If you're a male, or have a man in your life, when age creeps up over 40, as mine did this year, you begin to think about your prostate. Over 50 percent of men over 50 years of age may experience prostate problems. A common problem often treated with herbal preparations is benign prostatic hyperplasia, characterized by a benign (non-malignant) hyperplastic (enlargement) of the prostate. This can affect quality of life, including the number of times a man feel the urge to urinate, particularly at night, with an urge to urinate 3 to 4 times. The prostate enlargement resulting from BPH narrows the urethra, thus producing poor urinary flow. That can also translate into a host of other urinary symptoms including hesitancy or straining to urinate, painful urination, dripping after urination, increased urinary frequency, and a feeling that the bladder is not quite empty. BPH is a relatively poorly understood condition in terms of what is at work in the body to produce it. This condition costs American men over $1 billion per year.

A number of conventional drugs are used in the treatment of BPH, most notably finasteride (Proscar®). Several clinical studies have shown that it produces a moderate improvement over placebo. In Europe, up to 90 percent of BPH patients are treated with phytopharmaceuticals or herbal-derived products. A survey of German urologists also indicated that as much as 50 percent of these physicians prefer plant-based treatments to chemical drugs. The four primary plant materials used in Germany and other European countries for the treatment of BPH include Pygeum extracts, stinging nettle root extracts, pumpkin seed oil, and extracts of saw palmetto fruits. Our primary focus will be on saw palmetto.

Extracts of the fruits (berries) of saw palmetto (Serenoa repens) is the best known herbal treatment for BPH. In some European literature, the plant is referred to by its century-old obsolete name Sabal serrulata. In a number of German scientific papers, the herbal product is referred to as "sabal" fruits, but the name Serenoa repens is the correct botanical name for this small member of the palm family. It is important to know these name problems, because you can do a computer search on saw palmetto and miss important articles if "sabal" is not used in search terms.

The best-studied phytomedicine for the treatment of BPH are extracts of saw palmetto fruits. This past year in doing various call-in radio talk shows, inevitably a listener calls in with questions about saw palmetto. Most relate to how to best use it in terms of product forms, dosage and duration of treatment. These callers are for the most part already using saw palmetto products. Saw palmetto is number six on the list of the ten best-selling herbs in health and natural food markets at this point.

Saw palmetto is an American medicinal plant. It is a small woody member of the palm family that occurs from the coast of South Carolina to Georgia (especially southern Georgia), west to coastal Alabama, south throughout Florida. Florida is the state where saw palmetto is abundant, blanketing millions of acres in the state in saw palmetto thickets. Most land now used for Citrus production is in what used to be palmetto thickets. The vast majority of the commercial supply is harvested in wild habitats in Florida. The harvest, itself, is a daunting task. The berries ripen in the high humidity and heat of August and September. The plant comes by its name honestly. The thick, tough, leaf stems are lined with very sharp, saw-like teeth that can easily tear your clothes. Hidden beneath the cool shade of the saw palmetto shrub is a favorite resting haunt for the eastern diamondback rattlesnake, North America's largest rattlesnake. Each year, there are reports of rattlesnake bites during the saw palmetto harvest.

Several years ago, during the saw palmetto berry harvest, I went out with a harvesting crew on a photo shoot of the process. A crew of three pickers, their buyer and I left for the harvest at 4 a.m. We drove over 100 miles north of our meeting point to somewhere outside of Tampa, where the crew had staked-out a large field of palmetto berries not far from the coast. The actual harvest of the berries commenced just before sunrise. I had to use a flash to take my first set of pictures. It was still dark. I shot, and they picked to about 11 a.m., getting a full pick-up load, about a half ton of the fresh berries. The work was hard, involving filling five gallon buckets with the fruits, then transferring them to feed sacks. The workers were covered in sweat and the unusual scent of fresh saw palmetto fruits. A half a day's work by any standards was a day's work. Sometimes, it's important to stop and think on what it takes to get herb products from the field to your shelves. The berries then went to a large drying facility. The dried, cleaned berries are shipped to extractors, mostly in Europe, from where it comes back to the United States in the form of finished extracts for saw palmetto products.

Saw palmetto was introduced to the medical profession by Dr. J. B. Read, of Savannah, Georgia who published a paper on his clinical experience with the plant in the April, 1879 issue of the American Journal of Pharmacy. Read states, "By its peculiar soothing power on the mucous membrane it induces sleep, relieves the most troublesome coughs, promotes expectoration, improves digestion, and increases fat, flesh and strength. Its sedative and diuretic properties are remarkable. . . . Considering the great and diversified power of the saw palmetto as a therapeutic agent, it seems strange that it should have so long escaped the notice of the medical profession." By the 1890s the effect of the fruit preparation on the sexual organs became known. An "original communication" in the July 1892 issue of The New Idea , stated that "It also exerts a great influence over the organs of reproduction, mammoa, ovarium, prostate, testes, etc. Its action on them is a vitalizer, and is said to be the greatest known, tending to increase their activity and add greatly to their size." Largely used by Eclectic physicians in the United States into the 1920s, an interesting comment in the twenty-first edition of the United States Dispensatory, published in 1926 suggested its use for the future. The authors note, "It has been especially recommended in cases of enlarged prostate of old men."

Usage of American medicinal plants in the United States began to decline in the 1920s. However, at the same time, use expanded in Europe. By the 1930s, European physicians were widely using saw palmetto for the treatment of irritation of the bladder, urethra, and prostate. Now, saw palmetto, an American medicinal plant, has become largely a European phytomedicine.

Recently a major clinical study was published in the journal The Prostate. This large multicenter study involved dozens of researchers in France, Scotland, England, Italy, Portugal, the Czech Republic, Greece, Switzerland, Slovakia, and the United States comparing the use of Permixon® with the convention drug finasteride (Proscar®) in the treatment of 1,098 patients diagnosed BPH. Permixon® is a commercial saw palmetto extract product available in Europe, composed of 90 percent free and 7 percent esterfied fatty acids, among other components. It was given to patients for 26 weeks at a dose of 160 mg (two times a day morning and evening). Finasteride was given at a dose of 5 mg per day in the morning (following manufacturers stated dosage).

The researchers concluded that both treatments do relieve symptoms of BPH in about two-thirds of patients. The conventional drug, finasteride, produced a significant decrease in prostate volume size. The saw palmetto product did not reduce prostate size, suggesting different mechanisms of action for the efficacy of both drugs. One of the known side effects of finasteride is decreased libido and impotence. The saw palmetto product produced fewer complaints of decreased libido or impotence. This study confirms that the saw palmetto product is equally effective as the conventional drug in relieving symptoms of benign prostatic hyperplasia while producing fewer side effects.

The German health authorities, through the Commission E monograph on saw palmetto, allow use of the berry extract in the treatment of BPH stages 1 and 2, (at relatively early stages of the condition. Rare stomach upset is generally the only side effect attributed to saw palmetto. Prostate specific antigen (PSA) measurements are currently used as a diagnostic tool for determining chances of getting prostate cancer. Some physicians monitoring patients taking saw palmetto suggest that the fruit extracts may lower PSA levels, and warn fellow practitioners to be aware of this potential action, which could skew considerations for determining if prostate cancer is present. It is also very important for consumers to remember that BPH cannot be self-diagnosed nor is it a condition amenable to self-treatment. It is important to discuss the use of saw palmetto or other phytomedicines for BPH with your health care provider.

References:

1. Anon. 1892. "Saw Palmetto." Western Druggist(December): 355-356.
2. Brown, D. J. 1995. "Saw Palmetto: Herbal Prescription for Treatment of BPH." Drug Store News for the Pharmacist(April): 23-30.
3. Buck, A. C. 1996. Phytotherapy for the Prostate. British Journal of Urology, 78: 325-336.
4. Carraro, J.-C. et al. 1996. Comparison of Phytotherapy (Permixon) With Finasteride in the Treatment of Benign Prostate Hyperplasia: A Randomized International Study of 1,098 Patients. The Prostate, 29: 213-240, 1996.
5. Hale, E. M. 1898. "Saw Palmetto, Its History, Botany, Chemistry, Pharmacology, Provings, Clinical Experience and Therapeutic Applications." : 1-96.
6. Lowe, F. C. and J. C. Ku. 1996. Phytotherapy in Treatment of Benign Prostatic Hyperplasia: A Critical Review. Urology 48(1):12-20.