Index of Herbs

Herbal formula

Black Cohosh and St. John’s Wort

Also known as Remifemin plus, Remifemin plus Johanniskraut, Remifemin plus St. John’s wort, iCR+HP, Traubensilberkerze und Johanniskraut, Gyno-Plus (a different Korean formulation)

A German non-hormonal menopause tablet for hot flashes with low mood, backed by one maker-funded trial and with many drug interactions.

Main use: Menopausal symptoms with low mood

Early or mixed evidence

2 ingredients

Updated October 22, 2026

Key points

  1. 01

    Two plant extracts, no hormones

    Each tablet holds 3.75 mg of black cohosh extract and 70 mg of St. John’s wort extract. It contains no estrogen or progestogen and is not hormone therapy.

  2. 02

    One positive trial, funded by the maker

    In 301 women with hot flashes and low mood, 16 weeks of the tablets beat placebo on menopause and depression scores. Schaper & Brümmer funded it, and it ran at one Berlin center.

  3. 03

    EMA accepts only traditional use

    Europe’s herbal committee judged the trials unable to prove efficacy and, in a 2025 draft monograph, accepted the combination only as a traditional remedy for mild symptoms.

  4. 04

    Full St. John’s wort interaction warnings

    It must not be taken with warfarin, ciclosporin, tacrolimus, some HIV drugs, or irinotecan, can make the pill less reliable, and with SSRIs can contribute to serotonin syndrome.

  5. 05

    Liver, breast cancer, and mood cautions

    Stop at signs of liver trouble, do not use after breast cancer without your oncology team, and get help quickly for severe depression or thoughts of suicide.

Black cohosh and St. John’s wort is a fixed-combination menopause tablet, best known as Remifemin plus. It is made by Schaper & Brümmer in Salzgitter, Germany, sold there as Remifemin plus Johanniskraut (co-marketed by MEDICE), and sold in Austria through MEDICE. Each green film-coated tablet contains 3.75 mg of a dry extract of black cohosh root and rhizome (Actaea racemosa, often still called Cimicifuga racemosa) and 70 mg of a dry extract of St. John’s wort herb (Hypericum perforatum). In Germany it is a licensed, pharmacy-only herbal medicine that does not need a prescription. Its label covers hot flashes and excessive sweating during the menopause when they come with psychological complaints such as low mood, nervousness, and irritability. It is not hormone therapy: it contains no estrogen or progestogen, and it should not be confused with the hormone treatments doctors prescribe for menopause.

The product has a long history in German-speaking countries. The European Medicines Agency’s (EMA’s) assessment report says a product with these two extracts has been sold in Germany for more than 30 years, containing both dry extracts since 1990, and in Austria since 2003. The maker’s research papers call the black cohosh extract iCR (isopropanolic Cimicifuga racemosa extract) and the combination iCR+HP. Other pairings of the two herbs exist: EMA lists traditional herbal products with different extracts registered in Austria and the United Kingdom, and a Korean product called Gyno-Plus, tested in a small 2007 trial, used different extracts again. In January 2025 EMA’s Committee on Herbal Medicinal Products (HMPC) released a draft European Union monograph for the Remifemin plus extract pair. It accepted the combination only as a traditional herbal medicine for mild menopausal complaints, not on the strength of its clinical trials.

The rationale is simple: black cohosh is the most studied herbal remedy for hot flashes, and St. John’s wort is the best-studied herb for mild to moderate depression, so combining them is meant to cover both physical and emotional menopause symptoms. The German prescribing information states that neither the mechanism nor the constituents responsible for the effect are sufficiently known. This page covers what is in the tablets, what the trials of this combination found and who paid for them, how it is labeled to be taken, and how to use it safely, especially the St. John’s wort drug interactions and the black cohosh liver warning. Results described here belong to this specific extract pair, not to every product that contains the two herbs. Nothing here is medical advice. Low mood that is severe, lasting, or accompanied by thoughts of self-harm needs professional care, not a menopause tablet.

See also

Herbs for Menopause and Hot Flashes Herbs for Low Mood and Depression

02 The blend

What’s in it

Ingredients in label order. Results from trials of this formula belong to the combination, not to any single herb in it.

  1. Black cohosh · Root and rhizome, dry extract

    3.75 mg dry extract per tablet (6–11:1, 40% isopropanol)

    Actaea racemosa

    The isopropanol extract used in Remifemin, the maker’s single-herb product, often called iCR in its research. The trial paper says each tablet corresponds to 22.5–41.25 mg of root and rhizome. The labeled 15 mg a day for the first eight weeks, and 7.5 mg after that, is above the 5 mg daily dose in EMA’s black cohosh monograph, a point EMA’s assessors noted. Black cohosh is the source of the product’s liver warning.

    Read the black cohosh monograph →

  2. St. John’s wort · Flowering herb, dry extract

    70 mg dry extract per tablet (3.5–6:1, 60% ethanol)

    Hypericum perforatum

    At 140–280 mg a day, far below the 500–1,200 mg daily dose EMA accepts for a similar ethanol extract in mild depression, so the tablets are not a full antidepressant dose. The trial paper gives 0.25 mg of total hypericin per tablet. The hyperforin content, which drives drug interactions, is not declared, and the leaflet carries the standard St. John’s wort interaction warnings.

    Read the st. john’s wort monograph →

03 Evidence

What the research shows

Early or mixed evidence

Our rating for menopausal symptoms with low mood, based on trials of this combination.

The main evidence is a single randomized controlled trial. Uebelhack and colleagues (Obstetrics and Gynecology 2006) randomly assigned 301 women aged 45 to 60, with menopausal complaints that had a pronounced psychological component, to the tablets or a matching placebo (dummy pill) for 16 weeks. Women took two tablets twice a day for eight weeks, then one tablet twice a day, the dose still on the label. To enter, they needed a score of 15 to 23 on the 17-item Hamilton Depression Rating Scale (HAMD), a clinician-rated depression scale. The overall Menopause Rating Scale (MRS) score fell by 50% with the tablets and 19.6% with placebo. The HAMD score fell from 18.9 to 11.0 points (41.8%) with the tablets and from 18.9 to 16.5 (12.7%) with placebo, a difference of 5.6 points (95% confidence interval 4.6–6.5). Both results were highly significant, and the hot flash factor of the MRS fell by 53.4% against 25.4%. Adverse events were similar in the two groups, and 2 of 151 women on the tablets and 9 of 150 on placebo left the study early.

The trial has important limits. It was supported by an unrestricted grant from Schaper & Brümmer and run by analyze & realize, a Berlin contract research company whose staff included the corresponding author. It took place at a single center with one investigator, a choice the authors made to reduce the placebo response that is common in menopause and depression trials. Placebo improved menopause scores by only about 20% here, a low figure that makes the difference between groups look large and that has not been tested by an independent replication. There was no group taking black cohosh alone, so the trial cannot show what St. John’s wort added. Its main outcome was a total symptom score rather than the frequency of moderate to severe hot flashes, which is why EMA’s assessors said it did not meet the European guideline for trials of hot flash treatments and could not be counted as proof of efficacy.

Two other studies are weaker. Briese and colleagues (Maturitas 2007) followed 6,141 women treated by 1,287 gynecologists across Germany between 2002 and 2004. Doctors chose either Remifemin alone (3,027 women) or the combination (3,114), so the study was open-label and not randomized, and the combination group started with worse mood scores. After statistical adjustment, the mood subscore at three months was 0.23 with the combination against 0.25 with black cohosh alone, statistically significant but a very small difference, which the authors considered clinically relevant. Possibly treatment-related adverse events occurred in 0.16% of women, and no liver dysfunction was reported. Schaper & Brümmer funded the study, and two of its four authors worked for the company. Chung and colleagues (Yonsei Medical Journal 2007) tested Gyno-Plus, a Korean product with a methanol St. John’s wort extract (84 mg per tablet) and a liquid black cohosh extract, in 89 women for 12 weeks; 77 finished. Symptom scores and hot flashes were lower than with placebo at 4 and 12 weeks. The maker, Jin-Yang Pharm, supported the work, and EMA set it aside because the product’s exact composition and dose were unclear.

Reviews mostly repeat these few studies. A systematic review by Laakmann and colleagues (Gynecological Endocrinology 2012) from University Hospital Hamburg-Eppendorf, which compared the trials qualitatively without pooling them, concluded that black cohosh alone was no better than placebo in most trials, while the combination with St. John’s wort improved menopausal complaints. For black cohosh on its own, the 2012 Cochrane review by Leach and Moore found 16 randomized trials with 2,027 women and no significant difference from placebo in daily hot flash frequency (three trials, 393 women) or symptom scores (four trials, 357 women); it excluded combination products. A 2023 meta-analysis by Sadahiro and colleagues (Menopause), which pooled 22 trials with 2,310 women including combination products, found improvements in overall symptoms and hot flashes but no significant effect on depressive symptoms or anxiety. A 2021 meta-analysis whose authors included two Schaper & Brümmer staff (Castelo-Branco and colleagues, Climacteric) reported that the combination outperformed black cohosh alone for psychological symptoms. The North American Menopause Society’s 2023 position statement does not recommend supplements or herbal remedies for hot flashes and calls hormone therapy the most effective treatment.

Regulators have weighed this record cautiously. EMA’s herbal committee began assessing the combination in 2021, and its January 2025 draft monograph concluded that the quality and outcomes of the two studies of this extract pair were not adequate to establish efficacy. It accepted the combination only as a traditional herbal medicine for the relief of mild menopausal complaints like hot flashes and sweating when associated with temporary mental exhaustion, based on more than 30 years of use. EMA’s website lists the assessment as finalized, but only the draft documents had been published at the time of writing. Germany’s existing authorization, renewed in March 2020, keeps its broader label. EMA’s assessors also noted that the daily St. John’s wort dose is much lower than in single-herb depression products, while the black cohosh dose is higher than in single-herb menopause products. Open questions remain: there is no independent trial, no comparison with either herb alone, with hormone therapy, or with prescription non-hormonal treatments, no randomized data beyond 16 weeks, and, according to the prescribing information, no product-specific pharmacokinetic studies.

04 In practice

How it is taken

In Germany the tablets are green, round, and film-coated, in packs of 60 to 180. Each contains 3.75 mg of black cohosh extract and 70 mg of St. John’s wort extract, plus 163 mg of lactose and a small amount of soy lecithin. The labeled dose matches the main trial: two tablets twice a day for the first eight weeks, then one tablet twice a day from week 9, taken morning and evening, swallowed whole with liquid, with or without food. Because of what it is for, the product is not intended for children, adolescents, or men, and the leaflet says there are not enough data to recommend doses for people with kidney or liver impairment. Do not take a double dose to make up for a missed one.

The effect is not immediate. The leaflet says improvement usually appears after 2–4 weeks and recommends taking the tablets for several months, but not for longer than six months without medical advice, so that other conditions are not overlooked. If the psychological complaints are unchanged after six weeks, see a doctor; the leaflet also advises talking to a doctor if you do not feel better, or feel worse, after 4–6 weeks. EMA’s draft monograph uses the same six-week and six-month limits. During treatment, avoid strong sun exposure and tanning beds, because St. John’s wort can make fair skin react more strongly to ultraviolet light.

Before starting, ask a pharmacist to check every medicine you take, including contraceptive pills, patches, rings, and implants, because St. John’s wort lowers the levels of many drugs. Women who could still become pregnant should consider a reliable non-hormonal method of contraception, as the leaflet advises. Remifemin, the single-herb product from the same company, contains only black cohosh and none of the St. John’s wort interactions. Supplements sold elsewhere that combine the two herbs use different extracts and doses, and the trial results here do not transfer to them. If low mood rather than hot flashes is the main problem, or if it is severe or lasting, it deserves a proper assessment, because depression has effective treatments and this product delivers well under a standard St. John’s wort antidepressant dose.

05 Caution

Before you use Black Cohosh and St. John’s Wort

In the trials, side effects were about as common as on placebo. In Uebelhack’s trial, 11.3% of women on the tablets and 9.3% on placebo reported adverse events in the first eight weeks, with no relevant differences in laboratory values; in Briese’s observational study, possibly related events occurred in 0.16% of women. The German leaflet lists rare digestive complaints and allergic skin reactions (up to 1 in 1,000 people), and, at unknown frequency, liver damage with black cohosh products, raised liver enzymes, swelling of the face or limbs, weight gain, tiredness or restlessness, and sunburn-like skin reactions in fair-skinned people after strong ultraviolet exposure. EMA’s draft monograph adds anxiety, mania, headache, nerve symptoms, and dizziness. Liver injury is the serious concern. In 2006 EMA reviewed 42 reports of liver injury in people using black cohosh; 16 were documented well enough to assess, and 4 showed a link in time between starting black cohosh and the liver reaction, including 2 cases of autoimmune hepatitis and 1 of fulminant liver failure. Its 2007 update called the link a signal. LiverTox, the US National Institutes of Health database on drug-induced liver injury, says products labeled black cohosh have been implicated in many cases of acute liver injury, some leading to emergency liver transplantation or death.

Interactions come mainly from St. John’s wort, which speeds up the liver enzyme CYP3A4 and related enzymes and the drug pump P-glycoprotein, lowering blood levels of many medicines. The German leaflet rules out use with ciclosporin, tacrolimus taken by mouth, HIV protease inhibitors such as indinavir and fosamprenavir, the cancer drug irinotecan, and warfarin; EMA’s draft monograph extends this to other coumarin anticoagulants such as phenprocoumon, everolimus, sirolimus, nucleoside reverse transcriptase inhibitors, imatinib, and other cancer drugs cleared the same way. The leaflet warns of weaker effects from digoxin, simvastatin, fexofenadine, benzodiazepines, methadone, amitriptyline, and hormonal contraceptives, which may cause breakthrough bleeding and less reliable contraception. With SSRIs such as sertraline or paroxetine, buspirone, or triptans, it can contribute to serotonin syndrome; SSRIs and SNRIs are also prescribed for hot flashes, so the two approaches should not be combined without a doctor. Tell your doctor one to two weeks before planned surgery, and stop the tablets at least a week beforehand. Enzyme activity returns to normal within about a week of stopping, so levels of other drugs can rise when you stop; take estrogens with it only on medical advice.

Who should not take it: anyone allergic to black cohosh, St. John’s wort, soy, or peanut; anyone taking the medicines listed above; and, according to the leaflet and EMA, anyone pregnant or breastfeeding, because safety has not been established. People with current or past liver disease should use it only after talking to a doctor. Anyone treated now or in the past for breast cancer or another hormone-dependent tumor should not take it without medical advice. In tumor-bearing transgenic mice, the same type of black cohosh extract increased the share of animals with lung metastases, though not primary breast tumors, according to the prescribing information; Memorial Sloan Kettering Cancer Center (MSKCC) notes that black cohosh may interfere with tamoxifen, and Quebec’s oncology practice committee (CEPO) recommended in 2013 that breast cancer survivors not use black cohosh or St. John’s wort for hot flashes. We found no human study of St. John’s wort with tamoxifen or aromatase inhibitors, so its effect on these drugs is unknown, but it lowers the levels of several other cancer drugs. People with bipolar disorder should not use it without their psychiatrist, since EMA lists mania as a possible effect. The tablets contain lactose.

Stop the tablets and see a doctor at once for signs of liver trouble: yellowing of the skin or eyes, dark urine, severe upper abdominal pain, nausea, loss of appetite, or unusual tiredness. Vaginal bleeding after 12 months without a period, bleeding with no clear cause, or changes in your periods need a doctor’s assessment, as do a new breast lump and night sweats with fever or weight loss. Low mood that lasts more than two weeks, affects daily life, or comes with hopelessness needs a clinician, and thoughts of suicide or self-harm need help right away from emergency services or a crisis line; in the US, call or text 988. Agitation, sweating, a fast heartbeat, tremor, or fever while taking an antidepressant or triptan can signal serotonin syndrome and need urgent care. Racing thoughts, little need for sleep, or reckless behavior can signal mania and are a reason to stop and seek help.

06 Questions

Frequently Asked Questions

Each tablet contains 3.75 mg of a dry extract of black cohosh root and rhizome, made with 40% isopropanol, and 70 mg of a dry extract of St. John’s wort herb, made with 60% ethanol. The other ingredients include lactose and soy lecithin. It is made by Schaper & Brümmer and sold in Germany as Remifemin plus Johanniskraut and in Austria. It contains no hormones.

One 16-week trial in 301 women with hot flashes and low mood found clear benefits over placebo on menopause and depression scores, but it was funded by the maker, ran at a single center, and has not been independently repeated. A large observational study and a small Korean trial of a different product pointed the same way. EMA’s herbal committee judged the evidence too weak to prove efficacy and accepted the combination only as a traditional remedy for mild symptoms.

No. It contains no estrogen or progestogen, and the leaflet still asks people taking estrogens or with hormone-dependent tumors to check with a doctor because the way black cohosh works is not fully understood. Hormone therapy remains the most effective treatment for hot flashes, and the North American Menopause Society does not recommend herbal remedies for them. If you already take estrogen, use this product only on a doctor’s advice. Other options are covered in our menopause guide.

It is not a treatment for depression. Its daily dose of St. John’s wort is well below the dose used in depression trials, and depression needs a proper assessment. Do not combine it with SSRIs such as sertraline or paroxetine, buspirone, or triptans unless your doctor agrees, because of the risk of serotonin syndrome, and it can lower levels of amitriptyline. See our low mood guide for safer next steps, and seek urgent help for thoughts of suicide.

Yes. St. John’s wort can lower hormone levels from contraceptive pills and other hormonal methods, which may cause bleeding between periods and make contraception less reliable. Pregnancy is still possible in perimenopause, so the leaflet advises women who could become pregnant to consider a reliable non-hormonal method while taking the tablets. The tablets themselves are not recommended in pregnancy or breastfeeding.

Only with your oncology team’s agreement. The leaflet and EMA advise people treated for breast cancer or other hormone-dependent tumors not to use it without medical advice. MSKCC notes that black cohosh may interfere with tamoxifen, St. John’s wort lowers the levels of several cancer drugs, and a Quebec oncology committee advised breast cancer survivors not to use either herb for hot flashes. A 2019 review co-written by Schaper & Brümmer staff argued the product is safe in this group, but no independent trial has tested it.

Serious liver injury is rare but has been linked to black cohosh products, occasionally needing a transplant, and the leaflet lists liver damage at unknown frequency. The trials of this combination reported no liver problems, but they were too small to detect rare reactions. People with liver disease should talk to a doctor first, and anyone taking it should stop and seek care for yellow skin or eyes, dark urine, severe upper abdominal pain, nausea, loss of appetite, or unusual tiredness.

Plain Remifemin contains only the black cohosh extract and none of the St. John’s wort drug interactions, while Remifemin plus adds St. John’s wort for mood symptoms and uses more black cohosh extract per day. Supplements sold elsewhere that pair black cohosh with St. John’s wort use different extracts and doses, and the trial results here do not apply to them. If mood is not part of your symptoms, a single-herb product avoids the interaction risk.

07 References

Sources

These references support the claims on this page. They are not an endorsement of any product. Each ingredient’s monograph carries its own full source list.

  1. Fachinformation: Remifemin plus Johanniskraut 70 mg/3,75 mg Filmtabletten

    Schaper & Brümmer GmbH & Co. KG, via Fachinfo-Service, 2023

    German prescribing information (April 2023): composition, indication, dosing, six-week and six-month limits, contraindications, interaction lists, side effects, 301-patient trial results, no product-specific pharmacokinetic studies, authorization 84016.00.00 renewed March 2020.

  2. Gebrauchsinformation: Remifemin plus Johanniskraut

    Schaper & Brümmer GmbH & Co. KG, 2023

    Patient leaflet revised April 2023: liver warning signs, breast cancer and estrogen cautions, bleeding to report, surgery advice, sunbed avoidance, pregnancy, side effects, lactose and soy content, MEDICE co-marketing.

  3. Patient Information Leaflet: Remifemin plus St. John’s wort 70 mg/3,75 mg film-coated tablets

    Schaper & Brümmer GmbH & Co. KG (English translation), 2020

    English translation of the German leaflet (March 2020), confirming the English product name and the advice to see a doctor if not better or worse after 4–6 weeks.

  4. Remifemin plus Johanniskraut Filmtabletten

    MEDICE Arzneimittel GmbH (Austria), 2026

    Austrian product information (status April 2026): same composition, non-prescription and pharmacy-only, contraindications including imatinib, marketing authorization held by Schaper & Brümmer.

  5. Black cohosh and St. John’s wort for climacteric complaints: a randomized trial

    Obstetrics and Gynecology (PubMed 16449108), 2006

    Uebelhack et al.: 301 women, 16 weeks; MRS score fell 50% vs 19.6%, HAMD 41.8% vs 12.7% (P < .001); single center and investigator; unrestricted grant from Schaper & Brümmer; run by analyze & realize.

  6. Black cohosh with or without St. John’s wort for symptom-specific climacteric treatment: results of a large-scale, controlled, observational study

    Maturitas (PubMed 17590291), 2007

    Briese et al.: 6,141 women at 1,287 practices, non-randomized; adjusted mood subscore 0.23 vs 0.25 at month 3; 0.16% possibly related adverse events; funded by Schaper & Brümmer, two authors company staff.

  7. Black cohosh and St. John’s wort (GYNO-Plus) for climacteric symptoms

    Yonsei Medical Journal (PubMed 17461529), 2007

    Chung et al.: 89 Korean women, 12 weeks, 77 completed; Kupperman Index and hot flashes lower than placebo; different extracts (84 mg methanol St. John’s wort extract per tablet); supported by Jin-Yang Pharm.

  8. Efficacy of Cimicifuga racemosa, Hypericum perforatum and Agnus castus in the treatment of climacteric complaints: a systematic review

    Gynecological Endocrinology (PubMed 22385322), 2012

    Laakmann et al.: qualitative review of randomized trials; black cohosh alone mostly no better than placebo; the combination with St. John’s wort improved climacteric complaints.

  9. Black cohosh (Cimicifuga spp.) for menopausal symptoms

    Cochrane Database of Systematic Reviews (PubMed 22972105), 2012

    Leach and Moore: 16 trials, 2,027 women, single-herb products only; no significant difference from placebo in hot flash frequency (393 women) or symptom scores (357 women).

  10. Black cohosh extracts in women with menopausal symptoms: an updated pairwise meta-analysis

    Menopause (PubMed 37192826), 2023

    Sadahiro et al.: 22 trials, 2,310 women, including combination products; improved overall symptoms and hot flashes; no significant effect on anxiety or depressive symptoms.

  11. Review & meta-analysis: isopropanolic black cohosh extract iCR for menopausal symptoms - an update on the evidence

    Climacteric (PubMed 33021111), 2021

    Castelo-Branco et al., including two Schaper & Brümmer authors: reports iCR+HP superior to iCR alone for psychological symptoms.

  12. Benefit-risk profile of black cohosh (isopropanolic Cimicifuga racemosa extract) with and without St John’s wort in breast cancer patients

    Climacteric (PubMed 30626212), 2019

    Ruan et al., two authors from Schaper & Brümmer: review arguing iCR and iCR+HP are a safe option for breast cancer survivors on endocrine therapy.

  13. European Union herbal monograph on Hypericum perforatum L., herba and Cimicifuga racemosa (L.) Nutt., rhizoma (Draft)

    European Medicines Agency (EMA/HMPC/884573/2022), 2025

    Draft of 22 January 2025: traditional use only for mild climacteric complaints with temporary mental exhaustion; dosing; six-week and six-month limits; contraindications; liver, breast cancer, and UV warnings; mania listed.

  14. Assessment report on Hypericum perforatum L., herba and Cimicifuga racemosa (L.) Nutt., rhizoma (Draft)

    European Medicines Agency (EMA/HMPC/107224/2023), 2025

    Uebelhack, Briese, and Chung studies not accepted as proof of efficacy; product marketed in Germany for over 30 years and Austria since 2003; St. John’s wort dose below and black cohosh dose above single-herb monographs.

  15. Combination: Hyperici herba - herbal medicinal product

    European Medicines Agency, 2025

    Overview page for the combination assessment: added to the inventory January 2021, draft consultation February to May 2025, status listed as assessment finalized.

  16. European Union herbal monograph on Cimicifuga racemosa (L.) Nutt., rhizome (Revision 1)

    European Medicines Agency (EMA/HMPC/48745/2017), 2018

    Isopropanol dry extract (DER 6–11:1) at a daily dose of 5.0 mg for menopausal complaints; not longer than six months without medical advice.

  17. European Union herbal monograph on Hypericum perforatum L., herba (Revision 1)

    European Medicines Agency (EMA/HMPC/7695/2021), 2022

    Adopted 23 November 2022: ethanol 50–68% dry extract at 500–1,200 mg a day for mild depressive symptoms; hyperforin threshold of 1 mg a day for interaction warnings.

  18. EMEA Public Statement on herbal medicinal products containing Cimicifugae racemosae rhizoma: serious hepatic reactions

    European Medicines Agency, 2006

    42 case reports reviewed, 16 sufficiently documented, 4 with a temporal association (2 autoimmune hepatitis, 1 hepatocellular injury, 1 fulminant hepatic failure); advice to stop at signs of liver injury.

  19. Assessment of case reports connected to herbal medicinal products containing Cimicifugae racemosae rhizoma (black cohosh, root), Rev. 1

    European Medicines Agency (EMEA/HMPC/269258/2006 Rev. 1), 2007

    Revised May 2007: the connection between black cohosh products and hepatotoxicity should be seen as a signal; long-term safety not studied.

  20. Black Cohosh

    LiverTox, National Institute of Diabetes and Digestive and Kidney Diseases (PubMed 31643322), 2025

    Updated April 2025: products labeled black cohosh implicated in many cases of acute liver injury, some leading to emergency liver transplantation or death.

  21. St. John’s Wort

    National Center for Complementary and Integrative Health (NIH), 2025

    Updated May 2025: depression evidence; small hot flash studies; interacts dangerously with many medicines, including birth control pills, cyclosporine, warfarin, HIV and cancer drugs; serotonin effects; sun sensitivity.

  22. Black cohosh

    Memorial Sloan Kettering Cancer Center, About Herbs, 2022

    May interfere with tamoxifen (clinical relevance unknown); liver injury case reports; people with breast cancer or at risk should consult their physicians.

  23. Pharmacological and non-hormonal treatment of hot flashes in breast cancer survivors: CEPO review and recommendations

    Supportive Care in Cancer (PubMed 23435567), 2013

    Quebec oncology practice committee: recommends that breast cancer survivors not use sertraline, phytoestrogens, black cohosh, or St. John’s wort to treat hot flashes.

  24. The 2023 nonhormone therapy position statement of The North American Menopause Society

    Menopause (PubMed 37252752), 2023

    Supplements and herbal remedies not recommended for hot flashes; hormone therapy remains the most effective treatment; recommended non-hormone options include CBT, hypnosis, SSRIs or SNRIs, gabapentin, and fezolinetant.