Black Cohosh
Black cohosh is a North American plant taken mainly for menopausal symptoms — hot flashes, mood changes, and sleep disruption. Results in studies are mixed. NCCIH says evidence is not strong enough to recommend it. Rare liver damage has been reported; women with hormone-sensitive conditions should consult a doctor first.
Black cohosh is a plant native to North America used in herbal medicine, particularly for menopausal symptoms. NCCIH says study results are mixed for hot flashes and other menopausal symptoms and that the evidence is not strong enough to recommend it. MSK says it may relieve menopausal symptoms including hot flashes, insomnia and mood disturbances. NCCIH advises that rare cases of liver damage have been reported in people who took black cohosh supplements, and that women with certain hormone-sensitive conditions should talk to their health care provider before use.
Where to get it
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Traditional & historical use
Black cohosh (Actaea racemosa, formerly Cimicifuga racemosa) has been used by Native Americans for centuries, primarily for female reproductive conditions including menstrual irregularities and menopausal symptoms. European settlers adopted its use for 'change of life' symptoms. NCCIH notes it has a long history of use.
Active compounds & mechanisms
Key compounds: triterpene glycosides (actein, cimicifugoside), formononetin (isoflavone), isoferulic acid, fukinolic acid, caffeic acid derivatives, tannins
The mechanism of black cohosh is not fully understood. Early research suggested oestrogenic activity via phytoestrogen-like compounds, but current evidence does not show clinically significant oestrogen receptor binding. More recent research points to serotonergic activity — triterpene glycosides may modulate serotonin receptors (5-HT1A, 5-HT3) in hypothalamic thermoregulation, which could explain effects on hot flashes. Some compounds may also have dopaminergic and opioid receptor activity.
Research & evidence
Strong support Some support Weak or no supportColours show how well the sources back each point. The reason is next to each one.
NCCIH says study results are mixed for black cohosh for hot flashes and other menopausal symptoms, and the evidence is not strong enough to recommend it.
Mixed evidenceSome support. Results are mixed
Study details
study results are mixed, not strong enough to recommend
Source: NCCIH, Black Cohosh (Last Updated March 2023), What Have We Learned? View source
MSK says black cohosh may relieve menopausal symptoms including hot flashes, insomnia, and mood disturbances.
Mixed evidenceSome support. Results are mixed
Study details
may relieve menopausal symptoms
Source: MSK About Herbs, Black Cohosh (Last Updated August 2022), Clinical Summary View source
Rare cases of liver damage, including liver failure, have been reported in people who took black cohosh supplements; it is not known whether black cohosh caused these cases.
Limited evidenceWeak or no support. Mostly lab or animal studies
Study details
rare case reports of liver damage; causation uncertain
Source: NCCIH, Black Cohosh (Last Updated March 2023), What Do We Know About Safety? View source
Mental health notes
MSK notes that black cohosh may relieve mood disturbances and insomnia associated with menopause. One small study suggested possible benefit for anxiety in menopausal women, but evidence is limited.
Dosage
| Form | Amount |
|---|---|
| Any form | Do not use crude root or non-standardised preparations for a specific effect. Use only standardised extract. |
| Capsule | 20–40 mg standardised extract (standardised to triterpene glycosides as actein), twice daily. Remifemin (the most-studied branded extract) uses 2 × 20 mg/day. |
Side effects
Most common: stomach upset and rash. Rare but serious: liver damage has been reported in a small number of people. Stop use and seek medical attention if you develop jaundice or severe stomach pain.
Well documented Reported (case reports, anecdotal or one study) None reportedThe circle shows how well documented an effect is, not how serious it is. A rarely reported effect can still be serious, so always read ‘When to stop’.
| Effect | Frequency | When to stop |
|---|---|---|
| Gastrointestinal upset (nausea, stomach pain)Well documentedListed plainly by NIH, MSK or LiverTox | Common | If persistent or severe, stop use and consult a healthcare provider. |
| Rash or skin reactionsWell documentedListed plainly by NIH, MSK or LiverTox | Uncommon | Stop and talk to a doctor if you notice any unexpected or concerning symptoms. |
| Rare liver damage (hepatotoxicity)ReportedCase reports only | Rare (case reports) | Stop immediately and seek medical attention if you develop jaundice (yellowing of skin or eyes), dark urine, or severe abdominal pain. |
Safety & interactions
Safety
NCCIH says rare cases of liver damage (including liver failure) have been reported in people who took black cohosh supplements, but it is not known whether black cohosh was actually the cause. MSK says it may be associated with hepatotoxicity and advises caution. NCCIH says adverse effects may include GI upset and rash. MSK says black cohosh should not be used by women with hormone-sensitive cancers, and advises caution in women with pre-existing liver conditions. NCCIH says women with breast cancer, other hormone-sensitive conditions, or liver disorders should talk with their health care provider before using black cohosh.
Contraindications
NCCIH says women who have had breast cancer, other hormone-sensitive conditions, or liver disorders should talk with their health care provider before using black cohosh. NCCIH says it is unsafe to use during pregnancy — it can cause uterine contractions. MSK says do not use in women with hormone-dependent tumours (breast cancer, endometrial cancer) or with pre-existing liver conditions. See Drug interactions.
Drug interactions
MSK says black cohosh may potentiate hepatotoxicity of drugs with liver toxicity potential. Because rare cases of liver damage have been reported with black cohosh, combining it with other hepatotoxic medications may increase risk.
MSK notes that theoretical concerns exist around use of black cohosh with hormone-sensitive cancer therapies. NCCIH advises women with breast cancer to consult their healthcare provider before use.
Established: stated plainly by an authoritative source. Documented: supported by case reports or trial data. Theoretical: based on mechanism, animal data, or a cautious listing. Always check with your pharmacist or prescriber.
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