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n.

An eastern North American perennial herb (Cimicifuga racemosa) having large, pinnately compound leaves and racemes of small white flowers. Also called black snakeroot.

Brand names: Combination 5W™, Olivia's Secret™, One-A-Day® Menopausal Health, Pregnancy-6™, Remifemin™

Español:
• Raíz de culebra negra o cimicifuga racemosa en sus formas de dosificación oral

Black Cohosh, Cimicifuga racemosa oral dosage forms

What is black cohosh, Cimicifuga racemosa?

BLACK COHOSH or Cimicifuga racemosa (Estroven(TM), Olivia's Secret(TM), Remifemin(TM), One-A-Day® Menopausal Health, and many others) is a dietary supplement (herbal remedy) that is being promoted to help support female health problems, like the symptoms of menopause (hot flashes). Unlike estrogens, there is no evidence at this time that black cohosh is helpful for preventing brittle bones (osteoporosis) or that it protects against heart disease after menopause. Black cohosh is also promoted to ease menstrual pain or pre-menstrual syndrome (PMS). Nurse-midwives sometimes use black cohosh as an aide during labor, however, the risks of use during pregnancy or labor are not fully known. The FDA does not recognize black cohosh as being safe or effective for any use at this time, and warns against its use in pregnancy.

Many women may want to discuss the risks and benefits of both drug and herbal treatments with their prescriber prior to choosing treatments. Many black cohosh products are combined with other herbs or vitamins, so you should be aware of the other ingredients in these products.

What should I tell my health care provider before I take this medicine?

It is important for you to tell your prescriber or other health care professional that you are using. Some herbs exert potent effects and may interact with other drugs you are taking.

You should discuss black cohosh with your health care professional BEFORE taking it if you have any of these conditions:
• cancer
• diabetes mellitus
• endometriosis or uterine fibroids
• high blood pressure
• infertility
• kidney disease
• liver disease
• menstrual changes or irregular periods
• mood swings
• unusual vaginal or uterine bleeding
• an unusual or allergic reaction to black cohosh, soybeans, tartrazine dye (yellow dye number 5), other medicines, foods, dyes, or preservatives
• pregnant or trying to get pregnant
• breast-feeding

How should I use this medicine?

Black cohosh is usually taken orally (i.e., swallowed) with a sip of water. Follow the directions on the package labeling, or talk to your health care professional.

Black cohosh should not be used for longer than 6 months without the advice of a health care professional. Do not use if you are pregnant or breast-feeding. Talk to your obstetrician-gynecologist or certified nurse-midwife.

This herb is not for use in children under the age of 18 years.

What if I miss a dose?

Missing a dose is probably not harmful. If you miss a dose, simply resume taking it on your previous schedule. Do not take double doses to catch up, however.

What drug(s) may interact with black cohosh?

• blood pressure medications (may increase or decrease blood pressure medicine effects)
• estrogens and other female hormones
• fertility treatments
• medicines for treating diabetes (may cause changes in blood sugar control)

For many herbs, interactions with other medications are unknown. That is why you should always be careful when mixing herbal remedies with traditional medications. If you take any other medications, consult with your health care professional prior to taking black cohosh.

Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines, nutritional supplements, or herbal products. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.

What should I watch for while taking black cohosh?

Since black cohosh is derived from a plant, allergic reactions are possible. Stop using this herb if you develop a rash. You may need to see your health care professional, or inform them that this occurred. Report any unusual side effects promptly.

Different brands of black cohosh might contain different amounts of active ingredient, so be careful to use the same brand. It is recommended that you use a brand from a reliable manufacturer. A standardized product is more likely to contain the same amount of herb from dose to dose. Your health care professional or pharmacist can assist you in finding a product.

If you are taking black cohosh for menstrual or menopausal symptoms, visit your prescriber or health care professional for regular checks on your progress. You should have a complete check-up every 6 months. You will need a regular breast and pelvic exam while on black cohosh therapy. Follow your prescriber's guidelines.

If you have any reason to think you are pregnant; stop taking black cohosh at once and contact your prescriber or health care professional.

If you are going to have elective surgery, you may need to stop taking this herb before the procedure. Let your health care professional know you are taking black cohosh prior to scheduling the surgery.

What side effects may I notice from using black cohosh ?

Side effects that you should report to your prescriber or health care professional as soon as possible:
• difficulty breathing, shortness of breath, or wheezing
• easy bruising
• fast heartbeat, slow heartbeat, or palpitations
• headache
• high blood pressure
• severe nausea or vomiting
• skin rash or itching
• swelling of any area of the throat, tongue, skin, or body
• unusual tiredness

Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome):
• heartburn
• mild upset stomach

Where can I keep my medicine?

Keep out of the reach of children.
Store at room temperature; do not freeze. Throw away any unused herb after the expiration date.

GENERAL INFORMATION REGARDING DIETARY SUPPLEMENTS:
Dietary supplements include amino acids, vitamins, minerals, herbs, botanicals, and other plant-derived substances, and extracts of these substances. These products are easy to identify as they must state "Dietary Supplement" on the label. A "Supplement Facts" panel is provided on the label for most products. Supplements are not drugs and are not regulated like drugs. You should note that rigid quality control standards are not required for dietary supplements. Differences in the potency and purity of these products can occur. Scientific data to support the use of a dietary supplement for a certain disease or ailment may not be available. This product is not intended to diagnose, treat, cure or prevent any disease.

The Food and Drug Administration suggests the following to help consumers protect themselves:
• Always read product labels and follow directions.
• "Natural" doesn't mean a product is safe for humans to take.
• Look for products containing ingredients with the "USP" notation. This indicates the manufacturer followed the standards of the US Pharmacopoeia.
• Supplements produced or distributed by a nationally known food or drug company are more likely to be made under tight controls as these companies have standards in place for their other products. You can write to the company for more information about how the product was made.

Last updated: 12/10/2003 2:08:00 PM

Important Disclaimer: The drug information provided here is for educational purposes only. It is intended to supplement, not substitute for, the diagnosis, treatment and advice of a medical professional. This drug information does not cover all possible uses, precautions, side effects and interactions. It should not be construed to indicate that this or any drug is safe for you. Consult your medical professional for guidance before using any prescription or over the counter drugs.

Description

Black cohosh (Cimicufuga racemosa) is a member of the Ranunculaceae family. Its nicknames of squawroot and snakeroot denote its Algonquian heritage and differentiate it from the common snake root plant (Aristolochia serpentaria). It should also not be confused with blue cohosh (Caulophyllum thalictroides); their only similarity is that both are roots.

Black cohosh grows from a gnarled black root, hence its name; it has a smooth stem and big multiple leaves with jagged edges. In summer, white flowers develop from what are called racemes. These flowers emit a stinky odor. The plant, which can grow to 9 ft (1 m) tall, is a native North American plant found on hills and in forests located at high levels. It is found from Ontario, Canada to Maine to the southern states of Georgia and Missouri.

Black cohosh contains several components, as outlined by James F. Balch, MD and Phyllis A. Balch, CNC in their book Prescription for Nutritional Healing, Second Edition:

• actaeine
• cimicifugin
• estrogenic substances
• isoferulic acid
• oleic acid
• palmitic acid
• pantothenic acid
• phosphorus
• racemosin
• tannins
• triterpenes
• vitamin A

General Use

Black cohosh has a history of usage for women's health problems, dating back to the Algonquian natives living in the Ohio Valley. However, according to Michael Castleman in The Healing Herbs, the Algonquians also boiled the roots in water and drank the concoction for fatigue, arthritis, sore throat, and a typical occurrence of that time, rattlesnake bites. The Eclectic doctors of the 1800s also recommended black cohosh for what they called "hysterical" diseases, i.e. female reproductive diseases as well as fevers, rashes, sleeplessness and malaria. A popular patent medicine company of the same era, the Lydia E. Pinkham's Vegetable Compound, sold a potion containing black cohosh for menstrual complaints.

Today, black cohosh is still used for gynecological problems from menstruation to menopause, with several studies over the past 40 years backing up this pattern of usage. Michael T. Murray, ND, a well-known natural medicine author, outlines some of this research regarding menopause in his paper Hormone Replacement Therapy vs. Black Cohosh in Menopause. Growing numbers of menopausal women are turning to black cohosh rather than allopathic treatment to manage their symptoms. A 2002 study of menopausal women in the San Francisco Bay area found that women taking black cohosh and other herbal remedies for their symptoms reported higher satisfaction with their treatment than women receiving conventional allopathic therapy.

The most famous research was a 1982 open study in which 629 women took 80 mg of black cohosh over a period of six to eight weeks. Over 80% of the women experienced relief from several menopausal symptoms—hot flashes, perspiration, headaches, vertigo, heart palpitations, irritability, sleep disturbances and depression. A later random study focused on 60 women under 40 years of age who had hysterectomies, with one ovary remaining. The women were either given black cohosh or hormone replacement therapy (HRT) of estrogen or estrogen-progestin combinations. Although the HRT met with better results, the study concluded that black cohosh was a favorable natural alternative for post hysterectomy.

A 1998 German clinical study showed that black cohosh has good therapeutic results in treating symptoms of menopause and also that black cohosh did not show any hormone-like activity as previously thought. A second German study, published in 2002, reported that black cohosh has antiestrogenic effects.

Because the collective results of a number of studies show synthetic hormone replacement therapy, which contains estrogen, increases breast cancer risk by 1–30%, black cohosh is being considered as an alternative. A 1998 study at the University of Bridgeport in Connecticut reviewed eight previous studies of black cohosh as treatment for menopausal symptoms. This study stated that black cohosh is a safe alternative to estrogen replacement therapy (ERT) for women where ERT is contraindicated or declined. Some contraindicated conditions from ERT include a history of estrogen-dependent cancer, unidentified uterine bleeding, liver disease, gallbladder disease, endometriosis, uterine fibroids and fibrocystic breast disease.

In a 1999 in vitro study at the New York College of Osteopathic Medicine, several herbs, including black cohosh, hops, and vitex, were shown to inhibit the growth of T-47D cells. The study concluded that these herbs may be useful in preventing breast cancer.

A 1999-2000 study at Cedars-Sinai Hospital in Los Angeles, California, focused on the efficacy and safety of several traditional phytomedicines, including black cohosh root extract, to treat women's gynecological conditions, such as PMS and menopause. This study concluded that both dong quai and black cohosh are safe to use to relieve menopausal symptoms, but only black cohosh showed efficacy. The study stated that information regarding safety for use during pregnancy and lactation is still small in amount and suggested pharmacists study scientific literature to help decide the value of recommending these herbs for use.

A 1999 national survey of 500 midwives belonging to the American College of Nurse-Midwives and 48 nurse-midwife education programs was undertaken by the West Virginia University School of Medicine. The purpose was to determine if colleges were educating their students in the use of herbs to stimulate labor. Of the 172 surveys returned, 90 used herbal preparations and 82 did not. Herbal usage was broken down as: black cohosh (45%), evening primrose oil (60%), blue cohosh (64%), and castor oil (93%). Those who used these herbs did so because they are natural, and those who refrained from using them cited the lack of sufficient research about the safety.

Black cohosh can sometimes bring relief from tinnitus (ringing in the ears) as James A. Duke, Ph.D. relates in The Green Pharmacy. He refers to a professional flutist who suffered this condition for many years and a black cohosh tincture caused his tinnitus to decrease considerably.

Black cohosh can also decrease blood pressure by "opening the blood vessels in the limbs (peripheral vasodilation)" according to a study referred to by Michael Castleman in The Healing Herbs. A person with hypertension should first consult a physician.

Other possible benefits of black cohosh are to alleviate muscle spasms, reduce neuralgia pain, and relieve bronchial infections by stopping the compulsion to cough. Black cohosh has also been recommend as a glandular tonic.

Preparations

Black cohosh may be taken in capsule, extract, tea, or tincture.

To make a tea, boil 1/2 tsp powdered black cohosh root for each cup (250 ml) of water for 30 minutes. After it cools, it can be sipped with lemon and honey to mask its bitter taste.

One teaspoon of black cohosh tincture can be taken on a daily basis. Ten to 30 drops of extract mixed in water can be taken daily. Two to five capsules (40 mg/capsule) may be taken daily. The German Commission E recommends taking two 20-mg capsules daily, one in the morning and one at night. These tablets are available under the name Remifemin, a black cohosh extract. A 2002 German study found that these standard dosages are effective for most women and that there is no therapeutic benefit from higher dosages.

Precautions

Black cohosh should not be used during pregnancy except at the time of birth. It should also not be taken by those with a chronic disease, or women taking birth control pills or HRT. Children under 12 years and adults over 62, should start with lower dosages.

The German Commission E recommends taking black cohosh for six months at a time only. However, recent studies with animals show no toxicity problems. It is always best to first consult a health care practitioner.

Side Effects

An overdose (over 900 mg/day) could cause dizziness, nausea and vomiting, diarrhea, pain in the abdomen, headaches, joint pains, and a lowered heart rate. These conditions could also appear sometimes when taking low dosages of black cohosh. Large dosages can also cause poisoning symptoms.

Interactions

Women taking black cohosh should not take it together with birth control pills; HRT; such sedatives as diazapam; or blood pressure medications.

Resources

Books

Balch, James F., MD, and Phyllis A. Balch. CNC. Prescription for Nutritional Healing, second edition. Avery Publishing Group, 1997.

Castleman, Michael. The Healing Herbs. Rodale Press, 1991.

Duke, James A., PhD. The Green Pharmacy. Rodale Press, 1997.

Heinerman, John. Heinerman's Encyclopedia of Healing, Herbs & Spices. Prentice Hall, 1996.

Landis, Robin, with Karta Pukh Singh Khalsa. Herbal Defence. Warner Books, Inc. 1997.

Mindle, Earl. Earl Mindell's Herb Bible. Simon & Schuster, 1992.

Murray, Michael, ND. Encyclopedia of Nutritional Supplements. Prima Publishing, 1996.

Murray, Michael, ND. The Healing Power of Herbs, second edition. Prima Publishing, 1995.

Rothenberg, Mikel, MD, and Charles Chapman. Dictionary of Medical Terms, third edition. Barron's Educational Series, 1994.

Periodicals

Kam, I. W., C. E. Dennehy, and C. Tsourounis. "Dietary Supplement Use Among Menopausal Women Attending a San Francisco Health Conference." Menopause 9 (January-February 2002): 72-78.

Liske, E., W. Hanggi, H. H. Henneicke-von Zepelin, et al. "Physiological Investigation of a Unique Extract of Black Cohosh (Cimicifugae racemosae rhizoma): A 6-month Clinical Study Demonstrates No Systemic Estrogenic Effect." Journal of Women's Health and Gender-Based Medicine 11 (March 2002): 163-174.

Stengler, Angela, ND and Mark Stengler, ND. "Black Cohosh." Natural Factors Research Information (September 10, 1998).

Tyler, Varro E., PhD, ScD. "Honest Herbalist: Five Herbs That Ease Menopause." Prevention Magazine (March 1999).

Zierau, O., C. Bodinet, S. Kolba, et al. "Antiestrogenic Activities of Cimicifuga racemosa Extracts." Journal of Steroid Biochemistry and Molecular Biology 80 (January 2002): 125-130.

Other

Hardy, M. L. Herbs of special interest to women [Abstract]. Cedars-Sinai Integrative Medicine Medical Group, Cedars-Sinai Hospital, Los Angeles, CA. 2000.

Lieberman, S. A review of the effectiveness of Cimicifuga racemosa (black cohosh) for the symptoms of menopause [Abstract]. University of Bridgeport, Connecticut, USA. 1998.

McFarlin B.L, M.H. Gibson, J. O'Rear, and P. Harman. A national survey of herbal preparation use by nurse-midwives for labor stimulation. Review of the literature and recommendations for practice [Abstract]. West Virginia University School of Medicine, Department of Obstetrics and Gynecology, Morgantown, 1999.

[Article by: Sharon Crawford; Rebecca J. Frey, PhD]

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