What Doesn't Have Evidence (Yet, or Ever)

The global menopause market is worth billions and growing fast. A substantial share of it consists of products with no demonstrated effect on the thing they're sold for.

This isn't a lecture about wasting money. It's about the more expensive cost: women spending two or three years on unevidenced products while symptoms that were treatable go untreated.

Supplements and botanicals

The 2023 evidence review from The Menopause Society examined this category and did not recommend supplements or herbal remedies for hot flushes.

Black cohosh is the most studied. Results across trials have been inconsistent, and systematic reviews have not established convincing benefit over placebo. There have also been rare reports of liver injury, which is worth knowing given that it's marketed as a gentle natural option.

Soy isoflavones and equol. Specifically listed as not recommended in the 2023 review, along with soy foods. This one is often defended by pointing to lower reported symptom rates in some Asian populations. That observation is real; the causal attribution to soy has not held up in trials.

Red clover, evening primrose oil, wild yam cream, dong quai, maca. No convincing evidence for hot flushes.

Two structural points about this category. Supplements are regulated as foods rather than medicines in most jurisdictions, so the burden of proving efficacy before sale doesn't apply. And "natural" carries no safety guarantee — botanicals are pharmacologically active, interact with prescription medication, and are not inert.

Compounded "bioidentical" hormones

This deserves particular attention because of a confusion the industry has been slow to correct.

Regulated body-identical hormones — estradiol, micronised progesterone — are licensed pharmaceutical products with structures identical to your own hormones, made to consistent standards, with known dosing. These are mainstream, evidence-based treatment.

Compounded bioidentical hormone therapy is something else: custom-mixed preparations from compounding pharmacies, frequently prescribed on the basis of saliva or serum hormone testing, and typically outside the standard regulatory approval process.

The problems are specific. Batch-to-batch consistency isn't assured. Absorption from creams and troches is variable. Efficacy and safety haven't been established through the usual process, and — worth noting — these products don't carry the same safety warnings as licensed HRT, which is sometimes marketed as evidence they're safer rather than evidence they've been assessed differently.

A 2020 review by the US National Academies of Sciences, Engineering, and Medicine concluded that the evidence did not support the routine use of compounded bioidentical hormone therapy. ACOG and The Menopause Society have both advised against it.

Hormone testing to guide treatment

Saliva hormone testing is widely sold and not validated for guiding menopause treatment. Levels fluctuate dramatically hour to hour and don't correlate reliably with symptoms or with the correct dose.

Serum testing has narrow legitimate uses — suspected premature ovarian insufficiency, women aged 40–45 in some circumstances, monitoring testosterone if prescribed. It is not, for most women, a way to determine what treatment you need. NICE is explicit that FSH shouldn't be used to diagnose perimenopause or menopause in women over 45.

If a service leads with hormone testing and then sells you a bespoke preparation based on the results, that's a business model rather than a clinical pathway.

Things that are good for you but not for hot flushes

A distinction that gets lost in this discussion.

The 2023 review found insufficient evidence to recommend exercise, yoga, mindfulness-based interventions, relaxation, paced breathing, cooling techniques, avoiding triggers, dietary modification or acupuncture for vasomotor symptoms.

That is not a verdict on their overall value. Exercise remains among the most beneficial things available for cardiovascular health, bone density, muscle preservation, mood and sleep — all of which matter enormously at this stage. Mindfulness has evidence for anxiety. A good diet is a good diet.

The finding is narrow: these don't reliably reduce hot flushes. Keep doing them for what they do work for. Don't rely on them as your hot flush treatment and then conclude you've failed.

How to evaluate the next thing you're offered

A few questions that filter most of it.

What exactly is being claimed, in specific terms? "Supports hormonal balance" is not a claim, because there's no measurable thing called hormonal balance and no test for it.

Is there a randomised controlled trial against placebo, in women like you? Placebo response in hot flush trials is famously large — often 30% or more — so uncontrolled before-and-after results are close to meaningless.

Who paid for the study, and how many people were in it?

Is it being sold by the same organisation that recommended it? Not automatically disqualifying, but relevant.

Does it require a test that a mainstream service wouldn't order?

The point

There are effective treatments for most menopausal symptoms. They're prescribed, they have names, and they have trial data behind them.

The main harm from the unevidenced end of the market isn't the money. It's the delay.

Sources

- The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573–590. - National Academies of Sciences, Engineering, and Medicine. The Clinical Utility of Compounded Bioidentical Hormone Therapy: A Review of Safety, Effectiveness, and Use. Washington DC: The National Academies Press; 2020. - Leach MJ, Moore V. Black cohosh (Cimicifuga spp.) for menopausal symptoms. Cochrane Database of Systematic Reviews. 2012;(9):CD007244. - National Institute for Health and Care Excellence. Menopause: identification and management (NG23), diagnosis recommendations. Updated 2024. - American College of Obstetricians and Gynecologists. Committee Opinion: Compounded Bioidentical Menopausal Hormone Therapy.