Herb & supplement monograph

Black Cohosh Drug Interactions, Uses, Effectiveness, Safety & More

Medically reviewed by Dr. Brian Staiger, PharmD, BCPS ·Updated July 2026

What is this page for?

First and foremost: how Black Cohosh interacts with medications. The heart of this page is the interaction list — every drug Black Cohosh is known to interact with, and how serious each one is.

But these pages have grown well beyond that into a full monograph — what Black Cohosh is, what people use it for and how strong the evidence is, its safety and side effects, and answers to the questions we’re asked most — written and reviewed by the clinical staff at HelloPharmacist. It’s educational information from our licensed clinical databases, not medical advice, and we don’t sell or endorse products. Our editorial policy

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Black Cohosh Drug Interactions: The Bottom Line

From the HelloPharmacist Editorial Team · Updated July 2026

Based on the available evidence, the overall risk of a clinically significant Black Cohosh drug interaction appears low for most people, though its possible effect on the liver deserves respect. None of the listed interactions are rated major, and nearly all rest on lab research, animal studies, or single case reports rather than well-controlled human trials.

Interactions deserving the most attention

The liver is the main theme worth watching. Black cohosh has been linked to rare reports of liver injury, so combining it with hepatotoxic drugs (medications that can stress the liver) is the concern we weigh most heavily; one case report described elevated liver enzymes in a person taking it with atorvastatin, which resolved after stopping the supplement. There is also a case report of serotonin syndrome with sertraline, so people on serotonergic antidepressants should be aware of that possibility.

What the rest of the list means

The long list of moderate interactions mostly comes from a theoretical concern that black cohosh may affect an enzyme the body uses to clear many medications. Human evidence here is conflicting, and one well-studied black cohosh product did not meaningfully change how that enzyme worked in people. In other words, most listed combinations are precautionary, not proven problems.

Check your medications against Black Cohosh

Based on HelloPharmacist’s Black Cohosh interaction data and reviewed under our editorial standards.

Interaction report

Drugs that interact with Black Cohosh

654 medications have a known interaction with Black Cohosh, graded by severity. Select any drug for the full evidence-based detail.

Don’t want to scroll the list? Just ask.

Tell us the medications you take and we’ll check each one against Black Cohosh using our pharmacist-reviewed interaction data.

AI summaries are generated from our Black Cohosh interaction data for education only — always confirm with your pharmacist. How we use AI

2,830 drugs

Read The List Like a Pharmacist

What Severity, Likelihood & Evidence Mean

Severity — How Serious It Can Be

Major. Clinically significant; generally best avoided, or used only under direct professional supervision.
Moderate. May need monitoring, a dose adjustment, or separating the times you take each one.
Minor. Generally not clinically significant, but still worth noting and mentioning to your pharmacist.
No known interaction. Checked against our sources with nothing documented — not the same as proven safety.

Likelihood — How Well It’s Documented

Likely. Well-controlled human studies have demonstrated the likely existence of this interaction
Probable. Interaction has not been documented in well-controlled studies, however, the interaction has been demonstrated in some small human studies or in controlled animal studies in conjunction with multiple case reports.
Possible. Interaction has been documented in animal or in lab research, or the interaction has been documented in humans but is limited to case reports or conflicting clinical research exists
Unlikely. Interaction has been demonstrated in animal or in lab research but has been shown not to occur in humans.

Where This Data Comes From

Interaction records are evidence-graded and sourced from the Natural Medicines database (TRC Healthcare), the same reference used by pharmacists and hospitals.
Each drug listed above links to the full report for that exact Black Cohosh combination — clinical detail, likelihood, evidence level, and citations.
Content is reviewed by licensed HelloPharmacist pharmacists — see our data sources and editorial standards.

The big picture

The kinds of drugs Black Cohosh affects

Every type of medication (drug category) Black Cohosh is known to interact with. Open any category for the detail — or search your exact drug in the checker above.

All 7 drug categories Black Cohosh interacts with

Atorvastatin (lipitor)Cisplatin (platinol-aq)Cytochrome P450 2d6 (cyp2d6) SubstratesEstrogensHepatotoxic DrugsSerotonergic DrugsOrganic Anion-transporting Polypeptide Substrates (oatp)

Atorvastatin (Lipitor)

Taking black cohosh with atorvastatin might increase the risk for elevated liver function tests.
In one case report, a patient taking atorvastatin (Lipitor) developed significantly elevated liver function enzymes after starting black cohosh 100 mg four times daily. Liver enzymes returned to normal when black cohosh was discontinued. It is unclear whether the elevated liver enzymes were due to black cohosh itself or an interaction between atorvastatin and black cohosh.

Likelihood Possible Evidence D

Cisplatin (Platinol-Aq)

Theoretically, black cohosh may reduce the clinical effects of cisplatin.
Animal research suggests that black cohosh might decrease the cytotoxic effect of cisplatin on breast cancer cells.

Likelihood Possible Evidence D

Cytochrome P450 2D6 (Cyp2D6) Substrates

Some research suggests that black cohosh might inhibit CYP2D6, but there is conflicting evidence.
Some clinical research suggests that black cohosh might modestly inhibit CYP2D6 and increase levels of drugs metabolized by this enzyme. However, contradictory clinical research shows a specific black cohosh product (Remifemin, Enzymatic Therapy) 40 mg twice daily does not significantly inhibit metabolism of a CYP2D6 substrate in healthy study volunteers. Until more is known, use black cohosh cautiously in patients taking drugs metabolized by CYP2D6.

Likelihood Possible Evidence B

Estrogens

Theoretically, black cohosh may alter the effects of estrogen therapy.
Some research suggests that black cohosh has estrogenic effects. This may enhance or inhibit the effects of estrogen therapy.

Likelihood Possible Evidence D

Hepatotoxic Drugs

Theoretically, taking black cohosh with hepatotoxic drugs may increase the risk of liver damage.
There is concern that black cohosh might be linked to cases of liver failure and autoimmune hepatitis.

Likelihood Possible Evidence D

Serotonergic Drugs

Combining serotonergic drugs with black cohosh might cause additive serotonergic effects.
Black cohosh might increase the risk of serotonin syndrome when combined with other serotonergic drugs. Black cohosh acts as an agonist at several serotonin receptor subtypes and might interact with other serotonergic medications. In one case, a 55-year-old female who had been on stable treatment with sertraline 50 mg and duloxetine 60 mg daily developed serotonin syndrome after taking black cohosh extract 40 mg daily for 3 days.

Likelihood Possible Evidence D

Organic Anion-Transporting Polypeptide Substrates (Oatp)

Black cohosh may inhibit one form of OATP, OATP2B1, which could reduce the bioavailability and clinical effects of OATP2B1 substrates.
In vitro research shows that black cohosh modestly inhibits OATP2B1. OATPs are expressed in the small intestine and liver and are responsible for the uptake of drugs and other compounds into the body. Inhibition of OATP may reduce the bioavailability of oral drugs that are substrates of OATP.

Likelihood Possible Evidence D

Monograph

Black Cohosh: Uses, Safety & Side Effects

Medically reviewed by Dr. Brian Staiger, PharmD, BCPS · Reviewed July 2026 ·

The bottom line

Black cohosh is a North American plant most often used to ease menopause symptoms like hot flashes, but the research is mixed and far from settled. It is generally well tolerated for short-term use, though rare reports of liver problems mean you should talk with your pharmacist or doctor before trying it, especially if you have liver disease.

Scientific name: Actaea racemosa
Family: Ranunculaceae
Part used: Roots and rhizomes (underground stems)
Common forms: Capsules, tablets, liquid extracts (tinctures), dried root for tea

People commonly use it for

Hot flashes and night sweats
Other menopause symptoms
Mood changes during menopause
Premenstrual syndrome (PMS)
Menstrual cramps

Popular and traditional uses — not proof it works. See “Uses & effectiveness” below for the evidence.

Safety at a glance

OverallUse caution

Generally well tolerated short-term, but rare liver concerns mean medical guidance is wise.

PregnancyPossibly Unsafe

When used orally in pregnant patients who are not at term. Black cohosh might have hormonal effects and menstrual and uterine stimulant effects. Theor...

Read the full pregnancy detail

BreastfeedingPossibly Unsafe

When used orally. Black cohosh might have hormonal effects. Theoretically, maternal intake of black cohosh might adversely affect a nursing child. Unt...

Read the full breastfeeding detail

Pregnancy & breastfeeding ratings are from Natural Medicines (Therapeutic Research Center). Safety guidance is general; always confirm with your pharmacist or doctor for your situation.

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Overview

Black cohosh is a tall flowering plant native to the woodlands of eastern North America. Its roots and underground stems (rhizomes) have a long history of use by Native Americans and were later adopted in herbal medicine. Today it is one of the most popular herbal supplements for women's health.

People most often take black cohosh to help with menopause symptoms such as hot flashes, night sweats, and mood changes. It is also sometimes used for premenstrual syndrome (PMS) and menstrual discomfort. You can find it as capsules, tablets, liquid extracts, and dried root for tea. Many products are standardized to a certain amount of triterpene glycosides, which are thought to be among the plant's active compounds.

How it works

Scientists are still not sure exactly how black cohosh works. Early ideas suggested it might act like the hormone estrogen, but most current research does not support that. Instead, it may affect brain chemicals and receptors involved in body temperature and mood, such as serotonin pathways.

The plant contains compounds called triterpene glycosides (including one called actein), along with other substances that may play a role. Much of what we know about these compounds comes from laboratory and animal studies, so it is not certain how they behave in the human body.

Effectiveness

Does Black Cohosh work?

Here’s what the research actually shows for each use — graded by Natural Medicines and reviewed by Dr. Brian Staiger, PharmD.

Evidence overview · 20 uses evaluated

1 Possibly effective 19 Insufficient evidence

How to read these evidence grades

Natural Medicines’ 7-point scale. We show each rating’s label word-for-word.

1EffectiveStrong, consistent evidence it works.

2Likely EffectiveGood evidence, though not yet conclusive.

3Possibly EffectiveSome evidence suggests a benefit.

4Possibly IneffectiveSome evidence it may not help.

5Likely IneffectiveFairly strong evidence it doesn’t help.

6IneffectiveStrong evidence it doesn’t work.

7Insufficient Reliable Evidence to RateToo little research to say either way.

Possibly Effective Menopausal symptoms