Lydia Pinkham’s Vegetable Compound was introduced in the United States in 1876 for menstrual cramps. The main herbal component of the vegetable compound is black cohosh (of course it also contains 18% alcohol). Black cohosh appears to be making somewhat of a comeback as women seek alternatives to conventional hormone replacement therapy. Black cohosh (Cimicifuga racemosa), also known by a variety of common names, such as blacksnake root, squaw root, rich weed and fairy candles, has been used in both traditional Native American medicine and by Chinese herbalists. The German Commission E has a black cohosh extract on its approved non-prescription drug list for "premenstrual discomfort, dysmenorrhea or climacteric neurovegetative ailments." Remifemin, the most commonly used brand of black cohosh in Germany, is standardized to its triterpene glycoside content. Each tablet contains 1mg of 27-deoxyactein, one of four identified triterpenes in black cohosh.¹The mechanism of action of black cohosh has remained somewhat elusive. Studies in oophorectomized rats demonstrated a selective reduction in luteinizing hormone without affecting either follicular stimulating hormone or prolactin levels. This selectivity was traced to an isoflavone which was demonstrated to bind to estrogen receptors. Further investigation led to the conclusion that the isoflavone was a contaminant due to the addition of other similar-looking herbs.² Later studies with a purer extract demonstrated a selective suppression of LH secretion along with an estrogenic effect.³ Subsequent investigations have demonstrated estrogenic activity⁴, no estrogenic activity⁵ and virtually no hormonal activity⁶ associated with black cohosh administration. Regardless of the underlying mechanism, black cohosh appears to offer short-term relief from the symptoms of menopause. Several studies published in the German literature have demonstrated improvement in symptoms for up to 12 weeks using a standardized black cohosh preparation (Remifemin). Liske and colleagues demonstrated up to a 6-month improvement in menopausal symptoms in a randomized placebo controlled study. Interestingly, the authors could not demonstrate any effect of black cohosh on levels of FSH, LH, sex hormone binding globulin, prolactin, estradiol, or vaginal cell proliferation.²

In usual doses, black cohosh appears to be relatively free of side effects. Gastrointestinal side effects occur in small numbers of patients.⁷ Black cohosh should not be consumed by pregnant or lactating women.Black cohosh has gained its recent popularity as a "natural" alternative to conjugated estrogens. Although the exact mechanism of action of the product has not been fully elucidated, it can be assumed to have estrogenic properties based on its relief of menopausal symptoms. Despite its status as a "natural" product, the same provisos as with any estrogenic drug should be considered in recommending its use. The risk of unopposed estrogen in women with an intact uterus and those at risk for breast cancer presumably holds true for black cohosh. References:

1. Pepping J. Alternative Medicines, Black cohosh: cimicifuga racemosa. Am J Health-Syst Pharm 1999;56:1400-1402.
2. Liske E. Therapeutic efficacy and safety of Cimicifuga racemosa for gynecologic disorders. Adv Ther 1998;15(1):45-53.
3. Duker EM, Kopanski L, Jarry H et al. Effects of extracts for Cimicifuga racemosa on gonadotropin release in menopausal women and ovariectomized rats. Planta Med 1991;57:420-4.
4. Eagon P, Tress N, Ayer H et al. Medicinal botanicals with hormonal activity. Proc Am Assoc Cancer Res 1999;40, Abstract.
5. Einer Jones N, Zhao J, Andersen K et al. Cimicifuga and Melbrosia lack estrogenic effects in mice and rats. Maturitas 1996:25:149-53.
6. Liske E, Wustenberg P. Therapy of climacteric complaints with Cimicifuga racemosa: herbal medicine with clinically proven evidence. Menopause 1998;5:250.
7. Stolze H. An alternative to treat menopausal complaints. Gyne 1982;3:14-16.