Benefits Of Black Cohosh For Menopause: A Godsend Or A Placebo?

By: Dr. Christine Horner

More than two centuries ago, deep in the shaded woods of the eastern United States, Native Americans discovered the root of a plant with the ability to improve a variety of conditions, including fever, arthritis, snake bites, menstrual cramps and menopausal symptoms. The rhizome-like root of black cohosh—scientifically named Cimicifuga racemosa and a member of the b uttercup family—has been extensively studied in this country and in Europe primarily as an alternative to hormone replacement therapy for menopausal symptoms.

Also called black snakeroot, bugbane, bugwort, squawroot and rattle root, it has been approved in Germany for menstrual discomfort , as well as the physical and psychological symptoms of menopause, including hot flashes, irritability, mood swings, anxiety, vaginal dryness and sleep disturbances.

What Makes Black Cohosh Great
Scientists have identified numerous active compounds in black cohosh, including triterpene glycosides (actein and cimicifugocide), saponins, cinnamic acid esters, and cycloartane glycosides (2007 Gaube). These biologically active ingredients have many health benefits, including balancing estrogen by mimicking; however, they are not “estrogenic.” In other words, they don’t bind to the estrogen receptor.

Rather, they work through a different pathway . Therefore, black cohosh has no adverse effects in the breast (2007 Hirschberg) or uterus (2006 Raus), and is safe to use in breast cancer patients, as we’ll detail below.

Myth or Reality?
Numerous clinical trials studying the effects of black cohosh on menopausal symptoms have mixed results: Some studies show excellent improvements, while others show it is no better than placebo.

Yes to Black Cohosh
On the plus side, in the majority of black cohosh studies, thousands of women have experienced significant improvements in hot flashes, mood swings, depression, anxiety and vaginal atrophy and dryness (2006 Wuttke). A big plus of this herb is that, unlike conventional therapies, such as hormonal drugs and antidepressants— which can increase the risk of uterine or breast cancer—, black cohosh does not.

In looking at the research, a placebo-controlled study of 244 Chinese women showed significant improvement in symptoms with black cohosh, according to two evaluation tools used for measuring the severity of menopausal symptoms: the Kupperman Index and the Menopause Rating Scale (2007 Bai). Another study conducted by the College of Nursing at Drexel University in Philadelphia concluded that black cohosh is a safe and effective alternative to pharmaceutical hormone replacement therapy (HRT). Yet in another study of 304 postmenopausal women, black cohosh was found to have good efficacy and tolerability—particularly for hot flashes (2012 Ross). 
Italian researchers point out that black cohosh may take up to three months to work. So don’t get discouraged if your symptoms don’t go away immediately. Be patient.

Because of positive results found by these types of studies, even the conservative Western medical association—the American College of Obstetricians and Gynecologists (ACOG)— recognizes that black cohosh has value for menopausal symptoms. 

Questionable Results
On the less than effective side, a number of clinical trials, including the 2006 “Herbal Alternatives for Menopause Trial” (HALT) sponsored by the National Center for Complementary and Alternative Medicine (NCCAM), showed conflicting results. However, reviewers point out that these studies are plagued with design flaws, including lack of uniformity of the herbal preparation and dosing, inconsistencies in pre-evaluation and outcome measures, and the absence of placebo groups (2005 Low Dog). They also did not report many of the beneficial side effects.

My View

Beyond Menopause
Studies show that black cohosh has numerous benefits beyond alleviating menopause symptoms. Because of its anti-inflammatory properties, it is beneficial for arthritis. Using a variety of mechanisms, it helps to improve and preserve bone density, and therefore lowers the risk of osteoporosis (Seidlova-Wittke 2012; 2007 Sethi and Aggarwal; 2006 Wuttke).

Plus, black cohosh also appears to help with mood swings and anxiety. It does this by attaching to opiate receptors in the central nervous system (2008 Reame). Activation of these receptors is known to soothe emotions, relieve pain, lower core temperature and balance sex hormones. Black cohosh also turns on receptors for the neurotransmitters serotonin and dopamine—both of which have antidepressant effects (Kanadys 2008).

Safe and Effective for Breast Cancer Patients
When it comes to breast cancer, don’t fear. Not only is black cohosh safe for breast cancer patients, it actually has protective effects against their disease. Spanish researchers documented that black cohosh has anti-estrogenic effects and inhibits the growth of tumors (2006 Garita-Hernandez). In fact, a study published in the Journal of Nutrition and Cancer in 2007 found that this herb relieves menopausal symptoms in breast cancer patients without estrogenic effects in the body or breast.

In other studies, black cohosh was found to enhance the tumor-killing effects of the breast cancer drug Tamoxifen (2007 Al-Akoum) while relieving many of its side effects, including hot flashes, sweating, sleep problems and anxiety

This herb is also safe to take with aromatase-inhibiting drugs (2007 Nisslein). For 90 percent of patients, the tolerability of black cohosh is rated good, or very good (2011 Rostock).

Side Effects
Side effects are rare occurring in less than five percent of individuals. The most common symptoms are gastrointestinal including abdominal pain, diarrhea, nausea, vomiting, and weight gain.

A few years ago, several cases of liver toxicity were reported in women taking black cohosh. A thorough investigation was immediately launched to determine if black cohosh was the cause. In one of the studies, Italian researchers reviewed the literature finding 42 cases of suspected hepatotoxicity. Only four of those cases had a possible association, but after further analysis none were found to be associated (Firenzuoli 2011).

Another meta-analysis of five double-blind, randomized-controlled studies of black cohosh— as well as a prospective study of 107 patients taking black cohosh for 12 months— found no hepatotoxicity (Naser 2011).  

German and U.S. researchers conducted numerous studies to evaluate the effects of black cohosh on the liver and none found any toxicity (2011, 2010, 2009 Teschke; Mahady 2008). They did, however, find problems with authenticity, as well as impurities and adulterants in a few of the black cohosh products, which they note may have been responsible for the liver damage. A United States court case ruled that research consistently holds that black cohosh is non-hepatotoxic.

One of the best studies that cleared black cohosh of its wrongful liver-toxicity scare was conducted in Egypt (Nasar and Nafeh 2009). Eighty-seven postmenopausal women were given a daily dose of 40 mg of black cohosh for 12 months. Total hepatic blood flow was measured by Doppler ultrasound. Liver function was also assessed by blood tests measuring prothrombin time; serum albumin; bilirubin; and the liver enzymes gamma-glutamyltransfer ase, alkaline phosphatase, alanine aminotransfera se, and aspartate aminotransfera se The researchers found no changes in any of these measures in any of the women in 12 months. They concluded that black cohosh does not affect the liver.  

Getting the Best Results
No herb works well if your diet and lifestyle are poor. Eating a healthy diet, getting daily exercise balanced with the right amount of rest, and practicing effective stress-reducing techniques are a few of the basic foundations that help herbs to be more effective.

Everyone’s chemistry is different. Because we are not the same, no single herb works well for everyone. Some women suffer with low estrogen levels, others have poor utilization of estrogen, still others may have imbalances of estrogen to progesterone, erratic fluctuations of hormones, and/or sluggish metabolism of hormones. Different herbs and nutritional substances are needed to improve each of those imbalances. Therefore, the most effective menopausal formulas combine several different substances. For instance, Italian researchers found that when black cohosh is combined with isoflavones and lignans, symptomatic improvements were significantly better.

Therefore, w hen it comes to alleviating menopausal symptoms, always start with healthy diet and lifestyle changes first. Sometimes your symptoms may go away with a few simple changes, such as going to bed by 10 P.M.

If you find that you still need help, select a high-quality menopausal formula that contains therapeutic doses of several herbs, in luding black cohosh. In my opinion, the research supports that black cohosh can be very helpful for menopausal symptoms and has a variety of other health benefits too. Not only can it help to alleviate hot flashes, but it also supports bone density, improves mood, and has anti-breast cancer actions.  Remember that it can take up to three months for significant improvements to occur. If possible, it is best to a void taking pharmaceutical HRT because of its potentially dangerous side effects. Natural approaches such as those listed here are always best to try first.

References:

Wuttke, W., et al. “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) Mar-Apr: 13(2): 185-96

Bai, W., et al. “Efficacy and tolerability of a medicinal product containing an isopropanolic black cohosh extract in Chinese women with menopausal symptoms: a randomized, double blind, parallel-controlled study versus tibolone.” Maturitas (2007) Sep 20; 58(1): 31-41

Ross, S.M. “Menopause: standardized isopropanolic black cohosh extract (remifemin) is found to be safe and effective for menopausal symptoms.” Holist Nurs Pract (2012) Jan-Feb; 26(1): 58-61

Pockaj, B., et al. “Pilot evaluation of black cohosh for the treatment for hot flashes in women.”  Cancer Invest (2004) 22(4): 515-21

Low Dog, T. “Menopause: a review of botanical dietary supplements.” Am J Med (2005) Dec. 19: 118

Gaube, F., “Gene expression profiling reveals effects of Cimicifuga racemosa NUTT. (black cohosh) on estrogen receptor positive human breast cancer cell line MCF-7. BMC Pharmacol (2007) Sep 20; 7: 11

Hirschberg, A., et al. “An isopropanolic extract of black cohosh does not increase mammographic breast density or breast cell proliferation in postmenopausal women.” Menopause (2007) Jan-Feb; 14(1): 89-96

Raus, K., et al. “First-time proof of endometrial safety of the special black cohosh extract (Actaea or Cimicifuga racemosa extract) CR BNO 1055.” Menopause (2006) Jul-Aug; 13(4); 678-91

Garita-Hernandez, M. et al. “The growth inhibitory activity of the Cimicifuga racemosa extract Ze 450 is mediated through estrogen and progesterone receptor-independent pathways.” Planta Med (2006) Mar; 72(4): 317-23

Al-Akoum, M,. et al. “Synergistic cytotoxic effects of tamoxifen and black cohosh on MCF-7 and MDA-MB-231 human breast cancer cells: an in vitro study. Can J Physol Pharmacol (2007) Nov; 85(11):1153-9

Nisslein, T. and Freudenstein, J. “Coadministration of the aromatase inhibitor formestane and an isopropanolic extract of  black cohosh in a rat model of chemically induced mammary carcinoma.” Planta Med (2007) Apr; 73(4): 318-22

Rostock, M., et al. “Blaci cohosh (Cimicifuga racemosa) in tamoxifen-treated breast cancer patients with climacteric complaints- a prospective observational study.” Gynecol Endocrinol (2011) Oct; 27(10): 844-8

Reame, N., et al. “Black cohosh has central opioid activity in postmenopausal women: evidence from naloxone blockade and positron emission tomography neuroimaging.” Menopause (2008) Sep-Oct; 15(5): 832-40

Kanadys W., et al. “Efficacy and safety of black cohosh (Actaea/Cimicifuga racemosa) in the treatment of vasomotor symptoms—review of clinical trials.” Ginekol Pol (2008) Apr; 79(4): 287-96

Seidlova-Wuttke, D., et al. “Osteoprotective effects of Cimicifuga racemosa nd it triterpene-saponins are responsible for reduction of bone marrow fat.” Phytomedicine (2012) Jul 15; 19(10): 855-60

Sethi, G., Aggarwal, B., et al. “Mending the bones with natural products.” Chem Biol (2007) Jul; 14(7):738-40

Firenzuoli, F., et al. “Black Cohosh Hepatic Safety: Follow- up of 107 patients consuming a special Cimicifuga racemosa rhizome herbal extract and review of the literature.”  Evid Based Complement Alternat Med (2011) 2011:  821392.doi.

Naser, B., et al. “Suspected black cohosh hepatotoxicity: no evidence by meta-analysis of randomized controlled clinical trials for isopropanolic black cohosh extract.”  Menopause (2011) Apr; 18(4): 366-75

Teschke, R., et al. “Suspected black cohosh hepatotoxicity—challenges and pitfalls of causality assessment.” Maturitas (2009) Aug 20; 63(4):302-14

Teschke, R., et al. “Suspected hepatotoxicity by Cimicifuga racemosa rhizome (black cohosh, root): critical analysis and structured causality assessment.” Phytomedicine (2009) Jan; 16(1): 72-84

Teschke, R., et al. “Black cohosh hepatotoxicity: quantitative causality evaluation in nine suspected cases.” Menopause (2009) Sep-Oct; 16(5):956-65

Teschke, R., et al. “Black cohosh and suspected hepatotoxicity: inconsistencies, confounding variables, and prospective use of a diagnostic causality algorithm. A critical review.” Menopause (2010) Mar; 17(2): 426-40

Teschke, R., et al. “Herb induced liver injury presumably caused by black cohosh: a survey of initially purported cases and herbal quality specifications.” Ann Hepatol (2011) Jul-Sep; 10(3): 249-59

Mahady G., et al. “United States Pharmacopeia review of the black cohosh case reports of hepatotoxicity.” Menopause (2008) Jul-Aug; 15(4 Pt 1): 628-38

Nasr, A. and Nafeh, H. "Influence of black cohosh (Cimicifuga racemosa) use by postmenopausal women on total hepatic perfusion and liver functions." Fertil Steril (2009) Nov; 92(5); 1780-2.

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