Dosage and Administrations of Black Cohosh.
- Botanical Data of Black Cohosh.
- Narrative History of Black cohosh.
- Application and Uses of Black cohosh.
- Phytochemicals,constituents and functional mechanism of Black Cohosh.
- Historical Development of Black Cohosh.
- Black Cohosh Physiology.
- Clinical studies of Black Cohosh.
- Dosage and Administrations of Black Cohosh.
- Skunk Bugbane and Application.
- How Search engine think about black cohosh.
- Photo Gallery of Cimicifuga racemosa.
Dosage and Administrations of Black Cohosh.
How much to take or Dosages:
Black cohosh can be taken in several forms, including crude, dried root, or rhizome (300-2,000 mg per day) or as a solid, dry powdered extract (250 mg three times per day). Tinctures can be taken at 2-4 ml per day. Standardized extracts of the herb are available and contain 1 mg of deoxyacteine per tablet. The usual amount is 40 mg twice per day. Black cohosh can be taken for up to six months, and then it should be discontinued.
Clinical studies of C. racemosa have almost all utilized Remifemin?, a standardized extract containing triterpene glycosides calculated as 27-deoxyactein (1 mg/tablet). The usual dose had been two tablets twice/day (equivalent to 4 mg triterpene glycosides per day). Dosages twice this amount have been used in some studies. Recent information from the makers of Remifemin? claims that half this dose (i.e. one tablet, twice daily or a total of 2 mg triterpene glycosides) is as effective as two tablets twice daily for the relief of climacteric symptoms. [Note: 40 drops of the standardized Remifemin? liquid extract is equivalent to 40 mg of herbal drug, or two tablets containing a total of 2 mg triterpene glycosides (Schaper and Brummer GmbH, 1997).]
Liske and Wustenberg (1998) of Schaper and Brummer GmbH report that a recent randomized double-blind clinical study of a special isopropanolic extract of the root stock of black cohosh in the treatment of climacteric complaints found similar efficacy and results from a dosage of 40 mg/day as from 127 mg/day for 6 months, adding that the Kupperman-Menopause Index values already showed improvement after two weeks of treatment.
The British Herbal Compendium recommends a dose of 40-200 mg dried rhizome, or 0.4-2 mL of a 1:10 60% ethanol tincture (Bradley, 1992). However, Newall et al. (1996) report a dose range of 2-4 mL for this tincture, based on the British Pharmacopoeial Compendium, 1934. They further describe a dose range of a liquid extract (BPC 1898) of 1:1 in 90% alcohol as 0.3-2.0 mL. The dosage for the decoction of the rhizome is given as 0.3-2.0 g, 3 X/day.
Side Effects:Black cohosh has an estrogen-like effect, and women who are pregnant or lactating should not use the herb. Large doses of this herb may cause abdominal pain, nausea, headaches, and dizziness. Women taking estrogen therapy should consult a physician before using black cohosh.
Toxicity,Cautions and Contra-Indications: No toxicity. Side effects are extremely rare. Rare cases of pyrogenia but requiring no need of treatment. People with gastrointestinal disease may experience diarrhea. Avoid in case of hemorrhagic disease, hypermenorrhea, first three months of pregnancy, spontaneous abortion, and during severe flu.
Side Effects:Gastric irritation, nausea, dizziness on overdose.
Special Precautions:Physician should review use at 6 month intervals.
Standardization involves measuring the amount of certain chemicals in products to try to make different preparations similar to each other. It is not always known if the chemicals being measured are the "active" ingredients. The dose of black cohosh is often based on the amount of the chemical 27-deoxyactein. The German product, Remifemin?, used in most human studies, contains an alcoholic extract of black cohosh standardized to contain 1 milligram of 27-deoxyactein in each 20 milligram tablet. The manufacturing process and dosing recommendations for Remifemin? have changed over the past 20 years, and doses used in different studies are not always the same. A standardized liquid formulation of Remifemin has also been used in some studies.
Adults (18 years and older):
Tablets:For menopausal symptoms, studies have used 20 milligram or 40 milligram Remifemin? tablets (containing 1 or 2 milligrams of 27-deoxyactein) twice daily or 40 drops of a liquid extract. Some clinical studies have used 20 milligrams taken twice daily.
Dried rhizome (root): The British Herbal Compendium recommends 40 to 200 milligrams of dried rhizome daily in divided doses, although traditional doses have been as high as 1 gram three times daily.
Tincture/Liquid: The British Herbal Compendium recommends 0.4 to 2 milliliters of a (1:10) 60% ethanol tincture daily.
Children (younger than 18 years) :There is not enough scientific information to recommend black cohosh in children.
Liquid extract : 0.3 to 1.8 ml. NF 1.0 ml.
Tincture : 1.8 to 3.6 ml.
Root powder N.F. : 1.0 gram.
Root powder : 0.3 to 2.0 grams U.S. Dispensory.
Official Recognition and Medical References:
UK - General sale list Scedule 1, Table A 200 mg maximum single dose
German Commission E - 2.3.89, menopause, lowering symptoms related to PMS, and painful menstruation
PDR of Herbal Medicine p. 746
Extractum Cimicifugae U.S.P.
Extractum Cimicifugae Liquidum U.S.P.
Formulation and dosage:
All studies have tested Remifemin, a commercial product manufactured in Germany but widely available in the United States.
The formulation of Remifemin has changed somewhat over the years, however,such that equivalent doses are not always comparable.
The manufacturer (Schaper and Brummer) now estimates that the dose of the currently available preparation which best approximates the doses which previously have been tested is 40 mg po bid, with each 20 mg tablet standardized to contain 1 mg of triterpene glycosides.
There are over 120 OTC products containing black cohosh at various doses ranging from 20-550 mg. Some are standardized and some are not.
Commonly Reported Dosage:the APA guide noted that "a daily dosage of 40 to 200 miligrams is typical(for raw root).A decoction is made using 1/2 tea-spoon powdered root per cup of water;2 teablespoons are taken every few hours,up to 1 cup per day.The tincture is taken in dosage of up to 1 teaspoon per day"2.
Property and Channel Tropism:
Allergies:Avoid if allergic to black cohosh or other members of the Ranunculaceae (buttercup or crowfoot) family. In nature, black cohosh contains small amounts of salicylic acid (which is found in aspirin), but it is not clear how much (if any) is present in commercially available products. Black cohosh should be used cautiously in people allergic to aspirin or to other salicylates.
Pregnancy and Breastfeeding:
Safety during pregnancy and breastfeeding has not been established. Black cohosh may relax the muscular wall of the uterus, and some nurse-midwives in the United States use black cohosh to stimulate labor. There is one report of severe multi-organ damage in a child delivered with the aid of both black cohosh and blue cohosh ( Caulophyllum thalictroides ), who was not breathing at the time of birth. The child survived with permanent brain damage. However, blue cohosh is known to have effects on the heart and blood vessels and may have been responsible for these effects.
Tinctures may be ill-advised during pregnancy due to potentially high alcohol content.
Side Effects and Warnings:
Black cohosh is generally well tolerated in recommended doses and has been studied for up to six months. High doses of black cohosh may cause frontal headache, dizziness, perspiration, or visual disturbances. Several side effects have been noted in studies, including constipation, intestinal discomfort, loss of bone mass (leading to osteoporosis), irregular or slow heart beat, low blood pressure, nausea and vomiting.
It is not clear if black cohosh is safe in individuals with hormone-sensitive conditions such as breast cancer, uterine cancer, or endometriosis. There is controversy as to whether black cohosh is similar to estrogen in its mechanism, although recent studies suggest that it may not be. The influence of black cohosh on anti-estrogen drugs (like tamoxifen) or hormone replacement therapy is not clear. It is not known if black cohosh possesses the beneficial effects that estrogen is believed to have on bone mass, or the potential harmful effects such as increased risk of stroke or hormone-sensitive cancers.
Hepatitis (liver damage) and fulminant liver failure has been reported with the use of black cohosh containing products. Liver transplantation has been required in some patients. These reports are concerning, although the cases have been criticized by some as not being adequately substantiated. Nonetheless, patients with liver disease should consult a licensed healthcare professional before using black cohosh.
Black cohosh should be used cautiously in patients with a history of blood clots or stroke, seizure disorder, taking medications for high blood pressure, known allergy to aspirin/salicylates, liver disease, or hormone-sensitive cancers.
German health authorities list stomach discomfort as a potential side effect.A few people who have consumed the leaves or roots have developed nausea,vomiting,and stomach upset,and miscarriages have followed large doses.And warns against taking black cohosh for more than six months(for any purpose) because so little is known about its long-term effects.
As its estrogen-like component,pregnant and nursing women should probably avoid the herb."Some herbalist extend this warning to women with estrogen-dependent cancer and women who are taking birth control pills or estrogen supplements after menopause.The same precaution applies to individuals with certain types of heart disease or those taking sedatives or blood pressure medications"3.Anyone who wants to take black cohosh,but particularly the aforementioned individuals,should talk to a doctor first.
Certain estrogens, notably estradiol, are associated with an increased risk of breast, ovarian, or endometrial cancers. In contrast, the estrogen estriol is associated with some degree of protection against these cancers because it acts as a weak partial antagonist to estradiol. The action of Remifemin is interpreted as "estriol-like" by the manufacturers, and the German Commission E has not included any contraindications for use in patients with estrogen-dependent tumors. Although it has been recommended that such individuals should consult their physicians prior to use (Schaper and Brummer GmbH, 1997), recent research on the proliferative effect of black cohosh (isopropanolic/aqueous) extract on breast cancer cells (MCF-7, an estrogen receptor-positive cell line) showed no stimulatory activity. In addition, the root extract (Remifemin?) dose-dependently inhibited the DNA synthesis-antagonizing estrogenic activity produced by estradiol in vitro, and, with tamoxifen, increased inhibition of MCF-7 breast cancer cell proliferation. Accordingly, the authors of the study concluded that for patients with a history of mammary cancer, use of black cohosh extract (Remifemin) is not contraindicated (Foster, 1999, citing a presentation by J. Freudenstein and C. Bodinet, 23rd International Symposium on Phyto-Estrogens, University of Gent, Belgium, January 15, 1999). Previously, Nesselhut et al. (1993) demonstrated a dose-dependent antiproliferative activity of the root extract (Remifemin) in estrogen-dependent breast cancer cell lines and later found the breast cancer cell-antiproliferative activity of tamoxifen increased when black cohosh extract was combined (Nesselhut et al., 1998).
In a recent review of black cohosh research, Liske (1998) states that the therapeutic efficacy of the commercial extract is not attributable to hormonal (estrogenic) effects. The latest Remifemin brochure (Schaper and Brummer GmbH, 1997) makes no claims regarding any estrogenic effects, such as increased vaginal epithelium thickness or alteration in hormone levels, including prolactin, estrogen, progesterone, FSH and, notably, LH-inhibition. A previous clinical study had demonstrated a decline in LH attributed to Remifemin? at the formerly recommended higher dose (Duker et al., 1991).
In a randomized double-blind clinical trial of patients (ages 43-60) treated for climacteric complaints (n=152) with a special isopropanolic extract of black cohosh root (40 mg/day and 127 mg/day for 6 months), indications of an estrogen-like effect were absent all in tests (changes in levels of estradiol, prolactin, FSH, and LH). The degree of cellular proliferation of the vagina was also not affected by the treatment (Lisk and Wustenberg, 1998).
Brinker (1998) lists black cohosh root as a plant that could potentiate the effects of sedative or tranquilizing agents.
Toxicity and Contraindications:
Spoerke notes that the toxicity data on Black Cohosh is conflicting. As with many herbs, researchers confuse information from homeopathic provings (on sensitive people) with research data on the herb. All other sources say it is non-toxic. This is probably due to a mild non-violent emetic effect and the ability to cause nausea in large doses. Large doses may produce giddiness and headache. Black Cohosh is contraindicated in the first trimester of pregnancy. Used in the third trimester, it can hasten delivery. The FDA classifies this herb as undefined safety: "No pharmacologic evidence of any therapeutic value."
No specific drug interactions have been identified (Blumenthal et al., 1998). Standardized extracts have been used in conjunction with physician-monitored estrogen replacement therapy with minimal side effects (Warnecke, 1995; Petho, 1987).
A multicenter post-marketing surveillance study of a standardized combination product (Schaper and Brummer GmbH Co.) containing an extract of black cohosh (1 mg triterpene glycoside/tablet) and St. John's wort (0.25 mg hypericin/tablet) reported very good tolerability in menopausal patients in 99% of cases, according to physician assessment of global tolerability in over 800 women ages 46-55 (Liske, 1997).
A case of nocturnal seizures was reported in a 45-year-old woman who for about 4 months had combined separate bottled products of black cohosh, Vitex agnus-castus (Nature's Herbs, Utah) and evening primrose oil, to regulate her menstrual cycle. Her sister had been taking the same regimen for one to two years and had recommended she try it. The nocturnal seizures stopped upon discontinuation of the products for 3 days while in hospital and she was discharged (Shuster, 1996).
Pregnancy and Lactation:
Black cohosh alone does not at this time have an established safe dosage for any indication of use during pregnancy or labor. The American Herbal Products Associations Botanical Safety Handbook (1997) lists black cohosh as a class 2b and 2c herbal medicine, meaning an herb that should not be taken during pregnancy, nor while nursing, respectively (McGuffin et al., 1997). An assessment of risks and benefits of use during pregnancy or labor should be undertaken with the assistance of an informed health care provider. Brinker (1998) cites empirical evidence contradicting large doses in nursing mothers and pregnancy.
Black cohosh is sometimes used by herbalists in combination with blue cohosh (Caulophyllum thalictroides) to induce and aid labor. There is a recent anecdotal report of a child born with no spontaneous breathing who subsequently suffered brain hypoxia and where unknown/unreported doses of a combination of black cohosh and blue cohosh was used to induce labor. The authors of this anecdotal report queried the possible role of the herb in contributing to the infant's initial low APGAR scores (Gunn and Wright, 1996), but also raised the question of post-birth resuscitation mismanagement. Unfortunately, no indication of dose was given, so conclusions about the toxicity of either herb in labor cannot be definitive. In response to Gunn and Wright (1996), Baillie and Rasmussen (1997) write that as the basis of the authors' concerns, they had cited a paper in which the resinous fraction of black cohosh was injected intravenously and that a hypotensive effect has not otherwise been observed in humans and only in some species of animals (Baillie and Rasmussen, 1997). The pharmacological contribution of black cohosh when used in conjunction with blue cohosh is unknown. However, blue cohosh (Caullophyllum) used alone was recently implicated in a case of an infant who suffered the chance of permanent injury, possibly related to the third trimester overdosage by the mother from taking blue cohosh at two times the recommended dose for 3 weeks (Jones and Lawson, 1998).
Little information exists regarding the use of Actaea (or Cimicifuga) species during lactation. No record of adverse effects on lactation, or nursing children were found (NAPRALERT, 1997). No evidence from animal or human studies exist regarding the entry of constituents into breast milk. The documented estrogen-blocking receptor activity of black cohosh (Liske, 1998) has as yet unclear implications for lactation, although other herbs with similar phytoestrogenic effects are reputed to promote milk flow. Several studies provide evidence that prolactin levels are not affected with use; however, these studies were conducted with non-lactating subjects (Schaper and Brummer GmbH, 1997).
Ethnobotanical records of use indicate that an infusion of the rhizome was used postpartum by the Iroquois to promote milk flow (Moerman, 1986). No current descriptions of use as a lactogogue were found. The German Commission E Monograph on black cohosh rhizome published in 1989 does not contraindicate its use during lactation (Blumenthal et al., 1998). However, Brinker (1998) lists black cohosh root as a plant product that could potentially irritate the digestive tract of breast-feeding babies and cause them upset stomach and colic.
The American Materia Medica of 1919 noted that large doses given prenatally could induce labor prematurely. As an aid to labor (partus accelerator), "a fluid extract or 2-5 grains" (130-325 mg) was employed. Postpartum hemorrhage was thought to be prevented by the herb, and it was suggested in a special single dose of 30 minums (1.8 mL) upon the delivery of the baby's head (Ellingwood, 1983). A tincture made from the fresh roots was given before, during, and after labor, commonly in small doses (Ellingwood, 1983) during the last 4 weeks of pregnancy as a partus preparator. Black cohosh was believed to reduce irritability of the uterus or false labor when given in 5-6 drops (0.984 mL), every 3-4 hours. A report written in 1885 on 160 childbirths stated that the tincture was mildly sedating, reduced discomforts in the first stage of labor, increased rhythmicity of contractions in the second stage, but specifically relaxed the cervical tissues, thus reducing lacerations (Brinker, 1996).
Brunton in 1892 claimed that doses of up to 890 mg/day of black cohosh fluid extract appeared to be safe (Brunton, 1892). However, Novitch and Schweiker (1982) called for additional safety testing owing to reports of "respiratory and circulatory effects on animals." Currently, occasional gastric discomfort is the only noted side effect (Blumenthal et al., 1998). Shengma (mainly A. foetida and A. dahurica) can cause vomiting "due to gastric irritation" (Chang and But, 1986).
Mild gastric discomfort may occur with doses between 40-160 mg/d.
Side effects, including nausea and vomiting, vertigo, uterine contractions and bradycardia, have been reported in doses higher than 160 mg/day.
It is unknown whether long-term use of black cohosh could have stimulatory effects on the breast or uterus which could theoretically increase cancer risk,although studies with estrogen sensitive breast cancer cells do not demonstrate proliferative activity.
The German Commission E report recommends that the duration of use should not exceed 6 months, based on a lack of toxicology studies available at the time of their 1989 review (Blumenthal et al., 1998).
From large doses, Willard (1991) describes a "mild non-violent emetic property" which can cause nausea as well as giddiness and headache. McGuffin et al. (1997) list the following side effects from large doses: vertigo, vomiting, nausea, headache, impaired circulation and eyesight.
Overdosing of shengma Actaea (=Cimicifuga) species used in TCM is reported to cause lassitude, vertigo, tremor, severe headache, slow pulse, and collapse (Chang and But, 1986).
Overdoses may produce nausea, vomiting, and dizziness, and may reduce pulse rate and induce perspiration. Overdosing during pregnancy can cause premature birth (Duke, 1985). Although not listed as toxic, it is classified by the FDA as an herb of undefined safety.
Interactions with Drugs:
The potential estrogen-like effects of black cohosh remain debated, and the active chemical contents of black cohosh have not been clearly identified. Although recent studies suggest no significant effects of black cohosh on estrogen receptors in the body, caution is warranted in people taking both black cohosh and estrogens due to unknown effects. The influence of black cohosh in combination with tamoxifen is not clear in studies, and it is not known if tamoxifen counteracts the effects of black cohosh. One trial suggests that black cohosh may not be useful in the short-term treatment of tamoxifen-related hot flashes, although further study is needed in this area.
Black cohosh may lower blood pressure, and therefore should be used cautiously with other hypotensive agents, such as beta-blockers like metoprolol (Lopressor, Toprol) or propranolol (Inderal) and calcium-channel blockers like diltiazem (Cardizem, Tiazac) or verapamil (Isoptin, Calan). Black cohosh may contain small amounts of salicylic acid, and may increase the anti-platelet effects of other agents such as aspirin.
Black cohosh may alter the way the liver breaks down or metabolizes certain drugs. In theory, due to possible alcohol content in some tinctures of black cohosh, combination with disulfiram (Antabuse) or metronidazole (Flagyl) may cause nausea and vomiting.
Interactions with Herbs and Dietary Supplements:
Black cohosh should be used cautiously in people taking herbs with possible estrogen-like effects, such as alfalfa, bloodroot, burdock, hops, kudzu, licorice, pomegranate, red clover, soy, thyme, white horehound, and yucca. Information in this area is limited. In nature, black cohosh contains small amounts of salicylic acid, and may increase the anti-platelet effects of other agents such as aspen bark, birch, poplar, willow bark, and wintergreen. This is a theoretical concern, and it is not clear if the amounts of salicylates present in commercial or processed black cohosh products have significant effects in humans.
Seizures were reported in a woman taking a combination of black cohosh, chaste tree (berries and seeds), and evening primrose oil for four months, who also consumed alcohol. The cause of her seizures is not clear.
Both black cohosh and blue cohosh ( Caulophyllum thalictroides ) are used by nurse-midwives in the United States to assist birth. There is one report of severe multi-organ damage in a child delivered with the aid of both black cohosh and blue cohosh who was not breathing at the time of birth. The child survived with permanent brain damage. However, blue cohosh is known to have effects on the heart and blood vessels and may have been responsible for these effects. Pennyroyal and black cohosh should not be used together, as there is a possibility of increased toxicity and death.
Black cohosh may lower blood pressure. Other herbs that may lower blood pressure include aconite/monkshood, arnica, baneberry, betel nut, bilberry, bryony, calendula, California poppy, coleus, curcumin, eucalyptol, eucalyptus oil, flax/flaxseed oil, garlic, ginger, ginkgo, goldenseal, green hellebore, hawthorn, Indian tobacco, jaborandi, mistletoe, night blooming cereus, oleander, pasque flower, periwinkle, pleurisy root, shepherd's purse, Texas milkweed, turmeric, and wild cherry.
In theory, black cohosh may increase the risk of bleeding when taken with herbs and supplements that are believed to increase the risk of bleeding. Multiple cases of bleeding have been reported with the use of Ginkgo biloba , fewer cases with garlic, and two cases with saw palmetto. Numerous other agents may theoretically increase the risk of bleeding, although this has not been proven in most cases. Some examples include: alfalfa, American ginseng, angelica, anise, Arnica montana , asafetida, aspen bark, bilberry, birch, bladderwrack, bogbean, boldo, borage seed oil, bromelain, capsicum, cat's claw, celery, chamomile, chaparral, clove, coleus, cordyceps, danshen, devil's claw, dong quai, evening primrose, fenugreek, feverfew, flaxseed/flax powder (not a concern with flaxseed oil), ginger, grapefruit juice, grapeseed, green tea, guggul, gymnestra, horse chestnut, horseradish, licorice root, lovage root, male fern, meadowsweet, nordihydroguairetic acid (NDGA), onion, papain, Panax ginseng, parsley, passionflower, poplar, prickly ash, propolis, quassia, red clover, reishi, Siberian ginseng, sweet clover, rue, sweet birch, sweet clover, turmeric , vitamin E, white willow, wild carrot, wild lettuce, willow, wintergreen, and yucca.
Black cohosh may alter the way the liver breaks down or metabolizes certain herbs and supplements.
Ames test (Salmonella microsomal assay) results showed no in vitro evidence of mutagenic potential of the isopropanolic extract of black cohsh (Liske, 1998). Dosages of 0.32 to 1,000 mg/plate were used with negative and positive controls (Schaper and Brummer GmbH, 1997).
Toxicity in Animal Models:
Toxicity assessments for the minimum lethal dose of the chloroform extract range from as low as NLT3.0 mg/kg s.c. for 30 days in the rabbit, to as high as NLT1 g/kg p.o. for 30 days in the rat (NAPRALERT, 1997). In Wistar rats given up to 5,000 mg Remifemin granulate/kg for 26 weeks, no conspicuous chemical or organ toxicities were observed (Korn, 1991). In human studies with the fluid extract, up to 890 mg/day was given with no evidence of toxic effects (Novitch and Schweiker, 1982).
Toxicity in Human:
There is some study about the Pharmacokinetics of 23-epi-26-deoxyactein in women after oral administration of a standardized extract of black cohosh proposed that Single doses of black cohosh extract containing 1.4, 2.8, or 5.6 mg of 23-epi-26-deoxyactein were administered to 15 healthy, menopausal women.The result proposed that No acute toxicity or estrogenic hormone effects were observed. Pharmacokinetic analyses of 23-epi-26-deoxyactein in sera indicated that the maximum concentration and area under the curve increased proportionately with dosage, and that the half-life was ~2 h for all dosages. Less than 0.01% of the 23-epi-26-deoxyactein was recovered in urine 24 h after administration. No phase I or phase II metabolites were observed either in clinical specimens or in vitro(231.).
1: What is Black Cohosh?Black Cohosh - A Lady's Herb.
2,3: see The American Pharmaceutical Association Practical Guide to Natural Medicines,1st Ed,p86.
4: see Zhong Guo Yao Dian(Chinese Pharmacopoeia) and Zhong Hua Ben Cao(The Chinese Materia Medica).
♥The article and literature was edited by herbalist of MDidea Extracts Professional.It runs a range of online descriptions about the titled herb and related phytochemicals,including comprehensive information related,summarized updating discoveries from findings of herbalists and clinical scientists from this field.The electronic data information published at our official website www.mdidea.com and www.mdidea.net,we tried best to update it to latest and exact as possible.
♣ last edit date: