A review of 158 studies grades the evidence for non-hormonal menopause remedies

A large share of women going through menopause use something other than hormone therapy — herbs, supplements, acupuncture, mind-body practices. The evidence behind those choices has been difficult to characterise, because it is spread across hundreds of small trials of varying quality and because the reviews summarising it have generally not applied a formal certainty framework.

A systematic review published in Climacteric on January 7, commissioned to inform the International Menopause Society's updated recommendations on women's midlife health, applies one [s1].

How it was built

The authors searched six databases for the period January 2022 to December 2024, looking for randomised controlled trials and systematic reviews of complementary therapies for menopause [s1]. Outcomes covered menopausal symptoms generally, vasomotor symptoms, genitourinary symptoms, cardiometabolic outcomes, sleep, bone health, and safety [s1].

From 3,187 citations, 158 studies were included: one overview, 36 meta-analyses, seven systematic reviews, and 114 randomised controlled trials [s1].

Quality was assessed with the Cochrane risk-of-bias tool RoB2 for trials, AMSTAR 2 for systematic reviews, and GRADE for certainty of evidence [s1]. GRADE is the part that makes this review useful: it separates "a trial found an effect" from "we can be confident an effect exists," which is precisely the distinction that gets lost in the marketing of these products.

What reached moderate certainty

Four findings cleared moderate certainty [s1]:

• Black cohosh, for vasomotor and general menopausal symptoms
• Chinese herbal medicine, for menopausal symptoms, sleep, and blood pressure
• Acupuncture combined with Chinese herbal medicine, for sleep
• Vitamin D, for fracture risk

One finding reached high certainty, and it is about safety rather than efficacy: high-certainty evidence supports the safety of vitamin D [s1].

The review also reports promising evidence for acupuncture, Chinese herbal medicine, other herbs, nutrients, and mind-body and touch therapies across a range of symptoms — but states that most of it was of low or very low certainty [s1].

What that grading actually means

Moderate certainty in GRADE means the true effect is probably close to the estimate, but further research could change it. Low and very low certainty mean the estimate may be, or is likely to be, substantially wrong.

So the honest reading of this review is not "black cohosh works." It is closer to: of a very large and mostly weak literature, four claims survive formal assessment at a level where they are probably about right, and one safety claim survives at a higher level.

That is a modest yield from 158 studies. It is also a more informative result than a narrative review that lists everything with a positive trial behind it, which is what much of the existing summary literature does.

The authors' own conclusion states that vitamin D, black cohosh, Chinese herbal medicine, and acupuncture combined with Chinese herbal medicine may improve some menopausal symptoms, but that overall evidence remains limited, and that more rigorous research is needed on both efficacy and safety [s1].

On safety

The review reports that most complementary therapies were safe [s1]. That is a summary judgement across a large number of interventions, and readers should note two things about it.

First, safety in short randomised trials is not the same as safety in extended real-world use, particularly for herbal preparations where the product a consumer buys may differ in composition from the standardised extract a trial used.

Second, this is a symptom-management literature, and interactions with prescribed medication are the usual concern with herbal products rather than intrinsic toxicity. A review scoped to menopause outcomes is not designed to detect that.

Why the commissioning matters

This review was written to inform an update of the International Menopause Society's recommendations [s1]. Evidence syntheses commissioned to feed a guideline tend to be scoped tightly and graded conservatively, because they will be used to justify or decline a recommendation.

It also means the review is best read as an input rather than a conclusion. What a professional body does with a finding of moderate-certainty evidence for black cohosh — recommend it, mention it, or say the evidence is insufficient to recommend — is a separate decision that has not been made in this document.

What to watch

The published IMS recommendations, and how they treat the four moderate-certainty findings; whether any of the low-certainty interventions are taken up in adequately powered trials; and whether the vitamin D fracture-risk finding is reconciled with the broader, contested vitamin D supplementation literature outside the menopause context.

This article describes a published systematic review and is informational only. It is not medical advice and does not recommend any supplement, herbal product, or therapy. Herbal and dietary supplements can interact with prescribed medication.

Sources

• [s1] Maunder A, Mardon AK, Rao V, Torkel S, Metri NJ, Liu J, Yang G, Giese N, Mantzioris E, Abdul Jafar NK, Rodrigues de Souza GE, Al-Kanini I, Romero L, Panay N, Pedder H, Ee C, 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, published online 2026-01-07.