Dr Clare Materia Medica

Also Known As: Cimicifuga,

Scientific Name: Cimicifuga racemosa.

Family: Ranunculaceae.

People Use This For: Black Cohosh is used for symptoms of menopause, inducing labor in pregnant women, premenstrual syndrome (PMS), painful periods, nervous tension, indigestion, rheumatism, and as a mild sedative.

Safety: Possibly safe when used orally and appropriately. Black cohosh has been safely used in some studies lasting up to a year; 1,2,3 There is concern that black cohosh might cause liver damage in some patients. Several case reports link black cohosh to liver failure or autoimmune hepatitis; 4,5,6,7,8,9,10,11,12,13,14,15,16,17 however, there is no conclusive evidence that black cohosh is the cause of liver damage in these patients.18 Until more is known, monitor liver function in patients who take black cohosh for more than three months. Analysis of 9 Cases of Suspected association between Black Cohosh and Hepatitis concluded that there is little if any hepatotoxic risk by the use of Black Cohosh in these cases. Menopause 2009 Sep-Oct: 16(5):956-65 Teschke R, Bahre R, Fuchs J, Wolff A. It is concluded that the use of BC may not exert an overt toxicity risk, but quality problems in a few BC products were evident that require additional regulatory quality specifications. Ann Hepatology. 2011 Jul-Sep;10(3):249-59

Pregnancy and Lactation: Refer to Medical Herbalist

Effectiveness: POSSIBLY EFFECTIVE

Menopausal symptoms. Some black cohosh extracts seem to modestly reduce symptoms of menopause, such as hot flashes. However, there is considerable variability in the preparations used in clinical trials, and in the results obtained.19

INSUFFICIENT RELIABLE EVIDENCE to RATE

Osteoporosis: Preliminary clinical research suggests that postmenopausal women who take a specific black cohosh extract CR BNO 1055 (Klimadynon/Menofem, Bionorica AG) 40 mg/day have increased levels of bone-specific alkaline phosphatase (bALP), which is a marker of bone formation, after 12 weeks of treatment. 20 However, it is not known if this black cohosh extract can increase bone mineral density or decrease the risk of fracture. More evidence is needed to rate black cohosh for these uses.

Mechanism of Action: The applicable parts of black cohosh are the rhizome and root. The active constituents of black cohosh include phytosterin; isoferulic acid; fukinolic acid; caffeic acid; salicylic acid; sugars; tannins; long-chain fatty acids; and triterpene glycosides, including acetein, cimicifugoside, and 27-deoxyactein.21,22 Black cohosh has estrogen-like effects (not estrogenic effects) that are exerted by an unknown mechanism.21,23,20

Adverse Reactions: Black cohosh can commonly cause gastrointestinal upset.4,24,25 Black cohosh has associated with weakness and muscle damage in one case. In another case, a single patient developed symptoms of cutaneous pseudolymphoma 6 months after starting a specific black cohosh extract (Remifemin). Symptoms resolved within 12 weeks of discontinuing black cohosh.26 There are two case reports of cutaneous vasculitis in menopausal women who took black cohosh-containing products. In these cases, both women were taking a combination product containing black cohosh 40 mg (Estroven, Amerifit Brands). Symptoms resolved within 3 months of discontinuing the product.27 Interactions with Herbs & Supplements: Refer to a Medical Herbalist. Interactions with Drugs: Atorvastatin (Lipitor) One report of significant interaction. Chemotherapy: Refer to a Medical Herbalist. Hepatotoxic Drugs: Refer to a Medical Herbalist. Interactions with Foods: None known.

Interactions with Lab Tests: Liver Function Tests: Elevated liver function tests have not been documented in clinical trials.20 Theoretically, some patients taking black cohosh might experience elevated liver function tests.

Interactions with Diseases or Conditions: Breast Cancer: Refer to Medical Herbalist.

Hormone-Sensitive Cancers/Conditions: Black cohosh doesn't seem to affect estrogen receptors. Refer to Medical Herbalist.

Kidney Transplant: Refer to Medical Herbalist.

Liver Disease: Refer to Medical Herbalist.

Dosage/Administration: Dr Clare’s Blend: 1gm/day Oral: 0.5-1gms/day

Specific References: BLACK COHOSH 1. Raus K, Brucker C, Gorkow C, Wuttke W. First-time proof of endometrial safety of the special black cohosh extract (Actaea or Cimicifuga racemosa extract) CR BNO 1055. Menopause 2006;13:678-91. Newton KM, Reed SD, LaCroix AZ, et al. Treatment of vasomotor symptoms of menopause

2. with black cohosh, mulitbotanicals, soy, hormone therapy, or placebo. Ann Intern Med 2006;145:869-79. Available at: http://www.annals.org/cgi/reprint/145/12/869.pdf.

3. Geller SE, Shulman LP, van Breemen RB, et al. Safety and efficacy of black cohosh and red clover for the management of vasomotor symptoms: a randomized controlled trial. Menopause 2009;16:1156-66.

4. Whiting PW, Clouston A, Kerlin P. Black cohosh and other herbal remedies associated with acute hepatitis. Med J Aust 2002;177:440-3.

5. Lontos S, Jones RM, Angus PW, Gow PJ. Acute liver failure associated with the use of herbal preparations containing black cohosh. Med J Aust 2003;179:390-1.

6. Cohen B, Schardt D. Center for Science in the Public Interest. Letter to Food and Drug Administration. Commissioner Mark McClellan, MD, PhD. March 4, 2004. Cohen SM, O'Connor AM, Hart J, et al. Autoimmune hepatitis associated with the use of

7. black cohosh: a case study. Menopause 2004;11:575-7.

8. Levitsky J, Alli TA, Wisecarver J, Sorrell MF. Fulminant liver failure associated with the use of black cohosh. Dig Dis Sci 2005;50:538-9.

9. MHRA. Black cohosh (Cimicifuga racemosa) - risk of liver problems. Herbal Safety News IdcService=SS_GET_PAGE&useSecondary= true&ssDocName=CON2024131&ssTargetNodeId=663.

10. Lynch CR, Folkers ME, Hutson WR. Fulminant hepatic failure associated with the use of black cohosh: a case report. Liver Transpl 2006;12:989-92.

11. Chow ECY, Teo M, Ring JA, Chen JW. Liver failure associated with the use of black cohosh for menopausal symptoms. Med J Aust 2008;188:420-2.

12. Mahady GB, Low Dog T, Barrett ML, et al. United States Pharmacopeia review of the black cohosh case reports of hepatotoxicity. Menopause 2008;15:628-38.

13. Hepatotoxicity with black cohosh. Australian Adv Drug Reactions Bull 2006;25:6. Available at: www.tga.gov.au/adr/aadrb/aadr0604.htm#a1.

14. Dunbar K, Solga SF. Black cohosh, safety, and public awareness. Liver Int 2007;27:1017.

15. Patel NM, Derkits RM. Possible increase in liver enzymes secondary to atorvastatin and black cohosh administration. J Pharm Pract 2007;20:341-6.

16. Joy D, Joy J, Duane P. Black cohosh: a cause of abnormal postmenopausal liver function tests. Climacteric 2008;11:84-8.

17. Australian Adverse Drug Reactions Advisory Committee. Black cohosh and liver toxicity - an update. Aust Adv Drug Reactions Bull 2007;26:11.

18. Teschke R, Bahre R, Genthner A, et al. Suspected black cohosh hepatotoxicity - challenges July 2006.

Available at: http://www.mhra.gov.uk/home/idcplg? and pitfalls of causality assessment. Maturitas 2009;63:302-14.

19. Shams T, Setia MS, Hemmings R, et al. Efficacy of black cohosh-containing preparations on menopausal symptoms: a meta-analysis. Altern Ther Health Med 2010;16:36-44.

20. Wuttke W, Gorkow C, Seidlova-Wuttke D. Effects 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;13:185-96.

21. Kruse SO, Lohning A, Pauli GF, et al. Fukiic and piscidic acid esters from the rhizome of Cimicifuga racemosa and the in vitro estrogenic activity of fukinolic acid. Planta Med 1999;65:763-4.

22. Loser B, Kruse SO, Melzig MF, Nahrstedt A. Inhibition of neutrophil elastase activity by cinnamic acid derivatives from Cimicifuga racemosa. Planta Med 2000;66:751-3. Einer-Jensen N, Zhao J, Andersen KP, Kristoffersen K. Cimicifuga and Melbrosia lack

23. oestrogenic effects in mice and rats. Maturitas 1996;25:149-53.

24. Pepping J. Black cohosh: Cimicifuga racemosa. Am J Health Syst Pharm 1999;56:1400-2.

25. Liske E. Therapeutic efficacy and safety of Cimicifuga racemosa for gynecologic disorders. Adv Ther 1998;15:45-53.

26. Meyer S, Vogt T, Obermann EC, et al. Cutaneous pseudolymphoma induced by Cimicifuga racemosa. Dermatology 2007;214:94-6.

27. Ingraffea A, Donohue K, Wilkel C, Falanga V. Cutaneous vasculitis in two patients taking an herbal supplement containing black cohosh. J Am Acad Dermatol 2007;56:S124-6.