Cimicifuga racemosa hot flashes menopause supplement root extract benefit, side effects by Ray Sahelian, M.D.
April 6 2015

Cimicifuga racemosa, also known as black cohosh, snakeroot, bugbane and rattle weed, is native to eastern North America, and has historically been used by Native Americans for a variety of female conditions. Cimicifuga racemosa contains a variety of phytoestrogens. The German Commission E has approved Cimicifuga racemosa for the treatment of menopause symptoms, premenstrual syndrome - pms, and dysmenorrhea, however they recommend treatment be limited to 6 months.
   Studies have shown inconsistent results in reducing hot flashes in postmenopausal women. At this time there is debate in the herbal community on the role and effectiveness of Cimicifuga racemosa in treating female conditions, but it appears that this herb could play a positive role.

Hot flashes, does this herb help?
Research regarding the benefits of this herb for treating hot flashes or menopausal symptoms has provided conflicting results

Climacteric. 2015. Cimicifuga racemosa extract for relieving menopausal symptoms: a randomized controlled trial. To evaluate the effectiveness of black cohosh extract 40 mg/day for relieving moderate to severe menopausal symptoms and improving quality of life in Thai women. Participants were peri- or postmenopausal Thai women aged at least 40 years, who have moderate to severe menopausal symptoms evaluated using the Kupperman index (KI). Outcome measures included KI, frequency of hot flushes, Menopause-Specific Quality of Life (MENQOL) score, participants' global satisfaction and safety outcomes. A black cohosh extract of 40 mg/day is not superior to a placebo for relieving moderate to severe menopausal symptoms or improving quality-of-life scores in Thai women.

Pilot evaluation of Cimicifuga racemosa for the treatment of hot flashes in women.
Cancer Invest. 2004. Pockaj BA, Loprinzi CL. Mayo Clinic, Scottsdale, Arizona
Hot flashes cause significant morbidity in postmenopausal women, including women with breast cancer. We undertook a pilot study to estimate the effectiveness of Cimicifuga racemosa to reduce hot flashes. Women who reported significant hot flashes (> or = 14 per week) were enrolled. Cimicifuga racemosa was given in the form of the commercial product Remifemin. The first week was a no-treatment baseline period, and therapy was given for the subsequent 4 weeks. Hot flash data were collected by daily questionnaires during baseline and Cimicifuga racemosa treatment weeks. Adverse effects were recorded. RESULTS: Twenty-one women completed the study. Their mean age was 56 years (range, 38-80). Thirteen patients had a history of breast cancer. Six patients were taking tamoxifen or raloxifene. Patients reported an average of 8.3 hot flashes per day during the baseline week. The reduction in mean daily hot flash frequency was 50% (95% CI, 34%-65%), while weekly hot flash scores were reduced 56% (95% CI, 40%-71%) at completion of the study. Overall, patients reported less trouble with sleeping, less fatigue, and less abnormal sweating. Cimicifuga racemosa appeared to reduce hot flashes and had a low toxicity. The efficacy found in this trial seems to be more than would be expected by a placebo effect (20%-30% hot flash reduction in previous trials).

Cimicifuga racemosa for the treatment of hot flushes in women surviving breast cancer.
Maturitas. 2003. Parque Humboldt, Prados del Este, Caracas, Venezuela.
To examine the effect of Cimicifuga racemosa (CR BNO 1055) on hot flushes caused by tamoxifen adjuvant therapy in young premenopausal breast cancer survivors. Between May 1999 and December 2001, we accrued 136 breast cancer survivors aged 35-52 years. After treatment with segmental or total mastectomy, radiation therapy and adjuvant chemotherapy, participants were in open-label randomly assigned (1-2) to receive tamoxifen 20 mg per day orally (usual-care group; n=46) or tamoxifen (same dose and posology) plus Cimicifuga racemosa (Menofem / Klimadynon, corresponding to 20 mg of herbal drug; intervention group n=90). Duration of treatment was 5 years for tamoxifen, according to international standards for adjuvant therapies, and 12 months for Cimicifuga racemosa. Follow-up included clinical assessment every 2 months; the primary endpoint was to record the number and intensity of hot flushes. Comparing patients assigned to usual-care group with those assigned to intervention group, the number and severity of hot flushes were reduced after intervention. Almost half of the patients of the intervention group were free of hot flushes, while severe hot flushes were reported by 24.4% of patients of intervention group and 73.9% of the usual-care group. Hot flushes were the most frequent adverse reaction to tamoxifen adjuvant therapy in breast cancer survivors. The combined administration of tamoxifen plus Cimicifuga racemosa for a period of 12 months allowed satisfactory reduction in the number and severity of hot flushes.

Cimicifuga racemosa for the treatment of hot flashes in women
Hot flashes cause significant disturbances in postmenopausal women, including women with breast cancer. A pilot study was undertaken to evaluate the effectiveness of Cimicifuga racemosa in reducing hot flashes. Women who reported significant hot flashes (greater than 14 per week) were enrolled. The first week was a no-treatment baseline period, and therapy was given for the subsequent 4 weeks. Patients reported an average of 8 hot flashes per day during the baseline week. The reduction in mean daily hot flash frequency was 50%, while weekly hot flash scores were reduced 56% at completion of the study. Overall, patients reported less trouble with sleeping, less fatigue, and less abnormal sweating. No patients stopped therapy because of adverse effects. Conclusion: Cimicifuga racemosa appeared to reduce hot flashes and had a low toxicity.
     My comments: The results of studies evaluating it in the therapy of menopausal symptoms have not been consistent, but the majority of studies lean towards this herbal extract providing some sort of benefit, but certainly not in any way as powerful as estrogen itself. But estrogen has its risks, and, if needed, should be used at the lowest effective dose and hopefully not for very extended periods.

Cimicifuga racemosa extract 40 mg, 90 Capsules - Natural Factors
Natural Support for Menopause Symptoms
Standardized Potency Women's Formula

Natural Factors Cimicifuga racemosa Extract capsules contain extract standardized to 2.5% triterpene glycosides. Containing valuable phytoestrogen, this herb has been used for a number of feminine conditions and recently been recognized for its ability to support menopause symptoms naturally.

Suggested Usage:  1 Cimicifuga racemosa capsule, 1- 2 times per day preferably before meals or as directed by a health care professional.

Supplement Facts
Cimicifuga racemosa root 40 mg
Extract triterpene glycosides (2.5%) 1 mg

Breast cancer
Cimicifuga racemosa has a non-estrogenic, or estrogen-antagonistic effect on human breast cancer cells. This leads to the conclusion that Cimicifuga racemosa treatment may be a safe, natural remedy for menopausal symptoms in breast cancer.

Chemicals within Cimicifuga racemosa can protect against cellular DNA damage caused by reactive oxygen species by acting as antioxidants.

Cimicifuga racemosa has anti-allergy properties.

Cimicifuga racemosa dried ethanolic extract in menopausal disorders: a double-blind placebo-controlled clinical trial.
Maturitas. 2005.
To compare the efficacy and safety of the Cimicifuga racemosa root extract Cr 99 with placebo in women with climacteric complaints. A multicenter, randomized, placebo-controlled, double-blind, parallel group study was conducted in 122 menopausal women (intention-to-treat population) with > or =3 hot flashes a day, treated over 12 weeks. The results indicate a superiority of the tested Cimicifuga racemosa extract compared to placebo in patients with menopausal disorders of at least moderate intensity according to a Kupperman Index > or =20, but not in the intention-to-treat population as a whole.

The Cimicifuga preparation BNO 1055 vs. conjugated estrogens in a double-blind placebo-controlled study: effects on menopause symptoms and bone markers.
Wuttke W, 2003.
In the present study, therapeutic effects of the Cimicifuga racemosa preparation CR BNO 1055 (Klimadynon / Menofem) on climacteric complaints, bone metabolism and endometrium will be compared with those of conjugated estrogens (CE) and placebo. The question whether Cimicifuga racemosa contains substances with selective estrogen receptor modulator (SERM) activity will be investigated. Sixty-two evaluable postmenopausal women were included in the double-blind, randomized, multicentre study, and treated either with (black cohsoh (daily dose corresponding to 40 mg herbal drug), 0.6 mg CE, or matching placebo, for 3 months. Menopausal symptoms were assessed by the menopause rating scale and a diary. Cimicifuga racemosa proved to be equipotent to CE and superior to placebo in reducing climacteric complaints. Under both verum preparations, beneficial effects on bone metabolism have been observed in the serum. Cimicifuga racemosa had no effect on endometrial thickness, which was significantly increased by CE. Vaginal superficial cells were increased under CE and Cimicifuga racemosa treatment. The results concerning climacteric complaints and on bone metabolism indicate an equipotent effect of Cimicifuga racemosa in comparison to 0.6 mg CE per day. It is proposed that black cohosh contains substances with SERM activity, i.e. with desired effects in the brain/hypothalamus, in the bone and in the vagina, but without exerting uterotrophic effects.

Dosage and availability
Cimicifuga racemosa is sold either by itself, or combined with other herbs and nutrients. The dosage of Cimicifuga racemosa extract used in the majority of clinical studies has  been based on the level of a key marker, 27-deoxyactein. The recommended dosage for the relief of menopausal symptoms is one tablet of 20 mg taken twice daily, or one 40 mg capsule daily, with benefits hopefully seen in one to three months.

Cimicifuga racemosa active ingredients
The root contains triterpine glycosides such as cimifugaside, 27-deoxyactein and actein.

Cimicifuga racemosa herb : What is the opinion of the medical establishment?
The field of hormone or herbal therapy during or after menopause is very complicated and there is no consensus within the medical community regarding the best option for long term therapy. The medical community seems to be shifting its viewpoint on hormone replacement. It appears that most traditional doctors now prefer using low doses of hormones for a brief period of time to treat menopausal symptoms, but prefer not to continue hormone replacement therapy indefinitely as in the past.

Cimicifuga racemosa side effects
No major side effects with Cimicifuga racemosa have been discussed in the medical literature. Mild side effects of headache, nausea, dizziness, etc have been mentioned.

Products sold over the counter and online
Cimicifuga racemosa research
Evaluation of the Botanical Authenticity and Phytochemical Profile of Cimicifuga racemosa Products by High-Performance Liquid Chromatography with Selected Ion Monitoring Liquid Chromatography-Mass Spectrometry.
J Agric Food Chem. 2006. Jiang B, Kronenberg F, Nuntanakorn P, Kennelly EJ. The Richard and Hinda Rosenthal Center for Complementary & Alternative Medicine, Department of Rehabilitation Medicine, College of Physicians & Surgeons, Columbia University, New York, New York, Department of Biological Science, Lehman College and The Graduate Center, City University of New York, Bronx, New York, and State Key Laboratory of Phytochemistry and Plant Resource in West China, Kunming Institute of Botany, The Chinese Academy of Sciences, Kunming, Yunnan, People's Republic of China.
Cimicifuga racemosa has become increasingly popular as a dietary supplement in the United States for the treatment of symptoms related to menopause, but the botanical authenticity of most products containing Cimicifuga racemosa has not been evaluated, nor is manufacturing highly regulated in the United States. In this study, 11 Cimicifuga racemosa products were analyzed for triterpene glycosides, phenolic constituents, and formononetin by high-performance liquid chromatography-photodiode array detection and a new selected ion monitoring liquid chromatography-mass spectrometry method. Three of the 11 products were found to contain the marker compound cimifugin and not cimiracemoside C, thereby indicating that these plants contain Asian Actaea instead of Cimicifuga racemosa. One product contained both Cimicifuga racemosa and an Asian Actaea species. For the products containing only Cimicifuga racemosa, there was significant product-to-product variability in the amounts of the selected triterpene glycosides and phenolic constituents, and as expected, no formononetin was detected.