Black Cohosh
HerbalAlso called · 8 names▾▴
black snakeroot, macrotys, bugbane, bugwort, rattleroot, rattleweed, Actaea racemosa, Cimicifuga racemosa
Herbal supplement (menopause symptoms)
Herbs and supplements are not FDA-approved before sale. About these sources
- Powder
- Liquid extract
- Capsule/tablet
Research strength: 1 / 5
According to NIH ODS, the American Herbal Products Association recommends that pregnant women not take black cohosh except under health professional supervision because pregnancy use has not been rigorously studied. The EMA's 2018 monograph does not recommend use during pregnancy because data are insufficient. EMA also says people who could become pregnant should consider effective contraception during treatment. The 2016 report describes black-cohosh use during labor at 38 weeks, not early pregnancy outcomes. NCCIH also cautions about pregnancy use. Ask your provider about your situation.
Last reviewed: 2026-10-16
Sources
- NIH Office of Dietary Supplements: Black CohoshUS government
- European Medicines Agency: EU herbal monograph on Cimicifuga racemosaEU agencyEuropean guidance
- NCCIH: Black CohoshUS government
- Blitz et al., 2016 labor case reportUS government
- Memorial Sloan Kettering Cancer Center: Black Cohosh
Research strength: 1 / 5
According to NIH ODS, the American Herbal Products Association recommends that pregnant women not take black cohosh except under health professional supervision because pregnancy use has not been rigorously studied. The EMA's 2018 monograph does not recommend use during pregnancy because data are insufficient. EMA also says people who could become pregnant should consider effective contraception during treatment. The 2016 report describes black-cohosh use during labor at 38 weeks, not second-trimester outcomes. NCCIH also cautions about pregnancy use. Ask your provider about your situation.
Last reviewed: 2026-10-16
Sources
- NIH Office of Dietary Supplements: Black CohoshUS government
- European Medicines Agency: EU herbal monograph on Cimicifuga racemosaEU agencyEuropean guidance
- NCCIH: Black CohoshUS government
- Blitz et al., 2016 labor case reportUS government
- Memorial Sloan Kettering Cancer Center: Black Cohosh
Research strength: 2 / 5
According to NIH ODS, the American Herbal Products Association recommends that pregnant women not take black cohosh except under health professional supervision because pregnancy use has not been rigorously studied. The EMA's 2018 monograph does not recommend use during pregnancy because data are insufficient, and says people who could become pregnant should consider effective contraception during treatment. A 2016 report described a 39-year-old at 38 weeks 5 days who took several doses to induce and augment labor and developed severe low blood sodium, 114 mmol/L. The authors said the cause was uncertain and could be multifactorial; dose and preparation were unknown. Memorial Sloan Kettering also summarizes this maternal case. Ask your provider about your situation.
Last reviewed: 2026-10-16
Sources
- NIH Office of Dietary Supplements: Black CohoshUS government
- European Medicines Agency: EU herbal monograph on Cimicifuga racemosaEU agencyEuropean guidance
- NCCIH: Black CohoshUS government
- Blitz et al., 2016 labor case reportUS government
- Memorial Sloan Kettering Cancer Center: Black Cohosh
Black Cohosh — Breastfeeding
Research strength: 1 / 5
LactMed reports no data on black cohosh use in nursing mothers or infants and no published milk levels, infant levels, or infant effects in its 2021 revision. LactMed says some sources advise against use because data are missing and estrogenic activity was a concern, while others do not contraindicate it. EMA does not recommend use while breastfeeding because safety has not been established, and NCCIH also cautions about use. LactMed notes that later studies found no estrogenic activity, but a 2007 study measured markers in postmenopausal women, not nursing families. The sources reviewed do not report a measured infant outcome from use through milk, and their advice differs because evidence is limited. Ask your provider about your situation.
Last reviewed: 2026-10-16
Pregnancy
NIH ODS reports that the American Herbal Products Association recommends against pregnancy use except under health professional supervision because it has not been rigorously studied. EMA's 2018 monograph says pregnancy safety is not established and use is not recommended for insufficient data; women of childbearing potential should consider effective contraception during treatment. Dugoua et al. (2006) searched seven databases and described pregnancy concerns as low-level, based on theory and expert opinion. The open-access 2016 Blitz case report describes a 39-year-old primigravida at 38 weeks 5 days who took several doses to induce and augment labor and developed severe hyponatremia, with serum sodium of 114 mmol/L. The authors said causality was uncertain and possibly multifactorial, and the exact dose and preparation were unknown. Memorial Sloan Kettering independently summarizes this maternal labor case, and a 2019 systematic review cites the report. These are case and review findings, not a measured risk rate. The NTP's 2023 animal study included perinatal exposure in rats; this is not human pregnancy evidence.
Breastfeeding
LactMed's entry, last revised May 17, 2021, says there are no data on use in nursing mothers or infants and no published information on maternal levels, infant levels, infant effects, or effects on lactation and breastmilk. It reports that some sources recommend against use because of missing safety data and possible estrogenic activity, while other sources do not contraindicate it. EMA says lactation safety is not established and use is not recommended because data are insufficient; NCCIH also cautions about breastfeeding. LactMed notes that recent studies found no estrogenic activity. Ruhlen et al. (2007) studied serum and breast estrogen markers in postmenopausal women using an extract and found no measured estrogenic effect; that study does not measure milk levels or infant outcomes. Dugoua et al. (2006) described lactation concerns as low-level and based on theory and expert opinion, and called for high-quality human studies.
Black cohosh is made from the plant's root and rhizome. NIH ODS describes powdered whole herb, liquid extracts, and dried extracts in pill form. ODS says preparations vary considerably in chemical composition and the active compounds responsible for any effect are not known. LactMed says supplements can contain multiple ingredients and labeled and actual ingredients may differ, so results from one product may not apply to another. Ruhlen et al. found that triterpene content varied between commercial preparations.
What was tested
The 2006 Dugoua review searched seven electronic databases and assessed pregnancy and lactation evidence; its concerns were based on theory and expert opinion rather than high-quality human outcome studies. The 2016 Blitz report is one term-labor case, not a controlled study; it reports several doses but no exact dose or preparation. The 2019 systematic review of herbal products during pregnancy cites the Blitz report but does not provide a black-cohosh-specific rate. NTP Study TR-603 conducted long-term studies in rats and female mice and included perinatal exposure in rats; these are animal data. LactMed reports no published black-cohosh milk or infant levels or infant effects.
Liver injury reports and causality
- Source A says
- EMA's 2018 monograph lists liver toxicity, including hepatitis, jaundice, and abnormal liver tests, as associated with Cimicifuga products, with frequency unknown. EMA's 2025 review says hepatotoxicity should continue to be closely monitored. (European Medicines Agency: EU herbal monograph on Cimicifuga racemosa, liver section, EMA/HMPC final addendum and PRAC review, PSUSA/00000755/202301)
- Source B says
- NIH ODS and NCCIH report liver injury cases involving products labeled as black cohosh but say the cause has not been established or is uncertain. USP's 2008 review assessed 30 nonduplicate reports, all rated possible and none probable or certain. Teschke et al. found no causality by the CIOMS liver-specific method in the cases they assessed. (NIH Office of Dietary Supplements: Black Cohosh Health Professional Fact Sheet, liver section, National Center for Complementary and Integrative Health: Black Cohosh, Mahady et al., United States Pharmacopeia review of black cohosh case reports, Teschke et al., Herb-induced liver injury presumably caused by black cohosh)
- Why they differ
- Regulators retain a precaution and monitoring response to reported cases, while case reviews question attribution because many reports lack complete data and product identity or ingredients may vary.
- What the evidence shows overall
- The sources support describing liver injury as a potential concern for products sold as black cohosh while making clear that causation and frequency are not established. EMA's current monitoring action remains relevant; the case reviews do not prove that liver injury cannot occur.
Breastfeeding advice when direct evidence is missing
- Source A says
- EMA does not recommend use during lactation because safety has not been established and data are insufficient. NCCIH cautions about use, and LactMed reports that some sources advise against it. (European Medicines Agency: EU herbal monograph on Cimicifuga racemosa, National Center for Complementary and Integrative Health: Black Cohosh, LactMed: Black Cohosh, source disagreement section)
- Source B says
- LactMed reports that other sources do not contraindicate use and that recent studies found no estrogenic activity. The estrogen-marker studies it cites were not breastfeeding studies. (LactMed: Black Cohosh, source disagreement section, Ruhlen et al., Black cohosh does not exert an estrogenic effect on the breast)
- Why they differ
- The sources agree that direct breastfeeding data are missing but weigh precaution differently. Older concern about estrogenic activity is also weighed against later studies of different extracts and populations.
- What the evidence shows overall
- The evidence gap and difference in advice should both be stated. A postmenopausal estrogen-marker study does not establish milk transfer, infant effects, or breastfeeding outcomes.
- NIH ODS says the American Herbal Products Association recommends that pregnant women not take black cohosh except under health professional supervision because pregnancy use has not been rigorously evaluated. (NIH Office of Dietary Supplements)
- EMA says pregnancy and lactation use is not recommended because data are insufficient, and women of childbearing potential should consider effective contraception during treatment. (European Medicines Agency)
- NIH ODS reports that USP recommended stopping use and consulting a healthcare practitioner for a liver disorder or symptoms such as abdominal pain, dark urine, or jaundice. ODS says FDA does not require this warning on black-cohosh product labels. (NIH Office of Dietary Supplements)
- EMA says people with a history of liver disorder should use Cimicifuga preparations with caution and should stop use and consult a doctor if signs of liver injury appear. (European Medicines Agency)
General research, not specific to pregnancy.
NIH ODS and NCCIH describe liver injury cases associated with products labeled as black cohosh, but say causation is uncertain. USP's 2008 review assessed 30 nonduplicate reports and rated all as possible, with none probable or certain; USP recommended a liver caution for products. ODS says FDA does not require that caution on U.S. product labels. EMA's 2018 monograph lists liver toxicity with frequency unknown, and its final 2025 review says hepatotoxicity should continue to be closely monitored while marketing authorisations remain unchanged.
- EMA lists liver toxicity, including hepatitis, jaundice, and changes in liver tests, as associated with Cimicifuga products; frequency is unknown. (European Medicines Agency: EU herbal monograph on Cimicifuga racemosa, liver section)
- NIH ODS quotes the USP caution to stop use and consult a practitioner for a liver disorder or symptoms such as abdominal pain, dark urine, or jaundice. ODS says FDA does not require this warning on U.S. black-cohosh labels. (NIH Office of Dietary Supplements: Black Cohosh Health Professional Fact Sheet, liver section)
- The USP committee review analyzed 30 nonduplicate reports of liver damage; all were assigned possible causality and none probable or certain. (Mahady et al., United States Pharmacopeia review of black cohosh case reports)
- The final EMA/HMPC review of PSUSA/00000755/202301 left the risk-benefit balance unchanged, recommended maintaining marketing authorisations, and said hepatotoxicity should remain closely monitored. (EMA/HMPC final addendum and PRAC review, PSUSA/00000755/202301)
- Teschke et al. assessed published and spontaneous reports and found a lack of causality by the CIOMS method in the cases they reviewed. (Teschke et al., Herb-induced liver injury presumably caused by black cohosh)
- NIH Office of Dietary Supplements: Black Cohosh Health Professional Fact SheetUS governmentSecondaryPage dated 2020-06-03Independent check
- LactMed: Black CohoshUS governmentSecondaryPage dated 2021-05-17Independent check
- National Center for Complementary and Integrative Health: Black CohoshUS governmentSecondary
- European Medicines Agency: EU herbal monograph on Cimicifuga racemosaEU agencySecondaryPage dated 2018-03-27Independent checkEuropean guidance
- EMA/HMPC final addendum and PRAC review, PSUSA/00000755/202301EU agencySecondaryPage dated 2025-11-19Independent checkEuropean guidance
- Dugoua et al., Safety and efficacy of black cohosh during pregnancy and lactationUS governmentPrimaryPage dated 2006-11-03Independent check
- Blitz et al., Severe Hyponatremia Associated with Use of Black Cohosh during Prolonged Labor and Unsuccessful Home BirthUS governmentPrimary
- Memorial Sloan Kettering Cancer Center: Black CohoshSecondaryIndependent check
- Muñoz Balbontín et al., Herbal Medicinal Product Use During Pregnancy and the Postnatal Period: A Systematic ReviewUS governmentPrimaryPage dated 2019-04-09Independent check
- Ruhlen et al., Black cohosh does not exert an estrogenic effect on the breastUS governmentPrimaryIndependent check
- National Toxicology Program Study TR-603US governmentPrimary
- Mahady et al., United States Pharmacopeia review of black cohosh case reportsUS governmentPrimaryIndependent check
- Teschke et al., Herb-induced liver injury presumably caused by black cohoshUS governmentPrimaryIndependent check
Last reviewed 2026-10-16
Independent check 2026-10-16
Not yet clinician-reviewed
Ask your provider about your situation.
Related
- Red Clover
- Dong Quai