Associates in Urology: Newsletter: Alternative Medical Therapy for BPH (Saw Palmetto)

Alternative Medical Therapy for BPH (Saw Palmetto)

Dr. Eric K. Seaman, MD / Dr. Bernard S. Strauss, MD

As we approach the millennium we seem to encounter more and more patients who include alternative medical therapies as part of their daily ritual. Alternative therapies include massage, meditation, dietary supplements, and also herbal medications or phytotherapy.

In the US, medical treatment of prostate enlargement (BPH) has been estimated to cost $2 billion. Surgery including prostatectomy or Transurethral resection (TURP) was previously the treatment of choice. In recent years, medications including alpha blockers (hytrin, cardura, flomax) and finasteride (proscar) have been used to treat milder forms of BPH.

Reports of phytotherapy (use of plant extracts) for treating BPH, date back to 15th century BC Egypt. Presently, phytotherapy is common in Europe and is gaining popularity in the US. In fact, $1 billion was spent on herbal medications in the US during the past year.

Saw Palmetto is the most commonly used herbal remedy for BPH, also known as Serenoa repens and Sabal serrulata. It is an extract made from the dried fruit of the American dwarf saw palmetto. Formulations include: Serenoa serrulata, Permicon, Serendar, Prostagutt, Prostaselect, Prastagalen, Prostavigol, and Strogen forte.

Possible Actions of Saw Palmetto
Several have been postulated including: anti-inflammatory effects, inhibition of aromatase, antiandrogenic and antiestrogenic effects. The most popular theory is interference with the enzyme 5 alpha reductase; this is the same enzyme blocked by the drug finasteride and prevents the conversion of testosterone to di-hydro-testosterone which has direct effects on the prostate. However, there are reasons for investigators to be skeptical. For example, some reports state that Saw Palmetto has no effect on Serum PSA; or prostate volume. Finasteride lowers both prostate volume and PSA.

The Medical Literature
A recent meta-analysis of existing evidence regarding the effectiveness of saw palmetto for the treatment of BPH was reported in the November, 1998 issue of JAMA (Witt et al, 280:1604). 18 randomized controlled trials including 2,939 patients were reviewed. Findings revealed that men treated with saw palmetto had a significant improvement in symptom score when compared to placebo, and, in fact, improvement was similar to that reported with finasteride.

However, the issues are a bit more complicated. It is generally agreed that a symptom score change of 3 or greater is noticeable by the patient. The mean improvement in this review was -1.41. Therefore, as with finasteride treatment, the implication is that only a minority of patients will notice a significant improvement in their symptoms.

Additional Caveats
Patients and physicians should realize the pitfalls of taking any herbal medication. Since these treatments are largely unregulated by the FDA, quality controls are less stringent. Side effects are reported in the same way as prescription drugs. There is a belief that since these are not prescription drugs, there is no danger in taking them.

Despite these caveats, more patients have become attracted to herbal remedies. Given that Saw Palmetto appears to have few side effects, and no effect on PSA, for the physicians of such patients, saw palmetto may serve as an indirect signal that patients need help and that further evaluation is indicated.