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Black cohosh

Actaea racemosa; Black snakeroot; Bugbane; Bugwort; Cimicifuga racemosa; Rattle weed; Squawroot

More than two centuries ago, Native Americans discovered that the root of the black cohosh plant (Actaea racemosa, formerly known as Cimicifuga racemosa) helped relieve menstrual cramps and menopausal symptoms, such as hot flashes, irritability, mood swings, and sleep disturbances. Today, people use black cohosh for these same reasons. In fact, the herb has been widely used in Europe for more than 40 years and is approved in Germany for premenstrual discomfort, painful menstruation, and menopausal symptoms.

Menopausal Symptoms

Studies confirm that black cohosh is effective for relieving menopausal symptoms, although some have found no improvement. Early German studies found black cohosh improved physical and psychological menopausal symptoms, including anxiety, hot flashes, night sweats, and vaginal dryness.

In a study of 120 women with the menopausal symptoms, black cohosh was more effective in relieving hot flashes and night sweats than the antidepressant fluxetine (Prozac).

Given the results of most clinical studies, many experts conclude that black cohosh may be a safe and effective alternative for women who cannot or will not take hormonal replacement therapy (HRT) for menopause. A 2010 review by researchers found that black cohosh provided a 26% reduction in hot flashes and night sweats (also known as vasomotor symptoms). More recently, studies have linked black cohosh to reduced sleep disturbance among menopausal women.

However, experts do not agree on the effectiveness and safety of using black cohosh to relieve symptoms of menopause. The American College of Obstetricians and Gynecologists (ACOG) reports that many of the early studies were poorly designed and did not evaluate the safety and effectiveness of black cohosh beyond 6 months of use. A 2009 study reported that black cohosh did not relieve hot flashes any more than placebo did. Still, the ACOG recognizes the value of black cohosh for menopausal symptoms.

Until further studies are conducted, some doctors recommend only short-term (less than 6 months) use of this herb for the relief of hot flashes.

Premenstrual Syndrome

Some studies suggest black cohosh can help ease premenstrual syndrome (PMS) and menstrual pain.

Hot Flashes Related to Breast Cancer Treatments

Breast cancer medications such as tamoxifen (Nolvadex) can cause hot flashes. While many breast cancer patients may take black cohosh to reduce the number and intensity of hot flashes, two well-designed studies concluded that the herb is no more effective than placebo. In addition, Yale researchers report that herbal medicines such as black cohosh may interfere with common breast cancer treatments, such as radiation and chemotherapy drugs.

There has been some concern that black cohosh may contain plant-based estrogens, or phytoestrogens, which can stimulate the growth of breast tumors. However, a case-control clinical study of 949 breast cancer cases and 1,524 controls found that black cohosh use had significant protective effects against breast cancer development. More research is needed. Patients with a history of breast cancer, risk factors for breast cancer, or who are actively engaged in breast cancer treatment, should talk to their doctor before taking black cohosh.


Preliminary studies suggest that black cohosh may help reduce inflammation associated osteoarthritis and rheumatoid arthritis. In a review of scientific studies, researchers concluded that a combination of black cohosh, willow bark (Salix spp.), sarsaparilla (Smilax spp.), guaiacum (Guaiacum officinale) resin, and poplar bark (Populus tremuloides) may help relieve symptoms of osteoarthritis. However, there is not enough human research to support the use of black cohosh alone for arthritis.


Laboratory studies have found that plant-based estrogens (called phytoestrogens) in black cohosh may inhibit bone loss, such as seen with osteoporosis. More research is needed.


Plant Description

Black cohosh is a tall, flowering plant found in rich, shady woods in eastern areas of North America. A member of the buttercup family, black cohosh is also known as black snakeroot, bugbane, bugwort, and squawroot. Its rhizomes and roots (both underground parts of the plant) are used for medicinal purposes.

What Is It Made Of?

Black cohosh contains glycosides (sugar compounds), isoferulic acids (substances with anti-inflammatory effects) and, possibly phytoestrogens (plant-based estrogens), among several other active substances.

Available Forms

Black cohosh is available in capsules, tablets, liquid tincture, and extracts that can be mixed in water, and dried root for a tea. A standardized preparation of black cohosh is recommended for use in menopause.

Black cohosh should not be confused with blue cohosh, a nicotine-like herb that has similar effects but has not been thoroughly tested for its safety and effectiveness.

How to Take It


There are no known scientific reports on the pediatric use of black cohosh, and it is not currently recommended for children.


The recommended dose of black cohosh ranges from 20 to 80 mg per day. The tablets should be standardized to contain 1 mg of 27-deoxyactein.

For black cohosh tincture, that equals 2 to 4 ml, 1 to 3 times per day in water or tea. Two capsules or tablets typically provide the recommended daily dose.

Although used traditionally, teas may not be as effective in relieving menopausal symptoms as the standardized extract of black cohosh. To make a black cohosh drink, put 20 g of dried root in 34 oz of water. Bring to a boil and then simmer 20 to 30 minutes until the liquid is reduced by a third. Strain, cover, and store in the refrigerator or a cool, dry place. The liquid keeps for up to 48 hours. Drink one cup 3 times daily.


The use of herbs is a time-honored approach to strengthening the body and treating disease. However, herbs contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, you should take herbs only under the supervision of a health care provider.

Some people who take high doses of black cohosh report side effects, including abdominal pain, shortness of breath, diarrhea, dizziness, headaches, joint pains, nausea, slow heart rate, tremors, visual dimness, vomiting, and weight gain. You should not use black cohosh if you have a hormone-sensitive condition, such as breast cancer, endometriosis, ovarian cancer, uterine cancer, or fibroid tumors.

It is not clear whether black cohosh stimulates the growth of breast cancer cells or inhibits their growth. Research has been limited and has produced mixed results. Women with a history of breast cancer, and those at a high risk for developing breast cancer (for example, a strong family history like a mother or sister with breast cancer), should not take black cohosh without talking to a provider.

A few cases of liver toxicity have been reported, but a direct association with the ingestion of black cohosh has not been demonstrated. However, you should not use black cohosh if you have liver damage or drink alcohol in excessive quantities. Pregnant and breastfeeding women should avoid black cohosh as the herb may stimulate contractions and lead to premature labor. However, some homeopathic practitioners recommend the use of black cohosh to induce labor in pregnant women who are at or past term. Even then, pregnant women should never use black cohosh unless under the strict supervision of a knowledgeable physician.

Possible Interactions

There are no known scientific reports of interactions between black cohosh and conventional medications. There is some concern about taking black cohosh along with medications that are toxic to the liver. Since so many medications affect the liver, it is possible that combining black cohosh with prescription medications could potentially be harmful to the liver. It is also possible that taking black cohosh could alter the effects of drugs that are metabolized by the liver. Speak with your physician and see the Precautions section.

Taking black cohosh can interact with other medicines, vitamins, and certain foods. Talk to your health care provider about possible interactions. Yale researchers also report that herbal medicines such as black cohosh may interfere with common breast cancer treatments, such as radiation and chemotherapy drugs.

Supporting Research

Amsterdam JD, Yao Y, Mao JJ, Soeller I, Rockwell K, Shults J. Randomized, double-blind, placebo-controlled trial of Cimicifuga racemosa (black cohosh) in women with anxiety disorder due to menopause. J Clin Psychopharmacol. 2009;29(5):474-83.

Bebenek M, Kemmler W, von Stengel S, Engelke K, Kalender WA. Effect of exercise and Cimicifuga racemose (CR BNO 1055) on bone mineral density, 10-year coronary heart disease risk, and menopausal complaints: the randomized controlled Training and Cimicifuga racemosa Erlangen (TRACE) study. Menopause. 2010;17(4):791-800.

Borrelli F, Ernst E. Black cohosh (Cimicifuga racemosa) for menopausal symptoms: a systematic review of its efficacy. Pharmacology Res. 2008;58(1):8-14.

Chung DJ, Kim HY, Park KH, et al. Black cohosh and St. John's wort (GYNO-Plus) for climacteric symptoms. Yonsei Med J. 2007;48(2):289-94.

Einbond L, Shimizu M, Xiao D, Nuntanakorn et al. Growth inhibitory activity of extracts and purified components of black cohosh on human breast cancer cells. Breast Cancer Research and Treatment. 2004;83(3):221-31.

Ernst E, Chrubasik S. Phyto -- anti-inflammatories. A systematic review of randomized, placebo-controlled, double-blind trials. Rheum Dis Clin North Am. 2000;26(1):13-27.

Frei-Kleiner S, Schaffner W, Rahlfs VW, Bodmer Ch, Birkhauser M. Cimicifuga racemosa dried ethanolic extract in menopausal disorders: a double-blind placebo-controlled clinical trial. Maturitas. 2005;51(4):397-404.

Fritz H, Seely D, McGowan J, et al. Black cohosh and breast cancer: a systematic review. Integr Cancer Ther. 2014;13(1):12-29.

Geller SE, Shulman LP, van Breemen RB, Banuvar S, Zhou Y, Epstein G, Hedayat S, Nikolic D, Krause EC, Piersen CE, Bolton JL, Pauli GF, Farnsworth NR. Safety and efficacy of black cohosh and red clover for the management of vasomotor symptoms: a randomized controlled trial.Menopause. 2009;16(6):1156-66.

Ismail R, Taylor-Swanson L, Thomas A, et al. Effects of herbal preparations on symptom clusters during the menopausal transition. Climacteric. 2015;18(1):11-28.

Jacobson JS, Troxel AB, Evans J, et al. Randomized trial of black cohosh for the treatment of hot flashes among women with a history of breast cancer. J Clin Oncol. 2001;19(10):2739-45.

Jiang K, Jin Y, Huang L, et al. Black cohosh improves objective sleep in postmenopausal women with sleep disturbance. Climacteric. 2015;18(4):559-67.

Leach MJ, Moore V. Black Cohosh (Cimicifuga supp.) for menopausal symptoms. Cochrane Database Syst Rev. 2012;9:CD007244.

McKenna DJ, Jones K, Humphrey S, Hughes K. Black cohosh: efficacy, safety, and use in clinical and preclinical applications. [Review]. Altern Ther Health Med. 2001;7(3):93-100.

Mahady GB, Low D, Barrett ML, Chavez ML, gardiner P, Ko R, Marles RJ, Pellicore LS, Giancaspro GI, Sarma DN. United Sates Pharmacopeia review of the black cohosh case reports of hepatotoxicity. Menopause. 2008;15(4 pt 1):628-38.

Mahady GB. Black cohosh (Actaea/Cimicifuga racemosa): review of the clinical data for safety and efficacy in menopausal symptoms. Treat Endocrinol. 2005;4(3):177-84.

Newton KM, Reed SR, LaCroix AZ, Grothaus LC, Ehrlich K, Guiltinan J. Treatment of Vasomotor Symptoms of Menopause with Black Cohosh, Multibotanicals, Soy, Hormone Therapy, or Placebo. Annals of Internal Medicine. 2006 December;145(12):869-79.

Niederhuber: Abeloff's Clinical Oncology. 5th ed. Philadelphia, PA: Elsevier Saunders; 2013.

Oktem M, Eroglu D, Karahan HB, Taskintuna N, Kuscu E, Zeyneloglu HB. Black cohosh and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomized trial. Adv Ther. 2007;24(2):448-61.

Palacio C, Masri G, Mooradian AD. Black cohosh for the management of menopausal symptoms: a systematic review of clinical trials. Drugs Aging. 2009;26(1):23-36.

Qiu SX, Dan C, Ding LS, et al. A triterpene glycoside from black cohosh that inhibits osteoclastogenesis by modulating RANKL and TNFalpha signaling pathways. Chem Biol. 2007;14(7):860-9.

Rakel. Rakel Integrative Medicine. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2012.

Reed SD, Newton KM, Lacroix AZ, Grothaus LC, Grieco VS, Ehrlich K. Vaginal, endometrial, and reproductive hormone findings: randomized, placebo-controlled trial of black cohosh, multibotanical herbs, and dietary soy for vasomotor symptoms: the Herbal Alternatives for Menopause (HALT) Study. Menopause. 2007;Publish Ahead of Print [Epub ahead of print].

Rockwell S, Liu Y, Higgins S. Alteration of the effects of cancer therapy agents on breast cancer cells by the herbal medicine black cohosh. Breast Cancer Research and Treatment. 2005;90(3):233-9.

Rostock M, Fischer J, Mumm A, Stammwitz U, Saller R, Bartsch HH. Black cohosh (Cimicifuga racemosa) in tamoxifen-treated breast cancer patients with climacteric complaints - a prospective observational study. Gynecol Endocrinol. 2011;27(10):844-8.

Ruediger O, Friede M, Liske E, Schnitker J, Freudenstein J, Zepelin H. Efficacy and safety of isopropanolic black cohosh extract for climacteric symptoms. Obstetrics & Gynecololgy. 2005;105:1074-83.

Sammartino A, Tommaselli GA, Gargano V, et al. Short-term effects of a combination of isoflavones, lignans and Cimicifuga racemosa on climacteric-related symptoms in postmenopausal women: a double-blind, randomized, placebo-controlled trial. Gynecol Endocrinol. 2006;22(11):646-50.

Schonberg MA, Wee CC. Menopausal symptom management and prevention counseling after the Women's Health Initiative among women seen in an internal medicine practice. J Womens Health (Larchmt). 2005;14(6):507-14.

Shams T, Setia MS, Hemmings R, McCusker J, Sewitch M, Ciam A. Efficacy of black cohosh-containing preparations on menopausal symptoms: a meta-analysis. Altern Ther Health Med. 2010;16(1):36-44.

Teschke R. Herb induced liver injury presumably caused by black cohosh: a survey of initially purported cases and herbal quality specifications. Ann Hepatol. 2011;10(3):245-59.

Tsukamoto S, Aburatani M, Ohta T. Isolation of CYP3A4 Inhibitors from the Black Cohosh (Cimicifuga racemosa). Evid Based Complement Alternat Med. 2005;2(2):223-6.

Viereck V, Grundker C, Friess SC, et al. Isopropanolic extract of black cohosh stimulates osteoprotegerin production by human osteoblasts. J Bone Miner Res. 2005;20(11):2036-43.

Walji R, Boon H, Guns E, Oneschuk D, Younus J. Black cohosh (Cimicifuga racemosa [L.] Nutt.): safety and efficacy for cancer patients. Support Care Cancer. 2007;15(8):913-21.

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Review Date: 2/3/2016  

Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network. Also reviewed by the A.D.A.M. Editorial team.

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