Enlarged Prostate
What Can You Do About It?

First the word, then the plant, lastly the knife.
--Attributed to Asclepius, the Greco-Roman god of medicine

sclepius, thought by some to have started out as an actual man who lived in Thessaly (a region of east-central Greece) circa 1200 B.C., was ahead of his time - maybe ahead of ours, judging by all the surgeons who are eager to slice and dice you. There's much to be said for his godlike wisdom regarding disease and how to deal with it.

He would surely agree that, if you must contract a disease, it's best to get one whose name starts with the word "benign." There aren't very many of these, so your options are limited - especially if you're a woman. But if you're a man who has gotten through middle age, or plans to, your chances are good. What's probably in store for you is benign prostatic hyperplasia or BPH, a condition that affects almost all men if they live long enough.

The actual incidence of BPH for men of different age ranges is controversial: it all depends on how the criteria are defined. In particular, the figures depend greatly on whether you're alive or dead, because examinations of the living (using the infamous digital rectal exam, every man's least favorite procedure) give very different results from measurements at autopsy. Suffice it to say that, by the time you retire, you will probably have it to some degree. Despite the indignity, however, it won't be life-threatening - hence the term "benign."

And if you get BPH and have to take something for it, try to find a remedy that is benign in its effects, i.e., one that does what it's supposed to without sandbagging you with unwanted side effects. That, of course, is where natural nutritional supplements, compared with prescription drugs, shine: they typically deliver good effects with few or no side effects. We'll get to the supplements - in particular, saw palmetto - later, but for now, let's see what BPH really is.

THE PROSTATE GLAND AND ITS UNWELCOME GROWTH

The prostate gland, shown at normal size.
The normal adult prostate gland is roughly the size and shape of a chestnut and weighs about 20 grams (0.7 ounce). It sits in front of the rectum at the base of the bladder, surrounding the neck of the bladder and the urethra. Consisting of three lobes, it is composed partly of glandular tissue whose ducts empty into the urethra, and partly of muscular fibers that encircle the urethra.

The thin, milky fluid secreted by the prostate during ejaculation is added to the seminal fluid, or semen, coming from the seminal vesicles, the pair of pouchlike glands situated above and behind the prostate on each side of the bladder. Together, these fluids constitute a potent brew of biochemicals that nourish the spermatozoa (from the testicles) and speed them on their way through the urethra toward their destiny.

Until a man reaches his forties, or maybe fifties or sixties, his prostate is likely to be well-behaved, doing its job without complaint (quite the contrary, in fact) as often as possible. Eventually, however, for unknown reasons that are probably due to age-related hormonal changes, it starts to grow - usually benignly - to the size of a lemon or an orange or even a grapefruit. There are two ways in which a tissue can grow benignly: hyperplasia and hypertrophy.

Hyperplasia is an abnormal increase in the number of normal (not cancerous) cells in their normal arrangement in the tissue in question. In other words, there are simply too many of them. With BPH, one often also sees the term benign prostatic hypertrophy used loosely as a synonym. Hypertrophy is an abnormal increase in the size of otherwise normal cells in their normal arrangement. In other words, they're simply too large.

Of the two, hyperplasia seems to be the prevalent prostatic disorder. Either way, however, the effect of BPH is a prostate gland whose size has become a problem because it is now compressing and possibly distorting the top of the urethra, which is pretty narrow to begin with. The most common symptoms are difficulty in initiating urination, decreased caliber and force of the urinary flow, frequent urination, difficulty in stopping the flow completely (leading to involuntary dribbling), a sensation (usually deceptive) of incomplete emptying of the bladder, and, occasionally, actual urinary retention, which can lead to urinary tract infections or more serious complications, such as kidney damage. Another annoying symptom is the need to urinate, often several times, during the night, a condition called nocturia.

WORD, PLANT, OR KNIFE?
Let's start by admitting that no one has ever talked his prostate back down to size, so forget about that. It used to be that the standard treatment for an overly large prostate was to cut it down to size - literally - or to remove it altogether. The former procedure, when it is carried out with a slender instrument inserted into the prostate via the urethra, is unpopularly known as the Roto-Rooter® job. Its more polite name is trans-urethral resection of the prostate, or TURP (to resect means to remove part of an organ). Unlike the much more invasive procedures of open surgery, TURP does not usually impair sexual potency or continence - a great blessing, all things considered - but it is still a risky operation that should be viewed only as a last resort.

In recent years, however, drugs have increasingly replaced the surgeon's grisly toolkit. Most notable of these drugs is Proscar® (generic name finasteride), which blocks the action of the enzyme, 5-alpha-reductase, that converts testosterone to a more potent androgenic hormone called dihydrotestosterone (DHT) in the liver.

Because DHT is believed to be the principal cause of prostate enlargement, the effect of finasteride is thus to shrink the prostate, alleviating the symptoms of BPH. It usually takes at least six months to reach peak efficacy. The principal (but relatively infrequent) side effects of finasteride are erectile dysfunction (impotence), decreased libido, decreased volume of ejaculate, gynecomastia (the abnormal growth of breast tissue in men), and allergic reactions.

Oddly, finasteride is also sold under the name Propecia® as a treatment for hair loss (it promotes hair growth), another condition probably caused mainly by DHT.

But what about plants - herbal remedies - as Asclepius advised? If he really did live around 1200 B.C., his advice was already in the category of "ancient wisdom," because phytotherapy, or the use of plant extracts, for treating enlarged prostate was first described in Egypt in the fifteenth century B.C. Countless remedies have been tried over the millennia, but during the last century, one has emerged as preeminent.

SAW PALMETTO TRIUMPHANT
Until the 1950s, most doctors in the United States treated enlarged prostate with a fat-soluble extract of the dried, ripe berries of saw palmetto, or dwarf palm, a shrub that grows in sand dunes on America's southeast seaboard and the islands of the Caribbean. (Its modern botanical name is Serenoa repens, but it is sometimes also called Sabal serrulata.) Saw palmetto had a long history of use as an effective remedy for the symptoms of BPH, although it was not believed to cause any shrinkage of the gland itself.

Then along came a variety of profitable prescription drugs for BPH, and saw palmetto fell out of favor with conventional doctors in America - but it remained popular in many European countries (Germany, Austria, and France, e.g.) and others around the world, where it continues to this day to be the first avenue of attack against the annoying symptoms of BPH. Meanwhile, more and more scientific studies of the benefits of saw palmetto have been accumulating, leading to a renewed interest in this herbal remedy in the United States.

A major study on saw palmetto was published last year in the Journal of the American Medical Association.1 The authors reviewed 18 recent studies encompassing a total of 2,939 men with symptomatic BPH who received saw palmetto, either alone or in combination with other phytotherapeutic agents, for at least 30 days.

From all the data, the authors concluded that saw palmetto improves urinary tract symptoms and urinary flow by anywhere from 24% to 43%. These results are about the same as those obtained with finasteride, but they are accompanied by fewer and milder side effects. In particular, the rate of erectile dysfunction associated with finasteride is 4.9%, whereas with saw palmetto it is only 1.1% (not much higher than the placebo figure of 0.7%). The authors state:

"In conclusion, the available evidence suggests that extracts from the saw palmetto plant, S. repens, improve urinary tract symptoms and flow measures in men with BPH. Compared with finasteride, S. repens produces similar improvements in urinary tract symptoms and flow measures, has fewer adverse treatment effects, and costs less."

Similar conclusions were reached by the authors of a recent editorial in the journal Urology,2 who also stated that "The safety of saw palmetto extracts has never been seriously questioned." In addition, they cited a large European study3 showing that a well-known saw palmetto product was found to cause "no change in standard blood tests and no change in serum prostate-specific antigen (PSA) levels during a 6-month treatment period." The PSA test is widely used as a marker for prostate cancer.

OTHER NUTRIENTS FOR ENHANCING HEALTHY PROSTATE FUNCTION
New information about various other prostate-enhancing substances appears regularly in the medical literature. Following is a brief review of nutrients other than saw palmetto.

Zinc
This essential element, which plays a vital role in a wide spectrum of bodily functions, including many aspects of hormone metabolism, was shown as long ago as the 1970s to reduce the size of the prostate gland and to diminish symptoms in most patients.5 It has also been shown to be a 5-alpha-reductase inhibitor, which, as we have seen, is advantageous. For these reasons, and more, adequate zinc intake is considered to be essential for prostate health.

Lycopene
This is the now-famous "tomato chemical" that has received so much attention for its anticancer properties - especially against prostate cancer. A chemical cousin of beta-carotene, it is a powerful antioxidant. In a recent study published in Cancer Research, the authors identified lycopene as ". . . the carotenoid with the clearest inverse relation to the  development of prostate cancer. . . . These data provide further evidence that increased consumption of tomato products and other lycopene-containing foods might reduce the occurrence or progression of prostate cancer."6

The trouble is, though, that one would have to eat about 3 pounds of tomatoes daily to get the optimal amount of lycopene, so supplementation with the concentrated lycopene is by far the best option. For more detailed information on the benefits of this compound, see Tomato Nutrient Lycopene Helps Fight Prostate Cancer - June 1999.

Vitamin D
This "sunlight" vitamin, known primarily for its role in calcium metabolism and the treatment of osteoporosis, is thought by many scientists to be more a hormone than a vitamin. Be that as it may, it turns out that a deficiency of vitamin D is linked to prostate cancer and high levels of PSA, the biomarker for that cancer.7

Vitamin E
Vitamin E is actually a family of compounds called tocopherols, of which alpha-tocopherol is the most common. Collectively, these molecules are powerful antioxidants whose value in that regard is well known. A Finnish study published last year showed a correlation between alpha-tocopherol supplementation and large reductions in the incidence of prostate cancer (32% lower) and in mortality from prostate cancer (41% lower).8

Mixed Tocopherols/Tocotrienols
While vitamin E is one of the most researched substances in medicine, it actually encompasses as many as eight different compounds. One of these, gamma-tocopherol, has recently been found to control the growth of a human prostate cancer cell line in vitro and to be superior to alpha-tocopherol in terms of cell inhibition.9 Mixed tocopherols/tocotrienols contain gamma-tocopherol.

Vitamin B2
A Japanese study about a decade ago revealed that vitamin B2 (riboflavin) is an effective inhibitor of 5-alpha-reductase.10 A one-to-one, age- and race-matched case-control study found that blacks over the age of 50 who had lower levels of prostate cancer had higher levels of riboflavin.11 Every such avenue toward reducing the body's production of DHT is worth pursuing in the interest of prostate health.

Pygeum
It has long been known that a standardized extract of the bark of Pygeum africanum, a large evergreen tree native to southern Africa, is effective in reducing the symptoms and clinical signs of enlarged prostate.12,13 This extract contains a variety of fat-soluble sterols and fatty acids that are believed to reduce prostatic inflammation and draw out deleterious substances that bind to the walls of the prostate. Its modes of action are likely to be partly similar to and partly different from those of saw palmetto, so it is beneficial to combine the two extracts in the same formulation. Pygeum has been in widespread use in Europe for several decades for the treatment of genitourinary disorders.

Stinging Nettle
Stinging nettle, Urtica dioica, is a common, perennial Eurasian herb, not to be confused with the completely different stinging nettle that is native to the southeastern United States. Extracts of U. dioica have long been used in the treatment of urinary-tract disorders, as well as gout and rheumatism. This herbal remedy has also been found to be effective against the symptoms of enlarged prostate, especially when used in combination with pygeum extract.11

Both of these extracts are believed to be 5-alpha-reductase inhibitors, and both also apparently inhibit the enzyme aromatase, which converts testosterone into the female sex hormone estradiol. Inhibition of aromatase is beneficial because estradiol, in addition to supplanting testosterone, stimulates the growth of prostate cells - exactly what those with BPH do not want.

Green Tea
Epidemiological studies show that in Asian countries, the incidence of prostate cancer is low compared to the West, and they indicate that green tea is a possible explanation for the difference.14 Indeed, studies on the biological effects of green tea have proved that one of its active ingredients, the polyphenol EGCG, induces cell death in human prostate cancer cells in vitro.15

Resveratrol
If this name sounds familiar, it's probably because you're a wine enthusiast and have read about the benefits to cardiovascular health of resveratrol, a polyphenolic compound found in red wine as well as a variety of other foods. To add to those benefits, resveratrol has also been found to be an effective inhibitor, in laboratory experiments, of the growth of prostate cancer cells.16 Although these results have yet to be confirmed in animal or human studies, it seems reasonable to supplement with the safe, natural compound resveratrol.

Selenomethionine
Selenium is a nutrient trace element that is essential for disease prevention and for the proper functioning of many bodily systems, including the prostate gland. Deficiency of this element has been associated with both heart disease and cancer. A recent laboratory study of the effects of selenomethionine (a seleno-organic compound that occurs naturally in some cereal grains and vegetables17) has shown that it is an effective inhibitor of the growth of prostate cancer cells.18

TAKE THEM ALL
All of these substances are safe, natural products that are known to help protect and support prostate function, by inhibiting the development of BPH or prostate cancer, or both. If you take them all, your chances of leading a benignly prostate-healthy life are now better than ever.

References

  1. Wilt TJ, Ishani A, Stark G, MacDonald R, Lau J, Mulrow C. Saw palmetto extracts for treatment of benign prostatic hyperplasia. JAMA 1998 Nov 11;280(18):1604-9. Erratum: JAMA 1999 Feb 10;281(6):515.
  2. Marks LS, TylerVE. Saw palmetto extract: newest (and oldest) treatment alternative for men with symptomatic benign prostatic hyperplasia. Urology 1999;53(3):457-61.
  3. Carraro JC, Raynaud JP, Koch G, et al. Comparison of phytotherapy (Permixon) with finasteride in the treatment of benign prostatic hyperplasia: a randomized international study of 1098 patients. Prostate 1996;29:231-40.
  4. Braeckman J. The extract of Serenoa repens in the treatment of benign prostatic hyperplasia: a multicenter open study. Curr Ther Res 1994;55:776-85.
  5. Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine, rev. 2nd ed. Prima Health, Rocklin, CA, 1998, pp. 755-6.
  6. Gann PH, Ma J, Giovannucci E, Willett W, Sacks FM, Hennekens CH, Stampfer MJ. Lower prostate cancer risk in men with elevated plasma lycopene levels: results of a prospective analysis. Cancer Res 1999 Mar 15;59(6):1225-30.
  7. Wilczek H. Importance of vitamin D in prostatic carcinoma. Cas Lek Cesk 1996;135:716-8.
  8. Heinonen OP, Albanes D, Virtamo J, Taylor PR, Huttunen JK, Hartman AM, Haapakoski J, Malila N, Rautalahti M, Ripatti S, Maenpaa H, Teerenhovi L, Koss L, Virolainen M, Edwards BK. Prostate cancer and supplementation with alpha-tocopherol and beta-carotene: incidence and mortality in a controlled trial. J Natl Cancer Inst 1998 Mar 18;90(6):440-6.
  9. Moyad MA, Brumfield SK, Pienta KJ. Vitamin E, alpha- and gamma-tocopherol, and prostate cancer. Semin Urol Oncol 1999 May;17(2):85-90.
  10. Nakayama O, Yagi M, Kiyoto S, Okuhara M, Kohsaka M. Riboflavin, a testosterone 5-alpha-reductase inhibitor. J Antibiot (Tokyo) 1990 Dec;43(12):1615-6.
  11. Kaul L, Heshmat MY, Kovi J, Jackson MA, Jackson AG, Jones GW, Edson M, Enterline JP, Worrell RG, Perry SL. The role of diet in prostate cancer. Nutr Cancer 1987;9(2-3):123-8.
  12. Krzeski T, Kazon M, Borkowski A, Witeska A, Kuczera J. Combined extracts of Urtica dioica and Pygeum africanum in the treatment of benign prostatic hyperplasia: double-blind comparison of two doses. Clin Ther 1993;15(6):1011-20.
  13. Barlet A, Albrecht J, Aubert A, Fischer M, Grof F, Grothuesmann HG, Masson JC, Mazeman E, Mermon R, Reichelt H, et al. Efficacy of Pygeum africanum extract in the medical therapy of urination disorders due to benign prostatic hyperplasia: evaluation of objective and subjective parameters. A placebo-controlled, double-blind, multicenter study. Wien lin Wochenschr 1990;102:667-73.
  14. Gupta S et al. Prostate cancer chemoprevention by green tea. Semin Urol Oncol 1999 May;17(2):70-6.
  15. Paschka AG, Butler R, Young CY-F. Induction of apoptosis in prostate cancer cell lines by the green tea component (-)-epigallocatechin-3-gallate. Cancer Lett 1998;130:1-7.
  16. Hsieh T, Wu JM. Differential effects on growth, cell cycle arrest, and induction of apoptosis by resveratrol in human prostate cancer cell lines. Exp Cell Res 1999;249:109-15.
  17. Barceloux DG. Selenium. J Toxicol Clin Toxicol 1999;37(2):145-72.
  18. Redman C, Scott JA, Baines AT, Basye JL, Clark LC, Calley C, Roe D, Payne CM, Nelson MA. Inhibitory effect of selenomethionine on the growth of three selected human tumor cell lines. Cancer Lett 1998 Mar 13;125(1-2):103-10.

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