Black Cohosh for the Treatment of Perimenopausal and Menopausal Symptoms
February 2000; Volume 3: 17-19
By Joya Tillem, MD
As baby boomer women now approach menopause, the search for an herbal remedy to curb symptoms has become increasingly important. Black cohosh has emerged as a possible solution, and may be the most promising herbal remedy for treating menopausal symptoms. This bitter root has a long history of traditional use by American Indians, has been widely studied in Germany, and is approved by the German Commission E for painful menstruation and symptoms of menopause. Several studies show that black cohosh is efficacious for menopausal symptoms.
A member of the Ranunculaceae (buttercup) family, black cohosh (Cimicifuga racemosa) is native to Eastern North America. Typically found in moist or dry woods, this widely cultivated, decorative wildflower is a hardy perennial that grows up to 9 ft and produces beautiful flowers on a tall stalk. The supplement, however, is derived from the black cohosh root and contains triterpene glycosides, which are believed to be the principal pharmacologically active constituents.
Known as "squawroot" by American Indians, black cohosh has been used historically for female conditions, rheumatism, and snake bites, and as an insect repellent. Its generic name, cimicifuga, was derived from its traditional use as a bug repellent; the Latin cimex means bug and the Latin fugare means to put to flight. In the early 20th century, black cohosh was an essential ingredient in Lydia Pinkham’s Vegetable Compound, an enormously popular patent remedy used for "female complaints." The root was part of the U.S. Pharmacopoeia from 1820 to 1926.
Black cohosh has been widely studied as an agent for:
a. breast cancer.
b. menopausal symptoms.
c. benign prostatic hyperplasia.
All the phytoconstituents of black cohosh are not yet known. The principal triterpene glycosides are xylosides, actein, and cimicifugoside. Anti-inflammatory, hypoglycemic, and hypotensive effects have all been measured in animals. Early on, the phytoestrogen/ isoflavone formononetin was isolated,1 but more recent investigations failed to show its presence.2 Other compounds isolated include fatty acids, resins, tannins, as well as butyric, salicylic, and oleic acids.
Black cohosh is used for common symptoms associated with menopause, hot flashes, and psychological symptoms including insomnia, depression, anxiety, and forgetfulness.
In vitro, black cohosh extract hinders the growth of breast cancer cells.3 In mice, black cohosh has been found to lack estrogenic effects. In one study, black cohosh (600 mg/kg) was administered to 10 immature mice, resulting in no uterine growth. In that same investigation, black cohosh was given to 12 ovariectomized rats. Vaginal smears after three days showed no signs of cornified cells.4
Black cohosh was studied as early as the 1940s as a natural agent for dysmenorrhea and menopausal symptoms.5 The majority of the reported investigations were performed in Germany, with almost all utilizing Remifemin, a commercial isopropanolic extract of black cohosh.
In 1982, 629 women with menopausal symptoms received 40 drops black cohosh (Remifemin) bid for 6-8 weeks. Outcome measures included hot flashes, sweating, headache, heart palpitations, and psychological disturbances. Eighty percent of participants showed improvement in menopausal symptoms at four weeks. Additionally, 93% of patients reported good tolerance without side effects.6
In gynecologic practices, two open-label studies were done looking at menopausal symptoms (n = 36, n = 50).7,8 Patients either refused hormone treatment (31 of 36) or had a contraindication to hormonal therapy (39 of 50). Both studies used 40 drops black cohosh extract (Remifemin) bid for 12 weeks. Efficacy criteria scales included Menopausal Index (Kupperman), Clinical Global Impressions (CGI), and Profile of Mood States (POMS). Results included a decrease in Kupperman index (< 15), a positive CGI, and a decrease on POMS including an overall elevation in mood, suggesting improvement.
A 12-week, nonblinded, controlled study of 60 patients compared the effectiveness of 40 drops black cohosh extract (Remifemin) bid vs. conjugated estrogens (0.625 mg/d) vs. 2 mg/d diazepam for menopausal symptoms. Outcomes were measured with the Meno-pausal Index, CGI, Self-Assessment Depression Scale (SDS), and Hamilton Anxiety Scale (HAMA). All three therapies decreased menopausal symptoms, with a significant decrease in the Kupperman index and the SDS index. All therapies equally reduced CGI, but not significantly.9
In 1987, a randomized, double-blind study compared a standardized extract of black cohosh (Remifemin) containing 2 mg of 27-deoxyactein per tablet to estrogen. Over 12 weeks, 80 women were given either two tablets Remifemin bid, conjugated estrogens 0.625 mg (plus three placebo tablets daily to equal two tablets bid), or two placebo tablets bid. Outcomes were based on Kupperman and HAMA scores, and maturation of vaginal epithelium. Cimicifuga conferred a benefit in menopausal symptoms which rivaled the benefits of estrogen replacement therapy with a decrease in Kupperman and HAMA scores (< 15). No improvement was noted in the participants taking placebo. The vaginal epithelium of those on black cohosh showed an increase in proliferation, whereas the estrogens showed only a small influence.10
A 1991 German prospective, placebo-controlled study of 110 menopausal women receiving 8 mg/d black cohosh extract (Remifemin) for eight weeks found that levels of luteinizing hormone but not follicle-stimulating hormone were significantly reduced.11 Although a clear mechanism remains elusive, these results imply that black cohosh confers some estrogen-like effects.
Most studies were performed with the commercially prepared isopropanolic extract of black cohosh Remifemin. The dose most supported by clinical data is 40 mg of herb daily in a standardized extract to contain 2.5% triterpene glycosides (or 2 mg triterpene glycosides/d). In liquid extracts, the total daily doses should be 40 drops of standardized extract containing 5% triterpene glycosides. Black cohosh is also available as a dried rhizome (recommended dose 40-200 mg/d) or an ethanol tincture (recommended dose 1:10 60%).12 A water/alcohol extraction method is used in a ratio of 60:40 to yield a decoction. (See Table 1 for price/formulation comparison.)
|Table 1-Black cohosh price and formulation comparison|
|Manufacturer/Product||Manufacturer's Recommended Dose||Formulation||Price/Quantity|
|Enzymatic Therapy Inc.||Each tablet contains standardized Cimicifuga||1 tablet bid||$27.95/60 tablets|
|RemifeminPlus||racemosa root and rhizome extract corresponding to 20 mg Cimicifuga racemosa.||Standardized for triterpene glycosides content (calculated as 27-deoxyactein); St. John's wort extract standardized to contain 250 mcg hypericin|
|Solgar Co.||Each vegicap contains 1 g total carbohydrate,||1-2 vegicaps/d,||$23.90/60 vegicaps|
|Sfp Black Cohosh||200 mg black cohosh extract, 200 mg raw black powder, 200 mg soy isoflavone concentrate||taken with meals|
|Nature's Herbs||Each capsule contains wild countryside black||1-3 capsules tid||$10.39/100 capsules|
|Black Cohosh Root||cohosh root (545 mg each)|
|Natrol||Each capsule contains 80 mg of guaranteed||1-2 capsules/d||$8.95/60 capsules|
|Black Cohosh||potency black cohosh 2.5% extract||with meals|
|The Vitamin Shoppe||Each capsule contains 40 mg black cohosh root||1 capsule/d||$8.50/60 capsules|
|Black Cohosh Extract||and rhizome extract standardized to contain|
|2.5% triterpene glycosides|
|Source: Online mail-order companies|
Although black cohosh has been widely used in Europe, long-term toxicity data are lacking in humans. The German Commission E recommends limiting use to six months.13 Side effects include occasional gastrointestinal disturbance. Because of lack of existing data, black cohosh is not recommended in pregnancy and lactation.14
In the pursuit of a remedy to aid women who want to move through menopause smoothly, hormone replacement therapy (HRT) has many benefits. In addition to helping with menopausal symptoms, HRT also offers likely cardioprotective effects15,16 and remains the cornerstone of osteoporosis prevention as well.17,18 Black cohosh is not known to offer these same benefits. However, several well-designed studies indicate that black cohosh is a safe and effective treatment for menopausal symptoms for those women who cannot or will not take HRT.
Studies thus far seem to indicate that black cohosh is safe and effective in decreasing the burden of menopausal symptoms.
a. has proven cardioprotective effects similar to traditional hormone replacement therapy.
b. appears to be safe and effective in decreasing menopausal symptoms.
c. increases bone density in post-menopausal women.
Dr. Tillem is a Fellow in Integrative Medicine and Health Services Research at Cedars-Sinai Integrative Medicine Medical Group in Los Angeles, CA.
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