Traditional North American herb with strong evidence for menopausal symptoms, particularly hot flashes. Comparable to low-dose HRT in trials, with favorable cardiovascular effects and no reproductive tissue risks.
Traditions: Native American, Eclectic medicine, Western herbalism (modern)
Multiple traditions agree on use.
Approved for climacteric (menopausal) neurovegetative ailments, premenstrual discomfort, and dysmenorrhea. Maximum 6 months use.
Official entries until 1926, indicating established use in early American medical practice.
Recommended 40-200mg dried herb daily in divided doses for menopausal symptoms and menstrual disorders.
Black cohosh has strong evidence for menopausal symptom relief, particularly hot flashes and somatic symptoms. Multiple meta-analyses show consistent benefits comparable to low-dose hormone therapy. Does not work for anxiety or depression specifically. More effective in women with severe symptoms.
43,759 participants across 35 studies; SMD -0.694 (p<0.0001) vs placebo. Comparable to low-dose estradiol and tibolone.
2,310 participants, 22 RCTs. Hot flashes: Hedges' g=0.315. Somatic symptoms: g=0.418. No effect on anxiety (p=0.438) or depression (p=0.131).
64 participants, 3 months. Black cohosh 40mg equivalent to low-dose transdermal estradiol for hot flashes (both p<0.001). Increased HDL (p<0.04), decreased LDL (p<0.003).
180 participants. 13mg nearly 2x effective as 6.5mg (17.0 vs 8.47 point reduction on Kupperman Index).
62 women with fibroids. iCR 40mg reduced fibroid volume -30% (p=0.016) while relieving menopausal symptoms.
Most studied preparation. Isopropanolic extract (iCR) has strongest evidence (>11,000 patients). 13mg high-potency extracts nearly 2x effective as 6.5mg.
Moderate evidence (>500 patients). May be more effective in women with severe symptoms (Kupperman Index ≥20).
Traditional preparation. Minimal clinical trial support. Variable triterpene content. Decoct (simmer) rather than steep.
Black cohosh has consistently strong evidence for physical menopausal symptoms—hot flashes, night sweats, somatic discomfort. This isn’t marginal. A meta-analysis of 43,759 participants across 35 studies found significant relief comparable to low-dose hormone replacement therapy [1].
Strong evidence (multiple meta-analyses):
Important null findings:
Black cohosh works for physical symptoms of menopause, not psychological ones. If you’re looking for mood support, this isn’t it. For that, the combination with St. John’s wort shows promise—but St. John’s wort has serious drug interactions.
Dose matters: A 180-person trial found 13mg high-potency extract nearly twice as effective as 6.5mg (17.0 vs 8.47 point reduction on symptom scale) [4]. Higher doses within studied ranges show stronger effects.
Who responds best: Women with moderate-to-severe symptoms. One trial found 47% symptom reduction in women with high baseline severity vs 21% placebo, but no difference in mild-symptom groups [5].
Unexpected benefits:
North American origin:
German Commission E approved indications (1989):
British Herbal Compendium (1992):
Etymology and historical context:
The consistency across American, German, and British traditions for women’s reproductive health—validated by modern RCTs—is notable. When regulatory bodies independently arrive at similar uses, confirmed by meta-analyses of 40,000+ participants, it’s worth paying attention.
Standardized isopropanolic extract (iCR) - Gold standard:
This is the first choice. It has the most evidence, most consistent results, pharmaceutical-grade quality.
High-potency extracts (e.g., Ze 450):
Ethanolic extract (moderate evidence):
Traditional dried herb (minimal evidence):
Week 1-12 (initial trial):
If inadequate response after 12 weeks:
Timing: Once daily is standard. May divide into twice daily for more consistent blood levels (active compounds have ~2-hour half-life).
This is not caffeine. Effects accumulate. Give it the full 12 weeks before deciding.
Evidence-based duration:
German Commission E recommendation: Maximum 6 months continuous use
Practical approach:
Baseline (1 week before starting):
During trial (weeks 1-12): Track daily or weekly. Compare:
What to expect:
What NOT to expect:
RED FLAGS - Discontinue:
What they report: “Hot flashes cut in half,” “sleeping through the night,” “feel like myself again physically.”
What they report: “Helped a little,” “not a dramatic difference,” “stopped bothering after a few months.”
Action: If non-responsive after 12 weeks at adequate dose (40-80mg standardized extract), discontinue. Consider alternatives (sage for hot flashes, vitex for perimenopausal cycling, HRT if appropriate).
The problem: Not all black cohosh products are standardized. Triterpene content varies wildly. Only pharmaceutical-grade, standardized extracts have clinical evidence.
What to look for:
Avoid:
Why it matters: The clinical evidence is on pharmaceutical-grade standardized extracts. If you use a random product without standardization, you’re not using what was studied.
Black cohosh is a solid, evidence-based option for physical menopausal symptoms—hot flashes, night sweats, somatic discomfort. It works comparably to low-dose HRT in trials, with favorable cardiovascular effects and no reproductive tissue risks.
When it works: 25-50% reduction in hot flash frequency, better sleep, reduced somatic symptoms. Most effective in women with moderate-to-severe baseline symptoms.
When it doesn’t: Mild symptoms, looking for anxiety/depression relief (wrong indication), poor-quality unstandardized products.
Safety profile: Remarkably safe. No liver toxicity in controlled trials of >1,000 patients. No weight gain. No endometrial proliferation. Reduces uterine fibroids. Improves cardiovascular markers.
Start with 40mg standardized isopropanolic extract daily, give it 12 weeks, track honestly. If it works, consider 6-month courses with 1-2 month breaks. If it doesn’t work by 12 weeks at adequate dose, move on.
This is a well-studied, safe, effective herb for a specific indication. Use it for that, not for what it doesn’t do.
Duration: Minimum 12 weeks to assess response. Safe up to 12 months. German Commission E recommends maximum 6 months continuous use; consider 1-2 month break, then resume if needed.
What to notice:
Start with 40mg standardized isopropanolic extract daily, taken with food. Effects build over 4-12 weeks - not immediate. Most effective in women with moderate-to-severe symptoms (if symptoms are mild, response may be minimal). Individual variation exists but less pronounced than adaptogens like ashwagandha. If inadequate response after 12 weeks, consider increasing to 80mg daily or trying higher-potency extract (13mg vs 6.5mg extract types show dose-response). Take once daily; may divide into twice daily (morning/evening) based on 2-hour half-life of active compounds.
Generally considered: safe
Contraindications:
Pregnancy/Nursing: Avoid during pregnancy and breastfeeding (lack of safety data in these populations). Traditional use was for dysmenorrhea in non-pregnant women.
Remarkably safe in controlled trials. Meta-analysis of 1,020 patients (3-6 months) showed no liver enzyme changes (AST p=0.37, ALT p=0.31). 12-month safety study (n=87) showed no hepatic changes. Weight gain concerns not supported by evidence (31 trials, 1,839 participants). No endometrial proliferation or estrogenic effects. Actually reduces uterine fibroid volume by 30% (beneficial, not harmful). Favorable cardiovascular effects (improves endothelial function, increases HDL, decreases LDL). Adverse event rates comparable to placebo. Discontinue if liver symptoms develop (abdominal pain, dark urine, jaundice) - this is precautionary based on rare case reports, not trial data. Not effective for anxiety or depression (only physical menopausal symptoms).