Saw palmetto for prostate disorders -- american family physician

Saw Palmetto for Prostate Disorders
ANDREA E. GORDON, M.D., and ALLEN F. SHAUGHNESSY, PHARM.D.
Harrisburg Family Practice Residency, Harrisburg, Pennsylvania
Saw palmetto is an herbal product used in the treatment of symptoms related to
benign prostatic hyperplasia. The active component is found in the fruit of the Amer-
ican dwarf palm tree. Studies have demonstrated the effectiveness of saw palmetto in
reducing symptoms associated with benign prostatic hyperplasia. Saw palmetto
appears to have efficacy similar to that of medications like finasteride, but it is better
tolerated and less expensive. There are no known drug interactions with saw pal-
metto, and reported side effects are minor and rare. No data on its long-term usage
are available. The herbal product also has been used to treat chronic prostatitis, but
currently there is no evidence of its efficacy. (Am Fam Physician 2003;67:1281-3. Copy-
right 2003 American Academy of Family Physicians.)
not fully understood. Some of the mecha-nisms proposed include anti-inflammatoryactivity,2 blocked conversion of testosterone to Saw palmetto,also known as Serenoa repens or Sabal serrulatum, is anherb that is most commonly usedto treat problems related to benign dihydrotestosterone (DHT),3,4 and prostate epithelial involution similar to effects noted medicinal element of saw palmetto is taken from the partially dried ripe fruit of the Relief of Symptoms
American dwarf palm tree, which is indige-nous to the coastal regions of the southern United States, from the Carolinas and Florida their effect on symptoms such as diminished urine stream, post-void dribbling, overflow BPH is a nearly universal result of the aging incontinence, and urinary retention, or by less process in men. As the prostate gland enlarges, it can cause both obstructive and irritative changes in prostate size, and residual volume.
symptoms; however, the size of the prostate In a Cochrane Review, investigators conducted gland is not predictive of the symptoms that studies comparing saw palmetto with placebo Saw palmetto is widely used in other coun- or other drugs.6 [Evidence level A: systematic tries; for example, it is used in 50 percent of review of randomized controlled trials RCTs] treatments for BPH in Italy and in 90 percent of The review combined the results of 21 trials with such treatments in Germany.1 The active part durations of four to 48 weeks. The 21 studies of the plant is the sterols and free fatty acids included a total of 3,139 men with a mean age found in the berry. The particular solvent used of 65 years (range: 40 to 88 years). According to in the extraction process affects the resulting the International Prostate Symptom Scale, formulation of the product. The most widely studied form of saw palmetto is Permixon, average urologic score of 14.4 points out of a which uses the solvent hexane; other formula- tions have used ethanol, methanol, and liquid from eight to 19).6 In the 13 studies that carbon dioxide as solvents. Historically, saw palmetto was administered with nettle root and improved symptom scores, individual symp- toms, and flow measures more than placebo.
Patients and physicians were more likely to See page 1226 fordefinitions of strength- most active, and the mechanism of action is palmetto treatment than with placebo. In the palmetto has not been compared with surgical approaches in the treatment of BPH. Saw pal- Key Points About Saw Palmetto
metto is also widely used for treatment ofchronic prostatitis, although scientific evi- Treatment of chronic prostatitis: evidence lacking Contraindications, Adverse Effects,
Mild gastrointestinal distress: infrequent and Interactions
Not known to interfere with the diagnosis of prostate cancer Varies; most studies have used 160 mg twice daily or 320 mg humans is gastrointestinal distress, which is mild and can be minimized by taking saw pal- $6 to $20 per month, depending on brand, for a dosage metto with food. Saw palmetto is believed to be quite safe, although formal toxicology Safe herbal medicine; effective for treatment of symptoms studies have not been completed. One study8 found no mutagenic or teratogenic effects inrats and dogs that were fed saw palmetto in a BPH = benign prostatic hyperplasia. dosage of 2 g per kg daily for six months, andthis dosage was well tolerated. No clinicallyrelevant changes in laboratory parameters 12 studies that reported nocturia results, saw have been found in human clinical trials.9 palmetto reduced nocturia by 25 percent com- There has been some concern that saw pal- metto could mask prostate cancer by lowering In two studies, saw palmetto and finasteride prostate-specific antigen (PSA) levels. How- had similar positive effects on urinary symp- tom scores and peak urine flow. Adverse effects 1,000 patients did not demonstrate this effect caused by saw palmetto were mild and infre- on PSA levels. The same study showed that quent and comparable to side effects from finasteride decreased PSA levels by 41 percent.
placebo. Withdrawal rates among patientsreceiving placebo, saw palmetto, and finasteride were 7.1, 8.9, and 9.0 percent, respectively.
Clinical studies have used a dosage of 160 mg twice daily or 320 mg once daily of a lipophilic extract containing 80 to 90 percent of the volatile oil. A daily dosage of 480 mg was notfound to be any more effective in a six-monthstudy of dosages.8 Teas are not considered tobe effective because they do not contain the volatile oils. The whole berries can be used at ANDREA E. GORDON, M.D., is on the faculty of the Harrisburg Family Practice Resi- the recommended dosage of 1 to 2 g daily.11 As dency, Harrisburg, Pa. She received her medical degree from Jefferson Medical College in Philadelphia. Dr. Gordon completed a family practice residency program at the Uni-versity of Connecticut, Hartford, and a fellowship in family practice faculty develop- ment at St. Margaret Memorial Hospital, Pittsburgh, Pa. She is currently enrolled in an because of the lack of standardization of such integrative medicine fellowship at the University of Arizona, Tucson.
ALLEN F. SHAUGHNESSY, PHARM.D., is director of research and associate director of the Harrisburg Family Practice Residency. He completed his doctorate and fellowship monly available for purchase may not be the training at the Medical University of South Carolina, Charleston. same as those used in clinical studies and, Address correspondence to Andrea E. Gordon, M.D., Harrisburg Family Practice Resi- therefore, may not produce the same results.
dency, 2501 N. Third St., Harrisburg, Pa., 17110-2098 (e-mail: agordon@pinnaclehealth.org). Reprints are not available from the authors. There are no known drug interactions with Saw Palmetto
saw palmetto. The cost for typical saw pal- rat ventral prostate. Br J Pharmacol 1984;83 4. Marks LS, Hess DL, Dorey FJ, Macairan ML, Cruz month at a dosage of 160 mg twice daily.
Santos PB, Tyler VE. Tissue effects of saw palmettoand finasteride: use of biopsy cores for in situ Final Comment
quantification of prostatic androgens. Urology2001;57:999-1005.
Saw palmetto is an effective treatment for 5. Marks, LS, Partin AW, Epstein JI, Tyler VE, Simon I, Macairan ML, et al. Effects of a saw palmetto effective as finasteride and is better tolerated, herbal blend in men with symptomatic benign pro-static hyperplasia. J Urol 2000;163:1451-6.
less expensive, and less likely to decrease PSA 6. Wilt T, Ishani A, MacDonald R. Serenoa repens for levels. No research has evaluated the effect of benign prostatic hyperplasia. Cochrane Database 7. Gerber GS, Kuznetsov D, Johnson BC, Burstein JD.
patients with BPH. Table 1 reviews the efficacy, Randomized, double-blind, placebo-controlled trial safety, tolerability, and cost of saw palmetto.
of saw palmetto in men with lower urinary tractsymptoms. Urology 2001;58:960-4.
The authors indicates that they do not have any con- 8. Small JK, Bombardelli E, Morazzoni P. Serenoa flicts of interest. Source of funding: none reported. repens (Bartram). Fitoterapia 1997;68:99-113.
9. Plosker GL, Brogden RN. Serenoa repens (Per- mixon). A review of its pharmacology and thera-peutic efficacy in benign prostatic hyperplasia.
1. Di Silverio F, D'Eramo G, Lubrano C, Flammia GP, Sciarra A, Palma E, et al. Evidence that Serenoa 10. Carraro JC, Raynaud JP, Koch G, Chisholm GD, Di repens extract displays an antiestrogenic activity in Silverio F, Teillac P, et al. Comparison of phytother- prostatic tissue of benign prostatic hypertrophy apy (Permixon) with finasteride in the treatment of benign prostate hyperplasia: a randomized interna- 2. Lowe FC, Ku JC. Phytotherapy in treatment of tional study of 1,098 patients. Prostate 1996;29: benign prostatic hyperplasia: a critical review. Urol- 11. Saw palmetto monograph. The Natural Medicines 3. Briley M, Carilla E, Roger A. Inhibitory effect of Per- Comprehensive Database. www.naturaldatabase.
mixon on testosterone 5a-reductase activity of the

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