WHO/EMA Monograph Plants · European
Black Cohosh (Cimicifuga racemosa) (Cimicifuga racemosa)
Preliminary EvidenceCompound
Hermetica Superfood Encyclopedia
Black cohosh (Cimicifuga racemosa) contains triterpene glycosides, particularly actein and 23-epi-26-deoxyactein, as its primary bioactive compounds. These constituents are thought to modulate serotonergic and dopaminergic pathways in the hypothalamus to reduce thermoregulatory dysfunction associated with menopause.
Black cohosh (Cimicifuga racemosa) is a perennial herb native to North America, primarily sourced from the rhizomes and roots of the plant, also known as Actaea racemosa. It is typically extracted using isopropanolic methods to produce standardized dry extracts containing triterpene glycosides as primary constituents.
A 2012 Cochrane review analyzed 16 RCTs (n=2,027 perimenopausal/postmenopausal women) using median 40 mg daily for 23 weeks, though results were mixed (PMID not provided). A 2009 double-blind RCT (n=28) found no significant anxiety reduction versus placebo (PMID:19745648), while a 2011 meta-analysis of 5 RCTs (n=1,117) confirmed safety with no liver enzyme elevations. Recent reviews (PMIDs:35403534, 37192826) suggest potential benefits but call for more rigorous trials.
Clinically studied doses range from 40-128 mg daily of isopropanolic dry extract (standardized to 2.5-5% triterpene glycosides) for 3-12 months. The most common dose in trials is 40 mg daily. Consult a healthcare provider before starting any new supplement.
Black Cohosh is a medicinal root/rhizome, not a nutritional food source; macronutrient content is negligible in typical supplemental doses (standardized extracts of 20-40mg dried rhizome equivalent per tablet). Primary bioactive compounds include: Triterpene glycosides (actein, 23-epi-26-deoxyactein, cimicifugoside) at approximately 2.5% w/w in standardized extracts — the 27-deoxyactein fraction is considered the principal marker compound; Phenolic acids including caffeic acid, isoferulic acid, and fukinolic acid (combined ~0.1-0.5% in dried root); Formononetin, an isoflavone-like compound, detected in some but not all preparations (trace to ~0.04% depending on extraction method — its presence remains debated in current literature); Cimiracemate A and B (hydroxycinnamic acid esters) contributing to antioxidant activity; Alkaloids including N-methylcytisine in trace amounts (<0.01%); Resin compounds (cimicifugin/macrotin) at approximately 6-7% of dried root. Micronutrient content in supplement doses is pharmacologically insignificant — no meaningful contribution to dietary vitamins or minerals. Fiber content in whole root preparations is present but negligible at supplemental doses. Bioavailability notes: Triterpene glycosides demonstrate moderate oral bioavailability; fat-soluble fractions benefit from co-administration with food; isopropanolic extracts (used in Remifemin, the most studied commercial preparation) show consistent standardization at 1mg 27-deoxyactein per 20mg tablet.
Black cohosh triterpene glycosides, including actein and cimiracemoside A, do not bind estrogen receptors (ER-alpha or ER-beta) at physiologically relevant concentrations, refuting earlier estrogenic theories. Current evidence suggests these compounds act as selective serotonin reuptake modulators and bind to 5-HT1A, 5-HT1D, and 5-HT7 receptors in the hypothalamic thermoregulatory center, dampening vasomotor instability. Additionally, dopaminergic activity via D2 receptor partial agonism and inhibition of monoamine oxidase (MAO) may contribute to reductions in luteinizing hormone (LH) surges linked to hot flash episodes.
Multiple randomized controlled trials (RCTs) have examined standardized black cohosh extract (most commonly Remifemin, 40 mg/day) over 4–24 weeks in peri- and postmenopausal women. A 2012 Cochrane-style meta-analysis of 16 trials found modest but statistically significant reductions in hot flash frequency (approximately 26% versus placebo), though heterogeneity across studies was high. One RCT (n=120) demonstrated significant improvement on the Green Climacteric Scale psychiatric subscale compared to placebo, suggesting mood-related benefits. Overall evidence is rated as moderate quality due to small sample sizes, short durations, and variability in extract standardization.
Black cohosh is generally well tolerated at standard doses (40–128 mg/day of standardized extract) with the most common adverse effects being mild gastrointestinal upset and headache. Rare but serious cases of hepatotoxicity have been reported, prompting the EMA and USP to recommend liver function monitoring with prolonged use; patients with pre-existing liver disease should avoid it. It may interact with tamoxifen by potentially competing for CYP2D6 metabolism, and caution is warranted in patients on antihypertensives due to additive hypotensive effects. Black cohosh is contraindicated in pregnancy due to potential uterotonic activity and should be used under medical supervision in hormone-sensitive conditions, despite its non-estrogenic mechanism.
5 documented interactions for Black Cohosh (Cimicifuga racemosa). Click any row to read the full explanation. Always consult your healthcare provider before combining supplements with medications.
Black cohosh may interfere with tamoxifen anti-cancer effects — this combination is controversial and potentially risky.
What to do: Avoid black cohosh during tamoxifen therapy unless specifically approved by your oncologist. The risk of interfering with cancer treatment outweighs menopausal symptom relief.
Timing: Take Tamoxifen as prescribed. Black Cohosh can typically be taken with a meal at a different time. As a general rule, space botanicals 1-2 hours from prescription medications. St. John's Wort is the most interaction-prone botanical — it affects dozens of drugs via CYP enzyme induction. Always inform your prescriber about herbal supplements.
Full interaction details →Both black cohosh and statins can affect the liver — rare but worth monitoring.
What to do: Monitor liver enzymes if using both. Report any liver symptoms.
Timing: Take Atorvastatin in the evening. Black Cohosh can be taken with breakfast or lunch. Red yeast rice contains natural lovastatin — never combine it with a prescription statin. Grapefruit extract and St. John's Wort both affect CYP3A4, which metabolizes most statins.
Full interaction details →Both black cohosh and acetaminophen can stress your liver — combining may increase risk of liver damage.
What to do: Avoid chronic combined use. Limit acetaminophen to less than 2g/day if using black cohosh regularly. Monitor liver function if using both long-term.
Timing: Take Acetaminophen as prescribed. Black Cohosh can typically be taken with a meal at a different time. As a general rule, space botanicals 1-2 hours from prescription medications. St. John's Wort is the most interaction-prone botanical — it affects dozens of drugs via CYP enzyme induction. Always inform your prescriber about herbal supplements.
Full interaction details →Black cohosh may interact with birth control hormones, though the clinical importance is uncertain.
What to do: Inform your prescriber. Monitor for breakthrough bleeding or side effects.
Timing: Take Combined Oral Contraceptives at the same time every day. CRITICAL: St. John's Wort induces CYP3A4 and can reduce contraceptive hormone levels enough to cause failure — breakthrough bleeding is a warning sign. Other botanicals are generally safe. Black Cohosh can be taken at any convenient time.
Full interaction details →Black cohosh may add to or interfere with your estrogen therapy in unpredictable ways.
What to do: Inform your prescriber about black cohosh use. Monitor for signs of estrogen excess.
Timing: Take Estradiol as prescribed. Black Cohosh can typically be taken with a meal at a different time. As a general rule, space botanicals 1-2 hours from prescription medications. St. John's Wort is the most interaction-prone botanical — it affects dozens of drugs via CYP enzyme induction. Always inform your prescriber about herbal supplements.
Full interaction details →Educational information only. Always consult a qualified healthcare provider before changing your supplement or medication regimen.
