Hormone replacement therapy not recommended
Hormone replacement therapy (HRT), heavily touted in the 1990’s as the answer to hot flashes, is now not recommended for hot flashes or other menopausal symptoms due to an increased risk of strokes, heart attacks, blood clots and breast cancer. These dangerous side effects of HRT were the findings of the Women’s Health Initiative, involving over 16,000 women.

Black Cohosh
For women suffering from menopausal hot flashes and looking for an alternative to HRT, black cohosh, may offer relief. Black cohosh is a traditional remedy among Native Americans used for gynecological conditions including menstrual pain. It has been approved for use by the German Expert panel, commission E, for hot flashes and other menopausal symptoms such as night sweats, anxiety, vaginal dryness, and heart palpitations. There are many studies showing that black cohosh is helpful in relieving the symptoms associated with menopause including hot flashes:

• Hot flashes were reduced from 4.9 to 0.7 times per day during 12 weeks of use.
• Black cohosh was as effective as low dose transdermal HRT (HRT skin patches) in relieving hot flashes and emotional symptoms, particularly anxiety and depression.
• Women with a shorter history of hot flashes (less than 3 years) were more likely to benefit from black cohosh than those with symptoms greater than 3 years.

Mechanism of action
Although, the actual mechanism by which black cohosh works is unclear, it may be due to an estrogen-balancing effect. Black cohosh was thought to work by binding and activating estrogen receptors but more recent studies show that this binding to receptors produces little if any estrogenic effect and may actually block some of these effects.

During menopause as estrogen and progesterone levels drop the pituitary land secretes more of lutenizing hormone (LH) which is believed to be one of the causes of hot flashes and menopausal symptoms. An earlier study suggested black cohosh decreased LH levels, however more recent studies demonstrated no change in LH, follicle stimulating hormone (FSH) or prolactin levels.

Dosage
Most studies demonstrated effectiveness using 40 milligrams of standardized extract per day. Commercial brands of black cohosh that have shown efficacy in clinical trials include Remifemin® and Klimadynon®, both of which are imported from Germany.

Side effects/ Safety
Studies have established that black cohosh is generally safe to use at recommended dosages and for periods of up to 6 months. Longer term safety studies have not been done. Side effects are generally seen at higher doses and include headaches and dizziness.

• Potential Liver Toxicity There has been several case reports of liver failure associated with black cohosh use. Although liver toxicity has not been confirmed in any larger study, patients with liver disease, should consult with a physician before use.
• Cancer Safety Issues. In animal studies, black cohosh did not stimulate growth of estrogen-receptor positive breast cancer tumors. In fact, black cohosh has shown to induce cell death in estrogen-receptor positive and negative breast cancer cell lines. Although these and other studies suggest that black cohosh is a safe, natural remedy for women with a history of breast cancer, patients are advised to consult their physician before use.
• Pregnancy and Breast Feeding Do not use during pregnancy or breast feeding as safety has not been established.