Written by Jianping Liu, Xun Li and the CAM-Cancer Consortium.
Updated March 9, 2017

Black cohosh (Actaea racemosa)

What is it?


Black cohosh (Actaea racemosa, synonym: Cimicifuga racemosa) is a medicinal plant originating from eastern North America. Black cohosh products are commercially available on the market such as Remifemin® (manufactured by Schaper & Brümmer, Salzgitter, Germany) which is an isopropanolic extract of black cohosh standardised to contain 1 mg of triterpenes per 20 mg of extract 1. Another standardised ethanolic extract of black cohosh is BNO 1055 (Menofem®/Klimadynon®), BIONORICA, Neumarkt, Germany) 2.


The characteristic chemical constituents of the roots and rhizomes of black cohosh include cycloartenol-type triterpenoids and cimicifugoside, as well as cinnamic acid derivatives 3.

Application and dosage

Black cohosh is a dietary supplement, usually available as tablets. The commonly used dosage for black cohosh is 40 to 80 mg of dried rhizome (root) daily.


Black cohosh has been used by native American Indians and Europeans for women’s conditions such as chronic ovaritis and amenorrhea 4. It was first listed in the U.S. Pharmacopoeia in 1830 under the name “black snakeroot” 5. It has been widely used for more than 40 years in Europe and was introduced in Germany in the 1940s for the treatment of menopausal discomfort, dysmenorrhoea, and climacteric neurovegetative complaints. More recently, black cohosh has been used as a therapy for menopausal symptoms such as hot flushes.

Claims of efficacy and alleged indications

Systemic breast cancer treatment can cause premature menopause, which results in hot flushes before the physiological menopause. Hot flushes are also the main adverse effect of the common anti-breast cancer treatment tamoxifen. Hormone replacement therapy (HRT) for hot flushes in breast cancer patients may not be appropriate because of evidence of a relationship between long-term use of HRT and increased risk of breast cancer and cardiovascular disease 6, and potential stimulation of cancer growth by HRT 7. There is therefore an increasing interest in finding safe and effective alternatives to HRT for the treatment of menopausal symptoms in breast cancer patients. Herbal preparations such as black cohosh are used as alternatives to HRT in the treatment of hot flushes 8.

Mechanism of action

The mechanism of action was proposed as being mediated by an inhibitory effect on the hypothalamus, or an effect on neurotransmitters 9, or a possible oestrogenic effect from the phyto-oestrogens 10.

A systematic review including 21 pre-clinical studies concluded that there is a potential antiproliferative effect on breast and prostate tumour cells as well as a theoretical beneficial use in prostate cancer patients.[14] This is, however, not likely to be due to an estrogenic component of the herb as preclinical studies consistently conclude a lack of specific estrogenic activity. The antiproliferative effects, which are observed in in vitro and/or in vivo models for both breast and prostate cancer, are likely to be causally impacted by the favourable disruption of anti/pro-apoptotic cellular machinery.

An in vitro study investigating 9 herbal extracts and 23 isoflavonoids found strong inhibitory effect in extract of black cohosh on breast cancer resistance protein-mediated transport of methotrexate 15. One animal study found that black cohosh presented some beneficial effect for breast cancer prevention and therapy, such as downregulating mitochondrial oxidative phosphorylation genes, but these findings were not consistent 16. Another recent animal study found chemopreventive potentials for mammary cancer, as black cohosh was found reduce Ki-67 and cyclin D1 protein expression in fibroadenomas by immunohistochemistry 17.

Prevalence of use

Specific prevalence data for the use of black cohosh by cancer patients are not available.

Legal issues

In most European countries and the US, plant-based preparations including herbal remedies are regulated as dietary supplements. However, the European Directive on traditional herbal medicinal products allows herbal medicines to be registered as drugs if they have been used medicinally for at least 30 years (including at least 15 years within EU countries) 11. Black cohosh has been granted a traditional herbal registration by the Medicines and Healthcare products Regulatory Agency for the relief of symptoms of the menopause, such as hot flushes, night sweats, and temporary changes in mood 12.

Cost(s) and expenditure

The average monthly cost of e.g. Remifemin is about US$20 or EUR11.


Jianping Liu, Xun Li, CAM-Cancer Consortium. Black cohosh (Actaea racemosa) [online document]. http://cam-cancer.org/The-Summaries/Herbal-products/Black-cohosh-Actaea-racemosa. March 9, 2017.

Document history

Most recent update in March 2017 by Barbara Wider.
Assessed as up to date in September 2013 by Barbara Wider.
Update and revision in June 2012 by Jianping Liu, Xun Li and Guoyan Yang.
Fully revised and updated in August 2009 by Jianping Liu and Xun Li.
Summary first published in March 2006, authored by Jianping Liu. 


  1. Piersen CE. Phytoestrogens in botanical dietary supplements: implications for cancer. Integr Cancer Ther 2003; 2(2): 120-38.
  2. Popp M, Schenk R, Abel G. Cultivation of Cimicifuga racemosa (L.) nuttal and quality of CR extract BNO 1055. Maturitas 2003; 44 (Suppl 1):S1-7.
  3. Mahady GB, Fabricant D, Chadwick LR, Dietz B. Black cohosh: an alternative therapy for menopause? Nutr Clin Care 2002;5(6):283-9
  4. Anonymous. Cimicifuga racemosa. Monograph. Alternative Medicine Review 2003; 8(2):186-9.
  5. Blumenthal M, ed. Herbal Medicine: Expanded Commission E Monograph. 1st ed. Newton, Mass: Integrative Medicine Communications; 2000.
  6. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J; Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-33.
  7. Schairer C, Lubin J, Troisi R, Sturgeon S, Brinton L, Hoover R. Menopausal estrogen and estrogen-progestin replacement therapy and breast cancer risk. JAMA. 2000;283(4):485-91.
  8. Graf MC, Geller PA. Treating hot flushes in breast cancer survivors: a review of alternative treatments to hormone replacement therapy. Clin J Oncol Nurs 2003;7(6):637-40.
  9. Einer-Jensen N, Zhao J, Andersen KP, Kristoffersen K. Cimicifuga and Melbrosia lack oestrogenic effects in mice and rats. Maturitas 1996;25:149-53.
  10. Kruse SO, Lohning A, Pauli GF, Winterhoff H, Nahrstedt A. Fukiic and piscidic acid esters from the rhizome of Cimicifuga racemosa and the in vitro estrogenic activity of fukinolic acid. Planta Med 1999; 65(8):763-4.
  11. De Smet P. Herbal medicine in Europe – relaxing regulatory standards. N Engl J Med 2005;352:1176-8.
  12. Medicines and Healthcare products Regulatory Agency. Guidance: Herbal Medicines Granted a Traditional Herbal Registration (THR), updated 7th March 2017. Available at: https://www.gov.uk/government/publications/herbal-medicines-granted-a-traditional-herbal-registration-thr/herbal-medicines-granted-a-traditional-herbal-registration, accessed 9th March 2017.
  13. Fritz H, Seely D, McGowan J, Skidmore B, Fernandes R, Kennedy DA, Cooley K, Wong R, Sagar S, Balneaves LG, Fergusson D. Black cohosh and breast cancer: a systematic review. Integr Cancer Ther. 2014;13(1):12-29.
  14. 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.
  15. Tamaki H, Satoh H, Hori S, Ohtani H, Sawada Y. Inhibitory effects of herbal extracts on breast cancer resistance protein (BCRP) and structure-inhibitory potency relationship of isoflavonoids. Drug Metab Pharmacokinet. 2010;25(2):170-9.
  16. Einbond LS, Soffritti M, Esposti DD, Wu HA, Tibaldi E, Lauriola M, He K, Park T, Su T, Huggins L, Wang X, Roller M, Brennan R. Pharmacological mechanisms of black cohosh in Sprague-Dawley rats. Fitoterapia. 2012 Apr;83(3):461-8.
  17. Einbond LS, Soffritti M, Degli Esposti D, Tibaldi E, Lauriola M, Bua L, He K, Genovese G, Su T, Huggins L, Wang X, Roller M, Wu HA. Chemopreventive potential of black cohosh on breast cancer in Sprague-Dawley rats. Anticancer Res. 2012;32(1):21-30.
  18. Zava DT, Dollbaum CM, Blen M. Estrogen and progestin bioactivity of foods, herbs, and spices. Proc Soc Exp Biol Med 1998;217:369-78.
  19. Wu XS. Remifemin improve gynecological malignant tumor postoperative patients of menopause syndrome for the clinical research. Dissertation for Master Degree of Dalian Medical University 2011; 1-20.
  20. Huang XF. The clinical research of Black cohosh extract in breast cancer patients with climacteric complaints. Dissertation for Master Degree of Manjing University of Chinese Medicine 2011;10-21.
  21. Borrelli F. Ernst E. Black cohosh (Cimicifuga racemosa): a systematic review of adverse events. American Journal of Obstetrics & Gynecology 2008;199(5):455-66.
  22. Huntley A. The safety of black cohosh (Actaea racemosa, Cimicifuga racemosa). Expert Opin Drug Saf 2004; 3(6):615-23.
  23. Ross SM. Menopause: a standardized isopropanolic black cohosh extract (remifemin) is found to be safe and effective for menopausal symptoms. Holist Nurs Pract. 2012;26(1):58-61.
  24. Bai WP, Wang SY, Liu JL, Geng L, Hu LN, Zhang ZL, Chen SL, Zheng SR. Efficacy and safety of remifemin compared to tibolone for controlling of perimenopausal symptoms. Chinese Journal of Obstetrics and Gynecology 2009;44(8): 597-600.
  25. Li YL, Cui MH, Gao S. Efficacy of remifemin for control of climacteric symptoms. Progress in Obstetrics and Gynecology 2011;20(6): 462-65.
  26. Sun NX, Jin ZJ, Jia XF, Li W. Black cohosh improves vaginal atrophy in postmenopausal women. Academic Journal of Second Military Medical University 2012;33(3): 339-42.
  27. Mahady GB. Low Dog T. Barrett ML. Chavez ML. Gardiner P. Ko R. Marles RJ. Pellicore LS. Giancaspro GI. Sarma DN. United States Pharmacopeia review of the black cohosh case reports of hepatotoxicity. Menopause 2008;15(4 Pt 1):628-38.
  28. Naser B, Schnitker J, Minkin MJ, de Arriba SG, Nolte KU, Osmers R. Schaper & Brümmer GmbH & Co. KG, Salzgitter, Germany. Suspected black cohosh hepatotoxicity: no evidence by meta-analysis of randomized controlled clinical trials for isopropanolic black cohosh extract. Menopause. 2011;18(4):366-75.
  29. Teschke R, Schwarzenboeck A, Schmidt-Taenzer W, Wolff A, Hennermann KH. Herb induced liver injury presumably caused by black cohosh: a survey of initially purported cases and herbal quality specifications. Ann Hepatol. 2011;10(3):249-59.
  30. Teschke R, Schmidt-Taenzer W, Wolff A. Spontaneous reports of assumed herbal hepatotoxicity by black cohosh: is the liver-unspecific Naranjo scale precise enough to ascertain causality? Pharmacoepidemiol Drug Saf. 2011;20(6):567-82.
  31. Firenzuoli F, Gori L, Roberti di Sarsina P. Black cohosh Hepatic Safety: Follow-Up of 107 Patients Consuming a Special Cimicifuga racemosa rhizome Herbal Extract and Review of Literature. Evid Based Complement Alternat Med. 2011;2011:821392.
  32. Huang Y, Jiang B, Nuntanakorn P, Kennelly EJ, Shord S, Lawal TO, Mahady GB. Fukinolic acid derivatives and triterpene glycosides from black cohosh inhibit CYP isozymes, but are not cytotoxic to Hep-G2 cells in vitro. Curr Drug Saf. 2010;5(2):118-24.
  33. Teschke R. Black cohosh and suspected hepatotoxicity: inconsistencies, confounding variables, and prospective use of a diagnostic causality algorithm. A critical review. Menopause. 2010;17(2):426-40.
  34. Teschke R, Bahre R, Fuchs J, Wolff A. Black cohosh hepatotoxicity: quantitative causality evaluation in nine suspected cases. Menopause. 2009;16(5):956-65.
  35. Teschke R, Bahre R, Genthner A, Fuchs J, Schmidt-Taenzer W, Wolff A. Suspected black cohosh hepatotoxicity--challenges and pitfalls of causality assessment. Maturitas. 2009;63(4):302-14.
  36. Teschke R, Schwarzenboeck A. Suspected hepatotoxicity by Cimicifugae racemosae rhizoma (black cohosh, root): critical analysis and structured causality assessment. Phytomedicine. 2009;16(1):72-84.
  37. Rockwell S, Liu Y, Higgins SA. Alteration of the effects of cancer therapy agents on breast cancer cells by the herbal medicine black cohosh. Breast Cancer Res Treat. 2005;90(3):233-9.