standardised to 8–10% GLA, for 6–12 weeks
- Best for
- Women with breast tenderness alongside menopausal symptoms; low expectations for hot flashes
- Cautions
- May lower the seizure threshold in people on phenothiazines or with epilepsy. Mild antiplatelet effect with warfarin. Generally very well tolerated otherwise.
Hops contain 8-prenylnaringenin, one of the most potent plant oestrogens known, which is why it keeps appearing in menopause blends. A 2006 Belgian RCT of 67 women found a standardised hop extract (100 mcg 8-PN) reduced hot flashes and Kupperman index scores at 6 weeks but not 12, and a 2010 crossover trial of 36 women found a reduction in menopause scores versus placebo. Both are small; a 2016 RCT in 120 women found a 500 mg hop extract reduced hot flash scores over 12 weeks. Hops also has sleep data in combination with valerian.
- Key evidence
- 2006 RCT of 67 women on standardised hop extract (Heyerick et al.) and 2016 RCT of 120 women
- Studied dose
- 100–250 mcg 8-prenylnaringenin from a standardised hop extract daily, or 500 mg hop extract, for 12 weeks
- Best for
- Hot flashes with poor sleep; women who tolerate plant oestrogens
- Cautions
- Oestrogenic: avoid with hormone-sensitive cancers. Sedating, so do not combine with sedatives or drive after taking. Can worsen depression in a few people. Avoid in pregnancy.
How to choose
- First, ask whether hormone therapy is an option. If you are under 60 or within 10 years of menopause with no breast cancer, clot or stroke history, it is more effective than anything below and current guidance supports it. Herbs are the second line, not the first.
- If hot flashes are the main problem and HT is off the table, start with a standardised black cohosh extract for 12 weeks, with a liver test at baseline if you have any liver risk, and switch to red clover isoflavones if nothing has changed.
- If sweating is the dominant symptom and you want the lowest-risk option, try sage tablets for 8 weeks before anything else.
- If low mood and irritability are bigger than the hot flashes, St John's wort is the best-evidenced herb, but only if you take no other prescription medication; otherwise ask about an SSRI or CBT.
- If broken sleep and anxiety dominate, magnesium glycinate in the evening and ashwagandha are the reasonable picks, alongside the CBT-I and paced-breathing approaches in the lifestyle section.
- Whatever you choose for symptoms, take vitamin D and get enough calcium for bone, and ask for a bone density scan if you are over 65 or have risk factors.
What to skip
Dong quai
Traditionally a 'female ginseng', but the only placebo-controlled trial (71 women, 24 weeks) found it no better than placebo for hot flashes or vaginal symptoms. It is also photosensitising and contains coumarins that interact with warfarin.
Maca root
Popular for libido and 'hormone balance', but the two small menopause RCTs (one of 20 women) are from a single manufacturer and the 2011 systematic review called the evidence inadequate. It does not change oestrogen levels.
Wild yam cream
The diosgenin in wild yam can be converted to progesterone in a laboratory, not in the human body. A 2001 RCT found the cream no better than placebo. 'Natural progesterone' creams that work have pharmaceutical progesterone added.
Bioidentical compounded hormones
Not a herb, but often sold alongside them. Compounded preparations are not tested for dose accuracy, and the hormones are the same molecules as regulated HT products, which are themselves bioidentical and far better monitored.
Safety and when to see a clinician
- See a clinician if you have any bleeding after menopause (12 months without a period), bleeding between periods or after sex, a breast lump or nipple discharge, pelvic pain, or hot flashes that started suddenly with weight loss or palpitations, which can signal thyroid disease.
- Black cohosh and ashwagandha both carry liver injury reports. Stop and get liver tests if you develop fatigue, nausea, dark urine, pale stools, itching or yellowing of the eyes or skin.
- Plant oestrogens (red clover, hops, soy isoflavones) and black cohosh should be discussed with an oncologist first if you have had breast, ovarian or endometrial cancer or take tamoxifen or an aromatase inhibitor.
- St John's wort interacts with the pill, warfarin, statins, HIV drugs, immunosuppressants, some chemotherapy and every antidepressant; do not start it without a pharmacist checking your medication list.
- Surgery: stop red clover, dong quai, garlic, omega-3 above 1 g and evening primrose 7–10 days before an operation because of bleeding risk.
- Hot flashes in perimenopause can coexist with pregnancy; several herbs here (black cohosh, sage, red clover, hops, dong quai) are unsafe in pregnancy, so use contraception until 12 months after your last period if under 50.
What matters as much as any herb
- Cognitive behavioural therapy for menopause (4–6 sessions, group or self-help) reduced the impact of hot flashes by about 50 percent in the MENOS trials and is recommended by NICE; it also improves sleep and mood.
- Paced breathing (6 breaths per minute for 15 minutes twice a day) cut hot flash frequency by around 40 percent in early trials; later trials were mixed but it is free and harmless.
- Weight loss of 10 percent in overweight women reduced hot flashes in a 2010 RCT of 338 women; fat tissue insulates and alters oestrogen metabolism.
- Alcohol, spicy food, caffeine and hot rooms are the commonest triggers in symptom diaries. Keeping a two-week diary identifies yours faster than any supplement trial.
- Resistance training two to three times a week is the one intervention that improves bone density, muscle mass, sleep and mood at once; a 2019 Swedish RCT also found 15 weeks of it halved hot flash frequency.
Frequently asked questions
What is the best herb for hot flashes?
Black cohosh has the most trials and a 2021 meta-analysis found it reduces hot flashes modestly more than placebo, though earlier reviews disagreed. Red clover isoflavones and sage are the next best supported. Expect a 30–50 percent reduction at best; hormone therapy achieves 75–90 percent.
Is black cohosh safe for the liver?
For most women, yes. Roughly 80 cases of liver injury have been reported worldwide against tens of millions of users, and many involved adulterated or combination products. Use a standardised single-ingredient extract, do not exceed 40 mg/day, avoid it with existing liver disease, and stop immediately if you notice dark urine, pale stools, itching or jaundice.
Can I take herbs for menopause after breast cancer?
Avoid plant oestrogens (red clover, hops, soy extracts) and dong quai. Black cohosh is not oestrogenic and has been used in breast cancer survivors in trials, but check with your oncologist, especially on tamoxifen. Sage, CBT, paced breathing and non-hormonal prescription options (SSRIs, gabapentin, fezolinetant) are the usual approach.
How long do menopause herbs take to work?
Most trials ran 8–12 weeks and the benefit, where there was one, appeared from week 4. If a herb has done nothing by 12 weeks, stop it. Do not stack three or four; the trials tested single standardised products.
Does maca help with menopause?
The evidence is weak. The small trials are manufacturer-funded and a systematic review found them inadequate to draw conclusions. Maca does not change oestrogen levels; it may help libido slightly, which is the one area with slightly better data.
Is hormone therapy safer than herbs?
For healthy women under 60 or within 10 years of menopause, modern HT (transdermal oestrogen plus micronised progesterone if you have a uterus) has a well-mapped risk profile, is regulated and monitored, and is far more effective. Herbs are less effective, less regulated, and not risk-free, as the black cohosh liver reports and St John's wort interactions show. 'Natural' does not mean safer.
What helps menopause insomnia naturally?
CBT for insomnia is the best-evidenced non-drug treatment. Magnesium glycinate, ashwagandha and a hops-valerian combination have small trials for sleep. Treating the hot flashes that wake you, with HT or black cohosh, often fixes sleep more than a sleep supplement does. You can ask AskMN to walk through the options for your situation.
References
- The 2022 hormone therapy position statement of The North American Menopause Society. Menopause (2022)View source
- Leach MJ, Moore V. Black cohosh (Cimicifuga spp.) for menopausal symptoms. Cochrane Database of Systematic Reviews (2012)View source
- Castelo-Branco C, Gambacciani M, Cano A, et al.. Review and meta-analysis of the efficacy and safety of black cohosh in the treatment of menopausal symptoms. Climacteric (2021)View source
- Lethaby A, Marjoribanks J, Kronenberg F, et al.. Phytoestrogens for menopausal vasomotor symptoms. Cochrane Database of Systematic Reviews (2013)View source
- Uebelhack R, Blohmer JU, Graubaum HJ, et al.. Black cohosh and St. John's wort for climacteric complaints: a randomized trial. Obstetrics & Gynecology (2006)View source
- Cohen LS, Joffe H, Guthrie KA, et al.. Treatment of vasomotor symptoms in menopause: the MsFLASH randomized trials of omega-3 fatty acids and exercise. Menopause (2014)View source
- Bommer S, Klein P, Suter A. First time proof of sage's tolerability and efficacy in menopausal women with hot flushes. Advances in Therapy (2011)View source
- Newton KM, Reed SD, LaCroix AZ, et al.. Efficacy of a standardized isopropanolic black cohosh extract vs placebo in the 2006 HALT trial: Treatment of vasomotor symptoms with black cohosh, multibotanicals, soy, hormone therapy, or placebo. Annals of Internal Medicine (2006)View source
- Ayers B, Smith M, Hellier J, Mann E, Hunter MS. Group cognitive behavioural treatment for menopausal symptoms (MENOS 2): a randomised controlled trial. Menopause (2012)View source
- Black Cohosh: Fact Sheet for Health Professionals. NIH Office of Dietary SupplementsView source
- Menopause: treatment. NHSView source
- Linde K, Berner MM, Kriston L. Hypericum extract for depression (St John's wort). Cochrane Database of Systematic Reviews (2008)View source
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Ask about menopauseThis guide is educational and is not medical advice. Herbs and supplements can interact with prescription medicines and are not regulated like drugs. Talk with a clinician or pharmacist before starting anything new, especially if you are pregnant, breastfeeding, have a chronic condition, or take medication.