Saw Palmetto Extract: Nature’s Answer to Prostate Enlargement

The prostate is a single, doughnut-shaped gland about the size of walnut that lies below the bladder and surrounds the urethra. The prostate secretes a thin, milky, alkaline fluid which lubricates the urethra to prevent infection and increases sperm motility. Prostate secretions are extremely important to successful fertilization of the egg.

Benign (non-malignant) enlargement of the prostate gland is known medically as “benign prostatic hyperplasia” or BPH for short. Because an enlarged prostate can pinch off the flow of urine, BPH is characterized by symptoms of bladder obstruction such as increased urinary frequency, nighttime awakening to empty bladder, and reduced force and caliber of urination.

How common is BPH?

Very. Current estimates are that it affects over 50% of men in their lifetime. The actual frequency rate increases with advancing age from approximately 5-10% at age 30 to over 90% in men over 85 years of age.1

How is BPH diagnosed?

It is often recommended that men over the age of 40 have yearly prostate exams. This exam is not high tech. It simply involves a doctor inserting a gloved finger into the rectum and feeling the lower part of the prostate for any abnormality. However, in the case of BPH, often the prostate has not enlarged to a point recognized by physical exam. And, in the case of cancer, a digital exam is not reliable enough.

The classic enlarged prostate due to BPH will usually feel softer (boggy) than normal and may be two to three times larger than normal. In BPH the prostate is non-tender, this differentiates it from prostatitis. The classic finding in prostatic cancer is that the prostate feels much harder and the border is not as well defined.

The definitive diagnosis for BPH can be made with the aid of ultrasound measurements. But, because the symptoms of BPH and prostate cancer can be quite similar, a simple blood test is used to differentiate BPH from the more serious prostate cancer. The blood test measures the levels of a protein that is produced in the prostate – prostate-specific antigen (PSA). The PSA test is regarded as a highly significant and sensitive marker for prostate cancer. The normal value for PSA is less than 4 nanograms per milliliter. An elevation above 10 is highly indicative of prostate cancer.

There has been concern that the use of PSA as a screening test for prostate cancer is not reliable enough. Although an elevated level indicates prostate cancer about 90%, it must be kept in mind that mid-range elevations in PSA can be caused by BPH and that in some instances there may be prostate cancer yet PSA levels are not elevated. Despite the fact that this test is not perfect, it is a simple, relatively non-invasive test that can provide valuable information. PSA screening has been endorsed by the American Cancer Society, the American Urological Association, and other physicians’ groups.

If you are a man over the age 50 and if any of your immediate relatives – father, brother, or uncle – has had prostate cancer, an annual prostate exam and PSA test is a very good idea.

WARNING:PROSTATE DISORDERS CAN ONLY BE DIAGNOSED BY A PHYSICIAN. DO NOT SELF-DIAGNOSE. IF YOU ARE EXPERIENCING ANY SYMPTOMS ASSOCIATED WITH BPH OR PROSTATE CANCER, SEE YOUR PHYSICIAN IMMEDIATELY FOR PROPER DIAGNOSIS.

What causes BPH?

BPH is largely the result of hormonal changes associated with aging. It is clearly dependent upon the actions of male hormones (androgens) within the prostate. These changes within the prostate reflect the many significant changes in both male (androgen), female (estrogen), and pituitary hormone levels in aging men. The main male sex hormone testosterone (T) decreases with advancing age, but estrogen, prolactin, LH, and FSH levels are all increased. The ultimate effect of these changes is that within the prostate gland there is an increased concentration of testosterone and an increased conversion of this testosterone to an even more potent form known as dihydrotestosterone (DHT). The increase in testosterone and DHT is largely due to a decreased rate of removal combined with and increase in the activity of the enzyme 5-alpha-reductase, the enzyme that converts testosterone to DHT.2 Elevated estrogen levels are thought to be the key factor which inhibits the elimination of DHT from the prostate in BPH.

Is having an enlarged prostate dangerous?

If left untreated, BPH will eventually obstruct the bladder outlet resulting in the retention of urine and eventually kidney damage. As this situation is potentially life-threatening, proper treatment is crucial. In the past, medical treatment involved a procedure known as a TURP (trans-urethral resection of the prostate). Because this surgery is associated with a high rate of morbidity and will often make matters worse, it should be avoided unless absolutely necessary.

Are herbal medicines effective in the treatment of BPH?

Yes. But, the chance of clinical success with any of the botanical treatments of BPH appears to be determined by the degree of obstruction as indicated by the residual urine content (the amount of urine left in the bladder after urination as determined by ultrasound). For levels less than 50 ml, the results are usually excellent. For levels between 50 and 100 ml, the results are usually quite good. Residual urine levels between 100 ml and 150 ml will be tougher to produce significant improvements in the customary 4 to 6 week period. If the residual urine content is greater than 150 ml, saw palmetto extract and other botanical medicines are not likely to produce any significant improvement.

Is common in other parts of the world?

Yes. Interestingly, however, is the fact that in other parts of the world (particularly Europe) herbal treatments are more popular than drug therapy. According to a recent review article published in the British Journal of Urology plant-based medicines are much more popular prescriptions in Europe than their synthetic counterparts.29 Specifically in Germany and Austria botanical medicines are considered “first-line” treatments for BPH and account for greater than 90% of all drugs in the medical management of BPH. In Italy, plant extracts are prescribed 10 times more frequently than drugs like Proscar and Hytrin.29-31

There are about 30 different plant-based compounds currently available in Europe for the treatment of BPH. But, the most popular (and seemingly most effective) is the extract of saw palmetto berry.

What is saw palmetto extract?

Is is an extract made from the fruit of a palm tree (Serenoa repens) native to Florida that has been shown to significantly improve the signs and symptoms of BPH in numerous clinical studies. The mechanism of action is related to improving the hormonal metabolism within the prostate gland. As a result of multitude of effects, excellent results have been produced in numerous clinical studies. In summary, it can be stated that roughly 90% of men with mild to moderate BPH experience some improvement in symptoms during the first 4 to 6 weeks of therapy. All major symptoms of BPH are improved, especially nocturia.32-45

Although the saw palmetto extract has been shown excellent results in numerous clinical trials, results from a recent study are perhaps the most revealing.44 In this study, 305 men were given a dosage of 160 mg of the saw palmetto extract standardized to contain 85 to 95% fatty acids and sterols twice daily. After 45 days, 83% of patients estimated the drug was effective. After 90 days, the percentage increased to 88%. Similarly, global evaluations made by physicians after 45 and 90 days demonstrated 81% and 88% effectiveness, respectively. The objective evaluations demonstrated remarkable improvements in all measurements. Maximum urinary flow (ml/s) increased from 9.8 to 12.2, mean urinary flow rate (ml/s) increased from 5.8 to 7.4, prostate volume (mm³) decreased from 40,348 to 36,246; and the international prostate symptom score decreased from 19.0 to 12.4. No serious adverse reactions were reported.

While these results are impressive, perhaps the most impressive changes occurred in the quality of life scores as shown in Table 2.

Table 2. Quality of life scores

These improvements in quality of life scores demonstrate just how powerful of an effect that improving bothersome symptoms such as nocturia can have on an individuals mental outlook. Many men suffering from an enlarged prostate suffer from sleep deprivation. Improving sleep by reducing the number of times for nighttime urination is thought to be the major reason for the improvement in quality of life scores with saw palmetto extract. Another important finding from this study was that the saw palmetto extract had no demonstrable effect on serum prostatic specific antigen (PSA) levels.

How soon should I expect to see results with saw palmetto extract?

While the drug finesteride (Proscar) typically takes up to a year to produce significant benefit, saw palmetto extract produces better results in a much shorter period of time. Most patients achieve some relief of symptoms within the first 30 days of treatment with the saw palmetto extract.

Table 3 – Saw Palmetto Extract vs. Finesteride on Urine Flow Rate (ml/sec):
Pooled Data from Double-blind Studies

References:

1. Oesterling JE: Benign prostatic hyperplasia: a review of its histogenesis and natural history. Prostate 6(Suppl.):67-73, 1996
2. Horton R: Benign prostatic hyperplasia: A disorder of androgen metabolism in the male. J Am Geri Soc 32:380-5, 1984
3. Kappas A, Anderson KE, Conney AH, et al.: Nutrition-endocrine interactions: Induction of reciprocal changes in the delta-5-alpha- reduction of testosterone and the cytochrome P-450-dependent oxidation of estradiol by dietary macronutrients in man. Proc Natl Acad Sci USA 80:7646-9, 1983
4. Bush IM, et al.: Zinc and the prostate. Presented at the annual meeting of the AMA, 1974
5. Fahim M, Fahim Z, Der R, and Harman J: Zinc treatment for the reduction of hyperplasia of the prostate. Fed Proc 35:361, 1976
6. Leake A, Chrisholm GD, Busuttil A, and Habib FK: Subcellular distribution of zinc in the benign and malignant human prostate: Evidence for a direct zinc androgen interaction. Acta Endocrinol 105:281-8, 1984
7. Zaichick VY, et al.: Zinc concentration in human prostatic fluid: normal, chronic prostatitis, adenoma and cancer. Int Urol Nephrol 28:687-94, 1996
8. Leake A, Chisholm GD, and Habib FK: The effect of zinc on the 5-alpha-reduction of testosterone by the hyperplastic human prostate gland. J Steroid Biochem 20:651-5, 1984
9. Wallae AM and Grant JK: Effect of zinc on androgen metabolism in the human hyperplastic prostate. Biochem Soc Trans 3:540-2, 1975
10. Judd AM, MacLeod RM, and Login IS: Zinc acutely, selectively and reversibly inhibits pituitary prolactin secretion. Brain Res 294:190-2, 1984
11. Login IS, Thorner MO, and MacLeod RM: Zinc may have a physiological role in regulating pituitary prolactin secretion. Neuroendocrinology 37:317-20, 1983
12. Farnsworth WE, Slaunwhite WR, Sharma M, et al.: Interaction of prolactin and testosterone in the human prostate. Urol Res 9:79-88, 1981
13. Farrar DJ and Pryor JS: The effect of bromocriptine in patients with benign prostatic hyperplasia. Br J Urol 48:73-5, 1976
14. DeRosa G, Corsello SM, Ruffilli MP, et al.: Prolactin secretion after beer. Lancet 2:934, 1981
15. Corenblum B and Whitaker M: Inhibition of stress-induced hyperprolactinaemia. Br Med J 275:1328, 1977
16. Chyou PH, et al.: A prospective study of alcohol, diet, and other lifestyle factors in relation to obstructive uropathy. Prostate 22:253-64, 1993
17. Hart JP and Cooper WL: VItamin F in the treatment of prostatic hyperplasia. Report Number 1, Lee Foundation for Nutritional Research, Milwaukee, Wi, 1941
18. Scott WW: The lipids of the prostatic fluid, seminal plasma and enlarged prostate gland of man. J Urol 53:712-8, 1945
19. Boyd EM and Berry NE: Prostatic hypertrophy as part of a generalized metabolic disease. Evidence of the presence of a lipopenia. J Urol 41:406-11, 1939
20. Dumrau F: Benign prostatic hyperplasia: Amino acid therapy for symptomatic relief. Am J Ger 10:426-30, 1962
21. Feinblatt HM and Gant JC: Palliative treatment of benign prostatic hypertrophy: Value of glycine, alanine, glutamic acid combination. J Maine Med Assoc49:99-102, 1958
22. Hinman F: Benign Prostatic Hyperplasia. Springer-Verlag, New York, 1983
23. Tilvis RS and Miettinen TA: Serum plant sterols and their relation to cholesterol absorption. Am J Clin Nutr 43:92-7, 1986
24. Berges RR, et al.: Randomized, placebo-controlled, double-blind clinical trial of beta-sitosterol in patients with benign prostatic hyperplasia. Lancet 345:1529-32, 1995
25. Morton MS, Griffiths K and Blacklock N: The preventive role of diet in prostatic disease. Br J Urol 77:481-93, 1996
26. Messina M and Barnes S: The roles of soy products in reducing risk of cancer. J Natl Cancer Inst 83:541-6, 1991
27. Lahtonen R: Zinc and cadmium concentrations in whole tissue and in separated epithelium and stroma from human benign prostatic hypertrophic glands. Prostate 6:177-83, 1985
28. Sinquin G, et al.: Testosterone metabolism by homogenates of human prostates with benign hyperplasia: Effects of zinc, cadmium, and other bivalent cations. J Steroid Biochem 20:733-80, 1984
29. Buck AC: Phytotherapy for the prostate. Br J Urol 78:325-36, 1996
30. Lowe FC and Ku JC: Phytotherapy in treatment of benign prostatic hyperplasia: A critical review. Urology 48:12-20, 1996
31. Bach D, Schmitt M and Ebeling L: Phytopharmaceutical and synthetic agents in the treatment of benign prostatic hyperplasia. Phytomed 3:309-13, 1996
32. Boccafoschi and Annoscia S: Comparison of Serenoa repens extract with placebo by controlled clinical trial in patients with prostatic adenomatosis. Urologia 50:1257-68, 1983
33. Cirillo-Marucco E, Pagliarulo A, Tritto G, et al.: Extract of Serenoa repens (Permixon^R) in the early treatment of prostatic hypertrophy. Urologia 5:1269-77, 1983
34. Tripodi V, Giancaspro M, Pascarella M, et al.: Treatment of prostatic hypertrophy with Serenoa repens extract. Med Praxis 4:41-6, 1983
35. Emili E, Lo Cigno M and Petrone U: Clinical trial of a new drug for treating hypertrophy of the prostate (Permixon). Urologia 50:1042-8, 1983
36. Greca P and Volpi R: Experience with a new drug in the medical treatment of prostatic adenoma. Urologia 52:532-5, 1985
37. Duvia R, Radice GP and Galdini R: Advances in the phytotherapy of prostatic hypertrophy. Med Praxis 4:143-8, 1983
38. Tasca A, Barulli M, Cavazzana A, et al.: Treatment of obstructive symptomatology caused by prostatic adenoma with an extract of Serenoa repens. Double-blind clinical study vs. placebo. Minerva Urol Nefrol 37:87-91, 1985
39. Cukier (Paris), Ducassou (Marseille), Le Guillou (Bordeaux), et al.: Permixon versus placebo. C R Ther Pharmacol Clin 4/25:15-21, 1985
40. Champlault G, Patel JC and Bonnard AM: A double-blind trial of an extract of the plant Serenoa repens in benign prostatic hyperplasia. Br J Clin Pharmacol 18:461-2, 1984
41. Crimi A and Russo A: Extract of Serenoa repens for the treatment of the functional disturbances of prostate hypertrophy. Med Praxis 4:47-51, 1983
42. Champault G, Bonnard AM, Cauquil J and Patel JC: Medical treatment of prostatic adenoma. Controlled trial: PA 109 vs placebo in 110 patients. Ann Urol 18:407-10, 1984
43. Mattei FM, Capone M, and Acconcia A.: Serenoa repens extract in the medical treatment of benign prostatic hypertrophy. Urologia 55:547-52, 1988
44. Braeckman J: The extract of Serenoa repens in the treatment of benign prostatic hyperplasia: A multicenter open study. Curr Ther Res 55:776-85, 1994
45. Bach D and Ebeling L: Long-term drug treatment of benign prostatic hyperplasia–results of a prospective 3-year multicenter study using Sabal extract IDS89. Phytomed 3:105-11, 1996
46. Yasumoto R, et al.: Clinical evaluation of long-term treatment using Cernitin pollen extract in patients with benign prostatic hyperplasia. Clinical Therapeutics 17:82-6, 1995
47. Buck AC, et al.: Treatment of outflow tract obstruction due to benign prostatic hyperplasia with the pollen extract, Cernilton^®. A double-blind, placebo-controlled study. Br J Urol 66(4):398-404, 1990
48. Becker H and Ebeling L: Conservative therapy for benign prostatic hyperplasia (BPH) with Cernilton. Br J Urol 66:398-404, 1988
49. Habib Fouad K, et al.: Identification of a prostate inhibitory substance in a pollen extract. Prostate 26:133-139, 1995
50. Andro MC and Riffaud JP: Pygeum africanum extract for the treatment of patients with benign prostatic hyperplasia: A review of 25 years of published experience. Curr Ther Res 56:796-817, 1995
51. Guillemin P: Clinical trials of V1326, or Tadenan, in prostatic adenoma. Med Prat 386:75-6, 1970
52. Lange J and Muret P: Clinical trial of V1326 in prostatic disease. Med 11:2807-11, 1970
53. Wemeau L, Delmay J and Blankaert J: Tadenan in prostatic adenoma. Vie Medicale Jan:585-8, 1970
54. Viollet G: Clinical experimentation of a new drug from prostatic adenoma. Vie Medicale June:3457-8, 1970
55. Lhez A and Leguevague G: Clinical trials of a new lipid-sterolic complex of vegetal origin in the treatment of prostatic adenoma. Vie Medicale Dec:5399-5404, 1970
56. Thomas JP and Rouffilange F: The action of Tadenan in prostatic adenoma. Rev Int Serv 43:43-5, 1970
57. Huet JA: Prostatic disease in old age. Med Intern 5:405-8, 1970
58. Rometti A: Medical treatment of prostatic adenoma. La Provence Medicale 38:49-51, 1970
59. Gallizia F and Gallizia G: Medical treatment of benign prostatic hypertrophy with a new phytotherapeutic principle. Recent Med 9:461-8, 1972
60. Durval A: The use of a new drug in the treatment of prostatic disorders. Minerva Urol 22:106-11, 1970
61. Pansadoro V and Benincasa A: Prostatic hypertrophy: results obtained with Pygeum africanum extract. Minerva Med 11:119-44, 1972
62. Maver A: Medical therapy of the fibrous-adematose hypertrophy of the prostate with a new vegetal substance. Minerva Med 63:2126-36, 1972
63. Bongi G: Tadenan in the treatment of prostatic adenoma. Minerva Urol 24:129-39, 1972
64. Doremieux J, Masson JC and Bollack C: Prostatic hypertrophy, clinical effects and histological changes produced by a lipid complex extracted from Pygeum africanum. J Med Strasbourg 4:253-7, 1973
65. Del Valio B: The use of a new drug in the treatment of chronic prostatitis. Minerva Urol 26:81-94, 1974
66. Colpi G and Farina U: Study of the activity of chloroformic extract of Pygeum africanum bark in the treatment of urethral obstructive syndrome caused by non-cancerous prostapathy. Urologia 43:441-8, 1976
67. Donkervoort T, Sterling J, van Ness J and Donker PJ: A clinical and urodynamic study of Tadenan in the treatment of benign prostatic hypertrophy. Urol 8:218-25, 1977
68. Dufour B and Choquenet C: Trial controlling the effects of Pygeum africanum extract on the functional symptoms of prostatic adenoma. Ann Urol 18:193-5, 1984
69. Legramandi C, Ricci-Barbini V and Fonte A: The importance of Pygeum africanum in the treatment of chronic prostatitis void of bacteria. Gazz Medica Ital 143:73-6, 1984
70. Ranno S, et al.: Efficacy and tolerability in the treatment of prostatic adenoma with Tadenan 50. Progresso Medico 42:165-9, 1986
71. Frasseto G, et al.: Study of the efficacy and tolerability of Tadenan 50 in patients with prostatic hypertrophy. Progresso Medico 42:49-52, 1986
72. Bassi P, et al.: Standardized extract of Pygeum africanum in the treatment of benign prostatic hypertrophy. Minerva Urol 39:45-50, 1987
73. Duvia R, Radice GP and Galdini R: Advances in the phytotherapy of prostatic hypertrophy. Med Praxis 4:143-8, 1983
74. Belaiche P and Lievoux O: Clinical studies on the palliative treatment of prostatic adenoma with extract of Urtica root. Phytother Res 5:267-9, 1991
75. Romics I: Observations with Bazoton in the management of prostatic hyperplasia. Int Urol Nephrol 19(3):293-7, 1987
76. Wagner H, et al.: Search for the antiprostatic principle of stinging nettle (Urtica dioica) roots. Phytomedicine 1:213-24, 1994