Black Cohosh for Relief of Climacteric Symptoms

Daniel S. Fabricant

Steven J. Dentali

Elizabeth C. Krause

Norman R. Farnsworth

The botanical nomenclature of black cohosh—Actaea racemosa (L. syn.), Cimicifuga racemosa (L.) Nutt—originated with North American Indians. The term cohosh is thought to be an Algonquian word meaning “rough,” with reference to the texture of the thick, knotted roots and underground stems (rhizomes). A New World plant used by Native Americans, it was most abundant in the Ohio River Valley, but it could also be found from Maine to Wisconsin, south along the Allegheny Mountains to Georgia, and west to Missouri.

Various common names have been used to refer to black cohosh, including black snakeroot, bugbane, rattleroot, squawroot, and macrotys. It is a member of the Ranunculaceae, or buttercup family, which includes other medicinal plants such as aconite, goldenseal, and pulsatilla. It has been known by the scientific name C. racemosa and has recently been assigned back to Actaea racemosa. The generic name Cimicifuga derives from the Latin cimex (a kind of bug) and fugare (to put to flight), which is perhaps indicative of the use of some strongly smelling close relatives to repel insects. The species name racemosa refers to the flowering stalk, or raceme. The designation of rattleroot is indicative of the rattling sound made by the dry seeds in their pods. This plant prefers the shade of rich open hardwood forests, but it will tolerate some sunny spots.

Black cohosh has been used clinically for the relief of climacteric symptoms for over 50 years, and its popularity in the United States as a botanical dietary supplement has increased due to the recently recognized potential risks associated with classical estrogen or hormone replacement therapy (HRT) (1,2). The part of the black cohosh plant used in medicinal preparations is the root and rhizome (which is technically an underground stem). It was officially part of the United States Pharmacopeia (USP) from the first edition in 1820 to 1936 and in the National Formulary from 1936 to 1950. The Eclectic physicians used a preparation of black cohosh called macrotys. It was considered one of the best known specific medicines for heavy, tensive, aching pains as it was noted to have a direct influence on the female reproductive organs.

While the mechanism of action has not been completely elucidated, recent literature suggest that alleviation of climacteric symptoms is mediated through neurotransmitter regulation and not through classical estrogen receptor (ER) endocrine pathways (3,4).

CHEMISTRY

More than 60 triterpene glycosides, most with a 9,19 cycloartane skeleton, have been reported from the roots and rhizomes of A. racemosa (5,6). The compound 23-epi-26 deoxyactein (formerly 27-deoxyactein) is the constituent usually selected for standardization of commercial products based on its abundance in the roots and rhizomes (7, 8, 9, 10, 11, 12). While triterpenes are structurally similar to steroids and possess a broad range of biologic activity (13, 14, 15, 16), no significant ligand-binding affinity was found toward ER-β in the evaluation of 23-epi-26-deoxyactein, cimiracemoside F and cimicifugoside, and their respective aglycones (17). This, coupled with the lack of demonstrated estrogenic activity in A. racemosa extracts, has called into question the notion that black cohosh acts through direct ER binding by the triterpenes, as has been hypothesized (18, 19, 20, 21, 22).

Figure 11.1 • Triterpenes and phenolics of biologic interest.

The roots and rhizomes of black cohosh also contain a number of aromatic acids/polyphenolics with a wide array of biologic activities (5,23, 24, 25). Caffeic acid has shown pregnant mare antigonadotropin activity (26, 27, 28), rat uterine antispasmodic activity (29), and smooth muscle relaxant/antispasmolytic activity in the rat (30) and guinea pig ileum (31). Ferulic acid has demonstrated lutenizing hormone (LH) release inhibition (32), follicle-stimulating hormone (FSH) release stimulation (32), antiestrogenic activity (33), prolactin stimulation in cows (34) and inhibition in rats (32), and uterine relaxant/antispasmolytic activity in rats (35). Fukinolic acid produced an estrogenic effect on MCF-7 cells with reference to estradiol (36). A more recent study refuted this effect and demonstrated a lack of estrogenic effect for 10 other phenolic esters [caffeoylglycolic acid; 2-caffeoylpiscidic acid (cimicifugic acid D); 3,4-dihydroxyphenacyl caffeate (petasiphenone); 3,4-dihydroxyphenyl-2-oxopropyl isoferulate (cimiciphenol); 3,4-dihydroxyphenacyl isoferulate (cimiciphenone); cimicifugic acids A, B, E, F; and fukiic acid] from black cohosh (37).

Other studies on the phenolic acid constituents of black cohosh have shown antioxidant activity (24,38) that may correlate with or prove useful in the determination of the mechanism of action of black cohosh. In addition, a number of plant sterols and fatty acids generally regarded as ubiquitous in the plant kingdom are contained in the roots and rhizomes for which the biologic activities probably do not relate to the mechanism of action of black cohosh (5). Recently an alkaloid was reported from A. racemosa underground parts (39). Alkaloids have also been reported from other Actaea spp. (40,41) and while no biologic activity has yet been reported on these constituents, they may prove useful as biomarkers.

There has been some debate over the presence of the weakly estrogenic compound formononetin in the plant (42,43). While some maintain that formononetin does occur in A. racemosa (43), prior studies using plant material collected from different sites in the Eastern United States at different times of year failed to find formononetin (44,45). More recent studies on both commercial black cohosh products and wildcrafted materials, incorporating both high-performance liquid chromatography (HPLC) with mass spectral (MS) and photodiode array (PDA) detection, confirmed the prior findings of no detectable formononetin in black cohosh (8,46) (Fig. 11.1)

BOTANICAL DESCRIPTION

Actaea racemosa syn. Cimicifuga racemosa is an erect, smooth-stemmed perennial 1 to 2.5 m in height. Large compound leaves are alternately arranged and triternate on short clasping petioles. Basal leaf petioles are grooved in young specimens. This shallow, narrow sulcus in A. racemosa disappears as the petiole enlarges, whereas it remains present throughout the life of two related eastern North American species, A. cordifolia DC syn. C. rubifolia Kearney and A. podocarpa DC syn. C. americana Michx. (47). Terminal leaflets are acute and glabrous with sharp serrated margins, often trilobate, occasionally bilobed. Fruits are ovoid follicles occurring sessile on the pedicel. The flowering portion, the raceme, is a long wand-like structure with showy white flowers. The flowers possess numerous characteristic stamen and slender filaments with distinctive white anthers (48). The roots and rhizomes are branched and knotted structures with a dark brown exterior and are internally white and mealy or brown and waxy.
The upper surface has several buds and numerous large stem bases terminated, frequently by deep, cup-shaped, radiating scars, each which show a radiate structure or less frequently by fibrous strands. Lower and lateral surfaces exhibit numerous root scars and a few short roots. The fracture is horny, the odor slight, and the taste bitter and acrid (49).

EFFECTS ON CLIMACTERIC SYMPTOMS RELATED TO MENOPAUSE

With a history spanning over 50 years of clinical study mainly in Europe (50), black cohosh is one of the more popular alternatives to HRT. Most of the clinical research over this span has been done on the commercial extract product known as Remifemin. It is important to note that the formulation and dosage of Remifemin used in human studies has frequently changed over time. However, a number of other commercial formulations are also available. In 2005, black cohosh was reported to be the eighth best selling botanical dietary supplement in the United States with sales of approximately $9.7 million (51).

The results of clinical studies have been measured using a variety of parameters. Self-assessments, physician assessments, and physiologic parameters are used, usually in tandem to measure psychologic, neurovegetative, somatic and physiologic markers of menopause, or in the case of the treatment groups, relief from the climacteric symptoms of menopause. More significant when evaluating studies is the study design. More weight should be placed on studies following good clinical practice, i.e., those that incorporate the proper controls and are designed to address relevant caveats to climacteric symptoms, such as the placebo effect and issues unique to the product quality of botanical dietary supplements (52, 53, 54, 55, 56).

Placebo effects in menopausal trials are generally large (57), and reflect underlying fluctuations of symptoms. Therefore any well-designed study must adjust the appropriate variables [i.e., study duration, number of subjects (n), and/or dosage] to account for such an effect. In the evidence based medical (EBM) model, the gold standard in terms of efficacy involves randomized controlled trials (RCTs). Many RCTs on black cohosh exist. Over 3,000 subjects have been randomized, with the more recent studies adding layers of design sophistication. For example, double-blind, multicenter, placebo-controlled trials with details regarding clinical material specifications are becoming more prevalent (58, 59, 60).

A recent phase III, double-blind, randomized, placebo-controlled crossover trial for the management of hot flashes, was conducted over two 4-week periods to study the efficacy of black cohosh (1 capsule, 20 mg b.i.d.) using a daily hot flash diary (61). This study found that subjects receiving the black cohosh material reported a mean decrease in hot flash score of 20% (comparing the fourth treatment week to the baseline week) compared with a 27% decrease for patients on placebo (P=0.53), mean hot flash frequency was reduced 17% on black cohosh and 26% on placebo (P=0.36). Thus, the authors concluded that the study did not provide any evidence that black cohosh reduced hot flashes more than the placebo. Critics of the study point to the short duration and low dose as potential confounders of the results.

The Herbal Alternatives for Menopause Trial (HALT) compared the efficacy of black cohosh 160 mg per day against several other interventions (multibotanical with black cohosh, 200 mg per day, and nine other ingredients; multibotanical plus dietary soy counseling; conjugated equine estrogen, 0.625 mg per day, with or without medroxyprogesterone acetate, 2.5 mg per day) and placebo in 351 menopausal and postmenopausal women of ages 45 to 55 years with 2 or more vasomotor symptoms per day. Results did not suggest efficacy for any of the herbal interventions when compared to placebo at any time point over the 1-year course of the study (62).

The Jacobson study, spanning only 60 days of treatment, suggests that the short study duration may have limited the findings (59). In addition, all the study participants had a history of breast cancer. The outcome was that the median number of hot flashes decreased 27% in both the placebo and black cohosh groups. No significant differences were observed between
groups. Thus black cohosh, on the basis of this study, was no more effective than placebo in the treatment of hot flashes. The source and formulation of the extract used in this study was not specified. A more recent open-labeled study using breast cancer survivors, treated with either Tamoxifen or a combination of BNO 1055 with Tamoxifen, suggests a satisfactory reduction in the number and severity of hot flashes with the combination treatment group (63).

In another randomized, double-blind, placebo-controlled clinical study lasting 12 weeks, black cohosh was compared with standard conjugated estrogen (CE) therapy (0.625 mg per day). Patients’ physical and psychologic symptoms were measured every 4 weeks. The end result of the study was that the patients treated with black cohosh had a statistically significant lower index score compared with placebo, with both the Kupperman Menopausal (KM) and the Hamilton Menopausal (HAMA) scales, indicating a decrease in severity and frequency of hot flashes. In addition, this study showed an increase in the number of estrogenized cells in the vaginal epithelium, which could indicate an estrogenic action in this tissue (60).

In 2003, a similar and confusing study compared two different preparations of BNO 1055 extract to CE therapy (0.6 mg per day) (58). The study outcomes were patient self-assessment [diary and menopause rating scale (MRS)], CrossLaps (to measure bone resorption), bone-specific alkaline phosphatase (marker of bone formation), and endometrial thickness (measured by ultrasound). Both BNO 1055 extracts were equipotent to CE therapy and significantly greater than placebo at reducing climacteric complaints. In addition, the study showed that both BNO 1055 preparations had beneficial effects on bone metabolism in serum. Specifically an increase in bone-specific alkaline phosphatase and no reduction in bone resorption was noted indicating an increase in bone turnover formation. No change in endometrial thickness was observed in both BNO 1055 treatment groups, but it was significantly increased with CE therapy. An increase in superficial vaginal cells was observed in both the CE and BNO 1055 treatment groups. The authors of this study hypothesized that the activity of both BNO 1055 preparations were similar to the effects of Selective Estrogen Receptor Modulating (SERM), i.e., Raloxifene, therapy on bone and neurovegetative climacteric symptoms, without any uterotrophic effects (58).

A recent double-blind, randomized good clinical practice compliant study used two doses (low 39 mg, high 127 mg) of a Remifemin extract. Effectiveness was measured using the KM index, self-assessment depression scale (SDS), clinical global impression scale (CGI), and serum levels of LH, FSH, sex hormone binding globulin (SHBG), prolactin, and 17-β-estradiol, and vaginal cytology. Reductions in the KM and SDS indices were significant. Global efficacy (CGI) was scored at good to very good in 80% (low dosage) and 90% (high dosage) of the patients in the treatment groups (64). No effect on serum hormone levels or vaginal cytology was shown, prompting the authors of the study to suggest that black cohosh does not have a direct estrogenic effect on the serum hormone levels or vaginal epithelium (65). Two recent open studies using unspecified types of extracts showed reduced KM index scores. One study reported a significant reduction in 1 month (66). While the other, also, using the HAMA scale, recorded a 90% improvement in climacteric symptoms in menopausal women after 3 months of black cohosh administration (67).

Chung et al. (68) examined a combination of black cohosh and St. John’s wort (Gynoplus) in a multicenter RCT in 89 peri- or postmenopausal women with climacteric symptoms. Subjects were treated for 12 weeks with either the Gynoplus extract or placebo. In addition to climacteric complaints, investigators also examined effects on vaginal atrophy, serum hormone levels (FSH, LH), and lipid profiles (total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglyceride). Significant improvements in climacteric symptoms and hot flashes, as well as an increase in HDL were observed in the Gynoplus group by 4 weeks and maintained after 12 weeks, but there was no significant impact on vaginal atrophy.

More details of the human studies discussed here, as well as others, are presented in Table 11.1.

TABLE 11.1 Selected Black Cohosh Clinical Studies

Author (reference no.)	Year	Extract/Formulation/Dosage	Study Length	N	Outcome Measure/Result	Study Design
Kesselkaul (105)	1957	Remifemin 60 drops	2 wk	63	Alleviation of climacteric complaints in 95% of patients	Case series
Schotten (106)	1958	Remifemin 20 drops	3 to 4 wk	22	Alleviation of neurovegetative and psychic complaints associated with menopause and premenopause	Case series
Foldes (50)	1959	Remifemin, 3 tablets per day	Unknown	41	31 patients of the verum group responded to the treatment with a decrease in menopausal complaints.	Placebo-controlled, open, crossover, patient self-assessment
Starfinger (107)	1960	Remifemin, 3 to 20 drops per day	1 yr	105	Decreased climacteric complaints without incidence of side effects or resulting in nonphysiologic bleeding.	Case series
Brucker (108)	1960	Remifemin, tablets, variable dose	Variable	87 (517)	Alleviation of menopausal complaints	Case series
Heizer (109)	1960	Remifemin, 3 to 6 tablets per day	2 to 18 mo	66	Alleviation of menopausal (neurovegetative and psychic) complaints in 47% of patients with intact uteri and 35% with hysterectomies	Case series
Gorlich (110)	1962	Remifemin, tablets, variable dose	Variable	41 (258)	Alleviation of climacteric and vascular symptoms in 85% of patients	Case series
Schildge (111)	1964	Remifemin, fluid extract 60 drops per day	Variable	135	Euphoric and mild sedative-calming effects in all pts	Case series
Stolze (112)	1982	Remifemin, fluid extract 80 drops per day	6 to 8 wk	629	Alleviation of neurovegetative and psychologic menopausal symptoms in 80% of patients	Open, physician and patient self-assessment
Daiber (113)	1983	Remifemin, fluid extract 80 drops per day	12 wk	36	Alleviation of climacteric complaints (hot flashes, insomnia, sweating and restlessness)	Open, KMI, CGI
Vorberg (114)	1984	Remifemin, fluid extract 80 drops per day	12 wk	50	Significant or highly significant alleviation of menopausal (neurovegetative and psychic) complaints, study included subjects contraindicated to hormone therapy.	Randomized, open, KMI, CGI, POMS
Warnecke (115)	1985	Remifemin, fluid extract 80 drops per day	12 wk	20	Significant alleviation of symptoms (psychic and neurovegetative) in the black cohosh, conjugated estrogen anddiazepamgroups. Vaginal cytology of treatment group was comparable to estrogenic stimulation.	Randomized, open, KMI, HAMA, SDS, CGI, Karyopyknosis index, Eosinophil index.
Stoll (116)	1987	Remifemin, tablets equiv. to 8 mg extract per day	12 wk	26	Significant alleviation of climacteric symptoms (vaginal atrophy, neurovegetative, and psychic complaints) in comparison with estrogen and placebo groups	Double-blinded, randomized, placebo-controlled, KMI, HAMA, VMI (vaginal epithelium)
Petho (117)	1987	Remifemin, tablets, unspecified dose	6 mo	50	KMI decreased significantly from 17.6 to 9.2, correlates with a significant reduction in neurovegetative symptoms. Severity of subjective self-assessments of subjects physical and psychologic symptoms decreased.	Open, KMI, patient self-assessment
Lehman-Willenbrock and Riedel (118)	1988	Remifemin, tablets equiv. to 8 mg extract per day	6 mo	15	Significant alleviation of climacteric symptoms in black cohosh and drug treatment groups. No significant change in gonadotropin (FSH, LH) levels.	Randomized, open, KMI
Düker et al. (70)	1991	Remifemin, tablets equiv. to 40 mg dried herb per day	2 mo	110	LH suppression	In vitro study using blood from menopausal women taking black cohosh
Baier-Jagodinski (119)	1995	Cimisan T Tropfen, variable dose	4 to 8 wk	157	89% of patients showed symptom improvement after 4 wk. At final visit, the efficacy was assessed as follows: very good, 40%; good, 41%; sufficient, 12%; inadequate, 7%	Open, uncontrolled
Mielnik (66)	1997	Uncharacterized extract, 4 mg per day	6 mo	34	Alleviation of climacteric (neurovegetative) symptoms in 76% of patients after 1 mo	Open, KMI
Georgiev and Iordanova (67)	1997	Uncharacterized extract, unspecified dose	3 mo	50	Alleviation of climacteric symptoms in 90%. of patients. Increase in vaginal cell proliferation (VMI) in 40% of treated women	Open, KMI, HAMA, VMI
Nesselhut and Liske (120)	1999	Remifemin, tablets equiv. to 136 mg dried herb per day	3 mo	28	Good to very good alleviation of 10 menopausal symptoms in 80% of study participants.	Open, postmarket surveillance
Jacobson et al. (59)	2001	Remifemin, tablets equiv. to 40 mg dried herb per day	60 d	42^a	No change in median number or intensity of hot flashes	Double-blinded, randomized, placebo-controlled, patient self-assessment, VAS, MSS
Liske et al. (65)	2002	Unique C. racemosa preparation, equiv. to 39 or 127.3 mg per day	6 mo	152	No direct systemic estrogenic effect on serum levels of FSH, LH, SHBG, prolactin, and and 17-β-estradiol. No change in vaginal cytology. Higher dose had a more significant reduction in KM index after 6 mo. Significant reduction with both doses in neurovegatative and psychic complaints.	Drug equivalence trial, KMI, SDS, CGI
Hernandez-Munoz and Pluchino (63)	2003	BNO 1055	12 mo	136	Combination therapy with tamoxifen (20 mg) reduced severity and incidence of hot flashes.	Open, randomized, patient self-assessment
Wuttke et al. (58)	2003	Klimadynon/BNO1055	3 mo	62	Equipotent to 0.6 CE for relief of climacteric complaints and for bone resorption. No effect on endometrial thickness.	Randomized, double-blinded, placebo-controlled, multicenter, MRS
Verhoeven et al. (121)	2005	125 mg soy extract per day (providing 50 mg isoflavones including 24 mg genistein and 21.5 mg daidzein), 1,500 mg evening primrose oil extract (providing 150 mg gamma linoleic acid), 100 mg A. racemosa L. extract (providing 8mg deoxyacetein), 200mg calcium, 1.25 mg vitamin D, and 10 IU vitamin E, placebo group received 2,000 mg olive oil per day.	12 wk	124	Subjects were experiencing at least five vasomotor symptoms every 24 h at study entry. At wk 6 and 12, all scores in both groups had improved compared with baseline, though the overall difference in scores between the groups was not statistically significant.	Multicenter, randomized, placebo-controlled, double-blind study, Kupperman Index and Greene Climacteric Scales
Nappi et al. (122)	2005	Aqueous isopropanolic extract 40 mg per day	3 mo	64	Postmenopausal women were recruited. Both CR and low-dose TTSE2 significantly reduced the number of hot flushes per day (P<0.001) and vasomotor symptoms (P<0.001), starting at the first month of treatment. Such a positive effect was maintained throughout the 3 mo of observation, without any significant difference between the two treatments. An identical effect was evident also for both anxiety (P<0.001) and depression (P<0.001) which were significantly reduced following 3 mo of both CR and low-dose TTSE2. Total cholesterol was unchanged by CR treatment but significantly (P<0.033) reduced by 3 mo of low-dose TTSE2. A slight but significant increase of HDL-cholesterol (P<0.04) was found only in women treated with CR, while LDL-cholesterol levels were significantly lowered by 3 mo of both CR (P<0.003) and low dose TTSE2 (P<0.002). Triglycerides were not affected by both treatments, nor was liver function. FSH, LH, and cortisol were not significantly affected after the 3-mo treatment, while PRL (P<0.005) and 17-β-E₂ (P<0.001) were increased slightly only by low-dose TTSE2. Endometrial thickness was not affected by either CR or low-dose TTSE2.	Randomized, controlled clinical study
Frei-Kleiner et al. (123)	2005	6.5 mg dry rhizome extract; 60% ethanol extraction solvent; dose = 1 cap per day	12 wk	122	Menopausal women were recruited. The primary efficacy analysis showed no superiority of the tested black cohosh extract compared to placebo. However, in the subgroup of patients with a Kupperman Index ≥20 a significant superiority regarding this index could be demonstrated (P<0.018). A decrease of 47% and 21% was observed in the black cohosh and placebo groups, respectively. The weekly weighted scores of hot flashes (P<0.052) and the Menopause Rating Scale (P<0.009) showed similar results. Prevalence and intensity of the adverse events did not differ in the two treatment groups.	Multicenter, randomized, placebo-controlled, double-blind, parallel group study
Pockaj et al. (61)	2006	20 mg C. racemosa and rhizome extract standardized to contain 1 mg of triterpene glycosides as calculated by 27-deoxyacetin placebo	Two 4-wk crossover treatment periods	132	Toxicity was minimal and not different by treatment group. Patients receiving black cohosh reported a mean decrease in hot flash score of 20% (comparing the fourth treatment week to the baselineweek) compared with a 27% decrease for patients on placebo (P=0.53). Mean hot flash frequency was reduced 17% on black cohosh and 26% on placebo (P=0.36). Patient treatment preferences were measured after completion of both treatment periods by ascertaining which treatment period, if any, the patient preferred. Thirty-four percent of patients preferred the black cohosh treatment, 38% preferred the placebo, and 28% did not prefer either treatment.	Double-blind, randomized, crossover clinical trial. Primary end point was the average intrapatient hot flash score (a construct of average daily hot flash severity and frequency) difference between the baseline week and the last study week of the first treatment Climacteric Scale
Newton et al. (HALT) (62)	2006	(a) Black cohosh, 160 mg per day; (b) multibotanical with black cohosh, 200 mg per day, and nine other ingredients; (c) multibotanical plus dietary soy counseling; (d) conjugated equine estrogen, 0.625 mg per day, with or without medroxyprogesterone acetate, 2.5 mg per day; or (e) placebo.	1 yr	351	Women aged 45 to 55 years with two or more vasomotor symptoms per day were recruited. Vasomotor symptoms per day, symptom intensity, Wiklund Vasomotor Symptom Subscale score did not differ between the herbal interventions and placebo at 3, 6, or 12 mo or for the average over all the follow-up time points (P>0.05 for all comparisons) with one exception: at 12 months, symptom intensity was significantly worse with the multibotanical plus soy intervention than with placebo (P> 0.016). The difference in vasomotor symptoms per day between placebo and any of the herbal treatments at any time point was less than 1 symptom per day; for the average overall the follow-up time points, the difference was less than 0.55 symptom per day. The difference for hormone therapy vs. placebo was −4.06 vasomotor symptoms per day for the average over all the follow-up time points (95% CI, −5.93 to −2.19 symptoms per day; P>0.001). Differences between treatment groups smaller than 1.5 vasomotor symptoms per day cannot be ruled out. Black cohosh containing therapies had no demonstrable effects on lipids, glucose, insulin, or fibrinogen [Spangler et al. (124)].	Randomized, double-blind, placebo-controlled trial. Wiklund Vasomotor Symptom scale
Raus et al. (125)	2006	Dried aqueous/ethanolic (58% v/v) extract CR BNO 1055 of the rhizome of Actaea or CR (black cohosh)	1 yr	400	Postmenopausal women with symptoms related to estrogen deficiency were recruited. The lack of endometrial proliferation and improvement of climacteric complaints as well as only a few gynecologic organ-related adverse events are reported for the first time after a treatment period of 1 yr.	Prospective, open-label, multinational, multicenter study; endovaginal ultrasonography
Sammartino et al. (126)	2006	group A (N=40) was treated with 1 tablet per day per os containing a combination of isoflavones [soy germ extracts, Glycine max, no-OGM SoyLife: 150 mg, titrated in isoflavones (40%) = 60 mg], lignans [flaxseed extracts, Linum usitatissimum, no-OGM LinumLife: 100 mg, titrated in lignans (20%) = 20 mg] and C. racemosa [50 mg, titrated in triterpene (2.5%) = 1.25 mg] (Euclim1; Alfa Wassermann, Italy); group B (N=40) was treated with calcium supplements (Metocal, Rottapharm, Monza, Italy).	Three cycles of 28 days	80	Healthy postmenopausal women were recruited. At baseline no significant difference was detected in KI between groups A and B; however, after three cycles of treatment, KI was significantly (P>0.05) lower in group A compared with baseline and with group B.	Double-blind, randomized, placebo-controlled trial, Kupperman Index
Gurley et al. (127)	2006	Milk thistle (300 mg, three times daily, standardized to contain 80% silymarin), black cohosh extract (20 mg, twice daily, standardized to 2.5% triterpene glycosides), rifampin (300 mg, twice daily), and clarithromycin (500 mg, twice daily)	14 d	16	Young adults (8 females) (age, mean ± SD = 26 ± 5 years; weight, 75 ± 13 kg) compared with the effects of rifampin and clarithromycin, the botanical supplements milk thistle and black cohosh produced no significant changes in the disposition of digoxin, a clinically recognized P-gp substrate with a narrow therapeutic index. Accordingly, these two supplements appear to pose no clinically significant risk for P-gp-mediated herb-drug interactions.	Randomized controlled, clinical pharmacokinetic trial
Rebbeck et al. (128)	2007	Varied	Case-control design	949 breast cancer cases; 1,524 controls.	HRS varied significantly by race, with African American women being more likely than European American women to use any herbal preparation (19.2% vs. 14.7%, P>0.003) as well as specific preparations including black cohosh (5.4% vs. 2.0%, P>0.003), ginseng (12.5% vs. 7.9%, P<0.001) and red clover (4.7% vs. 0.6%, P<0.001). Use of black cohosh had a significant breast cancer protective effect (adjusted odds ratio 0.39, 95% CI: 0.22 to 0.70). This association was similar among women who reported use of either black cohosh or Remifemin (an herbal preparation derived from black cohosh; adjusted odds ratio 0.47, 95% CI: 0.27 to 0.82).	Population-based case-control study
Hirschberg et al. (129)	2007	Remifemin (batch no. 229690), one tablet twice daily. Each tablet contains 0.018 to 0.026 mL liquid extract of black cohosh rootstock (0.78 to 1.14:1), corresponding to 20 mg herbal drug (i.e., 2.5 mg dry extract, extraction agent isopropanol 40% [v/v]); 40 mg per day	6 mo	74	None of the women showed any increase in mammographic breast density. Furthermore, thermore, there was no increase in breast cell proliferation. The mean change ± SD in proportion of Ki-67-positive cells was 0.5% ± 2.4% (median, 0.0; 95% CI = −1.32 to 0.34) for paired samples. The mean change in endometrial thickness ± SD was 0.0 ± 0.9 mm (median, 0.0). A modest number of adverse events were possibly related to treatment, but none of these were serious. Laboratory findings and vital signs were normal.	Prospective, open, uncontrolled drug safety study
Chung et al. (68)	2007	Gynoplus (264 mg tablet with 0.0364 mL C. racemosa rhizome, equiv. to 1 mg terpene glycosides; 84 mg dried Hypericum perforatum extract, equiv. to 0.25 mg hypericin, with 80% methanol)	12 wk	89	Kupperman Index (KI) for climacteric complaints. Vaginal maturation indices, serum estradiol, FSH, LH, total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglyceride levels. Significant improvements in climacteric symptoms and hot flashes, as well as an increase in HDL (from 58.32 ± 11.64 to 59.74 ± 10.54) were observed in the Gynoplus group by 4 wk and maintained after 12 wk, compared to the placebo group. There was no significant impact on superficial cell proportion.	Randomized, double-blind, placebo-controlled trial.
Ruhlen et al. (21)	2007	Remifemin R and CimiPure (2.5% triterpenes; 40 mg capsule contains 1 mg 23-epi-26-deoxyactein)	12 wk followed by 12-wk washout	61	Subjects experienced relief of menopausal symptoms, with reversion to baseline after washout. No effect on serum estrogenic markers. No effect on pS2 or cell morphology in nipple aspirate.	Open study
Gurley et al. (130)	2008	Milk thistle (300 mg, three times daily, standardized to contain 80% silymarin), black cohosh extract (40 mg, twice daily, standardized to 2.5% triterpene glycosides), rifampin (300 mg, twice daily), and clarithromycin (500 mg, twice daily).	14 d	19	Young adults (9 women; age [mean ± SD] = 28 ± 6 years; weight = 76.5 ± 16.4 kg) Milk thistle and black cohosh appear to have no clinically relevant effect on CYP3A activity in vivo. Neither spontaneous reports from study participants nor their responses to questions asked by study nurses regarding supplement/medication usage revealed any serious adverse events.	Randomized controlled, clinical pharmacokinetic trial
^aAll with breast cancer history. Abbreviations: CGI, Clinician’s Global Impression scale; HAMA, Hamilton Anxiety scale; KMI, Kupperman Menopausal Index; VMI, Vaginal Maturity Index; SDS, Self-Assessment Depression scale; POMS, Profile of Mood States scale; MSS, unspecified menopausal index using the Likert scale; VAS, Visual Analog Scale; Open, open-labeled. (Adapted from Fabricant DS, Farnsworth NR, Black Cohosh (Cimicifuga racemosa). In: Coates P, Blackman MR, Cragg G, Levine M, Moss J, White J, eds. Encyclopedia of Dietary Supplements. New York, NY: Marcel Dekker, Inc.; 2005; pp.41-54.)