Benign prostatic hyperplasia (BPH) is a disease, but it’s so common that it seems to be part of human nature. If BPH is natural, there ought to be a natural way to reduce its bothersome symptoms. And perhaps there is.
Although it’s usually translated into everyday language as “enlargement of the prostate,” BPH is actually a bit more complex. It begins with tiny microscopic nodules in the central transition zone of the prostate. Its location is important because the transition zone surrounds the urethra, the tube that carries urine from the bladder out through the penis. Over time, the nodules of BPH enlarge and become macroscopic nodules.
It’s a slow process that starts in midlife and continues at a steady pace; nearly all men who live to the age of 85 have these macroscopic nodules of BPH. But they won’t cause any trouble unless they press on the urethra, restricting the flow of urine through the narrow tube much as a gardener’s foot can pinch a hose. About 25% of all 80-year-old men have symptoms of BPH that are troublesome enough to require treatment, and many others have milder symptoms that they can manage with simple lifestyle adjustments. In all, symptoms of BPH account for more than 1.7 million visits to doctors’ offices each year, and the medical and surgical treatments of BPH cost more than $2 billion annually.
Nearly every man of a certain age will ask this important question, but doctors have no answer. Each man must answer it for himself, and his response will depend mainly on how much he is bothered by the symptoms of BPH. One group of complaints is caused by the obstruction of the urethra (the foot on the hose). They include a weak, slow urinary stream, hesitancy and straining to urinate, prolonged voiding, dribbling at the end of urination, an inability to empty the bladder completely, and nighttime urination (nocturia). The other group of symptoms results from irritation of the bladder. They may include an urgent, sometimes uncontrollable, need to void, the frequent passage of small amounts of urine, and nighttime urination.
Men with complications such as urinary bleeding, recurrent urinary tract infections, acute urinary retention, and kidney damage due to the back-up of urine (hydronephrosis) need treatment. Fortunately, these problems are relatively uncommon. Men with uncomplicated BPH can reasonably decide to “live with” symptoms that don’t impair their quality of life to a significant degree. And men who are bothered enough to seek treatment can choose among prescription drugs, an expanding array of surgical therapies, and self-treatment with herbs.
Throughout recorded history, men have used plants for healing. Even today, about 80% of the world’s population, mostly in developing countries, relies on herbal and traditional medicine. And botanical extracts also have an important role in the industrial world; nearly 25% of all prescription drugs contain an active ingredient derived from plants.
All the botanicals used in licensed medications have passed strict government tests for purity, efficacy, and safety. Herbs sold as “nutritional supplements” are exempt from similar review. Men who decide to try alternative remedies for prostate problems should always remember that herbal therapy is alternative medicine even if it goes by the scientific name phytotherapy.
Herbal treatments for the prostate have been popular for generations in Europe, but they didn’t get much attention in the United States until the early 1990s. Since then, they’ve taken off; by the end of the decade, American men were spending more than $150 million a year on a variety of plant-based products, and sales have continued to soar. Men can buy herbs for the prostate in nearly all health food stores, in many pharmacies, and through more than 100 Web sites.
It’s easy to get herbs — but is it wise? Unlike their Italian and German colleagues, who prescribe herbs for 50%–90% of patients with BPH, American physicians have been reluctant to recommend botanicals. They can hardly be blamed, since few of the products have been evaluated scientifically. That’s starting to change, at least in the case of saw palmetto, the most popular and promising product. But it is just one of the many herbal remedies that are being touted so aggressively these days. What are your choices — and should you try herbs for your prostate?
Although it’s been evaluated and prescribed most extensively in Europe, saw palmetto (Serenoarepens, the dwarf palm) is actually an American native — and by the 18th century, Native Americans in the southeastern United States were already using berries from the plant to treat a variety of male urinary and reproductive ailments. As the old ways faded, European settlers came to view the plant as a weed. Not anymore: In Florida alone, planters harvest more than 2,000 tons of the berries each year, earning over $50 million for their efforts.
Saw palmetto extracts are prepared from the ripe berries of the plant. Dozens of brands are available in the United States, but the one that has been studied most extensively in Europe is a French brand, Permixon. The usual dose is 160 mg twice a day, but American brands are exempt from government standards, so you can’t be sure the tablets fulfill the label’s claim. When Canadian scientists evaluated popular brands in 2002, they found these products contained from 3% to 140% of the stated dosage; half had less than 20%, and the contents in some brands varied by up to 25% from batch to batch. It’s a real problem for all unregulated supplements; the best solution is to choose a brand that’s been certified by a private organization such as the United States Pharmacopoeia, ConsumerLab.com, or NSF International.
The active ingredient in saw palmetto is not known; the extracts used medicinally contain a mix of fattyacids along with smaller amounts of sterols, flavonoids, and other compounds. In animal and laboratory experiments, saw palmetto displays several effects on the androgen and estrogen (male and female hormone) receptors on prostate cells. Like the prescription drugs finasteride (Proscar) and dutasteride (Avodart), saw palmetto inhibits the enzyme that converts testosterone to dihydrotestosterone (DHT), the hormone that’s most active in the prostate. But since saw palmetto is much less active than finasteride and dutasteride in this respect, it does not shrink the prostate gland, nor does it lower PSA levels, as the prescription drugs do.
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Living with BPH For many men, a few simple adjustments can reduce the bother of BPH. Here are a few tips:
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Does saw palmetto work? To find out, a team of American scientists evaluated 24 separate studies; 18 of them conformed to reasonable standards for randomized controlled clinical trials. The scientifically acceptable trials lasted from 4 to 48 weeks, but most were short; the overall average was 9 weeks. In all, the studies included 2,939 men between 40 and 88 years of age; the average age was 65. The great majority of the trials were performed in Europe and were originally published in European medical journals.
The American reviewers analyzed the 18 studies in a group, using a statistical method called metaanalysis. They found that saw palmetto generally produced a reduction in subjective urinary tract symptoms; compared with a placebo, the herb reduced nighttime voiding by 25% and other bothersome complaints by 28%. In addition, saw palmetto appeared to produce objective improvements in urinary flow, increasing the rate by 28% and reducing the volume of urine that remained in the bladder after voiding by 43%. Finally, saw palmetto appeared safe; the side effects reported were mild and did not differ significantly from problems that the men attributed to the placebos.
Saw palmetto appears to be a reasonable option for men with bothersome BPH — but before you stock up, consider several caveats. First, most of the research was done in Europe; scientific methods there may differ from American standards, and the saw palmetto preparations available in the United States may not have the same effect as European brands. Second, because the trials were brief, the long-term benefits (and possible risks) have not been evaluated. Third, only one trial compared saw palmetto with a prescription drug for BPH. In that six-month European study of 1,098 men with moderate to severe symptoms, saw palmetto was as good as finasteride. However, American trials show that alphablockers are more effective than finasteride, and saw palmetto has not been tested head-to-head against the current champs —though a new one-year French study found that a combination of saw palmetto and the alpha blocker tamsulosin (Flomax) was not any more effective than the alpha blocker alone. Finally, consider cost; although prices vary widely by brand, saw palmetto is usually less expensive than a prescription drug for BPH, but it is not covered by insurance.
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The zones of the prostate
 The prostate contains glandular cells, muscle cells, and stromal (supporting) cells that are organized into zones. The transition zone surrounds the urethra and is the site of BPH. The peripheral zone contains most of the glandular cells and is the most common site of prostate cancer. |
Despite these qualifications, saw palmetto may be worth a try. If you are attracted to herbal therapy and have bothersome symptoms, look for a reputable brand evaluated by an independent lab and comparison shop for price. In many cases, the house brand of a large drugstore chain is a good place to start. Give saw palmetto a month or so. If you feel better, continue to take it; if not, either switch brands for one more month try or discuss a prescription medication with your physician.
Saw palmetto may reduce the symptoms of BPH, but there are other things it cannot do: The herb won’t prevent BPH from developing in the first place, it won’t affect sexual function, and it has no role in the prevention or treatment of prostate cancer.
The other herbs sold for “prostate health” share exactly the same limitations as saw palmetto, and they have not been evaluated as carefully. Still, it’s important to consider the information that is available about the herbal competition.
Widely used in Europe since 1969, Pygeumafricanum is extracted from the bark of the African plum tree. It includes sterols, terpenoids, and alcohols. In laboratory experiments, the extracts slow the growth of prostate cells from rats; they may have a similar effect on human cells.
Most of the research on P. africanum has been conducted in Europe using the French brand Tadenan, usually in a dose of 100 mg a day. The herb is readily available in the United States in Prostata and many other brands, either alone or combined with other ingredients.
American scientists recently reviewed 18 studies of P. africanum that involved a total of 1,562 men. Unfortunately, the trials were generally brief, averaging nine weeks in length. In addition, the design of the individual studies varied considerably, making it difficult to arrive at firm conclusions. Given these qualifications, the herb appeared to reduce symptoms; nighttime urination decreased 19%, urine flow rates increased by 23%, and the volume of urine remaining in the bladder after voiding fell by 23%. Adverse effects were infrequent and mild.
Because more data are available with saw palmetto, P. africanum would appear to be a second choice for herbal therapy of BPH symptoms.
Beta sitosterol is the major component in extracts from Hypoxis rooperi, the South African star grass. Like the other botanicals, it is most popular in Europe, particularly in the German brand Harzol. American scientists who reviewed four European trials concluded that beta sitosterols might produce short-term improvements in the symptoms of BPH. In one study, the results were quite dramatic, and in another the improvements appeared to persist for up to 18 months. But more research is needed to see if the herb has the potential to be a star or if it’s just a twinkle in the eye of true believers.
Extracts from the roots of Urtica dioica, the stinging nettle, are widely used in Germany to treat BPH. They contain a mix of chemicals, including lectins, phenols, sterols, and lignans. Only a few small studies have been reported; the most recent trial demonstrated some benefit, but it used a liquid preparation that has been taken off the market because of its unpleasant flavor.
Extracts of Secalecereale (rye) pollen are marketed in Sweden as Cernilton. In a laboratory experiment, the extract appeared to inhibit the growth of prostate cells. One trial compared rye pollen to P. africanum and found them equal in their ability to reduce BPH symptoms. But much more research is needed to see if rye pollen has a role in the herbal therapy of BPH or if it’s just something to sneeze at.
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Medications for BPH Unless their complications from BPH are serious, men have the luxury of a number of options, ranging from learning to live with the symptoms to having an operation. And now, less invasive surgical treatments offer even more possibilities. But before heading to the operating room or a natural food store, most men should consider prescription medications. Two types are available. Alpha blockers relax the muscles in the prostate and bladder neck, easing the flow of urine in about 70% of men with BPH. Doxazosin (Cardura) and terazosin (Hytrin) are usually taken at bedtime. Because both can lower blood pressure, doctors usually start with a 1 mg dose, then gradually increase it to a maximum of 8 mg (doxazosin) or 10 mg (terazosin). The selective alpha blocker tamsulosin (Flomax) is less likely to affect blood pressure; the usual dose is 0.4–0.8 mg, taken 30 minutes after dinner. The newest member of the group is alfuzosin (Uroxatral), which rarely affects blood pressure; the usual dose is 10 mg a day, taken immediately after a meal. Unlike the alpha blockers, finasteride (Proscar) and dutasteride (Avodart) actually shrink the prostate gland by reducing the hormone DHT. Unfortunately, they take many months to work and are likely to help only men with rather large glands. The usual dose is 5 mg a day of finasteride or 0.5 mg of dutasteride. Both drugs lower the PSA, sometimes complicating screening for prostate cancer, and cause reversible erectile dysfunction in a small percentage of men. Although many men benefit from alpha blockers alone, a major new study suggests that the combination of an alpha blocker and a DHT inhibitor may work better than either drug alone, particularly for reducing the progression of BPH and preventing acute urinary retention. |
Men with BPH already have many therapeutic choices, ranging from living with their symptoms to prescription medications to surgical interventions. Still, many men with enlarging prostates will be glad that their choices are enlarging to include herbal therapy.
At present, the herb of greatest interest is saw palmetto. It has been beneficial in clinical trials, and few side effects have been reported. It’s reasonable for men with symptoms of BPH to consider taking 320 mg of saw palmetto a day. But before planting themselves in the herbal therapy camp, men should remember that herbal products are exempt from FDA standards for efficacy, safety, and purity. There is no guarantee that a product will provide what its label promises — and in the case of PC-SPES, at least, it may contain some surprising and unwelcome ingredients. Before choosing herbal therapy, men should inform their doctors and discuss the prescription drugs licensed for BPH. Most doctors are familiar with these medications, but few have any expertise with herbal remedies. It’s an unfortunate situation that leaves the choice to the patient, at least until information about herbs is rooted in medical science.
It’s clear that plants contain more than a seed of promise for men with BPH. It’s also clear that well-designed long-term trials in American men are needed to resolve lingering uncertainties. Research is the only way to learn if the seeds of promise will flower into treatments that can help relieve symptoms of BPH.
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Herbs that deliver more than they promise — and less Western medical science has a lot to learn about alternative and complementary medicine, and the National Center for Complementary and Alternative Medicine is funding new research for that purpose. Objective research has already provided support for saw palmetto as a treatment for BPH, but not all the information is so positive. PC-SPES is a case in point. A mix of eight herbs that was brought to the United States from China in 1996, it was heavily promoted as a treatment for prostate cancer. Self-treatment for BPH is one thing, self-treatment for cancer quite another. But medical studies showed that PC-SPES was active against some prostate cancers, at least briefly, and at least 10,000 men paid up to $486 a month to try it. Then the roof fell in. First, it became clear that any benefit depended on the product’s estrogen-like effects — and that it had the same potentially serious side effects as high-dose estrogen therapy. Next, researchers found that the product was contaminated with prescription medications, including the potent estrogen diethylstilbestrol (DES), the anticoagulant warfarin (Coumadin), and the anti-inflammatory indomethacin (Indocin). Exit PC-SPES, enter the lawyers. PC-SPES delivered less benefit than it claimed and provided more chemicals, and side effects, than it admitted. This case should caution men about all supplements. How could this happen? Unfortunately, the 1994 Dietary Supplement and Health Education Act removed supplements, classified as “dietary aids” from FDA jurisdiction. |
