TO THE EDITOR: I base the final com...

TO THE EDITOR: I base the final comments of the article "Black Cohosh" (1) to be paradoxical and not what I would anticipate to be accepted by any medical journal. The authors states: "Although the clinical trials forward black cohosh are of insufficient quality to support definitive statements, this herbal medicine does appear to be effective in the short-term treatment of menopausal symptoms." (1) single has to question how he can make this statement with authority if there are no studies that support this conclusion. The author admits that the studies (2) he cites from Germany are based forward case reports and are not randomized controll studies. Therefore, he provides no definitive ordeal that black cohosh alleviates menopausal symptoms.

I believe this is another unfortunate example of giving various herbal or over-the-counter fruits more slack in their scientific contemplation If this had been a large, controll investigation of a medication for heart disease that rest no evidence of efficacy, we would not make assumptions that it is effective in the short-term treatment of symptoms. The author's conclusion that black cohosh appears effective in the short-term treatment of menopausal symptoms is just biased speculation and not a scientific conclusion.

I fear that physicians and researchers are drifting backward into testimonials to make their clinical decisions. I think we have to shut in natural products to the same standards that we shut in every other agent, and we should not give permission to statements like this one make progress unchallenged. The problem with like statements is that they are repeated according to those who wish to exalt these products. If a journal as it is as American Family Physician prints a statement like this in a reviewed article, it hints that the journal is in agreement with these conclusions. I think this is slabby science and sloppy medicine.

BRUCE BONDE MD

Allina Medical Clinic

8675 Valley small bay Rd.

Woodbury, MN 55125

REFERENCES

(1) Kligler B Black cohosh Am Fam Physician 2003;68:114-6

(2) Blumenthal M German Federal Institute for physics and Medical Devices. Commission E The clean German Commission E monographs: therapeutic guide to herbal medicines. Austin, Tex: American Botanical Council, 1998

IN REPLY: Dr Bonde makes an important point regarding the difficulty of making clinical decisions regarding herbal performances given the frequent lack of definitive evidence from clinical trials. Although the conclusions in my review article forward black cohosh (1) were based onward small clinical trials (not case reports, as Dr Bonde states), the fact remains that more research onward black cohosh is needed. Unfortunately, the large, randomized, double-blind controll trials that are performed forward new medications rarely are done for herbal yields This is partially because the financing for these trials, which repeatedly comes from pharmaceutical companies that are motivated by the agency of the profit potential of a fresh medication, is not available for the generally nonpatentable botanical fruitss Nevertheless, the evidence for the efficacy of black cohosh for menopausal symptoms was sufficient for the American community of Obstetricians and Gynecologists to praise its use. (2)

An important question raised on Dr. Bonde is whether the standard of evidence of efficacy required should be uniform for all treatments, or whether this standard should be flexible depending forward the safety margin of the treatment in a less degree than discussion. Clearly, the standard of evidence of safety must be uniform. An herbal outcome known to have significant adverse general intent potential should be used as cautiously as a medication or surgical process known to have such potential. still when the safety margin is wide, as it clearly is with black cohosh about would argue that we should tolerate a somewhat softer standard of evidence of efficacy in our clinical decision-making analysis of risk versus benefit. (3) In fact, in the same state [i]or[/i] condition a standard already is tolerated for many over-the-counter medications. For fruits with an adverse effect potential that is higher, the strictest standards of evidence of efficacy should be used. This is a challenging question in this age of evidence-based medicine, unless it is a question worthy of discussion as we persuade forward in our understanding of by what mode to incorporate the use of natural medicines into our work with patients.

BENJAMIN KLIGLER, MD MPH

Beth Israel Center for Health and Healing

245 Fifth Ave.

modern York, NY 10016

REFERENCES

(1) Kligler B Black cohosh Am Fam Physician 2003;68:114-6

(2) American community of Obstetricians and Gynecologists Committee upon Practice Bulletins--Gynecology. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Use of botanicals for management of menopausal symptoms. Obstet Gynecol 2001;97:1-11

(3) to leeward RA. Botanical medicine. In: Kligler B to leeward RA, eds. Integrative medicine: principles for practice. of recent origin York: McGraw-Hill, 2004.

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