Background
Black Cohosh is a North American wildflower that grows in moist, shady woods from New England to Missouri. Its other names are Black Snakeroot, Rattleroot, Bugbane, and Bugwort. Since common names are so variable, it's best to check that you're getting the right species: Cimicifuga racemosa (L.) Nutt. (botanists also call it Actaea racemosa L. or Actaea macrotys). Most of the herb that's available is still harvested from the wild, though that might be changing.
Do not confuse BLACK Cohosh with BLUE Cohosh (which is why checking the Latin name is important). Blue Cohosh is a completely different species (Calilophyllum thalictroides). It also is sometimes listed as for "female problems," but it has a substance like nicotine, so it's potentially toxic and dangerous.
BLACK Cohosh may seem new, but it has a long medical history. Native Americans used it for centuries and passed their knowledge to the European settlers. It was listed as an official drug of The Pharmacopoeia of the United States of America from 1830-1926 under the name Black Snakeroot. In the nineteenth century, there were herbal physicians called the Eclectics, who used it for rheumatism, endometritis, and menstrual and childbirth problems. Chinese herbal medicine also adopted it in the nineteenth century for reducing blood pressure and clearing the lungs, as well as for arthritis.
Black Cohosh was a major ingredient of an old-time remedy, Lydia Pinkham's Vegetable Compound for menstrual stress and nervous tension. It was a very popular medicine that's still sold today (and might be a possible source), though it might have been effective against "nervous tension" in part because it was be 36 proof!
It remained in use in Europe after American medicine became "scientific," being used for menopause specifically since the 1950's.
State of Current Knowledge
Knowledge of Black Cohosh will be a lot better soon. The National Institutes of Health have given a $7.9 million grant to the University of Illinois at Chicago to do the kind of rigorous research that others have not been able to afford to do on it and nine other herbs. Until then, we have to use the studies that exist, which are few and have little scientific rigor, being mostly small, brief, uncontrolled, and unrandomized.
Most of the studies were sponsored by the company (Schaper & Brummer) that manufactures a Black Cohosh supplement (Remifemin) in Europe. Remifemin is root extract, standardized to contain 1 mg. of triterpene glycosides, which they believe is the active ingredient. It appears, however, that it contains a number of active ingredients, including isoferulic and salicylic acids (anti-inflammatories) and others. In 1996, 10 million monthly units of Remifemin were sold, so there's been a lot of experience with it, but there have been no studies on its effect on bone resorption or its effect on heart disease, so it's not a complete substitute for HRT.
Not a Phytoestrogen(?)
One of the areas that's contradictory is whether or not it acts like estrogen. Though a few studies thought they saw it bind briefly with estrogen receptors and improve vaginal lining, the newer, more rigorous studies are not showing the same thing. If there is an estrogenic action, it's very small. Black Cohosh does seem to lower luteinizing hormone, which is a trigger for hot flashes but not apparently by imitating estrogen.
Two studies looked at two specific types of breast cancer cells in the test tube to see whether Black Cohosh bound with the estrogen receptors in the cells. It had either no effect or had an anti-estrogenic effect, boosting the effect of Tamoxifen (an anti-estrogen used to prevent breast cancer). These last two studies were not published in peer-review journals (no one checked them out for their quality), and one was done by an employee of the manufacturer of Remifemin, so they're iffy in quality.
Relieving Symptoms
Most of the studies used standard tests for reporting menopausal symptoms, in particular the Kupperman Index. It asks women to grade their symptoms on a scale of "severe," "moderate," "mild," and "not present." A high score means severe symptoms. The symptoms of menopause that it asks about are depressed mood, vertigo/dizziness, headache, heart palpitations, hot flashes, joint pain, loss of concentration, nervousness/irritability, profuse perspiration, and sleep disturbance. All of the studies showed that women who took Black Cohosh improved their Kupperman Index scores, sometimes by a lot.
A study of 629 women reported that 80% improved their Kupperman Index scores within 6 to 8 weeks (which agreed with another study that said 80% improved)-40% to 50% said there was marked improvement, 35% to 40% said there was some improvement. A double-blind study showed that Black Cohosh lowered the Kupperman Index score by more than half--slightly more effective than Premarin and a lot more than Valium. Another study that had 80 postmenopausal women divided into groups taking conjugated estrogen (Premarin) .625 mg per day, black cohosh root extract (Remifemin) 8 mg per day, or a placebo found that Black Cohosh lowered hot flashes from 5 per day to less than 1 per day, better than the estrogen alone did (though that might have been a flaw in the study).
Most relevant for those of us in the Hormone Jungle, another, more independent study, used 60 women who were under 40 who had had a hysterectomy but had kept one ovary. All the women had high Kupperman Index scores going into the study. Some took estriol (weaker estrogen), some took conjugated estrogen (something like Premarin, 1.25 mg), some took a combination of conjugated estrogen and progestin (something like Prempro), and others took Remifemin (8 mg of Black Cohosh root extract). They found no difference between the groups. All of them lowered the symptoms significantly.
Side Effects
The German Commission E, an expert panel commissioned by the German government to assess herbal products, recommends Black Cohosh without warnings, though they recommend taking it for only six months because there aren't any long-term safety studies. The Commission E doesn't have the same requirements as the FDA in America, but it's still an evaluation of the available information. The most common side effects are mild, short-lasting gastrointestinal complaints. One of the studies reported that 7% of the women had some digestion and intestinal problems.
At very high doses, you can experience dizziness, nausea, vomiting, diarrhea, abdominal pain, visual dimness, headache, tremors, joint pains, and a depressed heart rate. It did pass a rat toxicity test, so stopping the high dose should stop the symptoms.
Studies of whether Black Cohosh causes cancer are limited but have all turned up negative.
Because it does not seem to act like estrogen, it seems worth talking to your doctor about taking Black Cohosh if you can't take HRT because of liver and gallbladder disease, pancreatitis, endometriosis, fibroids, or fibrocystic disease.
Warnings
Ask your doctor before taking it if you
1. take tranquilizers or sedatives
2. have a blood pressure problem (it seems to lower arterial pressure)
3. are taking estrogen (the combination of the two is unknown)
4. have cancer
Don't take it at all if you
1. are pregnant (it starts contractions)
2. are breast feeding
Dose
The recommended dose is based on Remifemin, the most tested form. It's 20 mg of root extract, twice a day. You can also get the equivalent in tinctures. Another method is dried root, from which you can make a tea (one website recommended 20 g of dried root in 34 oz. of water, bring to a boil, then simmer 20 to 30 minutes until liquid is reduced by a third, strain, cover, and store in the refrigerator for up to 48 hours. That's a completely untested source, so don't quote me on that--and I have no idea what it tastes like!).
This content was written by staff of HysterSisters.com by non-medical professionals based on discussions, resources and input from other patients for the purpose of patient-to-patient support.
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