Pharmacologist Jerry Cott, Ph.D., of College Park, Maryland, knows how to evaluate the safety and effectiveness of drugs. For four years, he reviewed new drug applications for the Food and Drug Administration (FDA). Cott doesn’t distinguish between pharmaceuticals and herbal medicines. “They both have pharmacological effects,” he says. He’s become an expert on herbal pharmacology, serving as an adviser to the nation’s leading herb education organization, the American Botanical Council in Austin, Texas. Every day, Cott takes an herbal medicine, saw palmetto (Serenoa repens), to prevent the urinary bane of men older than fifty—noncancerous enlargement of the prostate gland, or benign prostatic hypertrophy (BPH), also known as benign prostatic hyperplasia.
“I’m fifty-five and don’t have BPH yet,” Cott explains. “There’s no proof that saw palmetto prevents it, but based on its mechanism of action, it should help. The great thing about saw palmetto is that it’s safe. The pharmaceuticals used to treat BPH all have side effects. I wouldn’t take any of them for BPH prevention. But saw palmetto is safe and it’s cheap. So I figure: Why not?”
BPH is a men’s health condition, but it’s also of concern to women. Women are often the caretakers of family health; they are often the ones husbands and male relatives turn to for health advice. Women should recognize BPH, understand its symptoms, and encourage men who develop those symptoms to treat the condition.
The prostate is a walnut-sized, donut-shaped gland located below a man’s bladder. It produces most of the fluid in semen. It also has a tube running through it, the urethra, which carries both urine and semen out of a man’s body.
Until middle age, most men hardly know they have a prostate. But after age thirty, the gland starts growing. Prostate growth might signal cancer, which is why men older than forty-five should have annual prostate checks. But most midlife prostate growth is noncancerous BPH.
As BPH progresses, the swelling prostate pinches the urethra. It’s painless, but it causes urinary difficulties: the feeling that you need to urinate immediately (urgency), difficulty getting started (hesitancy), decreased flow, difficulty finishing (dribbling), and having to get up at night to urinate (nocturia). By the time a man reaches fifty—often earlier—he can expect to get up at least once a night.
The prostate swells because of age-related hormonal changes. Blood levels of testosterone decline, while levels of other hormones, notably prolactin, increase. The ultimate result is an increase in the male sex hormone dihydrotestosterone (DHT) in the prostate. DHT causes BPH by stimulating the growth of prostate tissue. An enzyme, 5-alpha-reductase, converts testosterone to DHT. Both the herbal treatments and the main pharmaceutical treatment, Proscar (finasteride), work by interfering with this enzyme’s action.
Saw palmetto is a dwarf palm tree native to the southeastern United States. Native Americans of Florida and the Gulf Coast recognized its diuretic properties and for centuries used the plant’s fruit to treat urinary problems. During the nineteenth century, herbally inclined Eclectic physicians, forerunners of today’s naturopaths, adopted the plant. The Eclectic text King’s American Dispensatory (1898) said saw palmetto “reduces hypertrophy of the prostate, and has been lauded as ‘the old man’s friend.’ It is also reputed to strengthen the sexual appetite. Long continued use is said to slowly and surely cause women’s mammary glands to enlarge.” Saw palmetto has never been shown to increase either libido or breast size. But during the 1960s, European herbal medicine researchers discovered that the herb’s fruit contains fatty acids (liposterols) that act as 5-alpha-reductase inhibitors, validating the Eclectics’ use of the herb for BPH.
A dozen studies have shown that saw palmetto relieves BPH symptoms. The following are some examples.
- European researchers compared saw palmetto extract head-to-head against Proscar. The researchers gave the 1,098 participants either the herb (160 mg twice a day) or the drug (5 mg a day). After twenty-six weeks, both treatments showed about equal effectiveness. Proscar decreased BPH symptoms 39 percent, versus 37 percent for saw palmetto. Urine flow improved 30 percent in those taking the drug, 25 percent in men taking the herb. But saw palmetto caused fewer erection problems and less libido loss than the drug.
- A similar German comparison of saw palmetto and Proscar showed the same results. The researchers gave 309 men one or the other. Three years later, both groups showed about a 30 percent decrease in symptoms.
- Belgian researchers gauged BPH symptoms in 505 men, then gave them saw palmetto extract. Six weeks later, their prostates were smaller, their urine flowed more freely, and they reported significantly improved quality of life. After ninety days on the herb, 88 percent of the men called the treatment “effective.”
- Even the medically conservative—and historically anti-herb—Journal of the American Medical Association has published a positive saw palmetto study. Researchers in Minneapolis reviewed eighteen rigorous studies of the herb involving almost 3,000 men. Their conclusion: “Saw palmetto improves urologic symptoms and [urine] flow. Compared with Proscar, the herb produces similar improvement and was associated with fewer adverse reactions.”
The only reported side effect of saw palmetto is occasional, mild abdominal distress. Commission E, the German expert panel that judges the safety and effectiveness of herbal medicines for that nation’s counterpart of the FDA, endorses saw palmetto for BPH. An estimated 90 percent of German men with BPH use the herb to treat their symptoms.
Saw palmetto studies have used a standardized extract of the herb, 320 mg a day, split into two doses. But one daily dose would be more convenient. Recently, in a study of 100 men, European scientists compared two saw palmetto regimens: the standard two doses a day (160 mg each time), or one daily dose (320 mg). The single dose produced the same symptom improvement as the two smaller doses. Look for a standardized extract and take 320 mg once a day.
“I’m betting my prostate on saw palmetto,” says noted Maryland botanist and herbalist James Duke, Ph.D., author of The Green Pharmacy (Rodale, 1997) and other herb books. Duke, now seventy-two, has used the herb for six years to control his BPH. “My symptoms haven’t gotten any worse,” he says.
Pygeum: African prune
For centuries, southern Africans have used a tea made from the powdered bark of the pygeum tree (Pygeum africanum) to treat urinary problems. European researchers discovered that pygeum is rich in the 5-alpha-reductase inhibitor beta-sitosterol. A standardized extract has become a popular BPH treatment in Europe, based on several studies showing significant benefits.
Recently, researchers at the Minneapolis Veterans Affairs Hospital analyzed eighteen studies of pygeum involving more than 1,500 men. Compared with the placebo group, those who took pygeum enjoyed a significant decrease in nighttime urination and a significant increase in urinary flow. Side effects were mild and similar to those reported by the placebo group. The researchers concluded that the herb “significantly improves” BPH symptoms.
In pygeum studies, men using the herb took either 100 mg once daily or 50 mg twice. Both regimens produced equivalent benefits. French researchers confirmed this in a recent study involving 209 men, half of whom used each regimen for one year. Both groups recorded similar improvement. If you take pygeum, it’s most convenient to take 100 mg once a day.
Back in 1959, a Swedish urologist showed that pollen extracts of rye and other flowers help treat BPH. The product he developed, Cernilton, became popular in Scandinavia, and spread to England, where it is called ProstaBrit. The pollens contain natural 5-alpha-reductase inhibitors. Several studies show benefit.
- In a British study, sixty BPH sufferers took either a placebo or Cernilton. After six months, 30 percent of the placebo group reported improvement, but among those taking Cernilton, the figure was 69 percent.
- Polish researchers gave either Cernilton or a placebo to eighty-nine BPH sufferers. Four months later, 55 percent of the placebo group reported benefit, but in the Cernilton group, the figure was 78 percent. (At four months, this study was shorter than the six months recommended to show significant Cernilton benefits.)
Cernilton/ProstaBrit is available in some U.S. health-food stores in 189-mg capsules. The recommended dose is 2 capsules a day. It appears to be safe. In the studies, side effects were similar to those experienced by the placebo groups. But to be safe, don’t use this product if you have pollen hay fever.
In Turkey, Bulgaria, and the Ukraine, the traditional BPH remedy is pumpkin seeds. Duke is a believer. He snacks on handfuls of seeds, and blends them into a butter he calls “prosnut” butter. Pumpkin seeds, he explains, contain compounds called cucurbitacins that help prevent the conversion of testosterone into DHT. Two European studies show benefit.
- Swedish scientists gave either pumpkin seed extract or a placebo to fifty-three men with BPH. Three months later, the pumpkin seed group reported significantly greater relief with no side effects.
- German researchers gave pumpkin seed extract to 2,245 BPH sufferers. After twelve weeks, their symptoms decreased 41 percent and their quality of life improved 46 percent, with no side effects. There was no placebo group, so this study can’t be considered scientifically rigorous.
Alan Brauer, M.D., a Palo Alto, California-based physician who combines mainstream and alternative therapies, says that despite these studies, in his experience pumpkin seeds by themselves don’t do much to control BPH. “But in combination with saw palmetto and pygeum, they help,” he says.
Pumpkin seeds are also one of the richest plant sources of the essential trace mineral zinc—8 mg per half-cup serving. (Most supplements provide 10 to 30 mg.) Some research suggests that the mineral is a 5-alpha-reductase inhibitor, which would help treat BPH. In addition, an adequate zinc level is essential for men’s reproductive health.
Pumpkin seeds are sold in health-food stores and supermarkets. They can also be scooped from pumpkins, shelled, and roasted.
African star grass
Pygeum is not the only African herb used to treat BPH. South African herbalists have long recommended South African star grass root (Hypoxis rooperi) for prostate enlargement. European researchers have shown that this herb contains 5-alpha-reductase inhibitors. Recent studies show that it helps relieve BPH.
- German researchers gave 200 BPH sufferers either a placebo or star grass root (20 mg) three times a day. The placebo group showed no change in urine flow, but men taking the herbal extract experienced significantly increased flow.
- Another German team gave either a placebo or an herb extract (130 mg a day) to 177 men with BPH. Six months later, the placebo group showed no change in symptoms, but those taking the star grass extract showed significant improvement.
This herb is not easy to find in the United States. It has not been well-researched. It appears to be safe, but questions remain. The optimal dose remains unclear. The two studies used 20 mg and 130 mg a day.
Other helpful approaches
BPH expert Herbert Lepor, M.D., a professor of urology at New York University School of Medicine, offers men these tips.
- Take your time. As BPH develops, it takes longer to start urinating and even longer to finish. Don’t rush. Relax at the urinal, which helps start urine flow. Take extra time at the end, which helps push out the last few drops.
- Don’t drink fluids after 7 p.m.
- Watch the caffeine. Caffeine is a urinary irritant. Some men notice improvement in BPH symptoms when they limit consumption of coffee, tea, colas and chocolate.
- Check your medicine cabinet. Certain medications can aggravate BPH symptoms, among them: cold formulas and drugs for ulcers, irritable bowel syndrome, depression, and high blood pressure (hypertension). Check with your physician or pharmacist to see if any medications you take might aggravate BPH symptoms. If so, other drugs might be able to be substituted.
Last resorts: Pharmaceuticals and surgery
Herbal approaches clearly help control BPH with mild, if any, side effects. But they don’t always provide sufficient relief. Men who still get up several times a night despite herbal treatment should consider mainstream therapy—drugs or surgery.
Doctors currently prescribe any of three drugs to treat BPH: Proscar, Flomax (tamsulosin), and Hytrin (terazosin). All three are effective. However, Proscar may cause liver toxicity. If you take it, periodic liver-function tests are a good idea. Flomax and Hytrin may cause dizziness, sleepiness, loss of muscle strength, and in rare cases, impotence and loss of libido.
The surgical approach is called transurethral resection of the prostate (TURP). Under general anesthesia, the surgeon threads a flexible tube up the man’s urethra and snips away enough overgrown prostate tissue to relieve urethral pinching. TURP requires a few days of hospitalization and a week or two of recovery at home. TURPs usually provide long-term relief of BPH symptoms, but the operation carries a small risk of infection, incontinence, and erection impairment. Additionally, after a TURP, a strange thing happens during sex. Although orgasm feels the same, the man ejaculates into his bladder (known as retrograde ejaculation or dry orgasm) instead of from the penis. Semen then leaves the body during urination. Although post-TURP dry orgasm impairs fertility, an issue in some marriages, some couples like the change because lovemaking becomes less messy. If you opt for a TURP, understand that retrograde ejaculation is quite common afterward. Be emotionally prepared for it.
While drugs and surgery may become necessary for some men, others manage BPH on herbs alone, among them James Duke. “At my last check-up, my doctor said, ‘Just keep doing what you’re doing’,” Duke says.
San Francisco health writer Michael Castleman specializes in herbal medicine. His latest book is The New Healing Herbs (Rodale, 2001).