Which supplement used for menopause has rare risk of liver injury?

• A. Garlic
• B. Melatonin
• C. St. John's Wort
• D. Black cohosh

Answer: (D)

Herbal products used for menopause can carry liver safety concerns, even though such events are rare. Among these, black cohosh has the strongest signal for hepatotoxicity. There are case reports of various liver injuries linked to black cohosh, including hepatitis and cholestasis, in some instances progressing to acute liver failure. Because the exact cause isn’t fully understood, the risk is thought to be idiosyncratic or related to product quality in some cases. This is why liver monitoring and caution are advised with long-term use or when symptoms like jaundice, dark urine, or right upper quadrant pain appear.

Other commonly used supplements in this context—garlic, melatonin, and St. John’s Wort—do not have as clear or consistent a signal for liver injury. They have their own safety considerations (garlic’s bleeding risk and interactions, melatonin’s generally favorable liver safety profile, St. John’s Wort’s extensive drug interactions), but the specific rare risk of liver injury is most clearly associated with black cohosh. If you or a patient uses black cohosh, it’s prudent to monitor for liver symptoms and consult a clinician if any concerning signs arise.