Menopause & perimenopause
Black cohosh for menopausal symptoms
(Actaea racemosa, formerly Cimicifuga racemosa)
You may have considered trying black cohosh, but seen the conflicting reports and wondered whether it’s right for you. As one of the top ten selling botanical products in America, there must be something to it. Let’s take a closer look at why American women are getting back to their roots with this medicinal herb.
What is black cohosh?
Black cohosh is a controversial but popular herbal supplement used for generations by women the world over to treat symptoms of hormonal imbalance. At Women to Women we’ve found it to be an extremely useful phytocrine that boosts a woman’s own ability to balance estrogen by mimicking some of that hormone’s functions — not a panacea, but a form of natural, plant-based endocrine support that is most effective when layered overtop a core program built on optimal nutrition, dietary supplementation, and lifestyle modifications that support a woman in hormonal transition from the ground up.
The plant commonly referred to as black cohosh grows as a tall, graceful perennial indigenous to the shaded woodlands of eastern North America. Its fibrous, half-root/half-stem rhizomatous structure spreads quickly just beneath the surface of the forest floor. This rhizome is the portion of the plant containing the alkaloid chemicals of greatest interest for their medicinal properties.
What is black cohosh used for?
The Latin name for the black cohosh genus, Cimicifuga, from cimex, “a bug,” and fugo, “I drive away,” provides us a clue about one of its traditional uses — warding off “bugs” — and gardeners find it protects its cultivated companions nicely from harmful pests. But among Native American tribes, black cohosh was a favorite remedy for centuries for numerous bodily complaints, ranging from fever and rheumatism to menstrual cramps and snake bites. In successive generations, this herb has come into wider use by naturopaths, herbalists, and women worldwide to ease hot flashes and other symptoms of estrogen deficiency and imbalance.
Black cohosh, the subject of study for many decades throughout Europe, has been found effective time and again in reducing frequency and severity of hot flashes, irregular periods, and vaginal dryness. Though researchers in America continue to hotly debate this matter, in Europe women have rarely resorted to the conventional HRT American women spend millions on, largely because they prefer over-the-counter herbal preparations to pharmaceutical solutions.
How does black cohosh work?
In December of 2006, a large study looking at the effects of several herbal-combination regimens and menopausal hormone therapy concluded that black cohosh was no better than placebo in reducing menopausal hot flashes. Results of this study — called the Herbal Alternatives for Menopause Trial (HALT) and jointly funded by the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health — were a huge disappointment, but as the executive director of the American Botanical Council put it, “definitely not the last word.” He pointed out that not only was the study design flawed, but the authors omitted data showing a host of beneficial secondary effects when they published their findings in the Annals of Internal Medicine. While the mainstream media leapt on the findings as conclusive, the reality is that the results of this study are entirely inconsistent with the history of findings on black cohosh and menopause, and should be placed in context alongside them.
To date, the effects of black cohosh have been studied on thousands of menopausal women, with the preponderance of evidence well in favor of its benefit–risk ratio. When women rank their menopausal symptoms using two different assessment measures known as the Kupperman Index and the Menopause Rating Scale, black cohosh has more consistently delivered better results than many conventional therapies such as hormonal drugs and antidepressants in assuaging hot flashes, mood swings, vaginal atrophy, depression, anxiety and other menopausal symptoms — without increasing their risk of uterine or breast cancer. Not a difficult choice for us, distinguishing which of these two approaches is the more trustworthy!
So if black cohosh does work, then how does it work? Among others, the substances in black cohosh root believed to be most effective, or bioactive in the body, include the triterpene glycosides known as actein and cimicifugocide, plus saponins and acids. From the mid-1980’s the actions of this plant were thought to be attributable to the isoflavone known as formononetin, but more recent analysis of native black cohosh plant populations has not identified the presence of this isoflavone in roots or rhizomes.
Older research had also suggested black cohosh works through its estrogenic or hormone-like activity, but newer findings indicate that it does not universally bind to either of the known estrogen receptors like a true phytoestrogen. Instead, it is classified as a functional mimetic of a hormone, meaning that it is a plant which mimics — and supports — certain activities of a hormone in the body, the hormone being estrogen in the case of black cohosh.
Other laboratory researchers at the University of Illinois have recently linked constituents of black cohosh to human opiate receptors, the chemical receptors in the brain activated by opiates like heroin and morphine. The extract used in the Illinois study showed an agonist, or up-regulating, effect on the brain’s opiate receptors, which, with their ties to the central nervous system, are also closely associated with mood, body core temperature settings, and sex hormones. While a seratonergic (antidepressant) effect had been suggested as early as 2003, the Illinois study’s authors note that the opiate-agonistic activity on female neuroendocrinology may reveal a clue as to how black cohosh quells menopausal symptoms.
The beauty of new research being conducted on time-honored herbal remedies like black cohosh is that it allows us to design safe, natural phytotherapeutic combinations that fully support weakly functioning estrogen pathways. Whereas the conventional approach has been to uniformly address all menopausal women as estrogen-deficient, the functional medicine approach views various forms of hormonal dysregulation as the genesis of menopausal symptoms and health risks. These include not only low estrogen levels, but poor utilization of the estrogen that is present, imbalance of estrogen in relation to other hormones such as progesterone and testosterone, erratic fluctuations in hormone levels, and sluggish disposal of used and unnecessary or harmful metabolites of estrogen through detoxification in the liver and subsequent excretion.
This new research may also help explain why women with “normal” hormonal levels experience symptoms, as well as why black cohosh as a stand-alone preparation doesn’t work for every woman with midlife hot flashes. Simply put, not every woman’s chemistry is the same.
Black cohosh preparations — what to look for and typical dosages
Black cohosh can be taken in various forms: as an extract in an alcohol-based or water-based tincture, as a tea infusion, or in tablets or capsules formed from the dried powder. It is also available in proprietary combination products, such as the one we offer in our Personal Program.
If you decide to use black cohosh on its own, however, for maximal therapeutic benefit, the product label should state that it’s standardized to a minimum of 2% total triterpene glycosides (calculated as 26-deoxyactein — this is sometimes mistakenly listed as 27–deoxyactein, so be sure to check the label). In addition, black cohosh is generally a “wildcrafted” species, meaning it’s grown and harvested in the wild rather than being farmed. As with other stand-alone herbal remedies, you may want to check the label to be sure the ingredients are either ecologically wildcrafted or certified organically grown.
Optimal dosage will depend on your unique physiology; some practitioners recommend women start with a daily dose of 40 mg of the dried root powder twice a day, while others suggest 20 mg twice daily. You may want to consult with an herbalist or naturopath in determining which black cohosh product will work best for you as an individual. We’ve added 40 mg of black cohosh as one part of the isoflavone complex in our Herbal Equilibrium, which has been designed to address both the deficiencies and the imbalances in estrogen, progesterone and testosterone common to women in menopause and perimenopause.
Side effects and safety of black cohosh
Regardless of your state of health, we encourage you to fully disclose to your healthcare providers all over-the-counter supplements, medicinal foods, or herbal preparations you are using. Ideally, your relationship with your healthcare provider will be one of mutual trust. If you are guarded or unsure of where you stand, we hope you will seek out a provider with whom you can communicate freely.
Black cohosh is generally considered to be very well tolerated, with few if any side effects — though everyone’s different, and some women report mild GI problems when taking it. Comprehensive safety reviews on black cohosh suggest adverse events are rare when used appropriately. That said, there are a couple of exceptions.
First, if you have a history of liver problems, you may want to be closely monitored while on black cohosh, or consider alternatives such as soy for menopausal symptoms. Though a few case reports linking black cohosh with possible liver toxicity have been published, toxicologists have not substantiated these claims or identified causality regarding the metabolites of black cohosh to the liver — and a recent US court case ruled that research consistently holds that black cohosh is nonhepatotoxic.
Nonetheless, it’s always wise to err on the side of caution, and the United States Pharmacopoeia has recently recommended that labels on black cohosh products include the following safety precaution:
In rare cases black cohosh has been reported to affect the liver. Discontinue use and consult a healthcare practitioner if you have a liver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice.
On a more serious note for women undergoing treatment for breast cancer, we would caution you to consult with your oncologist before using black cohosh. This is because black cohosh may have an effect on how cancer cells respond to cisplatin (Platinol), doxorubicin (brand name Doxil, also formerly known as Adriamycin), or docetaxel (Taxotere)-based chemotherapeutic regimes.
On the other hand, there are numerous studies indicating the beneficial effects of black cohosh for breast cancer patients. Most recently, it has shown protective effects that may hold promise as a preventative for breast cancer. Additionally, a 2007 study published in the journal Nutrition and Cancer confirmed that black cohosh extract relieves menopausal symptoms without systemic or breast-specific estrogenic effects.
Most importantly, what we want for all women is that they feel comfortable enough with their healthcare providers to talk about all their options — including herbal remedies such as black cohosh and Herbal Equilibrium — whether they are facing hot flashes in menopause or a more serious condition such as breast cancer. At Women to Women, we’re here to provide the kind of support you need, when you need it.
Our Personal Program is a great place to start
The Personal Program promotes natural hormonal balance with nutritional supplements, our exclusive endocrine support formula, dietary and lifestyle guidance, and optional phone consultations with our Nurse–Educators. It is a convenient, at-home version of what we recommend to all our patients at the clinic.
If you have questions, don't hesitate to call us toll-free at 1-800-798-7902. We're here to listen and help.
We’re always happy to welcome new patients to our medical clinic in Yarmouth, Maine, for those who can make the trip. Click here for information about making an appointment.
Related to this article:
References & further reading on black cohosh for menopausal symptoms
Original Publication Date: 02/15/2007
Last Modified: 06/15/2009
Principal Author: Marcella Sweet