Black cohosh was choice as a first line of treatment for perimenopausal heart palpitations. Other women start taking HRT, then decide they would like to switch to black cohosh to see if it will take care of their symptoms. The transition from HRT to black cohosh should be made gradually over a five-to-eight-week period, following these steps:

1. Evaluate the importance of heart and bone protection with your health care provider. Black cohosh probably does not provide this protection. If your cardiovascular health is not an issue but your goal is to build bone strength, black cohosh can be taken with natural progesterone, which has bone-building properties.

2. Begin adding soy to your diet, and be certain you are getting adequate amounts of calcium daily (1500 mg). Boosting your soy and calcium intake is a gentle and natural way to protect your heart and bones.

3. Begin taking black cohosh (40 mg daily to begin) while you are still taking HRT.

4. For the first three to four weeks of the combined HRT/black cohosh regimen, gradually taper your dosage of estrogen. For instance, if you have been taking 1 mg of estrogen daily, take 1 mg one day and 0.5 mg every other day. Remember that you must continue to take a form of progesterone even as you taper down your estrogen, and that you are still taking black cohosh daily. Continue to take progesterone at your regular dosage; do not taper down the dosage of this hormone.

5. After three to four weeks, reduce your estrogen again, taking half your normal dosage every day. Follow this reduced estrogen dosage for two to three weeks, continuing with the black cohosh.

6. Then for one week, take half of your normal dosage of estrogen every other day. You may then discontinue the estrogen and take black cohosh along with progesterone if you choose. Black cohosh does not have to be opposed by progesterone the way estrogen does, but some women choose to take the combination of black cohosh with progesterone.

The literature on black cohosh states that its side effects are minimal, a very few patients will report stomach upset. But I have heard a few women report that the maximum dosage of 160 mg per day made them feel like their breasts were engorged. If this occurs, lowering the dose to 80 mg per day should take care of the side effect. Although no toxic effects are associated with black cohosh, you may want to use it to provide short-term relief from specific symptoms.

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