What is black cohosh?
Black cohosh (Cimicifuga racemosa) is a perennial dicot plant from the buttercup family (Ranunculaceae), and is native to North America, spanning from Canada to Georgia. Its roots and rhizomes (underground stems) are utilized in supplements. Black cohosh extracts can vary considerably depending on factors such as cultivation, harvesting, extraction techniques, solvent used, and standardization methods.[1][2]
The rhizomes of black cohosh are typically harvested during early autumn once the flowers have turned to fruit and the leaves have withered. The harvested rhizomes are cut into segments, dried, and propagated in spring to create new plants.[3]
The main active compounds in black cohosh, sometimes referred to as triterpene glycosides, include cycloartanol compounds (e.g., acteol, actein), cimigenol, and cimicifugoside. Other bioactives include flavonoids, (E)-isoferulic acid, dopargine (a derivative of dopamine), cimipronidine, salsolinol, and N(omega)-methylserotonin.
What are black cohosh’s main benefits?
Research on black cohosh primarily focuses on its potential benefits for perimenopause and postmenopause symptoms.
One meta-analysis revealed that the isopropanolic extract of black cohosh (iCR) was found to be more effective than placebo in alleviating neurovegetative symptoms (e.g., hot flashes, night sweats, palpitations) and psychological symptoms (e.g., depression) in women with natural perimenopausal and postmenopausal symptoms.[1] One of the studies within this meta-analysis also found that black cohosh improved sleep efficiency and decreased wake after sleep onset (WASO) compared to placebo.[4]
For women undergoing iatrogenic menopause (i.e., menopause brought about by medical interventions such as hysterectomy), the effects of black cohosh are inconsistent. In one placebo double-blind RCT menopausal women with breast cancer (many undergoing tamoxifen treatment) who received iCR for 2 months did not exhibit a significant reduction in the intensity and count of hot flashes compared to placebo. However, they reported notably-reduced night sweating.[5] It’s important to note that this study suffered from a small sample size and a high dropout rate, with hot flashes being self-reported by the participants. That said, longer-duration open studies (12–24 weeks) also have demonstrated significant reductions in induced hot flashes, sweating, and psychological symptoms in participants taking iCR.[1]
To validate these findings, more extended RCTs that assess climacteric symptoms (i.e., symptoms of perimenopause, menopause and/or postmenopause) using objective measurements[6] (e.g., increases in heart rate, finger blood flow, respiratory exchange ratio, skin temperature, and core body temperature) instead of self-reported questionnaires are essential.
What are black cohosh’s main drawbacks?
Black cohosh is generally considered safe, and clinical studies did not report significant side effects.
The administration of standard or high doses of black cohosh over 3–6 months does not appear to impact liver function. Likewise, black cohosh shows no significant effects on blood pressure, heart rate, body weight, or body mass index (BMI). Studies have also explored its impact on kidney function, total cholesterol, and triglycerides, revealing no overall effects except for a few studies reporting instances of increased high-density lipoprotein (HDL) cholesterol and decreased low-density lipoprotein (LDL) cholesterol.[1] Furthermore, trials comparing black cohosh to tibolone (a medication used to treat menopausal symptoms) found that people taking black cohosh exhibited fewer side effects (e.g., vaginal bleeding, spotting) than those taking tibolone.[1][7]
One meta-analysis indicated that 0.5% to 15% of menopausal women taking black cohosh experienced gastrointestinal discomfort.[8]
One animal study, coupled with in vitro testing on human cells, found that both in rats and in vivo black cohosh induced micronuclei (MN), which are biomarkers of genetic alterations, while also disrupting the folate pathway. This disruption led to non-regenerative macrocytic anemia in rats, characterized by enlarged red blood cells and inadequate bone marrow red blood cell replacement. Although these results indicate a potential risk associated with taking black cohosh, clinical studies are required to examine the impact on the human body.[9]
How does black cohosh work?
Initially, the presumed mechanism of black cohosh involved the activation of estrogen receptors. However, both in vitro and in vivo studies on black cohosh extracts yielded no evidence of estrogenic activity. Instead, it appears that black cohosh binds to receptors in the central nervous system responsible for functions like thermoregulation, mood, and sleep (e.g., mu-opioid,[10] serotonin, dopamine, c-aminobutyric acid). This mode of action clarifies why black cohosh does not influence estrogen levels, breast tissue density or proliferation, endometrial thickness, or vaginal cytology.[11][1]
Additionally, black cohosh showed anti-estrogenic properties in breast cancer studies. This anti-estrogenic effect was observed in vitro as a reduction in the growth of estrogen-responsive breast cancer cells.[12]
Another in vitro study found a potential nonestrogenic thermoregulatory mechanism of black cohosh, which may modulate the immune system by promoting nitric oxide (NO) production in cells treated with interferon gamma (INF-gamma).[11]
What are other names for Black Cohosh
- Cimicifuga racemosa
- Bugbane
- Bugroot
- Snakeroot
- Rattleroot
- Blackroot
- Black Snake Root
- Blue Cohosh (completely different herb)
Dosage information
If using an isopropanolic extract (usually sold under the brand name of Remifemin), 20-40mg daily is used in doses of 20mg; taking 20mg results in a once daily dosing, whereas taking 40mg is twice daily dosing of the 20mg. This dosage (20-40mg) confers 1-2mg of triterpenoid glycosides.
If using an aqueous:ethanolic extract of black cohosh root (ie. not Remifemin) then doses range from 64-128mg daily which are usually taken in two divided doses. This contributed about the same amount of triterpenoid glycosides.
It is not known whether or not black cohosh needs to be taken with food, although it is sometimes recommended to do so out of prudency.
Frequently asked questions
Black cohosh (Cimicifuga racemosa) is a perennial dicot plant from the buttercup family (Ranunculaceae), and is native to North America, spanning from Canada to Georgia. Its roots and rhizomes (underground stems) are utilized in supplements. Black cohosh extracts can vary considerably depending on factors such as cultivation, harvesting, extraction techniques, solvent used, and standardization methods.[1][2]
The rhizomes of black cohosh are typically harvested during early autumn once the flowers have turned to fruit and the leaves have withered. The harvested rhizomes are cut into segments, dried, and propagated in spring to create new plants.[3]
The main active compounds in black cohosh, sometimes referred to as triterpene glycosides, include cycloartanol compounds (e.g., acteol, actein), cimigenol, and cimicifugoside. Other bioactives include flavonoids, (E)-isoferulic acid, dopargine (a derivative of dopamine), cimipronidine, salsolinol, and N(omega)-methylserotonin.
The genus name of the black cohosh plant, Cimicifuga, derives from the Latin words cimex (bedbug) and fugare (to repel). This name arises from the strong and unpleasant smell that the leaves and flowers of certain species in this genus have. Another common name for black cohosh is bugbane, indicating its historical use as an insect repellent, often placed within pillows or mattresses.[15][3]
The term "cohosh" originates from an Algonquian term meaning "rough." This refers to the plant’s robust, knotted, and dark rhizomes.[3]
Historically, Indigenous people of North America, such as the Penobscot, Winnebago, and Dakota, utilized black cohosh for various purposes, such as the treatment of cough, cold, constipation, fatigue and rheumatism, malaria, kidney malfunctioning, and even to increase breast milk production.[3]
Research on black cohosh primarily focuses on its potential benefits for perimenopause and postmenopause symptoms.
One meta-analysis revealed that the isopropanolic extract of black cohosh (iCR) was found to be more effective than placebo in alleviating neurovegetative symptoms (e.g., hot flashes, night sweats, palpitations) and psychological symptoms (e.g., depression) in women with natural perimenopausal and postmenopausal symptoms.[1] One of the studies within this meta-analysis also found that black cohosh improved sleep efficiency and decreased wake after sleep onset (WASO) compared to placebo.[4]
For women undergoing iatrogenic menopause (i.e., menopause brought about by medical interventions such as hysterectomy), the effects of black cohosh are inconsistent. In one placebo double-blind RCT menopausal women with breast cancer (many undergoing tamoxifen treatment) who received iCR for 2 months did not exhibit a significant reduction in the intensity and count of hot flashes compared to placebo. However, they reported notably-reduced night sweating.[5] It’s important to note that this study suffered from a small sample size and a high dropout rate, with hot flashes being self-reported by the participants. That said, longer-duration open studies (12–24 weeks) also have demonstrated significant reductions in induced hot flashes, sweating, and psychological symptoms in participants taking iCR.[1]
To validate these findings, more extended RCTs that assess climacteric symptoms (i.e., symptoms of perimenopause, menopause and/or postmenopause) using objective measurements[6] (e.g., increases in heart rate, finger blood flow, respiratory exchange ratio, skin temperature, and core body temperature) instead of self-reported questionnaires are essential.
During menopause, the drop in estrogen levels results in gradual bone loss.
Supplementation with black cohosh in ovariectomized rats resulted in a reduction of bone loss from 53.7% to 38.7% over time.[13] Positive effects on bone metabolism were also observed in humans when measuring urinary markers and alkaline phosphatase. However, the only human trial to measure bone mineral density did not show any effects from black cohosh intervention.[14]
The combination of St. John’s wort (Hypericum perforatum) and high doses of iCR appears to be more effective at improving psychological climacteric symptoms, like depression, than black cohosh alone. Furthermore, the frequency of adverse events did not significantly differ between iCR taken alone or vs. iCR in combination with St. John’s wort.[1]
One randomized clinical study compared a 40 mg daily dose of an water extract of iCR to a standard therapy consisting of low-dose transdermal estradiol (25 mg 7-day patches) plus with 10 mg a day of dihydrogesterone for the last 12 days of the 3-month estradiol treatment. From the first month of treatment, both black cohosh and the standard treatment significantly reduced the daily count of hot flashes and the Greene climacteric scale score for vasomotor symptoms compared to baseline. These effects were maintained during the 3 months of follow-up, and no significant difference between the two treatments was noted.[16]
Although these results are promising, particularly for menopausal women who can’t undergo hormone replacement therapy (HRT) or who prefer to avoid estrogen-containing medications, there is a lack of studies comparing black cohosh with conventional medications (e.g., estrogens).
Black cohosh is generally considered safe, and clinical studies did not report significant side effects.
The administration of standard or high doses of black cohosh over 3–6 months does not appear to impact liver function. Likewise, black cohosh shows no significant effects on blood pressure, heart rate, body weight, or body mass index (BMI). Studies have also explored its impact on kidney function, total cholesterol, and triglycerides, revealing no overall effects except for a few studies reporting instances of increased high-density lipoprotein (HDL) cholesterol and decreased low-density lipoprotein (LDL) cholesterol.[1] Furthermore, trials comparing black cohosh to tibolone (a medication used to treat menopausal symptoms) found that people taking black cohosh exhibited fewer side effects (e.g., vaginal bleeding, spotting) than those taking tibolone.[1][7]
One meta-analysis indicated that 0.5% to 15% of menopausal women taking black cohosh experienced gastrointestinal discomfort.[8]
One animal study, coupled with in vitro testing on human cells, found that both in rats and in vivo black cohosh induced micronuclei (MN), which are biomarkers of genetic alterations, while also disrupting the folate pathway. This disruption led to non-regenerative macrocytic anemia in rats, characterized by enlarged red blood cells and inadequate bone marrow red blood cell replacement. Although these results indicate a potential risk associated with taking black cohosh, clinical studies are required to examine the impact on the human body.[9]
Initially, the presumed mechanism of black cohosh involved the activation of estrogen receptors. However, both in vitro and in vivo studies on black cohosh extracts yielded no evidence of estrogenic activity. Instead, it appears that black cohosh binds to receptors in the central nervous system responsible for functions like thermoregulation, mood, and sleep (e.g., mu-opioid,[10] serotonin, dopamine, c-aminobutyric acid). This mode of action clarifies why black cohosh does not influence estrogen levels, breast tissue density or proliferation, endometrial thickness, or vaginal cytology.[11][1]
Additionally, black cohosh showed anti-estrogenic properties in breast cancer studies. This anti-estrogenic effect was observed in vitro as a reduction in the growth of estrogen-responsive breast cancer cells.[12]
Another in vitro study found a potential nonestrogenic thermoregulatory mechanism of black cohosh, which may modulate the immune system by promoting nitric oxide (NO) production in cells treated with interferon gamma (INF-gamma).[11]
Both in vitro and in vivo studies show that black cohosh extracts lack estrogenic effects and don’t raise estrogen levels in the blood. Research on breast cancer cell lines suggests that black cohosh might be safe for menopausal women due to potential anti-estrogenic properties.[12]
Moreover, some studies have shown that black cohosh does not impact gonadotropin or estradiol levels in both healthy women and women with estrogen-dependent conditions like breast cancer. Additionally, black cohosh does not seem to affect levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, prolactin, sex-hormone-binding globulin, and testosterone.[1][5]
Update History
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