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Review of Black Cohosh: Herbal Remedy for MenopauseByun, Connie; Eaker, Ryan; Park, Justin; Reese, Kimberly; Ricks, Jennifer; Thompson, Meghan; Walls, Amanda

Virginia Commonwealth University School of Pharmacy, 410 N 12th Street, Richmond, VA 23223

Abstract

Black Cohosh is a herbal medicine that has been used for hormonal modulation and treatment of menopausal symptoms such as hot flashes, night sweats, sleep disruption, anxiety, and depression. Possible other indications include treatment of migraine and osteoporosis. It is derived from the Actaea racemosa (otherwise known as Cimicifuga racemosa) plant, commonly referred to as black bugbane, black snakeroot, or fairy candle. The root and rhizomes (root stems) are dried and made into powder for use as the drug. Black cohosh is available as capsules, fluid extract, tablets, or tinctures and is administered orally. The key active ingredient is a triterpene glycoside, specifically 27-deoxyacteine, which black cohosh is supposed to contain no less than 0.4% of, and clinical studies have been based on administering one to two milligrams of this substance twice daily (Micromedex).

Other ingredients may contribute to black cohosh’s activity. These include ferulic and isoferulic acid, methylcytisine, racemosin, other glycosides such as actein, cimicfugosides, and cimigosides, and the resin cimicifugin (Micromedex). There have been instances where a natural product was isolated from black cohosh, for example another triterpenoid glycoside, 25-acetylcimigenol xylopyranoside, which was found to block osteoclastogenesis in vitro, attenuating TNFα-induced bone loss in vivo (Qui).

While open-label trials demonstrated that black cohosh was effective at treating menopausal symptoms, small double-blind studies showed no effect, and therefore larger controlled trials are necessary to support its use. There is inconclusive data proving black cohosh’s ability to relieve migraine pain or prevent osteoporosis.

Black cohosh is believed to work by acting as a selective estrogen-receptor modulator (SERM), but it is unclear whether it acts by agonist or antagonist effect. In vitro trials have suggested black cohosh had an antagonistic effect on estrogen receptor-positive breast cancer cells. However, there is human data available to suggest agonist activity at estrogen receptors on osteoblast cells, leading to black cohosh’s possible ability to improve bone metabolism and formation. Black cohosh is contraindicated in pregnancy because it’s estrogenic activity could interfere with maintenance of the pregnancy (Micromedex).

Use of Black cohosh is associated with several side effects, including: bradycardia, dizziness, headache, tremors, giddiness, hepatitis, hepatotoxcitity, nausea, vomiting, hypotension, and vasodilatation.

Introduction

Results and Discussion

Side EffectsAcute hepatitis was reported in one patient taking 40mg black cohosh

every day for two weeks, and another patient developed autoimmune hepatitis after using black cohosh for three weeks (Micromedex).

Evidence was found in the literature to indicate black cohosh as a agent that potientially causes hepatotoxicity. One patient that was taking 1000mg of black cohosh every day for eight months experienced hepatic failure. Two patients experienced elevated liver enzymes and mild liver toxicity after taking black cohosh for the treatment of menopausal symptoms, and upon discontinuation of black cohosh, their liver function normalized. One patient developed jaundice and required a liver transplant after taking black cohosh for one week (Micromedex).

A study of 629 patients taking black cohosh resulted in 7% complaining of GI upset, nausea, and vomiting (Micromedex).

Animal tests in rabbits and cats showed hypotension as a side effect of black cohosh administration, although hypotension was not observed in dogs. Vasodilatation was observed after black cohosh administration in dogs (Micromedex).

Black cohosh (Actaea racemosa, Cimicifuga racemosa) behaves as a mixed competitive ligand and partial agonist at the human mu opiate

receptorStudy showed for the first time that black cohosh extracts contained components that have an affinity to the human µ opiate receptor . The opiate system in the brain is linked to mood, temperature, and sex hormonal levels which are all related to menopause symptoms. The research stated “a clinically used 75% ethanol extract of black cohosh acted as a partial agonist at the receptor”.

Black Cohosh and St. John’s Wort (GYNO-Plus) for Climacteric Symptoms

Double-blind randomized, placebo-controlled, multicenter study of 89 peri- or postmenopausal women experiencing climacteric symptoms were treated with Gynoplus, Jin-Yang Pharm., Seoul, or a matched placebo for 12 weeksKI (Kupperman index), which tests for items such as hot flush, vertigo, and headache. These decreased significantly in treatment group. There was no significant difference between hormone levels for the groups vaginal dryness and reduced libido did not improve significantly.

Qiu, Samuel X et al. A Triterpene Glycoside from Black Cohosh that Inhibits Osteoclastogenesis by Modulating RANKL and TNFα Signaling Pathways. Chemistry and Biology. Volume 14, Issue 7, 30 July 2007, Pages 860-869.

Micromedex. Black Cohosh. Alternative Medicine Database. Thomson Reuters. April 2008.

Conclusions

References

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Black cohosh is an herbal remedy commonly used by patients for the treatment of menapause., particularly in the management of hot flashes. Clinical data and safety trials on the herbal remedy lead to mixed results. Studies performed for this medication are rarely controlled and parameters for measuring the extent of a hot flash or inducing a hot flash are difficult. For this reason, data that either supports or disproves the efficacy of black cohosh are unsubstantial.

Also, there are few studies which give long term safety data for black cohosh or information for special populations, including safety in pregnant women. For this reason, use of black cohosh in the treatment of menapause and hot flashes is controversial and should be considered on a patient to patient basis.

Black cohosh is a popular alternative medicine preparation that comes from a buttercup plant grown in North America. It has been used for the treatment of menopausal symptoms. However, definitive clinical data about its efficacy is questionable. Further study is warranted to determine its safety and efficacy, due to the significant number of women who experience climacteric symptoms and are considering taking the supplement. The purpose of this study is to look at literature and several different experiments that have been performed on the herb, and determine what benefits it holds for women who are experiencing symptoms.