Many women experience menopausal symptoms after the fourth decade of their lives, and most often consider these symptoms to be a cause of anxiety and discomfort. For more than half a century, in postmenopausal women, the combination of estrogens with progestins, or hormone replacement therapy (HRT), has had beneficial effects on menopausal symptoms and osteoporosis, but recent clinical studies have questioned whether it is safe for the cardiovascular system. An increased risk of breast cancer has also been suggested. Therefore, efforts are underway to find alternative therapies for HRT. Ideally, the herbal medicine used as a replacement for HRT should have no estrogenic effects on breast and uterine tissue but have beneficial effects on menopausal symptoms and bone marrow. Plant estrogens in small doses have no effect on menopausal symptoms or have little effect, but in high doses they mimic the effects of estrogen. Therefore, the goal of researchers is to find other plant compounds. Black cohosh rhizome extract does not bind to estrogen receptors and in vitro has no estrogenic effects on breast cancer cells, mammary gland and uterine histology of ovariectomized rats. In addition, in this rat study model, an extract of black cohosh called BNO 1055 prevented the onset of hot flashes and the spread of osteoporosis. This extract reduces the main menopausal symptoms in postmenopausal women as much as conjugated estrogen and significantly more than placebo. No effects on the uterus or mammary glands have been observed in all European studies. Most likely, the effective compounds in black cohosh extract are mimics of neurotransmitters: dopaminergic, noradrenergic, serotonergic and gabaargic effects have been identified and the structure of some of them has been determined. Researchers have concluded that low doses of black cohosh extract are effective in relieving menopausal symptoms without estrogenic side effects. This evidence reinforces the role of black cohosh extract in replacing HRT.