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Complementary & Alternative Medicine
Index of Herbal Medicines, Supplements and Therapies
The decision to use products containing or claiming to contain black cohosh should be carefully considered.
Black Cohosh (Cimicifuga racemosa)
Be aware that the U.S. Food and Drug Administration does not strictly regulate herbs and dietary supplements. There is no guarantee of strength, purity or safety of products containing or claiming to contain black cohosh. Decisions to use herbs or supplements should be carefully considered. Individuals using prescription drugs should discuss taking herbs or supplements with a pharmacist or health care professional before starting.
Scientists have studied black cohosh for the following health problems:
Black cohosh has been used by Native North American Indians in their traditional medicine practices for various purposes, including amenorrhea and menopause. In the United States, there is evidence of the use of this herbal preparation for more than 100 years for gynecological complaints. Several studies in humans suggest that black cohosh may be safe and effective for improving symptoms of menopause, such as hot flashes, migraine headache and sleep disturbances. However, only short-term use of black cohosh for menopausal symptoms has been evaluated. It is not clear if there are benefits in people with hot flashes caused by medications such as tamoxifen. Relief of certain menopausal symptoms may possibly be enhanced by concurrent use with hormone replacement therapy, although this is controversial. The North American Menopausal Society recommends the use of black cohosh in conjunction with lifestyle changes as an option for management of mild vasomotor symptoms. Many studies have been small and have flaws in their designs. Therefore, although this early evidence is quite promising, better studies are necessary before a strong overall recommendation can be made.
Black cohosh is popular for treating symptoms of premenstrual syndrome, such as mood swings, breast tenderness, weight gain, and menstrual pain. Study of a combination product showed reductions in menstrually associated migraine headaces. However, there is not enough scientific evidence to support the use of black cohosh alone for symptoms of premenstrual syndrome.
Black cohosh has been used for pain and inflammation in Korean folk medicine. There is currently not enough evidence from studies in humans to support the use of black cohosh for arthritis. Although some research suggests that herbal preparations containing black cohosh may improve symptoms of rheumatoid arthritis or osteoarthritis, many other herbs have been present in these preparations. Therefore, it is not clear that any benefits are produced purely by black cohosh.
Several laboratory studies have reported that black cohosh may possess inhibitory effects on breast cancer cells. One study indicates that black cohosh may lower breast cancer risk, although a firm recommendation cannot be made at this time. Future research is warranted in this area.
Black cohosh has been suggested for many other uses, based on tradition or on scientific theories. However, these uses have not been thoroughly studied in humans, and there is limited scientific evidence about safety or effectiveness. Some of these suggested uses are for conditions that are potentially very serious and even life-threatening. You should consult a health care professional before taking black cohosh for unproven uses.
Amenorrhea (lack of menstrual period)
Chemotherapy-induced premature menopause
Emmenagogue (promoting menstrual flow)
Fibrocystic breast disease
Gingivitis (gum inflammation)
High blood pressure
Hormone replacement therapy
| Hot flashes in men (undergoing hormone replacement therapy or hormone ablation therapy) |
Mastitis (breast imflammation)
Myalgia (muscle aches)
Polycystic breast disease
Polycystic ovarian syndrome
Polymenorrhea (frequent periods)
Protection against chemotherapy side effects
Reduction of hot flashes in prostate cancer
Thrombocytopenia (low platelet counts)
Tinnitus (ringing in the ears)
Whooping cough (pertussis)
Patients with known allergies to black cohosh or other members of the Ranunculaceae plant family, such as buttercup, should avoid products that contain black cohosh.
In nature, black cohosh contains small amounts of salicylic acid. It is not known how much is present in commercially available preparations. As a result, patients with known allergies to aspirin or aspirinlike products, such as nonsteroidal anti-inflammatory drugs, including ibuprofen (Advil), should avoid black cohosh.
Scientific studies and natural medicine textbooks report that black cohosh is well tolerated by most people for up to six months. The most common side effect are thought to be mild, such as stomach discomfort and rashes, which occur infrequently. Possible side effects include headaches, dizziness, seizures, nausea, vomiting, sweating, constipation, low blood pressure, slow heartbeats, weight gain, loss of bone mass (leading to osteoporosis) and liver damage. Because black cohosh is believed to have estrogen-like properties, it should be avoided by people with estrogen receptor-positive breast cancer, a family history of breast cancer, ovarian cancer or endometrial cancer. In theory, black cohosh may increase the risk of bleeding, or it may increase the risk of blood clots caused by estrogen-like effects. You may need to stop taking black cohosh before surgery; discuss this with a health care professional.
Black cohosh should be used cautiously in patients with a history of blood clots or stroke, seizure disorder, known allergy to aspirin or salicylates, liver disease, or hormone-sensitive cancers or those taking medications for high blood pressure. Cases of liver damage and failure associated with black cohosh have been reported. Dysphoria and "heaviness in the legs" may occur.
Pregnancy And Breast-Feeding
Black cohosh is not recommended for pregnant women because its potential effects on the uterus may induce labor early. There is a report of damage to multiple organs in a child whose mother used black cohosh to induce labor.
There is not enough safety evidence to use black cohosh while breast-feeding. Although used internationally, little safety and efficacy data are available for homeopathic preparations of blue and black cohosh.
Interactions with drugs, supplements and other herbs have not been thoroughly studied. The interactions listed below have been reported in scientific publications. If you are taking prescription drugs, speak with a health care professional or pharmacist before using herbs or dietary supplements.
Interactions With Drugs
Because it is possible that salicylates may be present in black cohosh, the use of black cohosh with other salicylates such as aspirin or other blood-thinning medications theoretically may increase the risk of bleeding.
Because of the possibility that black cohosh may lower blood pressure, it should be avoided by patients also taking drugs that lower blood pressure, such as metoprolol (Lopressor, Toprol).
Because black cohosh is believed to have estrogen-like properties, it is possible that it may alter the effects of hormone therapies, such as birth control pills. Patients taking tamoxifen (Nolvadex) may experience increased side effects if taken with black cohosh. Other potential interactions include pain relievers, anesthetics, antidepressants, antihistamines, anti-inflammatories, cholesterol-lowering drugs, chemotherapy, antioxidants, drugs broken down by the liver, anti-seizure drugs, alcohol, and drugs used to treat osteoporosis.
Interactions With Herbs And Dietary Supplements
Because it is possible that salicylates may be present in black cohosh, its use with other salicylate-containing herbs, such as aspen bark, may increase the risk of bleeding. This is a theoretical risk and has not been reported in studies in humans. A risk may also exist when used with herbs such as Ginkgo biloba
Black cohosh may lower blood pressure; caution is advised if also taking other herbs or supplements that may affect blood pressure, such as garlic
Black cohosh may have estrogen-like properties and increase some effects of supplements such as soy or evening primrose oil
). Interactions with American pennyroyal, pain relievers, anesthetics, antihistamines, anti-inflammatories, cholesterol-lowering therapies, antioxidants, blue cohosh, and St. John's wort are possible.
A case of seizure was reported in a patient using an herb combination of black cohosh, chasteberry (Vitex agnus-castus
) and evening primrose oil
), as well as alcohol. It is not clear if black cohosh contributed to the cause of the seizure. Caution is advised if you are also taking SSRI or MAOI antidepressants. Check with your doctor and pharmacist before adding black cohosh.
The doses listed below are based on scientific research, publications or traditional use. Because most herbs and supplements have not been thoroughly studied or monitored, safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients even within the same brand. Combination products often contain small amounts of each ingredient and may not be effective. The appropriate dosing should be discussed with a health care professional before starting therapy; always read the recommendations on a product's label. The dosing for unproven uses should be approached cautiously, because scientific information is limited in these areas.
Doses of black cohosh are often based on the amount of the chemical 27-deoxyactein, which is believed to be its active ingredient. One commercially available product (Remifemin) contains one milligram of 27-deoxyactein in each 20-milligram tablet or in 20 drops of the liquid formulation.
For Menopausal Symptoms
Adults (Aged 18 Or Older)
Tablets: A dose of one or two tablets per day (containing one to two milligrams of 27-deoxyactein) has been taken by mouth.
Liquid: A dose of 20 to 40 liquid drops per day (containing one to two milligrams of 27-deoxyactein) has been taken by mouth.
Cut and dried rhizome (fleshy horizontal underground stem): A dose of 40 to 200 milligrams per day, divided into several doses, has been taken by mouth.
Powdered root or tea: A dose of one to two grams has been taken by mouth three times daily.
Extract: A dose of four milliliters of fluid extract or 250 to 500 milliliters of dry powder extract has been taken three times daily by mouth. A dose of 39 milligrams was was shown to have a similar rate of effectiveness as a 127.3-milligram dose of extract in one study. A clinically tested standardized extract dose of 40 to 80 milligrams a day has also been reported.
Tincture: A dose of four to six milliliters (1:5) has been taken daily by mouth.
Many types of combination products with unique dosing regimens are available.
Children (Younger Than 18)
The dosage and safety of black cohosh have not been studied in children. Use of black cohosh in children is not recommended.
Black cohosh has been suggested for the treatment of many conditions. However, scientific research provides only early support for the treatment of symptoms associated with menopause. More studies are needed before a strong recommendation can be made. Black cohosh should be avoided by pregnant or breast-feeding women and children. Black cohosh should be used cautiously by people with a known allergy to aspirin or nonsteroidal anti-inflammatory drugs, those taking drugs to treat high blood pressure, people with a seizure disorder or those with liver disease. There may be side effects or dangerous interactions because of the estrogenlike properties of black cohosh; however, several studies show that black cohosh has little or no estrogenic activity and even anti-estrogenic properties. This remains an area of controversy. This herb should be used only at recommended doses for less than six months. Consult a health care professional immediately if you experience side effects.
The information in this monograph was prepared by the professional staff at Natural Standard, based on thorough systematic review of scientific evidence. The material was reviewed by the Faculty of the Harvard Medical School with final editing approved by Natural Standard.
- Natural Standard: An organization that produces scientifically based reviews of complementary and alternative medicine (CAM) topics
- National Center for Complementary and Alternative Medicine (NCCAM): A division of the U.S. Department of Health & Human Services dedicated to research
Selected Scientific Studies: Black Cohosh
Natural Standard has reviewed all of the currently available medical literature to prepare the professional monograph from which this version was created.
Some of the more recent studies are listed below:
- Amato P, Marcus DM. Review of alternative therapies for treatment of menopausal symptoms. Climacteric 2003;Dec, 6(4):278-284. Review.
- Bai W, Henneicke-von Zepelin HH, Wang S, Zheng S, Liu J, Zhang Z, Geng L, Hu L, Chunfeng J, Liske E. Efficacy and tolerability of a medicinal product containing an isopropanolic black cohosh extract in Chinese women with menopausal symptoms: A randomized, double blind, parallel-controlled study versus tibolone. Maturitas. 2007 Jun 21.
- Borrelli F, Ernst E. Cimicifuga racemosa: a systematic review of its clinical efficacy. Eur J Clin Pharmacol 2002;58(4):235-241.
- Briese V, Stammwitz U, Friede M, Henneicke-von Zepelin HH. Black cohosh with or without St. John's wort for symptom-specific climacteric treatment-Results of a large-scale, controlled, observational study. Maturitas. 2007 Aug 20;57(4):405-14.
- Burke BE, Olson RD, et al. Randomized, controlled trial of phytoestrogen in the prophylactic treatment of menstrual migraine. Biomed Pharmacother 2002;Aug, 56(6):283-288.
- Cheema D, Coomarasamy A, El-Toukhy T. Non-hormonal therapy of post-menopausal vasomotor symptoms: a structured evidence-based review. Arch Gynecol Obstet. 2007 Jun 26.
- Chung DJ, Kim HY, Park KH, Jeong KA, Lee SK, Lee YI, Hur SE, Cho MS, Lee BS, Bai SW, Kim CM, Cho SH, Hwang JY, Park JH. Black cohosh and St. John's wort (GYNO-Plus) for climacteric symptoms. Yonsei Med J. 2007 Apr 30;48(2):289-94.
- Cohen SM, O'Connor AM, et al. Autoimmune hepatitis associated with the use of black cohosh: a case study. Menopause 2004;Sep-Oct, 11(5):575-577.
- Fugate SE, Church CO. Nonestrogen treatment modalities for vasomotor symptoms associated with menopause. Ann Pharmacother 2004;Sep, 38(9):1482-1499. Epub 2004;Aug, 03.
- Fugh-Berman A. "Bust enhancing" herbal products. Obstet Gynecol 2003;Jun, 101(6):1345-1349.
- Huntley A. The safety of black cohosh (Actaea racemosa, Cimicifuga racemosa). Expert Opin Drug Saf 2004;Nov, 3(6):615-623.
- Huntley A, Ernst E. A systematic review of the safety of black cohosh. Menopause 2003;Jan-Feb, 10(1):58-64.
- Kligler B. Black cohosh. Am Fam Physician 2003;Jul 1, 68(1):114-116.
- Liske E, Hanggi W, Henneicke-von Zepelin HH, et al. Physiological investigation of a unique extract of black cohosh (Cimicifugae racemosae rhizoma): a 6-month clinical study demonstrates no systemic estrogenic effect. J Womens Health Gend Based Med 2002;11(2):163-174.
- Lontos S, Jones RM, et al. Acute liver failure associated with the use of herbal preparations containing black cohosh. Med J Aust 2003;Oct 6, 179(7):390-391.
- Lupu R, Mehmi I, et al. Black cohosh, a menopausal remedy, does not have estrogenic activity and does not promote breast cancer cell growth. Int J Oncol 2003;Nov, 23(5):1407-1412.
- Mahady GB, Fabricant D, et al. Black cohosh: an alternative therapy for menopause? Nutr Clin Care 2002;Nov-Dec, 5(6):283-289.
- Moyad MA. Complementary/alternative therapies for reducing hot flashes in prostate cancer patients: reevaluating the existing indirect data from studies of breast cancer and postmenopausal women. Urology 2002;59(4 Suppl 1):20-33.
- Neff MJ. NAMS releases position statement on the treatment of vasomotor symptoms associated with menopause. Am Fam Physician 2004;Jul 15, 70(2):393-394, 396, 399.
- Oktem M, Eroglu D, Karahan HB, Taskintuna N, Kuscu E, Zeyneloglu HB. Black cohosh and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomized trial. Adv Ther. 2007 Mar-Apr;24(2):448-61.
- Pockaj BA, Loprinzi CL, Sloan JA, et al. Pilot evaluation of black cohosh for the treatment of hot flashes in women. Cancer Invest 2004;22(4):515-521.
- Rotem C, Kaplan B. Phyto-Female Complex for the relief of hot flushes, night sweats and quality of sleep: randomized, controlled, double-blind pilot study. Gynecol Endocrinol. 2007 Feb;23(2):117-22.
- Sun J. Morning/evening menopausal formula relieves menopausal symptoms: a pilot study. J Altern Complement Med 2003;9(3):403-409.
- Thomsen M, Vitetta L, et al. Acute liver failure associated with the use of herbal preparations containing black cohosh. Med J Aust 2003;Oct 6, 179(7):390-391.
- Vitetta L, Thomsen M, et al. Black cohosh and other herbal remedies associated with acute hepatitis. Med J Aust 2002;Oct 21, 177(8):440-443.
- Walji R, Boon H, Guns E, Oneschuk D, Younus J. Black cohosh (Cimicifuga racemosa [L.] Nutt.): safety and efficacy for cancer patients. Support Care Cancer. 2007 Jun 30.
Last updated September 04, 2008
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