Black cohosh: a cause of abnormal postmenopausal liver function tests

Management of menopausal symptoms in women with gynecologic cancers

OBJECTIVE

Women with gynecologic malignancies will be cured or may become long-term survivors. Management of menopausal symptoms is important in addressing their quality of life. We review the benefit and safety of hormone therapy use in these patients.

METHODS

MEDLINE was searched for studies on menopause management published in English through December of 2016.

RESULTS

Available data suggest that short-term use of hormone therapy in gynecologic cancer patients who do not have an estrogen-dependent malignancy do not adversely impact oncologic outcome and results in improvement of menopausal vasomotor and genitourinary symptoms. Evidence regarding safety of hormone therapy use in women with estrogen-dependent gynecologic malignances is currently lacking.

CONCLUSIONS

Candidates for hormone therapy in gynecologic oncology include women with menopausal symptoms diagnosed with low-grade, early-stage endometrial cancer, cervical, vulvar and vaginal cancer, and ovarian cancer.

Liver toxicity related to herbs and dietary supplements: Online table of case reports. Part 2 of 5 series

BACKGROUND

No online current list of potentially life-threatening, hepatotoxic herbs and dietary supplements based on PubMed case reports exists in a summarized tabular form.

METHODS

Documented case reports of herbs or dietary supplements (DS; includes herbs) appearing to contribute to liver injury were used to create an online "DS Toxic Table" of potentially hepatotoxic herbs and dietary supplements (PubMed, 1966 to June, 2016, and cross-referencing). The spectrum of DS induced liver injuries (DSILI) included elevated liver enzymes, hepatitis, steatosis, cholestasis, hepatic necrosis, hepatic fibrosis, hepatic cirrhosis, veno-occlusive disease, acute liver failure requiring a liver transplant, and death.

RESULTS

Over the past 50 years, approximately 21 herbs (minus germander and usnic acid that are no longer sold) and 12 dietary supplements (minus the nine no longer sold and vitamin A & niacin due to excess intake) posed a possible risk for liver injures in certain individuals. The herbs with the most number of reported publications (but not cases studies) in descending order, were germander, black cohosh, kava extract, and green tea extract.

CONCLUSION

These online DS Toxic Tables will contribute to continued Phase IV post marketing surveillance to detect possible liver toxicity cases and serve to forewarn consumers, clinicians, and corporations.

Use and perceived efficacy of complementary and alternative medicines after discontinuation of hormone therapy: a nested United Kingdom Collaborative Trial of Ovarian Cancer Screening cohort study

Supplemental digital content is available in the text.

Objective

Given that the Women’s Health Initiative reported in 2002 increased risks of breast cancer and cardiovascular events with hormone therapy (HT) use and many women discontinued use, we assessed the use and perceived efficacy of complementary and alternative medicines (CAMs) for menopausal symptom relief after discontinuation of HT.

Methods

Postmenopausal women aged 50 to 65 years within the United Kingdom Collaborative Trial of Ovarian Cancer Screening who were willing to take part in a secondary study were mailed a survey to evaluate menopausal symptom management. Use and perceived efficacy of CAMs for relief of vasomotor symptoms (VMS) upon discontinuation of HT were examined.

Results

The survey was sent to 15,000 women between July 2 and July 9, 2008. Seventy-one percent (10,662 of 15,000) responded, and 10,607 women with complete data were included. Ever use of HT was reported by 60.2% (6,383 of 10,607). At survey completion, 79.3% (5,060 of 6,383) had discontinued HT, with 89.7% (4,540 of 5,060) of the latter reporting using one or more CAMs for VMS relief. About 70.4% (3,561 of 5,060) used herbal remedies, with evening primrose oil (48.6%; 2,205 of 4,540) and black cohosh (30.3%;1,377 of 4,540) being most commonly used. Exercise was used by 68.2% (3,098 of 4,540), whereas other behavioral/lifestyle approaches were less frequently reported (13.9%; 629 of 4,540). Contrarily, more women (57%-72%) rated behavioral/lifestyle approaches as effective compared with herbal remedies (28%-46%; rating ≥4 on a “helpfulness” scale from 1-10). Among medical treatments, selective serotonin reuptake inhibitors were used by 10% and rated effective by 72.1%.

Conclusions

Although more women use over-the-counter medicines, behavioral/lifestyle approaches seem to provide better relief of VMS. There is a pressing need for better evidence-based lay information to support decision-making on CAM use for relief of VMS.

An Evidence-Based Systematic Review of Black cohosh (Cimicifuga racemosa, Actaea racemosa) by the Natural Standard Research Collaboration

An evidence-based systematic review of black cohosh (Cimicifuga racemosa, Actaea racemosa) by the Natural Standard Research Collaboration consolidates the safety and efficacy data available in the scientific literature using a validated, reproducible grading rationale. This article includes written and statistical analysis of clinical trials, plus a compilation of expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing.

Herbs and liver injury: a clinical perspective

Despite a perception that herbal and dietary supplements are safe, devastating liver injury has been reported to result from their use. The difficulty in characterizing liver injury attributable to herbal and dietary supplements stems from the permissive regulatory environment, the complexity of marketed products, and underreporting by the patients who use them. Despite these limitations, researchers, clinicians, and regulators have increasing awareness of the need for study in this area.

Black cohosh and liver toxicity: is there a relationship?

Herbal supplements are commonly used by patients for various problems. It is a well-known fact that most patients do not tell their physicians about the use of herbal supplements unless they are specifically asked. As a result, sometimes important information regarding drug side effects is missed in history taking. During our literature search, we found several retrospective studies and other meta-analyses that claim a lacking or weak link between black cohosh use and hepatotoxicity. We present a case of a 44-year-old female who developed subacute liver injury demonstrated on a CT scan and liver biopsy within a month of using the drug to resolve her hot flashes and discuss a possible temporal and causal association between black cohosh use and liver disease. Since the patient was not taking any other drugs, we concluded that the acute liver injury was caused by the use of black cohosh. We agree with the United States Pharmacopeia recommendations that a cautionary warning about hepatotoxicity should be labeled on the drug package.

Liver injury induced by herbal complementary and alternative medicine

Herbal and dietary supplement use is common. Most marketed products consist of complex mixtures. Although they are perceived as safe, instances of hepatotoxicity attributable to these products underscore their potential for injury, but the exact component that is responsible for injury is difficult to discern. The lenient regulatory environment in the United States, which opens the possibility of adulteration and contamination, adds to the challenge of disease attribution. Although many different herbal and dietary supplements have been reported to cause liver injury, in the United States, products used for bodybuilding and weight loss are the most commonly implicated.

Coagulation activation and fluid retention associated with the use of black cohosh: a case study

Black cohosh is one of the most popular herbal therapies for premenstrual discomfort, hot flushes and other climacteric and menopausal symptoms. Most often, it is tolerated well. However, there are some recent reports on serious adverse events, probably associated with this complementary and alternative herbal medicine. We report a case of coagulation activation, fluid retention and transient autoimmune hepatitis most likely triggered by the use of black cohosh. Diagnostic procedures aimed to explain lower leg edema are not uncommon in the age group of women suffering from climacteric and menopausal symptoms. Therefore, black cohosh-induced fluid retention and coagulation activation should be considered in differential diagnosis, especially if thrombosis has been excluded.

Black cohosh and suspected hepatotoxicity: inconsistencies, confounding variables, and prospective use of a diagnostic causality algorithm. A critical review

OBJECTIVE

The data of 69 cases of initially suspected black cohosh (BC)-induced liver disease were reviewed and analyzed to clarify whether BC hepatotoxicity really exists as a disease entity in these cases comparable to toxic liver disease being caused by various drugs and dietary supplements.

METHODS

The cases comprised 11 published case reports and 58 spontaneous reports to national regulatory agencies. The analysis includes assessment of causality for BC, data quality of the presented cases, and their inconsistencies and confounding variables.

RESULTS

The assessed data raise serious doubts on the initial claims of causality for BC in these cases and provide clear evidence of their poor quality, especially when spontaneous reports are considered. There are major inconsistencies for the same patient regarding reported data. Moreover, the analysis of all cases disclosed confounding variables. These include poor case data quality, uncertainty of BC product, quality, and identification, undisclosed indication, insufficient adverse event definition, lack of temporal association and dechallenge, missing or inadequate evaluation of alcohol use, comedication, comorbidity, reexposure test, and alternative diagnoses.

CONCLUSIONS

The presented data do not support the concept of hepatotoxicity in a primarily suspected causal relationship to the use of BC and failure to provide a signal of safety concern, but further efforts have to be undertaken to dismiss or to substantiate the existence of BC hepatotoxicity as a special disease entity. The future strategy should be focused on prospective causality evaluations in patients diagnosed with suspected BC hepatotoxicity, using a structured, quantitative, and hepatotoxicity-specific causality assessment method.

Safety and efficacy of black cohosh and red clover for the management of vasomotor symptoms: a randomized controlled trial

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of black cohosh and red clover compared with placebo for the relief of menopausal vasomotor symptoms.

METHODS

This study was a randomized, four-arm, double-blind clinical trial of standardized black cohosh, red clover, placebo, and 0.625 mg conjugated equine estrogens plus 2.5 mg medroxyprogesterone acetate (CEE/MPA; n = 89). Primary outcome measures were reduction in vasomotor symptoms (hot flashes and night sweats) by black cohosh and red clover compared with placebo; secondary outcomes included safety evaluation, reduction of somatic symptoms, relief of sexual dysfunction, and overall improvement in quality of life.

RESULTS

Reductions in number of vasomotor symptoms after a 12-month intervention were as follows: black cohosh (34%), red clover (57%), placebo (63%), and CEE/MPA (94%), with only CEE/MPA differing significantly from placebo. Black cohosh and red clover did not significantly reduce the frequency of vasomotor symptoms as compared with placebo. Secondary measures indicated that both botanicals were safe as administered. In general, there were no improvements in other menopausal symptoms.

CONCLUSIONS

Compared with placebo, black cohosh and red clover did not reduce the number of vasomotor symptoms. Safety monitoring indicated that chemically and biologically standardized extracts of black cohosh and red clover were safe during daily administration for 12 months.

Black cohosh hepatotoxicity: quantitative causality evaluation in nine suspected cases

OBJECTIVE

Black cohosh (BC), synonym for Actaea racemosa and Cimicifuga racemosa, is a herbal remedy for the treatment of menopausal symptoms. Recently, worldwide discussions have emerged as to whether its use maybe associated with the risk of rare hepatotoxicity in a few susceptible women.

METHODS

We have evaluated the causal relationship in nine cases with suspected hepatotoxicity by the use of BC. The updated Council for International Organizations of Medical Sciences scale was used to quantitatively assess the causality for BC.

RESULTS

In eight of nine patients with liver disease, causality for BC +/- comedication was excluded (n = 4) or unlikely (n = 4). The failure to ascribe causality in these cases was mainly due to alternative diagnosis, missing temporal association and dechallenge, and presentation of low quality data. In only one case, causality was possible for a BC preparation of an unknown brand taken for 2 months with an unknown daily dose. Confounding factors in this case include symptomatic cholelithiasis and fatty liver. Comedication with synthetic drugs and herbal or other dietary supplements was reported in five of nine patients.

CONCLUSIONS

In nine cases of patients with liver disease, causality for BC +/- comedication was possible (n = 1), unlikely (n = 4), or excluded (n = 4). Due to this lack of significant circumstantial evidence, the present study shows little, if any, hepatotoxic risks by the use of BC in the analyzed cases.

Suspected black cohosh hepatotoxicity--challenges and pitfalls of causality assessment

OBJECTIVES

Black cohosh (BC) is a herbal drug or herbal dietary supplement used for treatment of menopausal symptoms. Recently, however, reports have appeared about the occurrence of rare toxic liver disease in an assumed relationship with the use of BC.

METHODS

We have analyzed and reviewed the data of all 69 reported cases with suspected BC hepatotoxicity. Causality for BC was assessed utilizing the scale of the original structured quantitative Council for International Organizations of Medical Sciences (CIOMS), or the main-test as its updated form.

RESULTS

With the hepatotoxicity specific causality assessment methods, there was an excluded, unlikely, unrelated or unassessable causality for BC in 68 of 69 cases with liver disease. One patient had a possible causality for BC and a symptomatic cholelithiasis with confounding variables of fatty liver of unknown etiology; unknown BC brand including possible herbal mixture; unknown daily BC dosage; and an unassessable duration of BC usage. In general, the cases of the 69 patients were poorly documented. Confounding variables were: failure to identify the BC product; use of herbal mixtures with multiple ingredients in addition to BC; co-medication with synthetic drugs and dietary supplements including herbal ones; missing temporal association between BC use and development of liver disease; not specified modalities of BC treatment; failure of dechallenge after BC discontinuation; pre-existing liver diseases; insufficiently excluded other liver diseases; presence of alternative liver diseases.

CONCLUSIONS

The analysis of 69 cases shows little, if any, supportive evidence for a significant hepatotoxic risk of BC.

Advances in the Treatment of Menopausal Symptoms

Vasomotor symptoms and vaginal atrophy are both common menopausal symptoms. Hormone therapy is currently the only FDA-approved treatment for hot flashes. Current recommendations are to use the lowest dose of hormone therapy for the shortest period that will allow treatment goals to be met. Although the reanalysis of the WHI in 2007 by Roussow et al. provided evidence of coronary heart safety for users of hormone therapy under the age of 60 years and within 10 years of the onset of menopause, not all women desire or are candidates for hormone therapy. In this review we present an evidence-based discussion considering the effectiveness of hormonal and nonhormonal therapies for the relief of vasomotor symptoms and vaginal atrophy. Concern exists regarding systemic absorption of vaginal estrogen and possible adverse effects on the breast and uterus. Selective estrogen receptor modulators and estrogen agonists offer benefits through targeted estrogen agonist/antagonistic effects and are being evaluated with and without estrogen for symptomatic menopausal women. Centrally acting nonhormonal therapies that are effective for the relief of vasomotor symptoms include various antidepressants, gabapentin and clonidine. A limited number of clinical trials have been conducted with nonprescription remedies, including paced respiration, yoga, acupuncture, exercise, homeopathy and magnet therapy, and some, but not all of these, have been found to be more effective than placebo. Dietary herbal supplements, such as soy and black cohosh, have demonstrated mixed and inconclusive results in placebo-controlled trials. Potential therapies for vasomotor symptoms and vaginal atrophy require randomized, placebo-controlled trials of sufficient duration to establish efficacy and safety. Agents under investigation for vasomotor symptoms relief include neuroactive agents, such as gabapentin and desvenlafaxine; an estrogen receptor-β-targeted herbal therapy, MF-101; and the selective estrogen receptor modulator, bazedoxifene, paired with estrogen.

Menopausal hot flushes revisited

Vasomotor symptoms are generally recognized as one of the most common symptoms, or signs, of the menopause, together with menstrual cycle changes. The etiology of hot flushes is unknown, although several mechanisms have been implicated. The reduction in hot flushes with estrogen replacement therapy suggests a hormonal etiology. However, the levels of estrogens do not appear to correlate with hot flushes. It seems more likely that the rate of change of plasma estrogen concentrations influences the thermoregulatory system via the hypothalamus. During the past few decades, remedies for the treatment of hot flushes have advanced from simple sedatives and purgatives to the use of ovarian extracts and, finally, to pharmacological estrogen preparations. In view of the contraindications and side-effects of estrogens and progestogens in postmenopausal women, however, there is a need to consider treatments other than hormone replacement for the relief of hot flushes.

Effects of Cimicifuga racemosa extract on liver morphology and hepatic function indices

Cimicifuga racemosa (black cohosh) is a herbaceous perennial plant, that has been traditionally used for a variety of ailments (dyspepsia, climacteric complaints, muscular rheumatisms, menstrual cramps). From laboratory and clinical studies, black cohosh seems to have a relatively good safety profile, even if a number of case reports of hepatotoxicity were a matter of recent concern.

AIM

A number of case reports indicated that C. racemosa could induce hepatotoxicity. We evaluated the effects of black cohosh extract on liver morphology, and on levels of various hepatic function indices in rats.

METHODS

Wistar rats received 300mg/kg/day of C. racemosa extract by gavage, for 30 days. Biochemical analysis of serum was conducted by an automated, random-access clinical chemistry analyzer. Liver samples were used for hystomorphological and immunohistochemical examination, for the detection of apoptosis (TUNEL assay), and for the determination of GSH level (spectrophotometrical analysis).

RESULTS

C. racemosa extract does not affect liver morphology and hepatic function indices, in rats.

CONCLUSIONS

On the basis of experimental data, the use of 300mg/kg/day of black cohosh appears quite safe in rats. Nevertheless, in humans the safety of C. racemosa should be further monitored, in terms of patient-related factors.