Black Cohosh (Cimicifuga racemosa [L.] Nutt.)
  
Black Cohosh (Cimicifuga racemosa [L.] Nutt.)
Background
Black cohosh is popular as an alternative to hormonal therapy in the treatment of menopausal (climacteric) symptoms such as hot flashes, mood disturbances, diaphoresis, palpitations, and vaginal dryness. Several controlled trials and case series have reported black cohosh to improve menopausal symptoms for up to six months. Although these initial studies are suggestive, they have been few in number and have universally suffered from methodological weaknesses.
The mechanism of action of black cohosh remains unclear, and the effects on estrogen receptors or hormonal levels (if any) have not been fully elucidated. Recent publications suggest that there may be no direct effects on estrogen receptors, although this is an area of active controversy (1-8). Safety and efficacy data beyond six months are not available, although recent reports suggest safety of short-term use, including in women experiencing menopausal symptoms for whom estrogen replacement therapy is contraindicated (9;10). Nonetheless, due to a lack of long-term follow-up, caution is advisable until better-quality safety data are available. Use of black cohosh in high-risk populations (such as in women with a history of breast cancer) should be under the supervision of a licensed healthcare professional.
Synonyms
Actaea macrotys, Actaea racemosa L., actee a grappes, Amerikanisches wanzenkraut, baneberry, black snakeroot, botrophis serpentaria, bugwort, cohosh bugbane, Cimicifuga, Cimicifugae racemosae rhizoma, cimicifugawurzelstock, herbe au punaise, macrotys, Macrotys actaeoides, rich weed, rattle root, rattle snakeroot, rattle top, rattle weed, richweed, schwarze schlangenwurzel, solvlys, squaw root, Thalictrodes racemosa , Traubensilberkerze, Wanzwnkraut.
Note : Do not confuse black cohosh with blue cohosh ( Caulophyllum thalictroides ), which contains chemicals that may damage the heart and raise blood pressure. Do not confuse black cohosh ( Cimicifuga racemosa ) with cimicifuga foetida , bugbane, fairy candles, or sheng ma; these are species from the same family ( Ranunculaceae ) with different effects.
Evidence
These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.
Uses based on scientific evidenceGrade*Menopausal symptoms
Black cohosh is a popular alternative to prescription hormonal therapy for treatment of menopausal symptoms such as hot flashes, mood problems, perspiration, heart palpitations, and vaginal dryness. Initial human research suggests that black cohosh may improve some of these symptoms for up to six months. However, most studies are not well designed and results are not conclusive. Most research has used a specially designed questionnaire to measure menopausal symptoms which does not consider some of the important symptoms of menopause such as vaginal dryness, but does measure other symptoms which are not commonly associated with menopause, such as tingling sensations and dizziness. Well-designed studies are needed using black cohosh for longer than six months.
B
Joint pain
There is not enough human research to make a clear recommendation about the use of black cohosh for painful joints in rheumatoid arthritis or osteoarthritis.
C
* Key to grades
A: Strong scientific evidence for this use;
B: Good scientific evidence for this use;
C: Unclear scientific evidence for this use;
D: Fair scientific evidence against this use (it may not work);
F: Strong scientific evidence against this use (it likely does not work).
Uses based on tradition or theory
The below uses are based on tradition or scientific theories. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.
Anxiety, aphrodisiac, appetite stimulant, asthma, back pain, breast disease, breast pain/inflammation (mastitis), bone diseases, bronchitis, cervical dysplasia (abnormal pap smear), child birth (labor induction), cough remedy, decreased blood platelets, depression, diarrhea, dizziness, edema, endometriosis, fever, gall bladder disorders, headache, heart disease/palpitations, high blood pressure, infertility, inflammation, insect repellent, itchiness, kidney inflammation, liver disease, malaria, menstrual period problems, miscarriage, muscle pain, muscle spasms, ovarian cysts, pancreatitis, perspiration, pertussis (whooping cough), polycystic breast disease, polycystic ovarian syndrome, premenstrual syndrome (PMS), ringing in the ears, sleep disorders, snakebites, sore throat, tamoxifen-related hot flashes, uterine diseases and bleeding, vaginal discharge, yellow fever.
Dosing
The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy.
Standardization
Standardization involves measuring the amount of certain chemicals in products to try to make different preparations similar to each other. It is not always known if the chemicals being measured are the "active" ingredients. The dose of black cohosh is often based on the amount of the chemical 27-deoxyactein. The German product, Remifemin®, used in most human studies, contains an alcoholic extract of black cohosh standardized to contain 1 milligram of 27-deoxyactein in each 20 milligram tablet. The manufacturing process and dosing recommendations for Remifemin® have changed over the past 20 years, and doses used in different studies are not always the same. A standardized liquid formulation of Remifemin® has also been used in some studies.
Adults (18 years and older)
Tablets : For menopausal symptoms, studies have used 20 milligram or 40 milligram Remifemin® tablets (containing 1 or 2 milligrams of 27-deoxyactein) twice daily or 40 drops of a liquid extract. Some clinical studies have used 20 milligrams taken twice daily.
Dried rhizome (root) : The British Herbal Compendium recommends 40 to 200 milligrams of dried rhizome daily in divided doses, although traditional doses have been as high as 1 gram three times daily.
Tincture/Liquid : The British Herbal Compendium recommends 0.4 to 2 milliliters of a (1:10) 60% ethanol tincture daily.
Children (younger than 18 years)
There is not enough scientific information to recommend black cohosh in children.
Safety
The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects.
Allergies
Avoid if allergic to black cohosh or other members of the Ranunculaceae (buttercup or crowfoot) family. In nature, black cohosh contains small amounts of salicylic acid (which is found in aspirin), but it is not clear how much (if any) is present in commercially available products. Black cohosh should be used cautiously in people allergic to aspirin or to other salicylates.
Side Effects and Warnings
Black cohosh is generally well tolerated in recommended doses and has been studied for up to six months. High doses of black cohosh may cause frontal headache, dizziness, perspiration, or visual disturbances. Several side effects have been noted in studies, including constipation, intestinal discomfort, loss of bone mass (leading to osteoporosis), irregular or slow heart beat, low blood pressure, nausea and vomiting.
It is not clear if black cohosh is safe in individuals with hormone-sensitive conditions such as breast cancer, uterine cancer, or endometriosis. There is controversy as to whether black cohosh is similar to estrogen in its mechanism, although recent studies suggest that it may not be. The influence of black cohosh on anti-estrogen drugs (like tamoxifen) or hormone replacement therapy is not clear. It is not known if black cohosh possesses the beneficial effects that estrogen is believed to have on bone mass, or the potential harmful effects such as increased risk of stroke or hormone-sensitive cancers.
There are three cases reported in Australia of hepatitis (liver damage) in individuals who used combination herbal products containing black cohosh, requiring liver transplantation for severe liver failure in two of these patients. These reports are concerning, although the cases have been criticized by some as not being adequately substantiated. Nonetheless, patients with liver disease should consult a licensed healthcare professional before using black cohosh.
Black cohosh should be used cautiously in patients with a history of blood clots or stroke, seizure disorder, taking medications for high blood pressure, known allergy to aspirin/salicylates, liver disease, or hormone-sensitive cancers.
Pregnancy and Breastfeeding
Safety during pregnancy and breastfeeding has not been established. Black cohosh may relax the muscular wall of the uterus, and some nurse-midwives in the United States use black cohosh to stimulate labor. There is one report of severe multi-organ damage in a child delivered with the aid of both black cohosh and blue cohosh ( Caulophyllum thalictroides ), who was not breathing at the time of birth. The child survived with permanent brain damage. However, blue cohosh is known to have effects on the heart and blood vessels and may have been responsible for these effects.
Tinctures may be ill-advised during pregnancy due to potentially high alcohol content.
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