Poly-Cystic Ovary Syndrome (PCOS)

In PCOS, black cohosh has been studied as an adjunct to clomiphene, never a standalone. A randomised trial (n=194) found adding Cimicifuga racemosa to clomiphene cycles improved endometrial thickness, hormone profile and clinical pregnancy rate — 34.8% versus 17.2% ^{1Reference 1Shahin et al. · 2014RCTAdding Cimicifuga racemosa to clomiphene induction cycles in PCOS improves cycle outcomes and pregnancy rates — randomised trialView study →}.

A 2021 systematic review found three RCTs reporting improved pregnancy rates on the combination and concluded short-term use appears safe, while flagging serious risk-of-bias concerns and a lack of high-quality evidence ^{2Reference 2Fan et al. · 2021Systematic reviewSystematic review of black cohosh for management of PCOS-related infertilityView study →}. A separate clinical trial (n=100) found no difference in follicle number or endometrial thickness from adding it ^{3Reference 3Pourhoseini et al. · 2022Clinical trialCimicifuga racemosa with clomiphene for ovulation induction in PCOS: a clinical trialView study →}.

The results conflict, and the trials are small and methodologically weak. This is a fertility-clinic co-treatment, not a self-directed one. Black cohosh’s rare hepatotoxicity signal applies to this use as to any other.

A 2020 meta-analysis pooling five small RCTs found reductions in fasting blood sugar, fasting insulin, HOMA-IR, LDL, total cholesterol and triglycerides, but no effect on body weight or BMI ^{4Reference 4Heydarpour F et al. · 2020Meta-analysisEffects of cinnamon on controlling metabolic parameters of polycystic ovary syndrome: a systematic review and meta-analysis — [meta-analysis]View study →}; the umbrella meta-analysis flagged PCOS as a population where the lipid benefit was clearest ^{5Reference 5Sarmadi B et al. · 2023Meta-analysisThe effect of cinnamon consumption on lipid profile, oxidative stress, and inflammation biomarkers in adults: an umbrella meta-analysis of randomized controlled trials — [meta-analysis]View study →}. This is the same insulin-sensitising signal seen in diabetes applied to the insulin-resistant PCOS phenotype — not evidence of any effect on ovulation, androgens or the reproductive features that define the syndrome. The trials are few and small.

One randomised double-blind placebo-controlled trial (n=60, standardised extract, 12 weeks) reported improved oxidative-stress markers, insulin resistance (HOMA-IR), lipid profile, menstrual frequency and hirsutism score vs placebo ^{6Reference 6Hatami A et al. · 2026RCTThe effect of Vitex agnus-castus on oxidative stress, lipid profile and insulin resistance in women with polycystic ovary syndrome: a randomised, double-blind controlled trialView study →}, with supporting rat models (anti-Müllerian hormone, ovarian gene expression, hypothalamic KISS-1) ^{7,8Reference 7Abbaszadeh M et al. · 2026AnimalVitex agnus-castus extract improved the endocrine profile and gene expression in rat ovaries with polycystic ovary syndromeView study →Reference 8Feyzollahi Z et al. · 2021AnimalEffect of Vitex agnus-castus ethanolic extract on hypothalamic KISS-1 gene expression in a rat model of polycystic ovary syndromeView study →}. It is a single small trial; the metabolic and oxidative findings have not been independently replicated, and they rest on a standardised extract.

Licorice reproducibly lowers serum testosterone ^{11,12,13Reference 11Armanini D et al. · 1999Clinical trialReduction of serum testosterone in men by licorice — clinical trialView study →Reference 12Armanini D et al. · 2003Clinical trialLicorice consumption and serum testosterone in healthy man — clinical trialView study →Reference 13Armanini D et al. · 2004Clinical trialLicorice reduces serum testosterone in healthy women — clinical trialView study →}; in PCOS, adding it to spironolactone offset spironolactone’s renin/aldosterone rise while adding anti-androgen action ^{14Reference 14Armanini D et al. · 2007Clinical trialTreatment of polycystic ovary syndrome with spironolactone plus licorice — clinical trialView study →}, and a 2024 double-blind RCT with a low-calorie diet improved obesity, glycaemic and lipid indices in overweight women with PCOS ^{15Reference 15Hooshmandi H et al. · 2024RCTEffects of licorice extract with a low-calorie diet on obesity, glycemic and lipid indices in overweight/obese women with PCOS: a randomised, double-blind, placebo-controlled trialView study →}.

A moderate-dose trial found a null sex-steroid result ^{16Reference 16Sigurjonsdottir HA et al. · 2006Clinical trialLiquorice in moderate doses does not affect sex steroid hormones of biological importance — clinical trialView study →}; the effect needs a meaningful glycyrrhizin dose, which reintroduces the blood-pressure risk.

Marjoram’s traditional “cycle-regulating” reputation has real, if preliminary, human backing, and the trials used the tea, the form in which the herb is usually taken. A randomised, double-blind, placebo-controlled pilot gave women with PCOS marjoram tea twice daily for one month and found a significant reduction in the adrenal androgen DHEA-S plus improved insulin sensitivity, though several changes reached significance only within-group ^{17Reference 17Haj-Husein et al. · 2016RCTThe effect of marjoram (Origanum majorana) tea on the hormonal profile of women with polycystic ovary syndrome: a randomised controlled pilot study — randomised controlled trialView study →}; a second pilot RCT of a marjoram-plus-cinnamon tea over three months reported shifts in FSH and anti-Müllerian hormone with no major side effects ^{18Reference 18Majeed et al. · 2025RCTSafety and effectiveness of marjoram and cinnamon herbal tea supplementation in managing polycystic ovary syndrome: a pilot randomised, double-blind, controlled trial — randomised controlled trialView study →}.

Three independent rat models converge — marjoram improved hormonal profile, adiponectin-mediated insulin sensitivity, ovarian antioxidant enzymes and inflammation in DHEA- and letrozole-induced PCOS, the letrozole study tracing it to Nrf2 activation and NF-κB suppression ^{19,20,21Reference 19Rababa’h et al. · 2020AnimalThe ameliorative effects of marjoram in dehydroepiandrosterone-induced polycystic ovary syndrome in rats — animal modelView study →Reference 20Al-Harbi et al. · 2025AnimalProtective effect of marjoram against letrozole-induced ovarian damage in rats with polycystic ovarian syndrome (Nrf2 activation, NF-κB suppression) — animal modelView study →Reference 21Elfiky et al. · 2025AnimalExploring the therapeutic potential of marjoram (Origanum majorana L.) in polycystic ovary syndrome: serum metabolomics, network pharmacology and experimental validation — animal modelView study →}. Marjoram’s phytochemistry and antimicrobial activity are reviewed separately ^{22,23Reference 22Bina et al. · 2017ReviewSweet Marjoram: A Review of Ethnopharmacology, Phytochemistry, and Biological Activities — reviewView study →Reference 23Vági et al. · 2005Essential oil composition and antimicrobial activity of Origanum majorana L. extracts obtained with supercritical carbon dioxideView study →}.

Both human trials are small underpowered pilots, one of them testing a two-herb combination, and no trial has confirmed a clinical endpoint — no ovulation, no cycle regularity, no pregnancy rate.

A 2025 randomised placebo-controlled trial in women with PCOS found Salvia officinalis extract significantly lowered malondialdehyde (a lipid-peroxidation marker), improved total antioxidant capacity, and reduced triglycerides ^{29Reference 29Maleki-Hajiagha et al. · 2025RCTExploring the therapeutic impact of Salvia officinalis on lipid and oxidative stress markers in patients with polycystic ovary syndrome — a randomised placebo-controlled clinical trialView study →}. The endpoints are oxidative-stress and lipid biomarkers, not androgens, ovulation, cycle regularity or fertility — the features that define the syndrome. Oxidative stress and dyslipidaemia travel with the insulin-resistant PCOS phenotype, and the trial sits alongside the same group’s diabetes and hyperlipidaemia trials ^{30,31,32Reference 30Kianbakht et al. · 2011RCTAntihyperlipidemic effects of Salvia officinalis L. leaf extract in patients with hyperlipidemia: a randomised double-blind placebo-controlled clinical trialView study →Reference 31Kianbakht et al. · 2013RCTImproved glycemic control and lipid profile in hyperlipidemic type-2 diabetic patients consuming Salvia officinalis L. leaf extract: a randomised placebo-controlled clinical trialView study →Reference 32Kianbakht et al. · 2016RCTSalvia officinalis (sage) leaf extract as add-on to statin therapy in hypercholesterolemic type-2 diabetic patients: a randomised clinical trialView study →}.

Sage’s human results are tied to specific standardised extracts that do not transfer to tea or whole-leaf powder — commercial sage tea varies up to 20-fold in rosmarinic-acid content ^{33Reference 33Walch et al. · 2011Antioxidant capacity and polyphenolic composition as quality indicators for aqueous infusions of Salvia officinalis L. (sage tea)View study →}.

Peony’s use for hyperandrogenism and PCOS is long-standing but thinly evidenced. The only human data is an early open, uncontrolled study of Shakuyaku-kanzo-to (TJ-68) in 34 women with polycystic ovarian disease, reporting reduced serum testosterone ^{24Reference 24Takahashi et al. · 1994Clinical trialEffect of TJ-68 (shakuyaku-kanzo-to) on polycystic ovarian disease — human clinical studyView study →} — and that formula is peony plus licorice, where licorice independently and reproducibly lowers testosterone in controlled human trials. The human result therefore cannot be attributed to peony at all.

What is peony-specific is preclinical: paeoniflorin plus glycyrrhizin lowered ovarian androgen production in rats ^{25Reference 25Takeuchi et al. · 1991AnimalEffect of paeoniflorin, glycyrrhizin and glycyrrhetic acid on ovarian androgen production — rat in vivoView study →}, androgen-receptor-binding gallotannins (pentagalloylglucose) were isolated from the root ^{26Reference 26Washida et al. · 2009In vitroAndrogen modulators from the roots of Paeonia lactiflora (paeoniae radix) grown and processed in Nara prefecture, Japan — in vitroView study →}, a review places peony among plant-derived anti-androgens ^{27Reference 27Grant et al. · 2012ReviewAn update on plant derived anti-androgens — reviewView study →}, and paeoniflorin downregulates CYP17A1 to curb testosterone over-secretion in theca cells ^{28Reference 28Ong et al. · 2019In vitroPaeoniflorin extract reverses dexamethasone-induced testosterone over-secretion through downregulation of cytochrome P450 17A1 expression in primary murine theca cells — in vitroView study →}. The data point to reduced androgen synthesis, not aromatase induction — the older “reliable aromatase inducer” claim is unsupported.

Gymnema’s PCOS use rests on its well-evidenced glycaemic and insulin-sensitising action, insulin resistance being central to PCOS. There is no PCOS-specific trial.

In overweight women with PCOS, adding fennel to a hypocaloric high-protein diet produced no additional improvement in weight or androgenic indices beyond the diet by itself ^{9Reference 9Nadjarzadeh et al. · 2021RCTHypocaloric high-protein diet supplemented with fennel on androgenic/anthropometric indices in overweight women with PCOS — RCTView study →}. This is the only controlled test of fennel in PCOS, and the comparator was the intervention that works.

In adjacent appetite work, a crossover trial in nine overweight women found fennel tea reduced subjective hunger over a few hours but did not change food actually eaten at the following buffet ^{10Reference 10Bae et al. · 2015RCTFennel and fenugreek tea drinking suppresses subjective short-term appetite in overweight women — randomised crossover trialView study →}. Fennel’s stronger evidence is for primary dysmenorrhoea.