Natural treatments for benign prostatic hyperplasia

DEFINITION: Treatment of enlarged prostate not caused by cancer.

PRINCIPAL PROPOSED NATURAL TREATMENTS: Beta-sitosterol, grass pollen, nettle root (Urticadioica), pygeum (Prunus africana), saw palmetto (Serenoa repens)

OTHER PROPOSED NATURAL TREATMENTS: Antioxidants, Bixa orellana (annatto), flaxseed, flaxseed oil, green tea, maca, oat straw, pumpkin seeds, zinc

Introduction

Any man who lives long enough will almost certainly develop benign prostatic hyperplasia (BPH). Between 60 and 69 percent of men in their sixties, 80 percent of men in their seventies, and 90 percent of men over eighty show signs of such prostatic enlargement. Symptoms include difficulty in starting urination, a diminished force of the urinary stream, a sensation of fullness in the bladder after urination, and the need to urinate many times at night. Ultimately, the obstruction can become so severe that urination is impossible.

The most common treatment for BPH is surgery that removes most of the prostate gland. Alpha-blockers and 5-alpha reductase inhibitor medications can relieve symptoms of BPH, including finasteride (Proscar), dutasteride (Avodart), alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), silodosin (Rapaflo), and terazosin (Hytrin). Proscar has been shown to shrink the prostate and reduce the need for surgery. Tadalafil (Cialis), usually prescribed for erectile dysfunction, is also effective for BPH. However, all of these medications can cause significant side effects.

Principal Proposed Natural Treatments

Men who suspect they may have BPH should consult a physician to rule out prostate cancer. Many natural options are available that have good scientific backing. Indeed, there are few other conditions for which so many natural therapies have good supporting evidence for efficacy. However, there is one potential advantage for standard medications—some have been shown sufficiently effective at slowing the progression of BPH to help men avoid surgery, while this has not been shown to be true of any natural options.

Saw palmetto. The best-documented herbal treatment for BPH is the oil of the berry of the saw palmetto tree. This herb is so well-accepted in Europe that synthetic pharmaceuticals are considered alternative therapy for BPH. Saw palmetto offers two potential advantages over conventional drug treatmentit usually causes no side effects and does not change protein-specific antigen (PSA) levels. Laboratory tests that measure PSA are used to screen for prostate cancer. The widely used drug Proscar can artificially lower PSA levels, which may have the unintended effect of masking prostate cancer.

Despite its popularity, the scientific evidence that saw palmetto is effective for prostate enlargement is inconsistent. Several double-blind, placebo-controlled studies involving about nine hundred participants compared the benefits of saw palmetto with a placebo over one to twelve months. In all but three of these studies, the herb significantly improved urinary flow rate and most other measures of prostate disease. However, a one-year trial of 225 men saw that the palmetto product failed to prove more effective than the placebo. Furthermore, a large review of fourteen trials with 5,222 men found that saw palmetto did not improve urinary symptom scores or peak urine flow compared with the placebo. Subjects taking saw palmetto reported more overall symptom improvement than those taking the placebo, but this result is questionable because of a lack of consistency among the studies.

A double-blind study followed 1,098 men who received either saw palmetto or the drug Proscar over six months. According to the results, the two treatments were about equally successful at reducing noticeable symptoms, and none produced much in the way of side effects. However, Proscar lowered PSA levels, presenting a risk of masking prostate cancer. Saw palmetto did not cause this problem. On the other hand, careful measurements showed that Proscar caused men’s prostates to shrink by 18 percent, while saw palmetto caused only a 6 percent decrease in size. Although prostate size does not correlate well with the severity of symptoms, such a decrease in size might indicate a reduced likelihood of need for surgery. This is a potential advantage for the drug.

A fifty-two-week double-blind study of 811 men compared saw palmetto to a standard drug for BPH in another class: the alpha-blocker tamsulosin. Both treatments proved equally effective, but saw palmetto caused fewer side effects and caused some prostate shrinkage, while the drug allowed a slight prostate enlargement.

Although there are many theories about how saw palmetto works, none have been conclusively established to treat BPH. The best evidence suggests that the herb affects male hormones. Additionally, saw palmetto can interact with NSAIDs like ibuprofen (Motrin) and naproxen (Aleve), blood thinners, hormone treatments, and other supplements like ginkgo biloba and garlic, so it should be approached with caution.

Pygeum. The pygeum tree is a tall evergreen native to central and southern Africa. Its bark has been used since ancient times for urinary problems. At least seventeen double-blind trials, ranging in length from forty-five to ninety days, of pygeum for BPH have been performed, involving almost one thousand men. Many of these studies were poorly reported or designed. Nonetheless, overall, the results suggest that pygeum can reduce symptoms, such as nighttime urination, urinary frequency, and residual urine volume.

The best of these trials was conducted at eight sites in Europe and included 263 men between fifty and eighty-five years of age. Participants received fifty milligrams (mg) of a pygeum extract or the placebo twice daily. The results showed significant improvements in various measures of BPH severity.

Unlike the standard drug finasteride, pygeum does not work by affecting the conversion of testosterone to dihydrotestosterone. Rather, it contains compounds like phytosterols and ursolic and oleanolic acids that reduce inflammation in the prostate and inhibit prostate growth factors, substances implicated in inappropriate prostate enlargement. It is also a 5-lipoxygenase metabolite antagonist, which may decrease inflammation production. It is unknown whether pygeum can reduce the need for prostate surgery, but it does not likely affect PSA levels. However, its atraric acid and N-butylbenzene-sulfonamide may help reduce prostate disease development.

Nettle root. Persons who live in a locale where nettle grows wild will likely discover the powers of this dark green plant. Depending on the species, the fine hairs on its leaves and stem cause burning pain that lasts from hours to weeks. Both its leaves and roots can be used as medicine. The root is a popular treatment in Europe for BPH, but it has not been as well studied as saw palmetto or pygeum.

In a double-blind, placebo-controlled study in Iran, 558 men were given either a placebo or nettle root for six months. The results indicated that nettle root is significantly more effective than the placebo on all major measures of BPH severity. Benefits were seen in three other double-blind studies as well, enrolling more than 150 men.

Beta-sitosterol. Numerous plants contain cholesterol-like compounds called sitosterols and their close relatives sitosterolins. A special mixture of these, called beta-sitosterol, is used for the treatment of BPH.

A review of the literature, published in 1999, found four randomized, double-blind, placebo-controlled studies on beta-sitosterol for BPH, enrolling 519 men. All but one of these studies found significant benefits in both perceived symptoms and objective measurements, such as urine flow rate. The largest trial followed two hundred men with BPH for six months. After the study was completed, many of the participants were followed for an additional year, during which the benefits continued. Similar results were seen in a six-month double-blind trial of 177 men with BPH.

Further studies found that while beta-sitosterol does not shrink the prostate, it aids in limiting lower urinary tract symptoms commonly experienced with BPH. However, prescription alpha-adrenergic receptor antagonists or 5α-reductase inhibitors are more effective and can help reduce prostate size. Most practitioners advocate for beta-sitosterol's use for younger men with symptoms that do not yet necessitate a prescription regimen to control their BPH.

Beta-sitosterol can be taken as a supplement, but it is also found in cream cheese, pumpkin seeds, margarine, yogurt, soybean oil, peanut oil, and avocado oil.

Grass pollen. Grass pollen is also used to treat BPH. The grasses used for this preparation are 92 percent rye, 5 percent timothy, and 3 percent corn. Related grass pollen extracts are used for allergy shots. However, the grass pollen extracts described here are different in that they have their allergenic components removed. Grass pollen is also an entirely different product from bee pollen.

Two double-blind, placebo-controlled studies found that grass pollen extract can improve symptoms of prostate enlargement. There have also been open studies that compared grass pollen to different treatments for BPH.

In the first double-blind, placebo-controlled study, 103 men with BPH were assigned to take either a placebo or two capsules of a standardized grass pollen extract three times daily for twelve weeks. At the end of the study, 69 percent of the participants who had been taking the grass pollen had reduced the number of trips they had to make to the toilet at night. In the placebo group, only 37 percent reported improvement in this symptom. The amount of urine remaining in the bladder following urination was reduced in the treatment group by 24 milliliters (ml) and by 4 ml for the placebo group. Both of these were statistically significant improvements for those taking grass pollen.

The second double-blind, placebo-controlled study lasted longer but enrolled fewer participants. Fifty-seven men with prostate enlargement were enrolled in the study, with thirty-one taking ninety-two mg of the grass pollen extract daily for six months and the remaining twenty-six taking the placebo. As with the foregoing study, statistically significant improvements in the nighttime frequency of urination and emptying of the bladder were found with the use of grass pollen extract. Additionally, 69 percent of the participants receiving treatment reported overall improvement, while only 29 percent of the group taking the placebo felt they had improved, another statistically significant difference. An important finding in this study was that the prostates of the men taking grass pollen significantly decreased in size according to ultrasound measurements taken.

No one is certain how the grass pollen extract causes the beneficial results seen in the studies. One theory is that it inhibits the body’s manufacturing of prostaglandins and leukotrienes, which might relieve prostate congestion by reducing inflammation.

Combination treatment. A forty-eight-week double-blind trial of 543 men with early BPH compared saw palmetto and nettle root with Proscar and found equal benefits. The same combination proved superior to the placebo in a twenty-four-week double-blind study of 257 men. In a three-month, double-blind, placebo-controlled study of 144 men with BPH, the use of a combination product containing saw palmetto, grass pollen extract, beta-sitosterol, and vitamin E significantly reduced symptoms.

A six-month, double-blind, placebo-controlled trial of forty-four men given a saw palmetto herbal blend (with nettle root and pumpkin seed oil) found shrinkage in prostate tissue. No significant improvement in symptoms was seen, but the authors pointed out that the study size was too small to statistically detect such improvements if they did occur. Another small study failed to find significant benefit with a combination of pygeum and nettle root.

Other Proposed Natural Treatments

One study provides weak evidence that green tea extracts taken orally might reduce symptoms of BPH. Pumpkin seeds are approved for use in BPH in Germany. The mineral zinc is also commonly recommended in both Europe and the US as a treatment for prostate disease, as are both whole flaxseed and flaxseed oil, along with the herbs maca (Lepidium meyenii) and oat straw (Avena sativa). However, there is little meaningful evidence to indicate that any of these proposed options are effective.

In a large study investigating the influence of dietary patterns and supplement use on the risk of BPH, researchers followed 4,770 men, initially with normal-sized prostates, for seven years. Researchers found that antioxidant supplements did not significantly reduce BPH risk and that lycopene, zinc, and vitamin D supplementation had only a modest beneficial effect.

In a twelve-month, double-blind, placebo-controlled study of 136 men with BPH of moderate severity, the use of Bixa orellana (annatto) at a dose of 250 mg three times daily failed to improve symptoms. In a preliminary double-blind trial of seventy-eight older men, flaxseed extract modestly improved the urinary symptoms associated with benign prostatic hyperplasia (prostate enlargement) after four months of treatment.

Another potential treatment, Serenoa extract, was found in one Chinese study to be effective with few side effects, but in another study, these supplements were highly inconsistent in quality in the US, making the use of this treatment highly unpredictable. Because of these inconsistencies, further research of standardized Serenoa extract would be beneficial.

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