Autoimmune hepatitis associated with the use of black cohosh: a case study Stanley M. Cohen, MD, Anne M. O’Connor, MD, John Hart, MD, Nina H. Merel, MD, and Helen S. Te, MD ABSTRACT Herbal remedies generate more than $1.8 billion in annual sales in the United States. Herbal products have been associated with a wide spectrum of hepatic toxicities. With the recent Women’s Health Initiative Study demonstrating increased risk of breast cancer and cardiovascular events associated with hormone therapy, many women may resort to herbal remedies for persistent meno- pause symptoms. We report a case of autoimmune hepatitis likely triggered by the use of black cohosh (Actaea racemosa), an agent marketed to treat menopause symptoms. Given this case re- port, we recommend close monitoring of women using this herbal preparation. Key Words: Black cohosh – Actaea racemosa – Autoimmune hepatitis – Complementary and alternative medications – Phytoestrogens. E strogen and related compounds have been used to relieve symptoms associated with menopause. However, recent data from the Women’s Health Initiative (WHI) have shown that the use of combined estrogen plus progestin is associated with an increased risk of breast cancer, cardiovascular events, strokes, and pulmonary em- boli. 1 Based on this data, many women have discontin- ued or been taken off hormone therapy. Some women have resorted to the use of phytoestrogens and other herbal supplements. Herbal products have been associ- ated with a wide spectrum of hepatic toxicity. We re- port the first case of autoimmune hepatitis likely trig- gered by the use of black cohosh (Actaea racemosa), an herbal product marketed to treat menopause symptoms. CASE REPORT A 57-year-old woman presented with a 2-week his- tory of lethargy and fatigue. Her past history was sig- nificant for diabetes, polymyositis, obstructive sleep apnea, and hypertension. She had no history of liver disease. Her medications (all of which had been used for more than 2 years) included labetalol, fosinopril, verapamil, metformin, aspirin, and insulin. She also had been on hormone therapy with estrogen and pro- gesterone for several years; however, this was discon- tinued by her physician 6 months earlier based on data from the WHI study. Three weeks before presentation, the woman began using black cohosh tablets (unknown brand or dose) for hot flashes. She had no history of allergies. Family history revealed no liver disease or autoimmune diseases. The woman denied using alco- hol, tobacco, or drugs. She had no history of transfu- sions, tattoos, recent travel, or contact with others who were ill. A review of systems was otherwise negative. Physical examination was completely unrevealing. Laboratory data revealed significant elevations in the aspartate aminotransferase (AST) and alanine ami- notransferase (ALT) levels, with only a mildly elevated alkaline phosphatase (Fig. 1). The prothrombin time in- ternational normalized ratio (INR), complete blood cell count (CBC), electrolytes, albumin, and bilirubin were normal. Liver tests 9 months earlier had been normal. Serologies for hepatitis A, B, and C were negative. An- tinuclear antibody titer was positive at 1:640, homoge- neous pattern. An antinuclear antibody (ANA) titer from 4 years earlier had been negative. Smooth muscle antibody titer was negative. Right upper quadrant ultra- sound with Dopplers was unrevealing. Liver biopsy re- Received January 8, 2004; revised and accepted February 18, 2004 University of Chicago, Division of Gastroenterology, Liver Study Unit, Chicago, IL. Address correspondence to: Stanley Martin Cohen, MD, Rush Univer- sity Medical Center, Section of Hepatology, 1725 W. Harrison St., Suite 158, Chicago, IL 60612, USA. E-mail: skimdsmc@aol.com. Menopause: The Journal of The North American Menopause Society Vol. 11, No. 5, pp. 575-577 DOI: 10.1097/01.gme.0000142914.55849.6a © 2004 The North American Menopause Society   Text printed on acid-free paper. Menopause, Vol. 11, No. 5, 2004 575