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Dr. Tori Hudson, Portland, Oregon, Blog Healthline Blog

Endometriosis is a disorder characterized by one or more of the following: pelvic pain with menstruation, pelvic pain during non-menstrual part of the cycle, pain with intercourse, pain with bowel movements, infertility women, and a change in the menstrual cycle. Conventional therapy often starts with birth control pills and pain pills but then can move on to surgery followed by oral contraceptive pills or gonadotropin-releasing hormone agonists (GnRH-a). The GnRH-a medication reduces estrogen levels, and puts the woman in at least temporary menopause, with subsequent symptoms such as hot flashes, night sweats, reduced libido, mood changes and more. Even though the medication is designed to lower estrogen, the conventional response to the onset of the menopause symptoms is to add back low doses of estrogen therapy. Herbal menopause support is however another option, and perhaps even preferred, because we are not adding back any estrogen. Black cohosh (Actaea racemosa syn. Cimicifuga racemosa, Ranunculaceae) rhizome has been shown to ameliorate menopausal symptoms in scores of studies of perimenopausal and menopausal women. Black cohosh does not have estrogenic properties.

The purpose of this prospective, randomized, controlled study was to evaluate the effect of black cohosh compared to tibolone (a synthetic steroid hormone that acts as a Selective Tissue Estrogenic Activity Regulator [STEAR]) and is used to treat perimenopausal/menopausal symptoms; not available in the U.S.)

There were 116 women, and an average age of 28.5 years old, who received GnRH-a after their endometriosis surgery. One week after laparoscopic ovarian cyst removal surgery, all patients were treated with the first GnRH-a injection and in total, received 3 injections. At the same time as the first injection, received either black cohosh standardized extract (20 mg twice daily) or tibolone (2.5 mg/day) for 12 weeks. At baseline, 4, 8, and 12 weeks after the first GnRH-a injection, menopausal symptoms were scored using the Kupperman Menopausal Index (KMI), and hot flash score was recorded.

At 4, 8, and 12 weeks after GnRH-a therapy, there were no significant differences between the black cohosh extract and tibolone groups’ KMI scores, hot flash frequency, or measures of endometrial thickness.

The levels of 17β-estradiol (E2), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) levels decreased in both groups after the GnRH-a injections. After 12 weeks of treatment, the black cohosh group had significantly lower E2 and significantly higher FSH and LH levels compared to the tibolone group. These findings indicate that black cohosh does not have an estrogen-like effect, as do other studies.

There were no adverse effects regarding liver function, renal function, or serum lipids in either group and the incidence of adverse events was significantly lower in the black cohosh group than in the tibolone group. The episodes of vaginal bleeding or spotting and breast distending pain were significantly lower in the black cohosh group than in the tibolone group.

Commentary: This study is one more positive representation of the value of black cohosh standardized extracts of 40 mg/day in the treatment of perimenopause/menopausal symptoms, even in the presence of drug induced menopause. It is also reconfirming that the black cohosh extract did not affect liver function, renal function, lipid profile, or hormonal levels, and was well-tolerated.


Chen J, Gao H, Li Q, et al. Efficacy and safety of Remifemin on peri-menopausal symptoms induced by post-operative GnRH-a therapy for endometriosis: A randomized study versus tibolone. Med Sci Monit. 2014;20:1950-1957.

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