Black Cohosh and Menopause: Does This Herb Really Work?

Herbal supplements can seem like an appealing option for menopausal women interested in alternative treatments. Black cohosh, in particular, is a popular supplement that’s advertised as a natural and effective treatment method for common menopausal symptoms, particularly hot flashes. But just how effective is this herb, and is it truly safe to use? 

This article will give women a deeper understanding of the potential benefits and risks of supplementation and explore why hormone replacement therapy (HRT) is recommended over black cohosh and other dietary supplements.

What is black cohosh?

Black cohosh is a plant indigenous to North America that has been used throughout history and across cultures to treat a range of ailments, including pneumonia and malaria. It’s also been used to treat female reproductive health issues like irregular periods and stalled labor. 

The scientific name for black cohosh is Actaea racemosa or Cimicifuga racemosa. It’s also been referred to as snakeroot or black bugbane, among other names. Black cohosh supplements are produced using the plant’s root and stem and can be purchased in different forms.⁽¹⁾⁽²⁾

How does black cohosh work?

How black cohosh works is not fully understood. Some theories suggest it may increase estrogen levels or act on the body’s estrogen receptors. Researchers have also explored whether the herb affects levels of luteinizing hormone (LH) or follicle-stimulating hormone (FSH) — two other hormones involved in women’s reproductive health.⁽¹⁾ 

There’s also the theory that black cohosh may alter serotonin-related pathways in the brain. Its antioxidant and anti-inflammatory properties could also contribute to its effects.⁽¹⁾ However, studies have produced conflicting results regarding the effectiveness of black cohosh in relieving menopausal symptoms and its underlying mechanisms.

Black Cohosh Benefits for Menopause: What does the evidence say?

Various studies have been conducted on the relationship between black cohosh and the following menopausal symptoms:

Hot Flashes and Night Sweats (Vasomotor Symptoms)

Menopausal hot flashes and night sweats can significantly interfere with daily life. In a meta-analysis published in Menopause, which included data from more than 2,000 menopausal women, black cohosh extracts were found to reduce menopausal symptoms, including vasomotor symptoms.⁽³⁾ 

However, another study showed that black cohosh preparations were no more effective than a placebo treatment in reducing vasomotor symptoms in perimenopausal and postmenopausal women. The researchers concluded that the herb is not likely to be an effective treatment for hot flashes or night sweats.⁽⁴⁾

Sleep Disturbances

Many women experience sleep issues during menopause. Findings of a six-month randomized controlled trial showed that postmenopausal women between the ages of 45 and 60 who took black cohosh every day experienced improvements in sleep.⁽⁵⁾ However, because black cohosh is also known to reduce hot flashes in some women, it’s possible that the sleep improvements were due to reduced vasomotor symptoms rather than a direct effect on sleep.

Mood Swings and Psychological Symptoms

Mood changes, anxiety, and depression are common symptoms of menopause. One study found that black cohosh helped improve symptoms of anxiety and depression in menopausal women. However, the Menopause meta-analysis found no significant effect of black cohosh on these psychological symptoms.⁽³⁾⁽⁶⁾

Vaginal Dryness and Other Atrophic Changes

Hormonal fluctuations during menopause can cause physiological and structural changes in the vaginal tissue. The tissue may become thin and dry, potentially leading to symptoms like vaginal dryness, pain, and irritation. There isn’t currently enough evidence to determine if black cohosh has any effect on the vaginal tissue.⁽¹⁾⁽⁷⁾

Bone Health

Bone mineral density (BMD) is influenced by hormone levels. As levels of estrogen fluctuate during menopause and continue to decrease during postmenopause, women experience bone loss, increasing their risk of osteoporosis. Some research suggests that black cohosh may enhance the activity of osteoblasts, which are cells necessary for the formation and mineralization of bone. However, the evidence is limited, and more research is needed to confirm these effects.⁽⁷⁾ 

Weight Management

Weight gain is common during menopause. Low levels of estrogen have been associated with obesity and metabolic disorders.⁽⁸⁾ Claims that black cohosh may support weight management are largely based on the belief that it may have estrogen-like effects, yet there’s no conclusive evidence to support these claims.

Common Forms of Black Cohosh

Black cohosh dietary supplements are available in the following forms:⁽¹⁾⁽⁹⁾

• Powdered whole herb 

• Pills

• Tablets

• Capsules

• Tinctures

• Liquid extracts 

Side Effects and Precautions: Is black cohosh safe?

Although herbal supplements are often seen as a “natural” alternative to prescription medications, it doesn’t automatically mean they’re safe. Black cohosh can come with side effects and potential health risks.

Common Side Effects

Women who use black cohosh may experience side effects, including the following:⁽¹⁾

• Gastrointestinal distress

• Skin rashes
  

These side effects have also been reported in some studies:⁽¹⁾

• Breast pain

• Vaginal bleeding or spotting

• Joint and muscle pain

• Infections

Liver Safety (The Big Concern)

Using black cohosh may increase the risk of liver damage in some individuals. Over 80 cases of liver-related issues have been documented worldwide in connection with black cohosh use, such as hepatitis and liver failure.⁽¹⁾ 

However, it’s also possible that these effects were caused by other ingredients found in the supplements. Supplements do not require approval from the U.S. Food and Drug Administration (FDA), and there have been instances in which different species of herbs were found in black cohosh supplements, along with other compounds that were not labeled.⁽¹⁾⁽²⁾

Contraindications and Who Should Avoid It

Data on the safety of black cohosh is lacking, particularly for women with a history of breast cancer or other hormone-sensitive conditions, women who are pregnant, or those who are breastfeeding. Supplements are not recommended for women who are pregnant or breastfeeding unless administered under strict medical supervision. People with liver disorders should also avoid black cohosh. Women who are interested in supplementation for menopausal symptoms should consult with their doctor about potential health risks.⁽¹⁾⁽²⁾

Potential Drug Interactions

Potential drug interactions with black cohosh have not been extensively studied. Therefore, there isn’t much known about whether it’s safe to take with other supplements or prescription medications.⁽¹⁾

A 2024 case study demonstrated a potential drug interaction between black cohosh and serotonergic drugs. A woman taking black cohosh and antidepressants developed serotonin toxicity and rhabdomyolysis, a condition in which muscle tissue breaks down and releases harmful proteins into the bloodstream.^(10)(11) It’s important that women tell their doctor about all medications and supplements they are taking when discussing menopausal symptom treatment options.

Black Cohosh Compared to HRT

Black cohosh should not be considered a substitute for standard HRT. HRT reduces menopausal symptoms by supplementing the body’s declining levels of estrogen and progesterone during menopause. It’s unclear how black cohosh affects the body, and there’s more robust evidence to support the safety and efficacy of HRT compared to herbal supplements.

Additionally, black cohosh may not provide the symptom relief many women seek. A scientific review found that HRT was more effective than black cohosh in reducing daily hot flashes and other menopausal symptoms.⁽⁷⁾

Making an Informed Choice About Menopausal Symptom Treatment Options

Women should consult their healthcare provider if they have questions about HRT, black cohosh, or any other medications or supplements. The Menopause Society maintains that HRT is the most effective treatment for hot flashes and night sweats. The organization doesn’t recommend herbal remedies as effective nonhormonal treatment options due to insufficient evidence.⁽¹²⁾ 

However, this doesn’t mean that nonhormonal options can’t play a supportive role in a comprehensive menopause treatment plan. There’s consistent evidence to suggest that cognitive-behavioral therapy (CBT), weight management strategies, and certain antidepressants may benefit women experiencing menopausal symptoms.⁽¹²⁾ 

A doctor can provide accurate, personalized guidance to help women make informed choices about menopause treatment options that are tailored to their individual symptoms, health needs, and lifestyle.