Black Cohosh – a misunderstood herb
From pain relief to menopausal treatment
Black Cohosh is perhaps one of the most misunderstood herbs. Traditionally Black Cohosh was used by Indigenous North American tribes for all manner of pain management and inflammation. This included rheumatic pain, menstrual cramps, pain of childbirth, sore throat and back pain. It was also utilised for cough, insomnia and to treat snake bites.(1) In current times, however, Black Cohosh is widely used for menopausal symptoms including hot flashes, night sweats, vaginal dryness and atrophy, low libido and mood disturbances.(2-4) The herb became the focus of clinical research following the findings of a large-scale study which associated hormone therapy with serious adverse effects, which included stroke, pulmonary embolus, venous thrombolic events, gallbladder disease and increased breast cancer risk.(3) Hormone therapy is the standard conventional treatment for menopausal symptoms.
Is it effective for menopausal symptoms?
The most recent systematic review to date, undertaken by Castelo-Branco et al, concluded that Black Cohosh is effective for treating menopausal symptoms. This review specifically looked at isopropanolic extract of Black Cohosh.(4) Several other randomised controlled trials have demonstrated that Ze 450 Black Cohosh extract also provides symptomatic relief for menopausal women.(5-7) Generally, the findings reveal that Black Cohosh can reduce the intensity, frequency and severity of hot flashes and reduce night sweats. It can also improve sleep and psychological symptoms associated with menopause, and increase overall quality of life.(4, 8-12). Some studies have also indicated it may benefit the cardiovascular system.(10, 13) Overall, what this data suggests is that Black Cohosh is indeed effective for treating menopausal complaints. However, this may depend on the extract used. Dosage as well as treatment duration are other important considerations.
Hormone modulator not oestrogenic
Black Cohosh is thought to have a hormone-modulating activity, which explains why it can relieve menopausal complaints. Specifically, it is thought to act like a selective estrogen receptor modulator. Modulatory activity may take place in selected sites such as the vagina, bone tissue and fat tissue.(10) It was previously thought that it had oestrogenic activity.(14) Consequently, this notion created a theoretical concern that it could worsen oestrogen sensitive tumours.(15) However, newer studies have demonstrated that it may actually be protective against oestrogen-dependant cancers like breast cancer.(8) One human trial showed that breast cancer patients who take Black Cohosh with tamoxifen (a breast cancer drug) may possibly benefit from prolonged recurrence-free survival.(16) Black Cohosh may also have serotonergic, dopaminergic and opioid receptor activities, which may play a role in improving menopause symptoms and other conditions.(14)
A safe herb despite the label
The Australian Therapeutic Goods Administration (TGA) currently requires Black Cohosh supplements to have a label statement which advises of the possible risk of liver damage. This is due to reports in Australia and overseas of liver damage in patients taking the herb. This decision was made after an expert advisory group created by the TGA analysed the data in order to assess the risk.(17) Unfortunately, the group failed to adequately consider that the very few case reports on this issue are abysmally unreliable. In fact, these case studies have been appropriate critiqued.(4, 18) Additionally, high quality clinical studies have demonstrated that this herb is well tolerated and does not impact the liver when used in a typical therapeutic manner. Trials also show it produces significantly fewer side-effects compared to hormone therapy and a level of adverse effects similar to placebo.(3, 4, 19, 20)
A herbalist’s view – not just a menopause herb
While researchers scrambled to find in Black Cohosh, an effective alternative to hormone therapy, the ancient wisdom regarding its therapeutic value was dimmed. As a result, there is now a common perception that this plant is mainly a menopause herb. In fact, this herb is much more versatile. Herbalist Lesley Tierra suggests the herb is also beneficial for other female conditions such as menstrual irregularity, headache before menstruation, painful menses, and endometriosis. Moreover, she highlights its antispasmodic activity, useful for all nervous conditions including neuralgia, cramps, and nerve pain. She claims to have successfully used Black Cohosh in combination with White Peony in epilepsy, reducing the severity and duration of seizures. Furthermore, she utilises it for arthritic pain due to its antirheumatic properties.(15)
If you wish to give Black Cohosh a try for any of the above conditions, it is recommended you seek professional guidance and obtain a good quality supplement. Also, if you are experiencing menopausal symptoms and wish to try this herb, ensure you obtain an extract that has been proven to be effective in well executed clinical trials.
- Pengelly A, Bennett K. Appalachian plant monographs. Black cohosh – Actaea racemosa L. 2012 http://www.frostburg.edu/aces/appalachian-plants/.
- Braun L, Cohen M. Herbs and Natural Supplements, Volume 1: An Evidence-Based Guide: Elsevier Health Sciences; 2015.
- Leach MJ, Moore V. Black cohosh (Cimicifuga spp.) for menopausal symptoms. The Cochrane database of systematic reviews. 2012;2012(9):Cd007244.
- Castelo-Branco C, Gambacciani M, Cano A, Minkin MJ, Rachoń D, Ruan X, et al. Review & meta-analysis: isopropanolic black cohosh extract iCR for menopausal symptoms – an update on the evidence. Climacteric. 2021;24(2):109-19.
- Lopatka L, Totzke U, Schmid A, Käufeler R. Die Traubensilberkerze in der Behandlung menopausaler Beschwerden-Ergebnisse einer Therapiebeobachtung mit Cimifemin® uno. Journal für Menopause. 2014;14(2):16-21.
- Schellenberg R, Saller R, Hess L, Melzer J, Zimmermann C, Drewe J, et al. Dose-dependent effects of the Cimicifuga racemosa extract Ze 450 in the treatment of climacteric complaints: a randomized, placebo-controlled study. Evid Based Complement Alternat Med. 2012;2012.
- Drewe J, Zimmermann C, Zahner C. The effect of a Cimicifuga racemosa extracts Ze 450 in the treatment of climacteric complaints–an observational study. Phytomedicine. 2013;20(8-9):659-66.
- Al-Akoum M, Maunsell E, Verreault R, Provencher L, Otis H, Dodin S. Effects of Hypericum perforatum (St. John’s wort) on hot flashes and quality of life in perimenopausal women: a randomized pilot trial. Menopause. 2009;16(2):307-14.
- Beer A-M, Osmers R, Schnitker J, Bai W, Mueck AO, Meden H. Efficacy of black cohosh (Cimicifuga racemosa) medicines for treatment of menopausal symptoms – comments on major statements of the Cochrane Collaboration report 2012 “black cohosh (Cimicifuga spp.) for menopausal symptoms (review)”. Gynecol Endocrinol. 2013;29(12):1022-5.
- Fernandes ES, Celani MFS, Fistarol M, Geber S. Effectiveness of the short-term use of Cimicifuga racemosa in the endothelial function of postmenopausal women: a double-blind, randomized, controlled trial. Climacteric. 2020;23(3):245-51.
- Jiang K, Jin Y, Huang L, Feng S, Hou X, Du B, et al. Black cohosh improves objective sleep in postmenopausal women with sleep disturbance. Climacteric. 2015;18(4):559-67.
- Ross SM. Menopause: A Standardized Isopropanolic Black Cohosh Extract (Remifemin) Is Found to Be Safe and Effective for Menopausal Symptoms. Holist Nurs Pract. 2012;26(1).
- Kim E-Y, Lee YJ, Rhyu M-R. Black cohosh (Cimicifuga racemosa) relaxes the isolated rat thoracic aorta through endothelium-dependent and -independent mechanisms. J Ethnopharmacol. 2011;138(2):537-42.
- Bone K, Mills S. Principles and Practice of Phytotherapy: Modern Herbal Medicine. 4th ed: Churchill Livingstone Elsevier; 2013.
- Tierra L. Healing with the herbs of life. Berkleley: Crossing Press; 2013.
- Henneicke-von Zepelin HH, Meden H, Kostev K, Schröder-Bernhardi D, Stammwitz U, Becher H. Isopropanolic black cohosh extract and recurrence-free survival after breast cancer. Int J Clin Pharmacol Ther. 2007;45(3):143-54.
- Therapeutic Goods Administration. Black cohosh (Cimicifuga racemosa): New labelling requirements and consumer information for medicines containing Black cohosh 2007 https://www.tga.gov.au/alert/black-cohosh-cimicifuga-racemosa.
- Teschke R, Bahre R, Genthner A, Fuchs J, Schmidt-Taenzer W, Wolff A. Suspected black cohosh hepatotoxicity–challenges and pitfalls of causality assessment. Maturitas. 2009;63(4):302-14.
- Stoll W. Phytotherapeutikum beeinflusst atrophisches Vaginalepithel: Doppelblindversuch Cimicifuga vs. Oestrogenpräparat. Therapeutikon. 1987;1:23-31.
- Ulbricht C, Windsor RC. An Evidence-Based Systematic Review of Black cohosh (Cimicifuga racemosa, Actaea racemosa) by the Natural Standard Research Collaboration. J Diet Suppl. 2015;12(3):265-358.