Buying a packet of ‘menopause support’ tablets online takes me no more than a couple of minutes. A one-a-day tablet could apparently support my ‘hormonal balance’ and ‘mental clarity’, as well as ‘decreasing discomfort’ from hot flushes and sweating.
A quick search on the Amazon website had led me to the supplement manufactured in Britain by a legitimate-sounding company and which is recommended as an ‘Amazon Choice’ product.
The description reassures me that the product – at a cost of £5.99 for 30 tablets – is ‘scientifically formulated’, ‘premium grade’ and ‘quality assured’, so surely I can trust it?
I thought so; and many of the millions of British women who buy menopause supplements online clearly do so, too.
But when Good Health investigated some of the leading menopause supplements promoted on Amazon and Google (these were the products that ranked top in searches, or appeared at the top as ‘sponsored’, paid-for ads), we found that many do not contain what they claim – and some, worryingly, might even put your health at risk.
Menopause supplements are big business, accounting for 95 per cent of the global menopause market, which is valued at nearly £14 billion.
Women go through the menopause (defined as a year after their final period) on average at the age of 51 in the UK, but symptoms of the ‘perimenopause’ – such as hot flushes, memory problems and insomnia – can occur from around a decade beforehand, as their oestrogen levels start to fall.
Around 29 per cent of the UK’s 13 million perimenopausal or menopausal women have tried supplements to manage their symptoms, either in addition to or instead of prescription medicines such as HRT (hormone replacement therapy), according to a 2022 survey by the British Nutrition Foundation.
Black cohosh, a member of the buttercup family that grows in North America, is one of the most popular. Known scientifically as Cimicifuga racemosa, it is commonly used to combat symptoms such as hot flushes, sweats, joint aches and headaches.
It is available in both tablet or liquid forms, as well as being present in many multi-ingredient menopause supplements.
‘Black cohosh is one of the few herbal remedies for which there is some evidence base for effectiveness, particularly for management of vasomotor symptoms – sweats and flushes,’ says Dr Fionnuala Barton, a GP in Hertfordshire and a menopause specialist accredited by the British Menopause Society.
‘It has been known for decades to be helpful in menopause and there are some relatively high-level research studies that have shown it is effective.’
Scientists do not know exactly how it works, but theories include that it boosts or regulates levels of oestrogen or other hormones.
A Cochrane review in 2012, which examined 16 studies involving more than 2,200 women, found the evidence was ‘inconclusive’ as to whether black cohosh was more effective than a placebo for managing menopause symptoms.
But some individual studies have shown a positive effect.
For example, a randomised controlled trial (the gold standard for research) involving 84 women with an average age of 51, published in the journal Chinese Medicine in 2013, found that those who took black cohosh for eight weeks experienced a marked improvement in 21 menopause symptoms, including hot flushes, lack of libido and anxiety, compared with the women who took a placebo.
The herb is one of the few alternative remedies to be included in the National Institute for Health and Care Excellence (NICE) menopause management guidelines.
However, while NICE says there is ‘some evidence’ black cohosh can relieve hot flushes and sweats, it warns that the quality of products may vary and their ‘safety is uncertain’.
Since 1998, nearly 100 cases of serious side-effects from taking black cohosh, including liver damage and jaundice, have been reported to the UK’s medicines watchdog, the Medicines and Healthcare products Regulatory Agency (MHRA).
However, the true number of side-effects may be much higher as, according to some estimates, just one in ten adverse drug reactions is reported. Other possible side-effects include stomach problems, vomiting, headache and dizziness. It is not clear why black cohosh may trigger these.
In 2006, the MHRA decreed that all black cohosh supplements must carry warnings on the packaging and in patient information leaflets about the risk to liver health. It issued a fresh warning in 2012 after a woman required a liver transplant linked to black cohosh use.
Quite why the herb could cause liver damage is unclear, but scientists Good Health spoke to suspect problems are more likely when women take unregulated supplements, which may contain impurities, or take high-strength tablets for months at a time.
Because it can have a ‘medicinal’ effect, the MHRA says black cohosh supplements sold in the UK should be tested to ensure they adhere to strict quality and safety standards. Those that comply with these standards are given a Traditional Herbal Registration (THR) by the MHRA, which must be displayed on the packaging.
But some companies (both overseas and UK-based) are flouting the rules by selling unlicensed black cohosh online as ‘food supplements’ and promoting them with paid-for ads or sponsored listings on Amazon and Google. Yet these won’t typically have had the rigorous testing for safety or quality that THR products have.
What’s more, although any supplements marketed in this country are supposed to comply with British regulations, there is little that regulators can do to stop overseas manufacturers selling sub-par products to UK customers.
‘Enforcing rules on online sales is a difficult, often impossible, task,’ says Edzard Ernst, an emeritus professor at Exeter University and researcher specialising in the study of complementary medicine.
To investigate whether black cohosh supplements being marketed to women met safety standards and contained what they claimed on the packaging, we bought 20 products.
These included one each from High Street retailers Boots, Superdrug and Holland & Barrett; seven which were listed in the top sponsored and regular results for black cohosh on amazon.co.uk, and ten promoted in sponsored and ‘Shopping’ results on Google.
In total, six products (the three from the High Street and three bought online) carried the THR logo and the required patient safety warnings.
The other 14 were described as ‘food supplements’ or similar – and ten of these failed to mention any link to liver damage.
‘It’s serious when supplements do not contain patient information informing them who can and shouldn’t use the herb, as black cohosh may not be safe for some people to take, such as those with pre-existing liver conditions,’ says Dr Chris Etheridge, a leading medical herbalist and chair of the British Herbal Medicine Association.
We sent the samples to a laboratory in Switzerland which carried out HPTLC (high-performance thin layer chromatography) testing to identify whether they contained chemical markers unique to black cohosh.
The results showed nine of the supplements (six of them the THR products) contained the herb.
The remaining 11 supplements – all without a THR logo and which were bought via Amazon or promoted on Google – either did not contain black cohosh or the levels were so low as not to be detectable with standard tests. We then sent four of these products for further testing: the top three ‘sponsored’ supplements listed on Amazon (Nutrivity, BodyGenix and Dr Corbyn) and one of the top sponsored Google results (PipingRock).
Accredited UK-based laboratory ADACT Medical, which specialises in ensuring healthcare products comply with regulations, carried out two separate tests on these samples: one to establish whether they contained a combination of five chemical markers unique to black cohosh, and another highly sensitive test to measure the quantity of the herb in each tablet.
Standard THR products were used as a benchmark: these contain 6.5mg of black cohosh extract, which is equivalent to 42.5mg of black cohosh herb.
The tests revealed that a sample of the tablets made by U.S.-based firm PipingRock contained 242mg of black cohosh. This is nearly six times higher than the levels in approved THR products.
‘It would be extremely inadvisable to buy a strong product which may cause harm, since there are liver toxicity concerns with black cohosh,’ says Dr Etheridge.
Tests on the three Amazon supplements found none contained what was claimed on the label.
Instead, the products – all made in the UK – were weaker, with one also appearing to contain an undeclared, unapproved plant species.
For example, despite claiming to contain 100mg of black cohosh per tablet, Dr Corbyn supplements contained an average of 1.1mg of the herb – making them around 37 times weaker than THR tablets and more than 90 times weaker than claimed on the label. Yet when we checked last week, these were being promoted as ‘Amazon’s Choice’ black cohosh supplement.
Tests on Nutrivity 6.5mg black cohosh tablets revealed they were nearly 19 times weaker than the label claim, while chemical markers suggested they also likely contained the herb species, Actaea foetida, which is not used in licensed supplements in the UK.
This rings alarm bells for Dr Etheridge. ‘Undeclared components or adulteration with other plant species could have the potential for causing serious side-effects and/or toxicity,’ he says.
Colin Wright, a professor of pharmacognosy (the study of drugs from natural sources) at Bradford University, says manufacturers may substitute black cohosh for cheaper species grown in China.
Although there is no evidence that was the case in the four brands ADACT Medical tested for us, Professor Wright added that ‘adverse effects are more common with products that aren’t licensed herbal medicines [i.e. those with a THR mark] – substitution may explain some of this’.
‘It seems that black cohosh products which are not good quality are likely to be less effective or to not be effective, and they may be more likely to give toxic effects such as those we have seen reported to the MHRA,’ he says.He points to cases where other unregulated herbal products have caused harm, such as several cases where slimming remedies caused patients to go into kidney failure.
‘There’s no doubt that sometimes quite serious effects can be caused when herbal medicine preparations are of poor quality,’ he adds.
Michael Heinrich, a professor of ethnopharmacology and pharmacognosy at University College London, believes regulations around the sale of black cohosh should be tightened to ensure they can only be sold as medicines.
‘Food supplements simply need to contain what is on the label – but often not even this is the case. Black cohosh is known to have positive therapeutic effects, but may also have some side-effects, so in my view it must be [treated as] a medicine,’ he explains.
Dr Barton agrees there needs to be more protection for consumers. ‘In the menopause space particularly, there are companies trying to sell products to women who are in a vulnerable position and who want to believe something will make them feel better,’ she says.
‘There are people making a lot of money out of supplements who are trying to pull the wool over these women’s eyes.’
Two supplements found to be of poor quality in our tests – Nutrivity and BodyGenix – were among the most expensive at 30p per tablet (compared with 23p per tablet for the THR product MenoHerb).
Dr Barton urges patients to ‘be discerning’ when buying supplements, to look for the THR logo and be aware that price isn’t necessarily an indicator of quality. An Amazon spokesperson said: ‘We have proactive measures in place to prevent suspicious or non-compliant products from being listed, and we monitor the products sold in our stores for product safety concerns.
‘When appropriate, we remove a product from the store, reach out to sellers, manufacturers and government agencies for additional information or take other actions.’
After the Mail informed Amazon of our findings, it removed some of the products from sale. But the same supplements were still available to buy in larger pack sizes at the time of going to press.
A Google spokesperson said: ‘We don’t allow Shopping ads or free listings for supplements that make false or misleading claims. We have reviewed the listings in question and are removing those that violate our policies.’
PipingRock said all of its products conform with the U.S. Food and Drug Association regulations. A spokesman added: ‘Each product we manufacture undergoes hundreds of checks, in-process and post-production, for complete quality assurance. We guarantee that what’s in the product exactly matches what’s on the label.
‘Our products have the basic warning statement listed on the label, as results vary from person to person and it would be better for any customers who are not comfortable using the ingredients in the bottle or the dosage, we suggest they contact their health care practitioner.’
Black Cohosh: What our lab tests showed
Here’s how the products we tested compared against those with a Traditional Herbal Registration (THR), which meet the quality and safety standards set by the UK drug regulator. A black cohosh product must have a THR to be sold in the UK. Standard THR products contain 6.5mg of black cohosh extract per tablet, which is equivalent to an average of 42.5mg of black cohosh herb. The lab tests assessed the products on how much of the herb they contained.
WORST IN OUR TESTS
Dr Corbyn Menopause Support Black Cohosh 100mg
Retailer: amazon.co.uk
Cost: £5.99 for 30 tablets
Cost per tablet: 20p
Labelled strength: 100mg herb/6.67mg rhizome extract
THR logo: No
Levels found in lab tests: 1.1mg black cohosh herb; 99 pc less than claimed on packaging.
Nutrivity Black Cohosh Tablets 6.5mg
Retailer: amazon.co.uk
Cost: £17.99 for 60 tablets
Cost per tablet: 30p
Labelled strength: 6.5mg root extract [the equivalent of 42.5mg of the herb]
THR logo: No
Levels found in lab tests: 2.3mg black cohosh herb (19x weaker than THR products, 42.5mg). May also contain alternate species, Actaea foetida.
BodyGenix Black Cohosh 6.5mg
Retailer: amazon.co.uk
Cost: £8.99 for 30 tablets
Cost per tablet: 30p
Labelled strength: 6.5mg root extract [equivalent of 42.5mg of the herb]
THR logo: No
Levels found in lab tests: 16.8mg black cohosh herb; 2.5 times weaker than claimed.
PipingRock Black Cohosh 700mg Concentrated Extract
Retailer: pipingrock.com (promoted on Google)
Cost: £8.82 for 150 tablets
Cost per tablet: 6p
Labelled strength: 700mg ‘concentrated extract’ [equivalent of 540mg herb]
THR logo: No
Levels found in lab tests: 242mg black cohosh herb. Weaker than claimed but nearly 6x stronger than THR products.
BEST IN OUR TESTS
MenoHerb Black Cohosh Menopause Relief Tablets
Retailer: amazon.co.uk
Cost: £7 for 30 tablets
Cost per tablet: 23p
Labelled strength: 6.5mg rhizome and root extract
THR logo: Yes
Levels found in lab tests: 6.5mg black cohosh extract, equivalent of 42.5mg black cohosh herb. As described on label.
Higher Nature Black Cohosh Menopause Relief
Retailer: amazon.co.uk
Cost: £8.99 for 30 tablets
Cost per tablet: 30p
Labelled strength: 6.5mg rhizome and root extract
THR logo: Yes
Levels found in lab tests: 6.5mg black cohosh extract, equivalent of 42.5mg black cohosh herb. As described on label.
Boots Menolieve Black Cohosh Root Extract 6.5mg
Retailer: Boots
Cost: £10.30 for 30 tablets
Cost per tablet: 33p
Labelled strength: 6.5mg rhizome and root extract
THR logo: Yes
Levels found in lab tests: 6.5mg black cohosh extract, equivalent of 42.5mg black cohosh herb. As described on label.
Holland & Barrett MenoCool Black Cohosh Tablets
Retailer: Holland & Barrett
Cost: £9.99 for 30 tablets
Cost per tablet: 33p Labelled strength: 6.5mg rhizome and root extract THR logo: Yes
Levels found in lab tests: 6.5mg black cohosh extract, equivalent of 42.5mg black cohosh herb. As described on label.
Healthspan Black Cohosh Menopause Relief Tablets
Retailer: Superdrug
Cost: £10.99 for 30 tablets
Cost per tablet: 37p
Labelled strength: 6.5mg rhizome and root extract
THR logo: Yes
Levels found in lab tests: 6.5mg black cohosh extract, equivalent of 42.5mg black cohosh herb. As described on label.
Laura Adams is a tech enthusiast residing in the UK. Her articles cover the latest technological innovations, from AI to consumer gadgets, providing readers with a glimpse into the future of technology.
