Plant Part Used
Root/rhizome
Active Constituents
Triterpene glycosides including 27-deoxyactein, actein, cimicifugoside, cimifugin and cimiracemosides A-H; isoflavones including formononetin; aromatic acids including isoferulic acid, fukinolic acid and salicylic acid.(1),(2),(3),(4),(5),(25)
[span class=alert]This section is a list of chemical entities identified in this dietary supplement to possess pharmacological activity. This list does not imply that other, yet unidentified, constituents do not influence the pharmacological activity of this dietary supplement nor does it imply that any one constituent possesses greater influence on the overall pharmacological effect of this dietary supplement.[/span]
Introduction
Black cohosh rhizome has been used in Chinese medicine for centuries as a remedy for conditions such as headache, non-eruptive measles, gingivitis, uterine and rectal prolapse. Native Americans used black cohosh as a remedy for female related problems, including painful menses, problem childbirth, arthritic problems and as an antidote for snakebite. The Eclectic physicians of the turn of the century in America relied on preparations of black cohosh for many problems, including rheumatism and female complaints. The rhizome preparation of black cohosh was listed as a popular remedy in the early U.S. Pharmacopoeias from 1820 to 1936, demonstrating the interest in the medicinal value of this herb. Black cohosh has been used with success in Europe for over 40 years for treatment of symptoms associated with menopause.
Interactions and Depletions
Interactions
- Estrogen and estrogen-like medications including SERMs (tamoxifen, raloxifene). A laboratory study found that addition of black cohosh extract to tamoxifen therapy improved cytotoxicity in breast cancer cells.(26)
- Opioid binding medications, including opiate pain medicines. Black cohosh has been reported to have central opioid activity in postmenopausal women.(27) Stop use of black cohosh at least 2 days before surgery and anesthesia, as black cohosh may interact with medications used during anesthesia and post-op pain control.(28)
Dosage Info
Dosage Range
20-40mg (equivalent to 1mg-2mg of 27-deoxyactein), 2 times daily (standardized extract).
Most Common Dosage
40mg (equivalent to 2mg of 27-deoxyactein), 2 times daily (standardized extract).
Standardization
[span class=doc]Standardization represents the complete body of information and controls that serve to enhance the batch to batch consistency of a botanical product, including but not limited to the presence of a marker compound at a defined level or within a defined range.[/span]
The most current available medical and scientific literature indicates that this dietary supplement should be standardized to 1mg of triterpene glycosides calculated as 27-deoxyactein.
Uses
Frequently Reported Uses
- Climacteric symptoms associated with menopause And postmenopause
Other Reported Uses
- Arthritic Complaints; anti-inflammatory
- Headache
Toxicities & Precautions
General
This dietary supplement has a good safety profile with low toxicity, few and mild side effects and good tolerability.(6),(7)
Black cohosh is recommended to be taken for 6 months, followed by serum hormonal levels including estrogen (estradiol, estrone, estriol), DHEA, progesterone and testosterone.
Health Conditions
Black cohosh should be used with caution in those individuals with a liver condition or predisposed to a liver condition. There have been several reports of liver failure induced by black cohosh.(29),(30) A case of acute hepatitis involved a 47-year-old woman who used black cohosh for symptoms of menopause. She received a liver transplant three weeks after she started taking the herb. The report indicated the dose of black cohosh did not exceed the dosage recommended on the package; but no other dosage information was provided. It is not known if the supplement was adulterated or the past medical history of the patient. Black cohosh has been used with a low incidence of adverse effects in over 2,800 patients in reports and human clinical trials. A trial of 87 postmenopausal found no significant changes in total hepatic blood flow or any of the liver function tests after a year of treatment with standardized black cohosh.(31) However, regulatory agencies in the United States, Australia, Canada, and the European Union have released statements regarding the “potential association” between black cohosh and hepatotoxicity.(32)
Cutaneous vasculitis occurred in 2 patients on black cohosh therapy.(33)
Medical and scientific evidence indicates that constituents contained in this dietary supplement may have estrogenic activity. Until further research is performed, concern is warranted when recommending this dietary supplement to individuals who are susceptible to hormonally related cancers or who have a history of estrogen positive cancers.(8)
Side Effects
Large doses may cause nausea, vomiting, and headache. (9)
Pregnancy/ Breast Feeding
Do not use black cohosh in pregnancy, as it has reported uterine smooth muscle stimulant activity in laboratory studies. (10)
Age Limitations
Do not use in children under 2 years of age unless recommended by a physician.
Pharmacology
Hormonal balance activity
Clinical studies have reported positive effects on menopausal and post-menopausal complaints(11),(15),(35) with a good safety profile and few side effects(6) when using standardized extracts of black cohosh.(16) There are negative reports however, finding no benefit compared to placebo when using black cohosh extract for climacteric complaints and cognitive function during menopause and post menopause.(35),(36) It should be noted some negative studies did not use the recommended standardized product of black cohosh (see dosage and standardization). A review in 2008 of double blind, randomized, clinical trials in the evaluation of black cohosh’s efficacy reported the trials do not consistently demonstrate an effect of black cohosh on menopausal symptoms, but a beneficial effect of black cohosh on peri-menopausal women cannot be excluded.(37) Further studies need to be undertaken.
Black cohosh root and rhizome have been reported to have phytoestrogenic properties(11) though other studies have been unable to demonstrate estrogenic activity.(12),(13) Black cohosh contains the isoflavone formononetin, which has been reported to have estrogenic activity in laboratory rats.(14) Formononetin was reported to act as a competitor with estrogen in binding to uterine cells ex vivo.
Another constituent found in black cohosh, 27-deoxyactein, has also been reported to produce estrogen-like effects in humans.(17) In a controlled study, black cohosh tablets, standardized to 1mg of 27-deoxyactein, were given to 110 female patients in a university gynecological clinic. Patients received 2 tablets twice daily for 2 months. Half the patients took the black cohosh tablet, and half took a placebo. At the end of the required treatment period, both groups were tested for luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels, as increases in LH levels have been found in menopausal individuals complaining of hot flashes. There was no significant effect on the FSH serum concentration in either group. The study reported that black cohosh has positive effects on LH suppression in menopausal women, acting in an estrogen-like manner.
It should be noted, however, that naturally occurring estrogen in the body also affects the release of FSH through receptor binding; so even though black cohosh has estrogenic properties in the body, it does not have the exact pharmacology as naturally occurring estrogen. In another study, sixty-nine breast cancer patients completed a placebo-controlled study evaluating the impact of black cohosh on hot flashes and other menopausal symptoms experienced by these women. FSH and LH levels were also measured in the study. The results noted no significant difference between black cohosh and placebo in the number and intensity of hot flashes as well as other menopausal symptoms. Also, no differences were noted in the hormone levels measured.(13)
A laboratory study was designed to determine the binding affinity of three triterpene glycosides contained in black cohosh to estrogen receptor beta. Cimicifugoside, cimiracemoside F, and 27-deoxyactein were evaluated and of the three only 27-deoxyactein demonstrated any binding affinity, a weak four percent.(18) Of interest is a laboratory study reporting serotonergic activity (5-HT binding and increase in cAMP) of black cohosh extract, indicating another possible mechanism in improvement in mood and other climacteric symptoms.(38) A small clinical study found central opioid activity in postmenopausal women.(27)
A clinical study in 120 healthy, postmenopausal women compared black cohosh with fluoxetine (Prozac) for climacteric symptoms.(39) Black cohosh was found to be is more effective for treating hot flushes and night sweats, with fluoxetine being more effective in improvements in depressive symptoms.
Cimicifugoside is believed to affect the hypothalamus-pituitary system, producing a hormonal balancing effect in the female reproductive system.(21) The hypothalamus and pituitary glands control many aspects of human biochemistry, including hormonal release and regulation. Epidemiologic studies have suggested that consumption of phytoestrogen-rich foods may protect against breast cancer, and phytoestrogens such as genistein have been reported to both inhibit and stimulate the growth of some human breast cancer cells. Of recent interest is a report that phytoestrogen compounds found in black cohosh and other herbs such as vitex (chasteberry), hops and red clover may inhibit the growth of various breast cancer cell lines.(22),(23) Other studies have used breast cancer cell lines to demonstrate the estrogenic activity of black cohosh.(24)
Laboratory studies have reported that black cohosh may help protect against breast cancer in at risk individuals.(40) A laboratory study found that addition of black cohosh extract to tamoxifen therapy improved cytotoxicity in breast cancer cells.(26) A clinical study also has reported that black cohosh extract has no systemic or breast-specific estrogenic effects.(41) Also, no changes in endometrial thickness have been reported when using black cohosh extracts.(42)
Of interest is a clinical study in postmenopausal women treated with black cohosh found a decrease in the urinary concentration of N-telopeptides, a marker of bone resorption, and an increase in alkaline phosphatase, a marker of bone formation, in the third month of therapy. Serum from treated women did not modify the activity of alkaline phosphatase or the expression of three genes, runt-related transcription factor-2 (Runx-2), alkaline phosphatase, and osteocalcin, when added to the MC3T3-E1 osteoblastic cell line.(43) Based on the findings, more studies need to be performed to determine black cohosh’s role in protecting menopausal and postmenopausal women from bone loss.
A review of eight human studies on the effectiveness of an extract of black cohosh on alleviating menopausal symptoms reported that it is a safe, effective alternative to estrogen replacement therapy for those patients in whom estrogen replacement therapy is either refused or contraindicated.(15) Other literature reviews have specifically noted that no evidence exists supporting the use of black cohosh and other herbs with noted estrogenic activity for vaginal dryness and dyspareunia in the pre and post menopausal women who experience urogential atrophy.(19),(44)
A clinical trial found that infertile women being treated with clomiphene citrate (Serophene) reported improved induction and timed intercourse after follicular-phase supplementation with phytoestrogens from black cohosh.(45)
Other activity
Black cohosh is also used as an adjunctive therapy in the management of rheumatoid arthritis and headache. The constituent isoferulic acid has been reported to have anti-inflammatory effects in animals. Isoferulic acid may also decrease muscular spasm in laboratory animals, potentially aiding not only headache but also menstrual pain and cramping.(20) The constituent salicylic acid is also found in small quantities in black cohosh. It is presumed that salicylic acid also contributes to the anti-inflammatory and analgesic properties of black cohosh. A laboratory study reported that the anti-inflammatory activity of compounds in black cohosh may also be due to its modulation of a signaling mitogen activated protein kinase and transcription factor nuclear factor-kappaB activities.(46)
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