Black Cohosh

Effects and Benefits

Core Identification

Common Names:
- Black Cohosh
- Black Snakeroot
- Squaw Root
- Bugbane
- Rattleroot
- Rattleweed
- Fairy Candle

Latin Name: Actaea racemosa (syn. Cimicifuga racemosa)

Category: Herb

Note: Black cohosh is on the United Plant Savers' "at risk" list due to overharvesting; purchase from cultivated sources rather than wildcrafted.

Uses

Traditional Uses

• Women's reproductive health and childbirth - Native American medicine (Cherokee, Iroquois, Algonquin), thousands of years
• Menstrual cramps and uterine pain - Native American and early American medicine
• Rheumatism and joint pain - Native American medicine; Iroquois used it externally as a soak or steam bath
• Snakebite antidote - Native American medicine (hence "black snakeroot")
• Coughs, colds, and respiratory complaints - Cherokee medicine
• Fever reduction - Early American colonial medicine
• Nervous conditions and sedation - 19th century American medicine; main ingredient in Lydia Pinkham's Vegetable Compound

Modern Uses

• Menopausal symptoms (hot flashes, night sweats) | Research quality: Strong
• Key findings: Multiple clinical trials demonstrate significant improvement in hot flashes, sweating, and vasomotor symptoms. A German study of over 600 women found nearly 80% experienced improvement. Black cohosh has performed comparably to or better than low-dose estrogen replacement in some trials. Studies show it works within two to four weeks, with four out of five women rating effects as good or very good. It reduces luteinizing hormone (LH) levels by approximately 20%, which may explain its effectiveness.

• Source citations: Bone - Clinical Guide to Blending Liquid Herbs; Simon - The Chopra Center Herbal Handbook; Brewer - Encyclopedia of Vitamins; Barrett - Handbook of Clinically Tested Herbal Remedies

• Mood and psychological symptoms of menopause | Research quality: Moderate

• Key findings: German trials found black cohosh reduced anxiety and depressive moods associated with menopause. One study showed it outperformed diazepam and estrogen HRT in relieving depression and anxiety. Combination with St. John's Wort was 78% effective for hot flashes and psychological symptoms. Black cohosh lifts the "black cloud" of depression and is particularly suited for hormonal mood issues.

• Source citations: Chevallier - Encyclopedia of Herbal Medicine; Brewer - Encyclopedia of Vitamins; WRCHM - Western Materia Medica I; Groves - Grow Your Own Herbal Remedies

• Uterine fibroids | Research quality: Moderate

• Key findings: Research shows a 70% decrease in fibroid size in 3 months—better than medications. A 10-year follow-up study found fibroids remained smaller among postmenopausal women who had taken black cohosh (Remifemin) compared to those who took prescription drugs. Black cohosh eases uterine tension, contractions, and inflammation.

• Source citations: Groves - Grow Your Own Herbal Remedies; Amazing Wellness 2015-02

• Vaginal health, dryness, and sexual function | Research quality: Moderate

• Key findings: Studies show improvement in vaginal tissue, including increased proliferation and maturation of vaginal epithelium. May enhance blood circulation to the genitals. Some studies suggest black cohosh can relieve vaginal atrophy and hormonal imbalances related to menopause, consequently enhancing sexual desire and responsiveness.

• Source citations: Simon - The Chopra Center Herbal Handbook; Bone - Clinical Guide to Blending Liquid Herbs; Amazing Wellness 2014-04

• Premenstrual syndrome (PMS) | Research quality: Moderate

• Key findings: German Commission E approved for premenstrual discomfort. May help reduce congestion, breast tenderness, irritability, and mood changes associated with hormonal fluctuations preceding menstruation. Has antispasmodic properties that lessen menstrual discomfort.

• Source citations: Balch - Prescription for Herbal Healing; Barrett - Handbook of Clinically Tested Herbal Remedies

• Menstrual cramps (dysmenorrhea) | Research quality: Traditional/Moderate

• Key findings: Strong antispasmodic properties make it effective for uterine cramps and dull, dragging muscular pain in the back and pelvic region. May increase blood flow to the uterus, reducing intensity of painful cramps. Especially indicated for pain that improves with onset of menstrual flow.

• Source citations: Soule - The Woman's Handbook of Healing Herbs; Blankespoor - The Healing Garden; Wood - The Earthwise Herbal

• Hormone balancing, PCOS, and fertility | Research quality: Moderate

• Key findings: Black cohosh balances the hormonal interplay of the hypothalamus, pituitary, and ovaries. Improves brain-ovary hormone communication to regulate estrogen, FSH, and LH. Studies support its use in polycystic ovary syndrome (PCOS), showing increased fertility and improved hormone levels. Does not appear to stimulate estrogen-sensitive tumors—may actually inhibit them. Useful for irregular cycles, amenorrhea, and ovarian cysts.

• Source citations: Balch - Prescription for Herbal Healing; Blankespoor - The Healing Garden; WRCHM - Western Materia Medica I; Groves - Grow Your Own Herbal Remedies

• Rheumatism and arthritis | Research quality: Preliminary to Moderate

• Key findings: Traditional use for inflammatory joint conditions supported by research showing anti-inflammatory activity. Contains salicylates (nature's aspirin). A randomized, placebo-controlled trial found an herbal formula containing black cohosh improved pain and mood scores in arthritic patients. Particularly effective for rheumatic symptoms that worsen after menopause. Useful in rheumatoid and osteoarthritis.

• Source citations: WRCHM - Western Materia Medica I; Blankespoor - The Healing Garden; Chevallier - Encyclopedia of Herbal Medicine; Groves - Grow Your Own Herbal Remedies

• Muscle tension and spasm | Research quality: Traditional/Clinical Experience

• Key findings: Potent antispasmodic and relaxant properties. Effective for muscle tension combined with nervous system overactivity. Used for lower back discomfort, fibromyalgia, and "purple pain"—cold, congestive, dull aches where the person feels cold, clammy, and feeble.

• Source citations: Pursell - The Herbal Apothecary; Blankespoor - The Healing Garden; Wood - The Earthwise Herbal

• Nervous system support (anxiety, headache, tinnitus, vertigo) | Research quality: Traditional/Preliminary

• Key findings: Has sedative properties and is considered a "nervine" that calms and strengthens the nervous system. Its overall effect is to reduce overactivity and relieve pain. Used for nervousness, chronic headache, migraine, tinnitus, and vertigo. Works on psychological states characterized by brooding, withdrawal, and depression. Binds and activates serotonin (5-HT) receptors, contributing to mood-stabilizing effects.

• Source citations: Mars - Home Reference to Holistic Health; Wood - The Earthwise Herbal; Tierra - The Way of Herbs; DK - Herbal Remedies; Pursell - The Herbal Apothecary

• Respiratory support | Research quality: Traditional

• Key findings: Expectorant properties help break up mucus in the lungs. Used for bronchitis, asthma, and spasmodic coughs including whooping cough. Has bronchodilator effects that may reduce airway restriction.

• Source citations: Simon - The Chopra Center Herbal Handbook; WRCHM - Western Materia Medica I

• Labor preparation and childbirth | Research quality: Traditional

• Key findings: Traditional use to regulate uterine contractions and ease childbirth. In Germany, up to 45% of nurse-midwives use black cohosh to help induce labor at term. Ripens the uterus and helps descend the cervix. Should only be used in the final weeks of pregnancy under professional guidance.

• Source citations: WRCHM - Western Materia Medica I; Simon - The Chopra Center Herbal Handbook

• Bone health support | Research quality: Preliminary

• Key findings: Preliminary research suggests postmenopausal women taking black cohosh have increased levels of bone-specific alkaline phosphatase (bALP), a marker of bone formation. May increase osteoblast activity and help protect bones after menopause. Unknown if this translates to increased bone density or reduced fracture risk.
• Source citations: WRCHM - Western Materia Medica I; Groves - Grow Your Own Herbal Remedies

Active Compounds

Primary Active Ingredients:
- Triterpene glycosides (actein, cimicifugoside, 27-deoxyactein) - Primary compounds responsible for hormonal and anti-inflammatory effects; standardized extracts typically measure these compounds; work synergistically (none of the single ingredients work alone)
- Isoflavones (formononetin) - Phytoestrogen that acts similarly to estrogen in the body; works through the hypothalamus rather than direct estrogen receptor binding
- Isoferulic acid and caffeic acid - Contribute to anti-inflammatory properties
- Fukinolic acid - Potent inhibitor of neutrophil elastase, involved in anti-inflammatory action
- Salicylates - Aspirin-like compounds providing analgesic and anti-inflammatory effects
- Tannins - Astringent compounds
- Alkaloids (including N-methylcytisine) - Contribute to sedative and nervous system effects
- Cimicifugin (macrotin) - Resinous active principle comprising 15-20% of the root

Sources: Chevallier - Encyclopedia of Herbal Medicine; Simon - The Chopra Center Herbal Handbook; WRCHM - Western Materia Medica I; Pursell - The Herbal Apothecary

Dosage Information

Standard Dosage:
- Form: Standardized root extract (tablets or capsules)
- Amount: 40 mg per day (standardized to 1-2 mg triterpene glycosides)
- Frequency: One or two doses daily

Therapeutic Dosage:
- Form: Standardized extract (Remifemin or equivalent)
- Amount: 40-80 mg per day (some studies used up to 136 mg/day)
- Purpose: For menopausal symptoms, PMS, dysmenorrhea, fibroids
- Duration: Allow 2-4 weeks for initial benefits; 8-12 weeks for full effect; hormonal shifts may take at least 3 months to fully kick in

Maximum Safe Dosage:
- Daily maximum: Most studies use 40-80 mg standardized extract
- Warning threshold: The German Commission E recommends treatment not exceed 6 months, though newer research suggests longer use may be safe
- Higher doses can cause nausea, headache, and gastrointestinal upset; if headache occurs, a strong cup of green tea may help remedy it

Bioavailability Notes:
- Standardized extracts preferred—look for products standardized to triterpene glycosides (often 2.5% or containing 1-2 mg per dose)
- Remifemin is the most studied commercial preparation, standardized to contain 1 mg total triterpene saponins per 20 mg root equivalent
- Fresh root tinctures have double the strength of dried and are traditionally preferred for maximum potency

How to Take It

Timing:
- Best time of day: Morning and evening (split doses preferred for hormone balancing)
- With food or on empty stomach? With food recommended to reduce chance of stomach upset
- Specific timing notes: For hormone balancing, consistent daily dosing is crucial—ideally twice daily, morning and night. Effects build over time; allow 2-4 weeks for initial benefits. May be more effective when combined with other suitable herbs like sage or St. John's Wort as recommended by an herbal practitioner.

Synergies - What It Works Well With

Complementary Supplements:
1. St. John's Wort - Both support mood during menopause; combination was 78% effective for hot flashes and psychological symptoms in clinical trials | Traditional pairing for menopausal support, especially when nervous exhaustion or depression are present
2. Vitex (Chaste Tree Berry) - Both balance female hormones through different mechanisms | Combine for comprehensive hormone support, PMS, irregular cycles
3. Black Haw/Cramp Bark - Both antispasmodic for uterine and muscle pain | Combine for menstrual cramps and musculoskeletal inflammation
4. Blue Cohosh - Traditional pairing for labor preparation and menstrual issues | Use together for dysmenorrhea and childbirth (under professional guidance only)
5. Motherwort - Both support menopausal transition; motherwort adds cardiovascular support | Combine for hot flashes with heart palpitations
6. Meadowsweet and Willow - All contain salicylates for anti-inflammatory action | Combine for arthritis and musculoskeletal pain
7. Valerian and Skullcap - All support nervous system relaxation | Combine for anxiety, muscle tension, and sleep issues
8. Sage - Both address menopausal symptoms | Particularly effective combination for hot flashes

Avoidance - What NOT to Combine With

Supplement Interactions:
1. Blue Cohosh without guidance - Though traditionally paired, blue cohosh has different safety concerns and may cause adverse effects in newborns if used for labor | Use only under professional supervision
2. Other strongly sedating herbs (Kava, high-dose Valerian) - May cause excessive sedation | Use caution if combining

Drug Interactions:
1. Estrogen and hormone medications (birth control pills, HRT) - May interfere with hormonal action | Consult physician before combining | Severity: Moderate
2. Tamoxifen - Black cohosh may enhance antiproliferative effects; this could be beneficial but requires oncologist supervision | Severity: Moderate - consult oncologist
3. Immunosuppressants (Azathioprine, Cyclosporine) - Should not be used together | Severity: Moderate to Severe
4. Blood pressure medications - May potentiate blood pressure-lowering effects | Risk of hypotension | Severity: Mild to Moderate
5. Sedatives, tranquilizers, barbiturates - May have additive sedative effects | Severity: Moderate
6. Iron supplements - Black cohosh may bind to iron, reducing absorption | Take at different times | Severity: Mild

Food Interactions:
- No significant food interactions known
- Green tea may counteract sedative effects and can help remedy black cohosh-induced headaches

Safety Information

Long-Term Use:
- The German Commission E recommends limiting treatment to six months, though newer toxicology studies suggest longer use may be safe
- Most clinical trials have been 2-6 months in duration
- Monitoring recommendations: Periodic assessment of symptoms; consider liver function monitoring with long-term use
- Pregnancy: Contraindicated during the first and second trimesters due to potential effects on fetal development and emmenagogue properties. May be used in the final weeks of pregnancy to prepare for labor ONLY under the guidance of a qualified healthcare practitioner.
- Breastfeeding: Should be avoided while nursing
- Liver concerns: Rare cases of liver injury have been reported. Regulatory agencies (UK MHRA, European EMEA) recommend stopping use if signs of liver toxicity develop (dark urine, yellowing of skin/eyes, unusual fatigue, loss of appetite, stomach pain). These cases are relatively rare considering widespread use and are likely related to intentional adulteration with liver-toxic Chinese Actaea species rather than true black cohosh. True black cohosh and standardized Remifemin extract are considered safe.
- Estrogen-sensitive conditions: Research suggests black cohosh does not stimulate breast tissue and may actually have inhibitory/antiproliferative effects. Studies show it decreases breast cancer risk and has been safely used by breast cancer survivors, though consult healthcare provider.
- Heart conditions: Consult physician if you have heart disease
- Surgery: Discontinue at least 2 weeks before surgery
- Girls before puberty: Should not take black cohosh
- Side effects: About 10% of women experience mild stomach upset for the first 1-2 weeks. Occasional frontal headaches may occur (green tea can help). Large doses can cause nausea, vomiting, dizziness, visual disturbances, and low blood pressure.

Primary Uses At-a-Glance

Primary: Menopausal symptoms (hot flashes, night sweats), PMS, menstrual cramps, hormone balancing, mood and anxiety during menopause, uterine fibroids

Secondary: Arthritis and rheumatism, muscle tension, vaginal dryness, PCOS and fertility, nervous system support, labor preparation, bone health

Sources

Local Library:
- Balch, Phyllis - Prescription for Herbal Healing: Hormone balancing mechanisms, fibroids, infertility, menopause, PMS, drug interactions, usage considerations
- Barrett, Marilyn - The Handbook of Clinically Tested Herbal Remedies: Clinical trial summaries, Remifemin studies, dosage information, pharmacopoeial monographs, adverse reactions
- Blankespoor, Juliet - The Healing Garden: Hormone-balancing formula, musculoskeletal formula, dosing philosophy, traditional Cherokee and Iroquois uses, precautions
- Bone, Kerry - A Clinical Guide to Blending Liquid Herbs: Clinical studies review, contraindications, interactions, professional dosing
- Brewer, Sarah - Encyclopedia of Vitamins: LH mechanism, comparison with HRT, St. John's Wort combination, dose and side effects
- Chevallier, Andrew - Encyclopedia of Herbal Medicine: Key constituents, clinical trials, estrogenic properties, safety research
- DK - Herbal Remedies: Nervine properties, migraine, tinnitus, vertigo uses, combination recommendations
- Duke, James A. - Handbook of Medicinal Herbs: Dosing forms, contraindications, side effects, Commission E cautions
- Easley, Thomas - The Modern Herbal Dispensatory: Dosage forms, specific indications, green tea remedy for headaches
- Garrett, J.T. - The Cherokee Herbal: Cherokee traditional uses, ga na ge name, contraindications
- Groves, Maria Noel - Grow Your Own Herbal Remedies: Fibroid research (70% decrease), PCOS/fertility, bone protection, adulteration concerns, fresh vs dried potency
- Kavasch, E. Barrie - American Indian Healing Arts: Native American traditional uses, menopause, combination formulas
- Lopez, Maria Transito - Medicinal Plants at Home: Formononetin mechanism, menopausal symptom relief
- Mars, Brigitte - Home Reference to Holistic Health and Healing: Nervous system effects, flower essence uses, contraindications
- Moline, Peg - The Doctors Book of Natural Health Remedies: Hot flash research, Mayo Clinic overview, dosage
- Native American Herbalism Encyclopedia: Commission E approval, Remifemin trials, modern research summary, warnings
- Orr, Stephen - The New American Herbal: Native American history, Matthew Wood perspectives, cultivation notes
- Pursell, J.J. - The Herbal Apothecary: Estrogenic effects, serotonin binding, medicine cabinet preparations, anxiety and muscle tension uses
- Simon, David - The Chopra Center Herbal Handbook: German clinical studies, mechanism research, Ayurvedic analysis, practical use guidance
- Soule, Deb - The Woman's Handbook of Healing Herbs: Traditional Native American women's uses, menstrual applications, labor support, respiratory uses
- Tierra, Michael - The Way of Herbs: Biochemical constituents, energy and systems affected, formula combinations
- Wood, Matthew - The Earthwise Herbal: Psychological indications, estrogenic properties, cerebrospinal fluid mechanism, specific symptom pictures
- WRCHM - Western Materia Medica I: Comprehensive research summary, constituent analysis, Eclectic uses, specific indications, contraindications, toxicity data
- Amazing Wellness 2014-04: Libido and sexual function benefits
- Amazing Wellness 2015-02: 10-year fibroid follow-up study

General Knowledge:
- Core Identification, Description overview, framework organization
- German Commission E approval status and general safety profile