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Despite lack of scientific support, black cohosh is commonly purported to relieve menopausal symptoms. As part of the Hormonal Alternatives for Menopause (HALT) study (Journal Watch Women’s Health Feb 1 2007), investigators randomized symptomatic peri- or postmenopausal women to one of five standardized treatments for 1 year: black cohosh, multibotanical (black cohosh plus other herbs), multibotanical plus dietary counseling regarding soy, hormone therapy (0.625 mg estrogen with 2.5 mg medroxyprogesterone acetate or, for women without uteri, estrogen only), or placebo. Vaginal estrogen response was evaluated by microscopic examination of vaginal smears for maturation index at 3 and 12 months; vaginal dryness was assessed subjectively with an index score. Of 351 participants, 327 (92%) completed 12 months of follow-up, and 306 (87%) maintained their assigned treatment throughout the trial.
The treatment groups were similar at baseline in age (median, 52), demographics (primarily white and well educated), previous hysterectomy (11%), previous HT (40%), and number of vasomotor symptoms per day (mean, 6.5). The HT group experienced significantly less objective and subjective vaginal atrophy at 3 and 12 months than did the herbal and placebo groups, with no difference between the herbal and placebo groups. Among 313 women with intact uteri, 53 (16.9%) experienced abnormal bleeding, with no differences between the herbal and placebo groups. Among the 129 postmenopausal women, the HT group had significantly lower follicle-stimulating–hormone levels at 12 months than did the placebo group. The groups did not differ in other hormone levels (luteinizing hormone, estradiol, and sex-hormone–binding globulin).
Reed SD et al. Vaginal, endometrial, and reproductive hormone findings: Randomized, placebo-controlled trial of black cohosh, multibotanical herbs, and dietary soy for vasomotor symptoms: The Herbal Alternatives for Menopause (HALT) Study. Menopause 2008 Jan/Feb; 15:51.
Bouchard C. Herbal alternatives as substitutes for hormone therapy in urogenital atrophy: Scientific evidence is needed. Menopause 2008 Jan/Feb; 15:12.
Comment
Since the initial Women’s Health Initiative findings were published in 2002, fewer menopausal women are using HT, and symptomatic genital atrophy is probably becoming more prevalent. The lack of vaginal-estrogen responses, bleeding-pattern alterations, and serum-hormone responses in women using black cohosh demonstrates that this product does not have estrogenic activity. An editorialist advises clinicians to explain to women that “a natural product such as black cohosh is . . . not very effective” for urogenital atrophy, although we should not be surprised if some women ignore this advice. Clinicians can proactively ask their menopausal patients whether they have vaginal dryness or discomfort with sex and can offer vaginal estrogen — an effective treatment — when indicated.