What’s the Bottom Line?

What do we know about the effectiveness of complementary health approaches for menopause symptoms?

• Phytoestrogens,herbs, and other dietary supplements haven’t been clearly shown to relieve menopause symptoms.
• Research on hypnotherapy and mindfulness meditation is in its early stages, but some studies have had promising results.
• Acupuncture has not been shown to be more effective than simulated acupuncture for relieving hot flashes.
• Yoga seems to be at least as effective as other types of exercise in relieving menopause symptoms.
• The evidence doesn’t support claims that custom-mixed (compounded) bioidentical hormones are more effective than conventional hormone therapy.

What do we know about the safety of complementary health approaches for menopause symptoms?

• Dietary supplements may have side effects or interact with drugs, and little is known about their long-term safety.
• Psychological and/or physical approaches such as acupuncture, hypnosis, meditation, and yoga generally have good safety records.
• Custom-mixed bioidentical hormones haven’t been shown to be safer than other forms of hormone therapy, and their content may vary from batch to batch.

Some Basics About Menopause

Menopause is the time when a woman’s menstrual periods stop permanently. It usually occurs naturally, at an average age of 51, but surgery or the use of certain medications can make it happen earlier. During the years around menopause (a time called perimenopause or menopausal transition), some women have hot flashes, night sweats, difficulty sleeping, or other troublesome symptoms.

Conventional Treatment for Menopause Symptoms

• Hormone therapy, using either estrogen alone or estrogen and progestin, is the most effective therapy for menopausal hot flashes. However, hormone therapy may increase the risk of breast cancer, blood clots, and other serious medical problems. Therefore, if it’s used at all, it should be used at the lowest dose and for the shortest period that will control symptoms. Women with certain medical conditions (such as breast cancer, liver disease, or a history of blood clots) shouldn’t use hormone therapy.
• Non-hormonal medicines may also be used to treat menopause symptoms. In 2013, the U.S. Food and Drug Administration (FDA) approved a non-hormonal treatment for hot flashes and a treatment for vaginal symptoms associated with menopause.

What the Science Says About Complementary Health Approaches for Menopause Symptoms

Complementary approaches can be classified by their primary therapeutic input (how the therapy is taken in or delivered), which may be:

• Nutritional (e.g., special diets, dietary supplements, herbs, probiotics, and microbial-based therapies).
• Psychological (e.g., meditation, hypnosis, music therapies, relaxation therapies).
• Physical (e.g., acupuncture, massage, spinal manipulation).
• Combinations such as psychological and physical (e.g., yoga, tai chi, dance therapies, some forms of art therapy) or psychological and nutritional (e.g., mindful eating).

Nutritional approaches include what the National Center for Complementary and Integrative Health (NCCIH) previously categorized as natural products, whereas psychological and/or physical approaches include what was referred to as mind and body practices.

Nutritional Approaches

Many nutritional approaches such as dietary supplements have been studied for menopause symptoms. However, none has clearly been shown to be helpful. There’s little information on the long-term safety of dietary supplements, and some can have harmful side effects or interact with drugs. The sections below give more detail about several dietary supplements studied for menopause symptoms.

Phytoestrogens

• Phytoestrogens are substances from plants that have chemical structures similar to those of the female hormone estrogen. The isoflavones found in soy and red clover are examples of phytoestrogens. Flaxseed is another phytoestrogen source.
• Studies that tested isoflavones from soy or red clover for their ability to relieve menopause symptoms have had inconsistent results. Studies of flaxseed products found them to be no more effective than a placebo (an inactive substance) in reducing hot flashes.
• Phytoestrogens appear to be safe for short-term use, but their long-term safety hasn’t been established. Because phytoestrogen supplements may have effects like those of the hormone estrogen, they may not be safe for women who shouldn’t take estrogen.

Black Cohosh

• Black cohosh is an herb native to North America. The roots and rhizomes (underground stems) of the plant are used in dietary supplements.
• Studies that tested black cohosh for menopause symptoms have had inconsistent results. A 2012 research review concluded that there’s not enough evidence to support its use for menopause symptoms.
• Black cohosh generally has only mild side effects, if any. However, rare cases of liver damage—some of them very serious—have been reported in people taking commercial black cohosh products. It’s uncertain whether black cohosh was responsible for the liver damage. Nevertheless, people with liver disorders should consult a health care provider before taking black cohosh products. Anyone who develops symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice, while taking black cohosh should stop using it and consult a health care provider.

DHEA

• Dehydroepiandrosterone (DHEA) is a substance that’s naturally made in the body, where it’s converted into the hormones testosterone and estrogen. DHEA production decreases as people grow older, but the significance of this change, including whether it affects aging and menopause symptoms, is unclear.
• It’s uncertain whether DHEA is useful in treating menopause symptoms.
• The long-term safety of taking DHEA supplements is unknown. Some evidence suggests that even short-term use of these supplements may have harmful effects, including liver damage.

Dong Quai

• In traditional Chinese medicine, the herb dong quai is often used for women’s health problems, including menopause. However, very little research has been done on dong quai for menopausal symptoms, so no conclusions can be reached about its effects.
• Dong quai may interact with the anticoagulant (blood-thinning) drug warfarin (Coumadin).

Vitamin E

• A few studies have suggested that vitamin E supplements might be helpful for menopause symptoms. However, the amount of research is small, and the effect is also small. For example, in one study, women taking vitamin E averaged one fewer hot flash per day.
• Vitamin E, in the high doses found in supplements, may increase the risk of bleeding (including strokes due to bleeding in the brain) and interact with anticoagulant (blood-thinning) medications such as warfarin (Coumadin).

Other Dietary Supplements

• Other dietary supplements that have been studied for menopause symptoms include evening primrose oil, ginseng, kava, melatonin, and wild yam. However, very little research has been done on these products for menopausal symptoms, so no conclusions can be reached about their effectiveness. Kava supplements have been linked to a risk of severe liver disease.

Psychological and Physical Approaches

Only a small amount of research has been done on most psychological and physical approaches for menopause symptoms. However, the limited evidence currently available suggests that some of these approaches might help to relieve symptoms or make them less bothersome.

Acupuncture

• Acupuncture is a technique in which practitioners stimulate specific points on the body, most often by inserting thin needles through the skin.
• In studies that compared acupuncture to no treatment, acupuncture reduced the frequency and severity of hot flashes. However, studies that compared acupuncture with simulated acupuncture, including a 2016 study from Australia, showed no difference between the effects of the two treatments. Acupuncture appears to be less effective than hormone therapy in reducing the frequency of hot flashes.
• Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Improperly performed acupuncture can cause potentially serious side effects.

Hypnotherapy

• Hypnotherapy is the use of hypnosis for health-related purposes. Hypnosis is a state in which a person’s attention is concentrated and focused. In this hypnotic state, people have a heightened responsiveness to verbal messages (suggestions).
• In a study funded by the National Center for Complementary and Integrative Health (NCCIH), hypnotherapy reduced the frequency of hot flashes in menopausal women who had hot flashes often. The women in the study also said that hot flashes didn’t interfere with their lives as much and they slept better.
• Hypnosis is generally safe when practiced by trained, licensed health care providers. Side effects are rare, but hypnosis might worsen some types of psychological problems.

Mindfulness Meditation

• Mindfulness meditation is a type of meditation that involves completely focusing on experiences on a moment-to-moment basis.
• In an NCCIH-funded study, mindfulness meditation training reduced the bothersomeness of hot flashes in menopausal women and led to improvements in anxiety, perceived stress, self-reported sleep quality, and quality of life. However, the intensity of hot flashes did not change.
• Meditation is generally considered to be safe for healthy people. However, there have been reports that it might worsen symptoms in people with certain chronic physical or mental health problems. If you have an ongoing health issue, talk with your health care provider before starting meditation.

Yoga

• Yoga has historical origins in ancient Indian philosophy. Various styles of yoga typically combine physical postures and movement, breathing techniques, and meditation or relaxation.
• A 2018 evaluation of 13 studies (more than 1,300 participants) of yoga for menopause symptoms found that yoga reduced physical symptoms, such as hot flashes, as well as psychological symptoms, such as anxiety or depression. It seemed at least as effective as other types of exercise for relieving menopause symptoms.
• Overall, people who practice yoga have a low rate of side effects. However, injuries—some of them serious—have been reported. People with health conditions may need to modify or avoid some yoga poses.

Other Complementary Approaches

Bioidentical Hormones

• Bioidentical hormones are hormones from plant sources that are chemically similar or identical to hormones produced in the human body. Two kinds of bioidentical hormone products are used to treat menopause symptoms: (1) those that have gone through the same FDA approval process as other types of hormone therapy, and (2) custom-mixed preparations that compounding pharmacies prepare individually for patients. This fact sheet discusses only the custom-mixed products.
• It’s been claimed that custom-mixed bioidentical hormone preparations are more effective and safer than conventional hormone therapy, but scientific evidence to support this idea is lacking. Custom-mixed bioidentical hormones may actually be riskier than conventional treatment because less is known about their safety. Also, no regulatory agency oversees their preparation, and therefore their content may vary from batch to batch.

Clinical Practice Guidelines for Treating Menopause Symptoms

Several professional organizations have issued guidelines for health care providers on how to treat menopause symptoms. The guidelines discuss certain complementary health approaches.

• A 2015 position statement from the North American Menopause Society recommends hypnotherapy but acknowledges that the evidence favoring it is limited, conditionally recommends mindfulness-based therapies, and does not recommend acupuncture, yoga, or any natural products for managing hot flashes.
• Guidelines from the American College of Obstetricians and Gynecologists say that conventional hormone therapy is preferred over custom-mixed bioidentical hormones, and that phytoestrogens and herbal supplements have not been shown to be helpful for treating hot flashes.
• Guidelines from the American Association of Clinical Endocrinologists recommend against the use of custom-mixed bioidentical hormones and advise caution in the use of dietary supplements because of possible side effects and drug interactions. The guidelines also say that the effects of phytoestrogens are inconsistent and caution that women with a personal or strong family history of blood clots, cardiovascular disease, or breast, uterine, or ovarian cancer should not use soy-based treatments.
• Guidelines issued by a task force from several professional societies recommend against the routine use of DHEA.

More To Consider

• Keep in mind that although many dietary supplements come from natural sources, “natural” does not always mean “safe.” Also, a manufacturer’s use of the term “standardized” (or “verified” or “certified”) does not necessarily guarantee product quality or consistency.

• Tell all your health care providers about any complementary or integrative health approaches you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

Results of studies have been inconsistent as to whether acupuncture is beneficial for menopausal symptoms.

What Does the Research Show?

• A 2017 meta-analysis and systematic review of 13 randomized controlled trials involving 844 breast cancer patients found that acupuncture significantly alleviated menopause symptoms, but had no effect on hot flashes.
• A 2016 pragmatic, randomized controlled trial involving 209 perimenopausal and postmenopausal women aged 45 to 60 years found that a course of acupuncture treatments was associated with significant reduction in vasomotor symptoms and several quality-of-life measures, compared with no acupuncture, and that clinical benefit persisted for at least 6 months beyond the end of treatment. Statistically significant clinical improvement was observed after three acupuncture treatments, and maximal clinical effects occurred after a median of eight treatments.
• A 2018 randomized controlled trial involving a total of 360 women with menopause-related symptoms found that 8 weeks of electroacupuncture treatment did not seem to relieve menopausal symptoms, even though it appeared to improve participants’ quality of life.
• A 2013 Cochrane systematic review of 16 randomized controlled trials involving a total of 1,155 women found that compared to sham acupuncture, there was no evidence of any difference in their effect on hot flashes. When acupuncture was compared with no treatment, there appeared to be a benefit from acupuncture, but acupuncture appeared to be less effective than hormone therapy.

Safety

• Relatively few complications from the use of acupuncture have been reported to the U.S. Food and Drug Administration (FDA), in light of the millions of people treated each year and the number of acupuncture needles used. Still, complications have resulted from inadequate sterilization of needles and from improper delivery of treatments.
• When not delivered properly, acupuncture can cause serious adverse effects, including infections and punctured organs.

Research suggests that certain black cohosh extracts and some combination products containing black cohosh may reduce some menopause symptoms. Most of the research has been on the single extract Remifemin. Research on other black cohosh products has had inconsistent results. Guidelines released in 2015 indicate that there is a lack of consistent evidence for any benefit from black cohosh for menopause symptoms. But a 2017 review of research suggests that black cohosh extracts approved for treatment in Europe seem to decrease menopause symptoms.

What Does the Research Show?

• A 2016 review found that there is no high-quality, consistent evidence that black cohosh benefits patients with menopausal symptoms more than placebo.
• A 2017 systematic review and meta-analysis of 47 randomized controlled trials involving a total of 8,326 women with menopausal symptoms found that black cohosh was more effective than placebo in reducing vasomotor symptoms, but not significantly better than transdermal estradiol and progestogen.

Safety

• In clinical trials, people have taken black cohosh for as long as 12 months with no serious harmful effects.
• Black cohosh can cause some mild side effects, such as stomach upset, cramping, headache, rash, a feeling of heaviness, vaginal spotting or bleeding, and weight gain.
• Some commercial black cohosh products have been found to contain the wrong herb or to contain mixtures of black cohosh and other herbs that are not listed on the label.
• Cases of liver damage—some very serious—have been reported in people taking commercial black cohosh products. These problems are rare, and it is uncertain whether black cohosh was responsible.
• The risk of interactions between black cohosh and medicines appears to be small. Preliminary laboratory research, some of it supported by NCCIH, suggests that black cohosh might affect statin medicines, which are used to reduce blood cholesterol levels.
• It’s not clear if black cohosh is safe for women who have had hormone-sensitive conditions such as breast cancer.

Studies have had conflicting results on whether flaxseed helps with symptoms of menopause.

What Does the Research Show?

• A 2018 systematic review and meta-analysis found that flaxseed showed no significant effect on sexual function in menopausal women.
• A 2012 randomized controlled trial involving 90 postmenopausal women found that after 6 months of treatment, flaxseed was effective in reducing menopausal symptoms when comparing the beginning and end of the treatment using the paired t-test. However, when an analysis in variance was done, comparing flaxseed treatment with placebo, no significant differences were found.
• A 2012 randomized controlled trial involving 188 postmenopausal women found that after 6 weeks of treatment with flaxseed or placebo, there was no significant difference in reduction of hot flashes between the groups.

Safety

• Don’t eat raw or unripe flaxseeds, which may contain potentially toxic compounds.
• Flaxseed and flaxseed oil supplements seem to be well tolerated in limited amounts. Few side effects have been reported.
• Flaxseed, like any fiber supplement, should be taken with plenty of water, as it could worsen constipation or, in rare cases, cause an intestinal blockage. Both flaxseed and flaxseed oil can cause diarrhea.

There is some evidence suggesting that hypnosis may help improve certain menopausal symptoms, such as hot flashes. A 2015 position paper from the North American Menopause Society recommended hypnosis for managing hot flashes but acknowledged that favorable evidence is limited.

What Does the Research Show?

• A 2013 randomized controlled trial in 187 postmenopausal women found that clinical hypnosis significantly reduced self-reported and physiologically measured hot flashes. Although the mechanism of how clinical hypnosis works is unknown, the women in this same study who practiced hypnosis had significantly greater levels of satisfaction than the control group. A 2008 randomized trial found that hypnosis appears to reduce perceived hot flashes in breast cancer survivors and may have additional benefits such as improved mood and sleep.

Safety

• Hypnosis is considered safe when performed by a health professional trained in hypnotherapy. Self-hypnosis also appears to be safe for most people. There are no reported cases of injury resulting from self-hypnosis.
• Meditation is considered to be safe for healthy people. There have been rare reports that meditation could cause or worsen symptoms in people who have certain psychiatric problems, but this question has not been fully researched.

Studies on the effects of red clover on menopause symptoms, such as hot flashes, and on blood levels of cholesterol and other lipids have had inconsistent results.

What Does the Research Show?

• A 2016 systematic review and meta-analysis found that red clover significantly improved vaginal dryness and vaginal atrophy, but showed less therapeutic effect on psychology status, sexual problems, and sleeping disorders. The review concluded that red clover consumption may decrease frequency of hot flashes, especially in women with severe hot flashes (5 or more per day).
• A 2017 parallel, double blind, randomized control trial of 62 perimenopausal women aged 40 to 65, reporting 5 or more hot flushes per day and follicle stimulating hormone 35 or more IU/L, examined the effects of red clover extract combined with probiotics, compared with placebo, on vasomotor symptoms (i.e., hot flashes and night sweats). Results of the study suggest that moderate doses of red clover extract were more effective and superior to placebo in reducing physiological and self-reported vasomotor symptoms.
• A 2018 systematic review and meta-analysis found that red clover showed no significant effect on sexual function in menopausal women.

Safety

• Red clover extracts have been used in clinical studies for as long as 3 years with apparent safety.
• There are some concerns that red clover, which also contains phytoestrogens, might have harmful effects on hormone-sensitive tissue.

Soy isoflavone supplements or soy protein may help to reduce the frequency and severity of menopausal hot flashes, but the effect may be small.

What Does the Research Show?

• A 2016 systematic review and meta-analysis of 62 studies involving 6,653 women found that specific phytoestrogen supplementations, such as soy isoflavones, were associated with modest reductions in the frequency of hot flashes and vaginal dryness but no significant reduction in night sweats. However, many of the studies included in the review were of low quality.
• A 2018 systematic review and meta-analysis found that soy showed no significant effect on sexual function in menopausal women.

Safety

• Although information on adverse effects is limited, soy extracts appear to be generally safe when taken for short periods of time. However, long-term use of soy extracts (which contain phytoestrogens) has been associated with thickening of the lining of the uterus.
• Current evidence indicates that it’s safe for women who have had breast cancer or who are at risk for breast cancer to eat soy foods. However, it’s uncertain whether soy isoflavone supplements are safe for these women.

There is some evidence that yoga may reduce menopausal symptoms, but the effect is similar to other exercise interventions.

What Does the Research Show?

• A 2018 meta-analysis and systematic review of 13 randomized controlled trials involving 1,306 participants found that compared with no treatment, yoga reduced total menopausal symptoms including psychological, somatic, vasomotor, and urogenital symptoms. However, compared with exercise controls, only an effect on vasomotor symptoms was found.
• A 2010 review of 21 papers assessed mind and body therapies for menopausal symptoms. The researchers found that yoga, tai chi, and meditation-based programs may be helpful in reducing common menopausal symptoms including the frequency and intensity of hot flashes, sleep and mood disturbances, stress, and muscle and joint pain.

Safety

• Overall, clinical trial data suggest yoga as taught and practiced in these research studies under the guidance of skilled teacher has a low rate of minor side effects. It is not uncommon for practitioners to have some minor, transient discomfort, like in most physical activity programs.
• However, injuries from yoga, some of them serious, have been reported in the popular press.
• People with health conditions should work with an experienced teacher who can help modify or avoid some yoga poses to prevent side effects.

Menopause is the permanent end of a woman’s menstrual periods. Menopause can occur naturally or be caused by surgery, chemotherapy, or radiation. During the years around menopause, some women have hot flashes, night sweats, difficulty sleeping, or other bothersome symptoms. Natural products or mind and body practices are sometimes used in an effort to relieve menopausal symptoms such as hot flashes and night sweats.

Here are 4 things to know if you are considering a complementary health approach for managing menopausal symptoms:

1. Mind and body practices such as hypnosis, mindfulness meditation, and tai chi may help improve some menopausal symptoms. Researchers looked at mind and body therapies for menopausal symptoms and found that tai chi and meditation-based programs may be helpful in reducing common menopausal symptoms including the frequency and intensity of hot flashes, sleep and mood disturbances, stress, and muscle and joint pain. There is also some evidence that hypnotherapy may help women manage hot flashes.

2. Many natural products, such as black cohosh, soy isoflavone supplements, and DHEA, have been studied for their effects on menopausal symptoms, but scientists have found little evidence that they are helpful. There is also no conclusive evidence that the herbs red clover, kava, or dong quai reduce hot flashes.

3. Natural products used for menopausal symptoms can have side effects and can interact with other botanicals or supplements or with medications. For example, rare cases of liver damage—some of them very serious—have been reported in people taking commercial black cohosh products. Also, concerns have been raised about the safety of DHEA because it is converted in the body to hormones, which are known to carry risks.

4. Tell all your health care providers about any complementary health practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.