BPH: The Natural Approach
A Concise Update of Important Issues Concerning Natural Health
Ingredients
Reprinted with permission from THE STANDARD
Edited by Thomas G. Guilliams, Ph.D.
There are many conditions for which natural ingredients are
therapeutic equivalents to the pharmaceutical alternative. Benign
Prostatic Hyperplasia (BPH), in particular, is a condition where
natural medicine seems to be far superior to the synthetic drugs, but
the answer is more complete than simply saw palmetto extracts.
BPH: A General Review
BPH is an age-related non-malignant enlargement of the prostate
gland. It is a hyperplasia, in that it is due to increased numbers of
cells, as opposed to a hypertrophy (an increase in cell size). BPH is
very common, effecting almost 10% of the men in their 4th decade and
increasing every decade thereafter. According to the National
Institute on Aging more than half of the men in their 60s have
BPH and among men in their 70s and 80s the figure may
be as high as 90%.
As the prostate enlarges, it causes compression of the urethra
preventing the bladder from adequately releasing urine. Decreased
caliber and force of urination are classic signs. Residual urine,
distention of the bladder and more frequent urination (especially at
night) and urinary tract infections are common. Enlargement of the
prostate is usually confirmed by digital rectal examination.
There are two primary features involved with prostate enlargement.
The major one being hyperplasia, the nonmalignant increase in the
number of cells; and the second being prostatitis, the inflammation
of the prostate. We shall consider hyperplasia first and then discuss
the implications of inflammation.
Hyperplasia
Prostate cells, like most cells, are stimulated to grow by various
growth factors. Several studies have shown that epidermal growth
factor (EGF) and basic fibroblast growth factor (bFGF) are
responsible for stimulating prostate cell growth (1,2). Studies have
also linked increased levels of bFGF in the prostate with the
occurrence of BPH (3). Basically, growth factors are ultimately
responsible for the increase in cell proliferation; but they are not
the root problem.
While these growth factors are common to many cell types, in the
adult prostate they are stimulated primarily through the androgen
receptor. The two major androgen hormones involved are testosterone
(T) and dihydrotestosterone (DHT). When these hormones bind to the
androgen receptors on prostate cells, a complex set of secondary
messages are sent that signal the cell to produce and secrete growth
factors. These growth factors then bind to growth factor receptors on
the same or adjacent prostatic cells, causing another complex set of
secondary signals, resulting in mitosis and cell growth (division).
Understanding BPH requires an understanding of how all of these
factors effect one another, and how the changing hormonal shifts in
elderly men relate to BPH.
As men age, serum levels of testosterone drop while the levels of
estrogens and prolactin increase. While these may have only subtle
effects on other systems, the prostate gland is sensitive to these
changes. Both testosterone and DHT bind to the androgen receptor, but
DHT binds 5 times stronger than testosterone. Therefore, even though
the levels of testosterone are lower, the conversion of testosterone
to DHT via the enzyme 5-
a-reductase, keeps the androgen receptors
activated to stimulate growth factor production. This androgen
receptor stimulation is increased by the action of another hormone,
sex hormone binding globulin (SHBG) and estrogen. When SHBG is bound
to its receptor on the prostate cells and is also attached to
estrogen, it is able to sensitize (or amplify) the androgen signal
(4,5,6). In fact, it may be the very minute increase in estrogen
levels that convert a normal androgen signal to one that causes
hyperplasia. Estrogens also play a role in inhibiting the degradation
of testosterone and DHT via hydroxylation. Another factor that may
play a role is the increased activity of the 5-
a-reductase enzyme,
and androgen binding when prolactin is bound to prostatic cells.
Inflammation
Prostatitis describes any inflammation of the prostate, whether it
is caused by a bacterial infection or not. Inflammation of the
prostate from bacterial infections is often related to BPH since the
frequencies of urinary tract infections (UTI) increase as retention
of urine in the bladder increases. Both chronic and acute bacterial
prostatitis are seen and should be treated much like chronic and
acute UTIs. A chronic, nonbacterial prostatitis has also been seen in
a large group of men. This form of inflammation seems to be
associated with an elevated white blood cell count and abnormal
inflammatory cells in the prostate secretion. It is thought that this
could possibly be some form of autoimmune response.
Regardless of the type of inflammation, metabolites such as
leukotrienes, thromboxanes and prostaglandins; which are derived from
arachidonic acid via the lipoxygenase or cyclooxygenase enzymes are
involved. Anti-inflammatory agents that specifically block one or
more of these pathways would be helpful in reducing the inflammatory
symptoms associated with prostatitis.
Treatment Options
Several reviews exist on the current treatment approaches to BPH
(7,8). What follows is a general overview and not a comprehensive
review.
1. Surgery
Various forms of surgery are available to remove portions of the
prostate. These tend to treat the enlargement with good success but
have unpleasant side effects such as decreased sexual function
(impotence, pain, ejaculatory dysfunction) and bladder incontinence.
Newer procedures such as trans-urethral resections or incisions can
be done to remove portions of the prostate. These procedures work
well for removing portions of the prostate, but do little to address
the process that caused the enlargement to begin with. Complications
of scar tissue and infections are not uncommon in these
procedures.
2. Drugs
Two types of drugs are primarily used, 5-
a-reductase inhibitors
and alpha andrenoceptor blockers (alphablockers). Finasteride
(Proscar) is the most used 5-
a-reductase inhibitor. It blocks the
conversion of testosterone to DHT. Finasteride often requires 6
months to a full year before significant results are evident.
Alpha-blockers such as terazosin, prazosin and others act by relaxing
the muscles around the prostate, relieving many of the symptoms of
BPH. While having a more immediate effect on symptoms, it does not
change the underlying problems associated with the enlarged prostate
(7,8,9).
The Natural Approach
Diet
It has been reported that a high protein diet inhibits
5-
a-reductase activity, while a low protein diet stimulates the
enzyme. No large clinical studies have confirmed these results, and
other health conditions may play a greater role in dictating the type
of diet for the individual with BPH. It has been shown that the
combination of the amino acids glycine, alanine, and glutamic acid
relieves many of the symptoms of BPH in several studies. These
studies are quite old (10,11), and further research may be warranted
as additional support during BPH.
The use of Essential Fatty Acids (EFAs) is important at all times,
but BPH sufferers often are deficient in EFAs. The use of EFAs in the
form of Flaxseed Oil will provide both omega-3 (linolenic) and
omega-6 (linoleic), but much more linolenic. Linolenic acid is a
precursor to many of the "good" prostaglandins, which
will help suppress much of the prostaglandin-induced
inflammation.
Zinc
Zinc intake and absorption is critical for the prostate, especially
during BPH. Zinc has been shown to reduce the size of the prostate
and the symptoms in many of the patients with BPH (12,13). Zinc is
involved in various aspects of androgen metabolism. As has been
discussed earlier, estrogen levels are increased in elderly men.
Estrogen not only inhibits the hydroxylation of Testosterone and DHT;
it also prevents the absorption of zinc. Zinc has been shown to
inhibit the activity of 5-a-reductase (14). Zinc also reduces
prolactin binding to prostate receptors (15). While the exact levels
of supplemental zinc have not been determined experimentally, a dose
of approximately 50 mg (325% USRDA) should be both adequate and safe.
Since zinc is known to reduce the absorption of copper, it is wise to
include copper (1 or 2 mg) with a daily zinc supplementation regimen.
Saw Palmetto Extract
The Liposterolic extract of Saw Palmetto fruits (Serenoa repens,
or Sabal serulata) has been used extensively and for many years as
the drug of choice for BPH in Europe and has been getting more and
more attention here in the United States. The fatty acids include
capric, caprylic, caproic, lauric, palmytic, and oleic. The
phytosterols include b-sitosterol, stigmasterol and others. The
liposterolic extract of Saw Palmetto has three major activities that
improve BPH symptomology, they include: Inhibition of 5-
a-reductase
(16, 17, 18, 19); Inhibiting the binding of DHT to prostatic cells
(20); and Inhibiting both Lipoxygenase and Cyclooxygenase
(arachidonic acid cascades) (21). Saw Palmetto, by competing with
both the enzyme and receptor that stimulates growth factor secretion,
inhibits hyperplasia.
A three-year trial of 309 men, comparing Saw Palmetto Extract to
Finasteride (Proscar) showed a significant increase in urinary flow
rate and a 50% decrease in residual urine volume associated with the
Saw Palmetto group. While the finasteride group also showed
improvements, they were not as significant as the Saw Palmetto group,
and there were almost 6 times more dropouts in the finasteride group
due to unpleasant side effects (22). There have been many clinical
trials done with Saw Palmetto extracts showing effective treatment of
BPH.
Standard dosages of Saw Palmetto Extracts are those which yield
from 270 to 305 mg of fatty acids per day (often 320 mg of an 85- 95%
fatty acid extract). Fatty acid extracts of 85-95% are oil extracts
and are in soft gel capsules. Powdered extracts are also available
and are usually standardized anywhere from 20% to 55% fatty
acids.
Nettles Root Extract
Extracts of Stinging Nettle root (Urtica dioica L.) have been
used, singly or in combination with other botanicals for the
condition of BPH (22, 24, 25). Nettles root extract, as well as Saw
Palmetto extract, are both approved by the German government as
treatments for BPH. While the mechanism has not been fully
elucidated, two activities have been identified in nettle root
extracts that may be responsible for the activity. The first is the
inhibition of prostate Na+/K+ ATPase enzyme (26). By inhibiting this
crucial enzyme, prostate cells are prevented from proliferating and
therefore, this inhibits hyperplasia. The second activity is an
interference of the human sex-hormone binding globulin (SHBG). By
interfering with SHBG and its receptor, nettles root extracts prevent
the estrogen-induced amplification of the androgen signal, which is
thought to be one of the major players in BPH (27,28). A common
mixture of 120 mg of nettles root extract with 160 mg of saw palmetto
is used for many clinical trials.
Pygeum Extract
The Extract of Pygeum africanum bark has been used for more than
20 years in France in patients suffering from BPH. The mechanism has
not been fully worked out, but a few of the activities are known.
Pygeum extracts are known to inhibit the proliferative effects of
growth factors such as EGF, bFGF, and IGF-I. This activity was able
to inhibit the prostatic growth in an animal model, even when the
cells were stimulated to grow (29). This activity makes pygeum
extract an excellent synergist with saw palmetto because routes other
than the androgen receptor may stimulate growth signals.
Additionally, Pygeum extracts antagonize the production of
metabolites in the 5-Lipoxygenase pathway (30). This activity will
further reduce the inflammatory process in the prostate. Pygeum
extracts have been dosed anywhere from 50-200 mg per day with
excellent results.
Conclusion
The natural treatment approach to BPH is one of the triumphs of
natural medicine. It is quite unfortunate that more health care
professionals have not taken advantage of these approaches with the
millions of patients with this condition. The mechanisms are clear,
the results even more clear, and physicians should feel more than
confident using any number of products with these ingredients.
