Thanks to the University of North Carolina School of Pharmacy for the use of this article!
Black cohosh can be found in shady woodlands of the United States
particularly in the southeast, northern Oregon, Washington, and
The plant is hardy and tall with feathery racemes of white
measuring 1 to 3 feet long. The flowers bloom in June and
thrive in moist, shady areas. The stout, black rhizome
along with the
root are used for medicinal effects.
Black cohosh contains cimicifugin (macrotin) which has estrogenic
effects. Also found in assay are acetein (antihypertensive effects)
and ferulic/isoferulic acids (anti-inflammatory effects). The
following components can also be found: isoflavones, salicyclic acid,
tannins, resins, starch, and sugars.
History and Folk Use
The American Indians boiled black cohosh root in water and drank
it for rheumatism, sore throat, rattlesnake bite, gynecological
problems, and childbirth. In the 19th century, some physicians used black
cohosh for fever, rashes, insomnia, malaria, gynecological problems.
For treatment of the latter, black cohosh was often combined with alcohol to
produce "Pinkham's Compound."
Ferulic and isoferulic acid, both found in black cohosh, are
potent inhibitors of interleukin-8, which is produced upon stimulation of an
inflammatory response and serves as a chemoattractant for neutrophils. By
inhibiting these acids, inflammation is inhibited.
Black cohosh has been widely studies in the treatment of
menopause. In Germany, a commercial formulation, Remifemin®, is
available and is the most popular alternative to estrogen therapy.
This formulation contains 1 mg of triterpenes calculated as 27-deoxyacteine per
tablet. In 1997, over ten million monthly units of this extract were sold in
the United States, Germany, and Australia.
One large open study (Stolze, H) involving 131 physicians
female patients showed that cimicifuga extract was beneficial in
menopausal symptoms in over 80% of patients within 6-8 weeks.
table summarizes symptomatic relief provided by black cohosh:
Cimicifuga in the Treatment of Menopause
% No Longer Present
Total % Improved
After 6-8 weeks, complete resolution of symptoms was evident in a
large percentage of participants. The extract was well-tolerated,
with only 7% of patients reporting mild transient stomach complaints.
In a double-blind study (Warnecke, G), 60 patients were
given either cimicifuga extract (2 tablets twice per day, providing a daily
dosage of 4 mg 27-deoxyacteine), conjugated estrogens (0.625 mg daily), or
diazepam (2 mg daily) for 12 weeks. The Kupperman Menopausal Index
was used to assess symptomatic relief. This index quantifies
symptomatic involvement by grading severity: Severe = 3; Moderate = 2; Mild =
1; Not present = 0. A total score is achieved by adding all scores
together. Symptoms assessed are as follows:
Depressive moods, Feelings of vertigo, Headache, Heart
palpitation, Hot flashes,
Joint pain, Loss of concentration,
perspiration, Sleep disturbances
The following table summarizes the results:
Effect of Cimicifuga on Kupperman Menopausal Index
Compared to Conjugated
Estrogens and Diazepam
At 12 Weeks
Another double-blind study (Stoll, W), 80 patients were
given either cimicifuga extract (2 tabs BID, providing 4 mg 27-deoxyacteine
daily), conjugated estrogens (0.625 mg daily), or placebo for 12 weeks. Black
cohosh produced better Kupperman Menopausal Index scores, Hamilton Rating Scale
for Anxiety scores, and greater improvement in the patients' vaginal lining
(dramatic increase in the number of superficial cells). Daily
occurrences of hot flashes dropped from an average of 5 to less than 1 in the
cimicifuga group. The same drop in the estrogen group was only from 5
Black cohosh may be effective in inflammatory conditions such as
rheumatoid arthritis. It also may be helpful as an expectorant.
The BGA (the German equivalent to the FDA in the US) does not
list any contraindications or limitations for the use of cimicifuga.
Researchers have sought to discover if black cohosh may stimulate the growth
of estrogen-dependent breast tumor cells. These in
vitro studies have shown no stimulatory effects - in fact, the effects seem to
be inhibitory. In fact, combination of Remifemin® with
tamoxifen has been shown to potentiate the effects of tamoxifen.
Thorough toxicology studies have been performed on
Remifemin® and have not shown to produce any
mutagenic, or carcinogenic effects. One 6-month study in
rats used dosages of 1,800 mg/kg (~90 times the therapeutic dose) and
showed no adverse effects.
The German Commission E recommends that treatment with cimicifuga
be limited to 6 months (the standard recommendation for hormone replacement
therapy also). However, this recommendation was made prior to the
aforementioned toxicology studies. Current knowledge suggests that
cimicifuga is appropriate and safe for long-term continued use in patients who
are not pregnant and with no history of breast cancer. (Neither of
these conditions has been proven to be a contraindication to the use of black
cohosh. However, the lack of extensive research in these
populations warrants caution in the use of cimicifuga.)
Some side effects have been reported: dizziness, nausea,
vomiting, diarrhea, abdominal pain, visual dimness, headache, tremors,
joint pains, and depressed heart rate.
Oral contraceptives / ERT
Powdered root or as tea: 1-2 grams
Fluid extract (1:1): 4 mL (1 teaspoonful)
Solid (dry powdered) extract (4:1): 250-500 mg
Remifemin® (containing 1 mg of 27-deoxyacteine
2 tablets twice daily
Andersen, KP, et al. Cimicifuga and melbrosia lack
in mice and rats. Maturitas. 25(2):149-53,
Castelman, M. The Healing Herbs. Rodale Press,
PA. 1991. Pp. 75-78.
Covington, TR, et al. Handbook of Nonprescription
American Pharmaceutical Association, Washington, DC.
Duker, EM, et al. The use of black and blue cohosh in
New Zealand Medical Journal. 109(1032):410-11, 1996
Giesler, Michelle and Kimberly Jones. Cimicifuga
Cohosh. Presentation handout, Pharmacy 100, Fall 1997.
UNC-Chapel Hill, School of Pharmacy.
Hirabayashi, T, et al. Inhibitory effect of ferulic acid
acid on murine interleukin-8 production in response to influenza
in vitro and in vivo. Planta Medica.
Moore, M. Medicinal Plants of the Pacific West.
Books, Santa Fe, NM. 1993. Pp. 74-79.
Murray, MD. The Healing Power of Herbs. Prima
Rocklin, CA. 1996. p 376.
Murray, Michael and Joseph Pizzorno. Encyclopedia of
Medicine. Prima Publishing, Rocklin, CA. 1998.
Stoll, W. "Phytopharmacon Influences Atrophic Vaginal
Double-Blind Study: Cimcifuga vs. Estrogenic
Therapeuticum 1(1987): 23-31.
Stolze, H. "An Alternative to Treat Menopausal Complaints,"
Gyne 3(1982): 14-6.
Tyler, VE. The Honest Herbal. Pharmaceutical
Press, Binghamton, NY. 1993. pp.45-46.
Warnecke, G. "Influencing Menopausal Symptoms with a
Agent," Med Welt 36 (1985): 871-4.
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