Black Cohosh

    Researchedby:

    Fact-checked

    by:

    Last Updated: October 5, 2023

    Black Cohosh is the most popular supplement for menopause in North America, but the results of human studies are mixed. It holds some benefits for controlling hot flashes and night sweats.

    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

    Note that Black Cohosh is also known as:
    • Cimicifuga racemosa
    • Bugbane
    • Bugroot
    • Snakeroot
    • Rattleroot
    • Blackroot
    • Black Snake Root
    Black Cohosh should not be confused with:
    • 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

    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 is the etymology of black cohosh?

    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]

    How was black cohosh used by indigenous North Americans?

    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]

    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.

    Does black cohosh improve bone density?

    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]

    Can black cohosh be taken with St. John’s wort?

    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]

    Can black cohosh be used instead of HRT for symptoms of menopause?

    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).

    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]

    Does black cohosh have estrogenic properties?

    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

    New meta-analyses added

    minor

    Research written by

    Reviewed by

    FAQs added and database updated

    major

    Research written by

    Reviewed by

    Research Breakdown

    References

    1. ^Castelo-Branco C, Gambacciani M, Cano A, Minkin MJ, Rachoń D, Ruan X, Beer AM, Schnitker J, Henneicke-von Zepelin HH, Pickartz SReview & meta-analysis: isopropanolic black cohosh extract iCR for menopausal symptoms - an update on the evidence.Climacteric.(2021-Apr)
    2. ^Wobser RW, Takov VBlack CohoshStatPearls.(2023-01)
    3. ^Predny et al.Black cohosh (*Actaea racemosa*): an annotated bibliographyGen. Tech. Rep. SRS–97. Asheville, NC: U.S. Department of Agriculture Forest Service, Southern Research Station. 99 p..(2006)
    4. ^Jiang K, Jin Y, Huang L, Feng S, Hou X, Du B, Zheng J, Li LBlack cohosh improves objective sleep in postmenopausal women with sleep disturbance.Climacteric.(2015)
    5. ^Jacobson JS, Troxel AB, Evans J, Klaus L, Vahdat L, Kinne D, Lo KM, Moore A, Rosenman PJ, Kaufman EL, Neugut AI, Grann VRRandomized trial of black cohosh for the treatment of hot flashes among women with a history of breast cancerJ Clin Oncol.(2001 May 15)
    6. ^Sievert LLSubjective and objective measures of hot flashes.Am J Hum Biol.(2013)
    7. ^Wen-pei Bai, Shu-yu Wang, Jian-li Liu, Li Geng, Li-na Hu, Zhong-lan Zhang, Shu-ling Chen, Shu-rong ZhengEfficacy and safety of remifemin compared to tibolone for controlling of perimenopausal symptomsZhonghua Fu Chan Ke Za Zhi.(2009 Aug)
    8. ^Shams T, Setia MS, Hemmings R, McCusker J, Sewitch M, Ciampi AEfficacy of black cohosh-containing preparations on menopausal symptoms: a meta-analysisAltern Ther Health Med.(2010 Jan-Feb)
    9. ^Smith-Roe SL, Swartz CD, Shepard KG, Bryce SM, Dertinger SD, Waidyanatha S, Kissling GE, Auerbach SS, Witt KLBlack cohosh extracts and powders induce micronuclei, a biomarker of genetic damage, in human cells.Environ Mol Mutagen.(2018-Jun)
    10. ^Reame NE, Lukacs JL, Padmanabhan V, Eyvazzadeh AD, Smith YR, Zubieta JKBlack cohosh has central opioid activity in postmenopausal women: evidence from naloxone blockade and positron emission tomography neuroimaging.Menopause.(2008)
    11. ^Ruhlen RL, Sun GY, Sauter ERBlack Cohosh: Insights into its Mechanism(s) of Action.Integr Med Insights.(2008)
    12. ^Bodinet C, Freudenstein JInfluence of Cimicifuga racemosa on the proliferation of estrogen receptor-positive human breast cancer cells.Breast Cancer Res Treat.(2002-Nov)
    13. ^Seidlova-Wuttke D, Hesse O, Jarry H, Christoffel V, Spengler B, Becker T, Wuttke WEvidence for selective estrogen receptor modulator activity in a black cohosh (Cimicifuga racemosa) extract: comparison with estradiol-17beta.Eur J Endocrinol.(2003-Oct)
    14. ^Michael Bebenek, Wolfgang Kemmler, Simon von Stengel, Klaus Engelke, Willi A KalenderEffect of exercise and Cimicifuga racemosa (CR BNO 1055) on bone mineral density, 10-year coronary heart disease risk, and menopausal complaints: the randomized controlled Training and Cimicifuga racemosa Erlangen (TRACE) studyMenopause.(2010 Jul)
    15. ^Foster,SBlack Cohosh: A Literature ReviewHerbalGram: The Journal of the American Botanical Council.(1999)
    16. ^Nappi RE, Malavasi B, Brundu B, Facchinetti FEfficacy of Cimicifuga racemosa on climacteric complaints: a randomized study versus low-dose transdermal estradiol.Gynecol Endocrinol.(2005-Jan)
    17. ^Borrelli F, Ernst EBlack cohosh (Cimicifuga racemosa): a systematic review of adverse events.Am J Obstet Gynecol.(2008 Nov)
    18. ^Lontos S, Jones RM, Angus PW, Gow PJAcute liver failure associated with the use of herbal preparations containing black cohosh.Med J Aust.(2003 Oct 6)
    19. ^Cohen SM, O'Connor AM, Hart J, Merel NH, Te HSAutoimmune hepatitis associated with the use of black cohosh: a case study.Menopause.(2004 Sep-Oct)
    20. ^Levitsky J, Alli TA, Wisecarver J, Sorrell MFFulminant liver failure associated with the use of black cohosh.Dig Dis Sci.(2005 Mar)
    21. ^Lynch CR, Folkers ME, Hutson WRFulminant hepatic failure associated with the use of black cohosh: a case report.Liver Transpl.(2006 Jun)
    22. ^Dunbar K, Solga SFBlack cohosh, safety, and public awareness.Liver Int.(2007 Sep)
    23. ^Zimmermann R, Witte A, Voll RE, Strobel J, Frieser MCoagulation activation and fluid retention associated with the use of black cohosh: a case study.Climacteric.(2010 Apr)
    24. ^Mahady GB, Low Dog T, Barrett ML, Chavez ML, Gardiner P, Ko R, Marles RJ, Pellicore LS, Giancaspro GI, Sarma DNUnited States Pharmacopeia review of the black cohosh case reports of hepatotoxicity.Menopause.(2008 Jul-Aug)
    25. ^Brar HS, Marathi RCase of cholestatic drug-induced liver injury (DILI) associated with black cohosh.BMJ Case Rep.(2021 May 7)
    26. ^Wuttke W, Gorkow C, Seidlová-Wuttke DEffects of black cohosh (Cimicifuga racemosa) on bone turnover, vaginal mucosa, and various blood parameters in postmenopausal women: a double-blind, placebo-controlled, and conjugated estrogens-controlled study.Menopause.(2006 Mar-Apr)
    27. ^Huntley AThe safety of black cohosh (Actaea racemosa, Cimicifuga racemosa).Expert Opin Drug Saf.(2004 Nov)
    28. ^Lieberman SA review of the effectiveness of Cimicifuga racemosa (black cohosh) for the symptoms of menopause.J Womens Health.(1998 Jun)
    29. ^Osmers R, Friede M, Liske E, Schnitker J, Freudenstein J, Henneicke-von Zepelin HHEfficacy and safety of isopropanolic black cohosh extract for climacteric symptoms.Obstet Gynecol.(2005 May)
    30. ^Huntley A, Ernst EA systematic review of the safety of black cohosh.Menopause.(2003 Jan-Feb)
    31. ^Kanadys WM, Leszczyńska-Gorzelak B, Oleszczuk JEfficacy and safety of Black cohosh (Actaea/Cimicifuga racemosa) in the treatment of vasomotor symptoms--review of clinical trials.Ginekol Pol.(2008 Apr)
    32. ^Patel, NM et alPossible Increase in Liver Enzymes Secondary to Atorvastatin and Black Cohosh AdministrationJournal of Pharmacy Practice.(2007)
    33. ^Li J, Gödecke T, Chen SN, Imai A, Lankin DC, Farnsworth NR, Pauli GF, van Breemen RB, Nikolić DIn vitro metabolic interactions between black cohosh (Cimicifuga racemosa) and tamoxifen via inhibition of cytochromes P450 2D6 and 3A4.Xenobiotica.(2011 Aug 9)
    34. ^Hernández Muñoz G, Pluchino SCimicifuga racemosa for the treatment of hot flushes in women surviving breast cancer.Maturitas.(2003 Mar 14)
    35. ^Gurley BJ, Gardner SF, Hubbard MA, Williams DK, Gentry WB, Khan IA, Shah AIn vivo effects of goldenseal, kava kava, black cohosh, and valerian on human cytochrome P450 1A2, 2D6, 2E1, and 3A4/5 phenotypes.Clin Pharmacol Ther.(2005-May)
    36. ^Gurley BJ, Swain A, Hubbard MA, Williams DK, Barone G, Hartsfield F, Tong Y, Carrier DJ, Cheboyina S, Battu SKClinical assessment of CYP2D6-mediated herb-drug interactions in humans: effects of milk thistle, black cohosh, goldenseal, kava kava, St. John's wort, and Echinacea.Mol Nutr Food Res.(2008 Jul)
    37. ^Huang Y, Jiang B, Nuntanakorn P, Kennelly EJ, Shord S, Lawal TO, Mahady GBFukinolic acid derivatives and triterpene glycosides from black cohosh inhibit CYP isozymes, but are not cytotoxic to Hep-G2 cells in vitro.Curr Drug Saf.(2010 Apr)
    38. ^Yalçın M, Oğuz A, Beştepe EE, Sağlam NGU, Ergelen MBlack cohosh associated mania in a patient with unipolar depression.Int J Psychiatry Med.(2021 Mar)
    39. ^Burdette JE, Liu J, Chen SN, Fabricant DS, Piersen CE, Barker EL, Pezzuto JM, Mesecar A, Van Breemen RB, Farnsworth NR, Bolton JLBlack cohosh acts as a mixed competitive ligand and partial agonist of the serotonin receptor.J Agric Food Chem.(2003 Sep 10)
    40. ^Dernbach MR, Carpenter JE, Shah N, Carter GBBlack Cohosh Interactions with Prescription Medications Associated with Serotonin Toxicity and Rhabdomyolysis: A Case Report.J Emerg Med.(2024 May)
    41. ^Gail B MahadyBlack cohosh (Actaea/Cimicifuga racemosa): review of the clinical data for safety and efficacy in menopausal symptomsTreat Endocrinol.(2005)
    42. ^Dugoua JJ, Seely D, Perri D, Koren G, Mills ESafety and efficacy of black cohosh (Cimicifuga racemosa) during pregnancy and lactation.Can J Clin Pharmacol.(2006 Fall)
    43. ^Black Cohosh.Drugs and Lactation Database (LactMed®).(2006)
    44. ^Lupu R, Mehmi I, Atlas E, Tsai MS, Pisha E, Oketch-Rabah HA, Nuntanakorn P, Kennelly EJ, Kronenberg FBlack cohosh, a menopausal remedy, does not have estrogenic activity and does not promote breast cancer cell growth.Int J Oncol.(2003 Nov)
    45. ^Fritz H, Seely D, McGowan J, Skidmore B, Fernandes R, Kennedy DA, Cooley K, Wong R, Sagar S, Balneaves LG, Fergusson DBlack cohosh and breast cancer: a systematic review.Integr Cancer Ther.(2014 Jan)
    46. ^Ulbricht C, Windsor RCAn Evidence-Based Systematic Review of Black cohosh (Cimicifuga racemosa, Actaea racemosa) by the Natural Standard Research Collaboration.J Diet Suppl.(2015 Sep)
    47. ^Ingraffea A, Donohue K, Wilkel C, Falanga VCutaneous vasculitis in two patients taking an herbal supplement containing black cohosh.J Am Acad Dermatol.(2007 May)
    48. ^LeRoy ECA brief overview of the pathogenesis of scleroderma (systemic sclerosis).Ann Rheum Dis.(1992 Feb)
    49. ^Minciullo PL, Saija A, Patafi M, Marotta G, Ferlazzo B, Gangemi SMuscle damage induced by black cohosh (Cimicifuga racemosa).Phytomedicine.(2006 Jan)