Saw palmetto: alternative treatment for enlarged prostates

by Howard Bell

Saw Palmetto If youve ever hit a golf ball out of bounds on a Florida golf course, youve probably spent a fair amount of time crawling through native saw palmetto while trying to retrieve your ball. But did you know that the berries of this scrubby saw-toothed fan-palm can relieve urinary symptoms caused by benign enlargement of the prostate gland�

Normally a walnut-sized gland, the prostate sits beneath the bladder and surrounds the urethra, the tube that drains the bladder. Its primary purpose is to make fluid that transports sperm during ejaculation. For unknown reasons, the gland begins to grow in middle age. As it grows, it can squeeze the urethra, which causes:

• Difficulty when starting to urinate
• Weak stream
• Dribbling at the end of the stream

An enlarged prostate can also push against the bladder, which causes:

• Need to get up at night to use the bathroom
• Frequent urge to urinate
• A feeling that the bladder doesnt completely empty

Nearly every man develops an enlarged prostate at some point in his life. Usually, enlargement is benign hence the name benign prostatic hyperplasia (BPH). BPH is not prostate cancer. Saw palmetto is used to treat symptoms of benign enlargement, not prostate cancer.

Saw palmetto has been used in Europe for years to relieve urinary symptoms caused by BPH. Most U.S. doctors prefer to prescribe finasteride (Proscar) or alpha blockers. Finasteride is a hormone suppressor that cuts off the prostates supply of growth hormones. Alpha blockers relax the smooth muscle of the prostate and the neck of the bladder, allowing improved urine flow.

Mainstream medicine has shown little interest in saw palmetto, until recently. Now, a growing volume of research suggests that it works. Eighteen studies involving 3,000 men were analyzed in the November 11, 1998 issue of the Journal of the American Medical Association (JAMA). The analysis concluded that, when compared to finasteride, saw palmetto "produces similar improvement in urinary tract symptoms and urinary flow"; it also seemed to produce fewer side effects.

Timothy J. Wilt, MD, an internist and associate professor of medicine at the Minneapolis VA Center for Chronic Diseases Outcomes Research was the principal investigator for the JAMA report. "The bottom line," he says, "is that saw palmetto caused modest improvement in urologic symptoms."

No one knows how well saw palmetto works compared to alpha blockers, which, according to Dr. Wilt, are still the gold standard for treating the symptoms of BPH, despite side effects.

Samuel Benjamin, MD, actually prefers saw palmetto. "Its safer and more effective," he says. A family practitioner in Stony Brook, New York, Dr. Benjamin is director of the Complementary & Alternative Medicine Center at the State University of New York at Stony Brook. Hes prescribed saw palmetto to his patients for 15 years. "My patients are very satisfied with the results," he says. "Many of my patients comment that they can finally sleep through the night. Theyre pleased with the lack of side effects and they like the convenience and low cost."

"There is something to saw palmetto," says Dr. John McConnell, MD. "But we have no earthly idea how it works." Dr. McConnell is a urologist who chairs the Urology Department at the University of Texas Southwestern Medical School in Dallas. Hes a national leader in saw palmetto research, according to the American Urological Association. Dr. McConnell doesnt recommend saw palmetto to his patients, but he doesnt discourage them from using it.

Many researchers believe that saw palmetto prevents testosterone from converting to dihydrotestosterone (DHT). DHT is fertilizer for prostates, according to Dr. Benjamin. It is the culprit behind BPH because it attaches to receptors in the prostate cells and encourages the prostate cells to grow and multiply. At the same time, saw palmetto reduces the prostates appetite for DHT by reducing the number of prostate receptor sites where DHT can attach.

However, saw palmetto does not cure prostate cancer, prevent prostate cancer, prevent BPH, or reduce spasms in the prostates smooth muscle. "All it does is relieve symptoms," says Dr. Wilt. "So it wont do you any good to take it if you dont have those symptoms."

Studies summarized in JAMA and the Archives of Family Medicine concluded that:

• Men with BPH who used saw palmetto for three months experienced a significant decrease in receptor sites for DHT.
• In a study of 500 men with BPH, ultrasound scans showed that their prostate size decreased.
• Seven out of eight clinical trials showed significant relief from BPH symptoms.
• In a randomized, 6-month study of 1,098 men, saw palmetto worked as well as finasteride with fewer side effects.
• In 18 studies involving 3,000 men, saw palmetto caused:
  • a 28% improvement in urinary tract symptoms
  • a 25% reduction in evening trips to the bathroom
  • a 24% improvement in peak urine flow
  • a 43% reduction in residual urine in the bladder

Saw palmetto causes side effects less often than finasteride or alpha blockers. "There appear to be no significant risks," says Dr. McConnell. One percent of men using saw palmetto have problems with getting and maintaining an erection; this same side effect tends to occur in 5% of men using finasteride.

And unlike alpha blockers, saw palmetto does not cause fatigue, dry mouth, rapid heart beat and low blood pressure.

Dr. Benjamin says he has no trouble prescribing saw palmetto with a caveat. "I warn all my patients we dont have all the answers," he says. "The fact is, we dont know what the long-term effects are. We dont know how it interacts with other drugs. We just dont have the depth of research we need. But based on what we know so far, its safer and more effective than other alternative drugs."

Current research shows that saw palmetto does not lower blood prostate specific antigen (PSA), the traditional marker for prostate cancer. However, Dr. Benjamin isnt so sure. Hes concerned someday well discover it does, which could pose a problem. PSA levels are higher in men with BPH or prostate cancer, which keeps men on their toes. "If saw palmetto lowers PSA levels," he says, "it could mask the presence of cancer. It could give a man with prostate cancer an artificially low PSA level. For that reason, its important to get a baseline PSA test before starting saw palmetto." Its also a good idea to see your doctor before going on saw palmetto. "Dont assume your symptoms are caused by BPH," says Dr. McConnell. "It could be something more serious."

Dr. Benjamin and others recommend that men with moderate urinary symptoms from BPH take two 160 milligram capsules of saw palmetto extract each day. "Gel caps are better absorbed," says Dr. Benjamin. Purity is important. Make sure the extract contains 85%-95% fatty acids and sterols. Most doctors familiar with saw palmetto say the extract is not effective when taken as tea.

Saw palmetto is cheaper than other drugs used to treat BPH, although it is not covered by insurance. Plan to pay $3-$15 per month, according to Dr. Benjamin. Finasteride costs $75-$100 per month. Expect relief from urinary symptoms in six weeks to three months.

For now, saw palmetto is not regulated. "Many herbal products do not contain what their labels say they contain," says Dr. Benjamin. "Some contain pesticides and use dangerous chemicals in the extraction process." Short of opening your own testing laboratory, here are some precautions you can take. Buy saw palmetto that:

• has an expiration date on the label
• has a lot number on the label or the bottle
• is standardized to at least 85% fatty acids
• has a childproof cover
• has been tested for purity by an independent lab, if possible

Avoid brands of saw palmetto that claim to shrink the prostate, prevent cancer or increase sex drive. "Theres not the slightest evidence it does any of these," says Dr. McConnell.