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.

Source Identity

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.

Traditional Uses

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.


Pharmacology

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.

Common Indications

Black cohosh is used for common symptoms associated with menopause, hot flashes, and psychological symptoms including insomnia, depression, anxiety, and forgetfulness.

Laboratory/Animal Studies

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

Clinical Studies

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.

Dosage/Formulation

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
Remifemin™Plus 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



Safety

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

Conclusion

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.

Recommendation

Studies thus far seem to indicate that black cohosh is safe and effective in decreasing the burden of menopausal symptoms.

Black cohosh:

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.

References

1. Jarry H, et al. The endocrine effects of constituents of Cimicifuga racemosa. 2. In vitro binding of constituents to estrogen receptors [in German]. Planta Med 1985;4:316-319.

2. Struck D, et al. Planta Medica 1997;63:289.

3. Nesselhut T, et al. Examination of the proliferation potential of phytopharmaceuticals with estrogen-mimicking action in breast carcinoma. Arch Gynecol Obstet 1993;254:817-818.

4. Einer-Jensen N, et al. Cimicifuga and Melbrosia lack oestrogenic effects in mice and rats. Maturitas 1996;25:149-153.

5. Koch E. Hormonal Effects of Plants, 15. Stuttgart, Germany: Hippokrates; 1944:22.

6. Stolze H. The other way to treat symptoms of menopause. Gyne 1982:1;14.

7. Daiber W. Menopause symptoms: Success without hormones. Arztl Praxis 1983;35:1946.

8. Vorberg G. Treatment of menopause symptoms. ZFA 1984;60:626.

9. Warnecke G. Using phyto-treatment to influence menopause symptoms. Med Welt 1985;36:87.

10. Stoll W. Phytotherapy influences atrophic vaginal epithelium. Therapeutikon 1987;1:23.

11. Duker EM, et al. Effects of extracts from Cimicifuga racemosa on gonadotropin release in menopausal women and ovariectomized rats. Planta Med 1991;57:420-424.

12. Bradley P, ed. British Herbal Compendium. British Herbal Medicine Association; 1992;1:34-36.

13. Blumenthal M, ed. Therapeutic Monographs on Medicinal Plants for Human Use of the Commission E Special Expert Committee, Federal Health Agency, Germany (Draft). Austin, TX: American Botanical Council; 1993.

14. McGuffin M, et al. American Herbal Products Association’s Botanical Safety Handbook. Boca Raton, FL: CRC Press; 1997.

15. Grady D, et al. Hormone therapy to prevent disease and prolong life in postmenopausal women. Ann Intern Med 1992;117:1016-1037.

16. Hulley S, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA 1998;280:605-613.

17. Weiss NS, et al. Decreased risk of fractures of the hip and lower forearm with postmenopausal use of estrogen. N Engl J Med 1980;303:1195-1198.

18. Paganini-Hill A, et al. Menopausal estrogen therapy and hip fractures. Ann Intern Med 1981;95:28-31.