SAW PALMETTO FOR THE TREATMENT OF MEN WITH LOWER URINARY TRACT SYMPTOMS

Inhibitory effects of Centella asiatica (L.) Urban on enlarged prostate through androgen receptor and PI3K/Akt signaling pathways

Centella asiatica (L.) Urban (C. asiatica) is a traditional herbal medicine that has been used for wound healing and anti-inflammation since ancient times. Various biological effects of C. asiatica ethanolic extract (CAE) were previously reported. However, in our previous study, C. asiatica aqueous extract (CAA) exhibited higher inhibitory activity on benign prostatic hyperplasia (BPH) than CAE. Therefore, the aim of this study was to investigate the effect of CAA on BPH, and elucidate the inhibitory mechanism through in vitro and in vivo experiments as well as metabolite analysis of CAA. A BPH rat model was induced by daily subcutaneous injection of testosterone propionate (TP, 3 mg kg^-1) dissolved in corn oil for 4 weeks after castration. The experimental group, the CAA treatment group, was orally administered CAA (100 mg kg^-1) for 4 weeks while inducing prostatic hyperplasia. Saw palmetto extract (Saw, 100 mg kg^-1) and Finasteride (Fi, 1 mg kg^-1) were used as positive controls and were administered orally for 4 weeks. CAA significantly inhibited androgen receptor signaling related factors overexpressed by dihydrotestosterone (DHT) treatment in prostate cell lines. Afterwards, the testosterone-induced BPH model was used to verify the alleviation efficacy of CAA in prostatic hyperplasia. Prostate size and the thickness of the prostate tissue epithelium were significantly decreased in the group treated with CAA compared to those in the BPH group. The results of protein expression in the prostate tissue confirmed that CAA inhibited androgen receptor signaling in BPH and decreased the expression of growth factors. Moreover, CAA suppressed the expression of the PI3K/Akt pathway and cell proliferation-related factors compared to the BPH group. Taken together, these results indicate that CAA improves the inhibitory efficacy of BPH by inhibiting the androgen receptor and PI3K/Akt pathways, suggesting that CAA may be a promising candidate for biopharmaceutical formulations of BPH.

The Therapeutic Potential of Saw Palmetto Extract in Urological Disorders

Saw palmetto extract (SPE) has been widely used as a therapeutic remedy for urinary dysfunction in western countries. Furthermore, as an herb drug, it can be used as an alternative therapy for benign prostatic hyperplasia (BPH) due to its safety and minimum adverse effects. Reportedly, SPE improves the urinary symptoms, which mainly depend on anti-androgenic effects and effects on autonomic receptors in the lower urinary tract. However, the mechanisms of action responsible for the therapeutic roles of SPE have not been fully elucidated. Relevant studies indicate that SPE has some positive effects on the treatment of urological diseases in animals, and clinical trials are ongoing. In this review, we summarize the pharmacological properties and discuss the possible therapeutic mechanisms of SPE in urological diseases, including anti-androgenic effects, effects on autonomic receptors in the lower urinary tract, anti-inflammatory activity, anti-proliferative and pro-apoptotic effects, and highlight a potential therapeutic approach in the clinical treatment of patients with BPH, prostate cancer, chronic prostatitis (CP) and erectile dysfunction (ED).

Natural Hair Supplement: Friend or Foe? Saw Palmetto, a Systematic Review in Alopecia

Saw palmetto (SP), a botanical extract with antiandrogenic properties, has gained commercial popularity for its purported benefits on hair regrowth. To summarize published evidence on the efficacy, safety, and tolerability of supplements containing SP in the treatment of alopecia, we conducted a PubMed, Google Scholar, and Cochrane database search using the following terms: (saw palmetto and hair loss), (saw palmetto and androgenetic alopecia), and (saw palmetto and natural supplement and alopecia). Five randomized clinical trials (RCTs) and 2 prospective cohort studies demonstrated positive effects of topical and oral supplements containing SP (100-320 mg) among patients with androgenetic alopecia (AGA) and telogen effluvium. Sixty percent improvement in overall hair quality, 27% improvement in total haircount, increased hair density in 83.3% of patients, and stabilized disease progression among 52% were noted with use of various topical and oral SP-containing supplements. SP was well tolerated and not associated with serious adverse events in alopecia patients. Although robust high-quality data are lacking, supplements containing SP may be a treatment option for patients with AGA, telogen effluvium, and self-perceived hair thinning. Further large-scale RCTs focusing on the sole contribution of SP to hair growth outcomes are needed to confirm efficacy and determine long-term adverse events.

Comparison of Serenoa repens With Tamsulosin in the Treatment of Benign Prostatic Hyperplasia: A Systematic Review and Meta-Analysis

Studies reported that Serenoa repens was effective in relieving lower urinary tract symptoms (LUTS). This article carried out a systematic review and meta-analysis to compare Serenoa repens with tamsulosin in the treatment of benign prostatic hyperplasia (BPH) after at least 6-month treatment cycle. Four studies involving 1,080 patients (543 in the Serenoa repens group and 537 in the tamsulosin group) were included in the meta-analysis. The results were as follows: compared with tamsulosin, Serenoa repens had a same effect in treating BPH in terms of International Prostate Symptom Score (IPSS) (mean difference [MD] 0.63, 95% confidence interval [CI] [-0.33, 1.59], p = 0.20), quality of life (QoL) (MD 1.51, 95% CI [-1.51, 4.52], p = 0.33), maximum flow rate (Qmax) (MD 0.27, 95% CI [-0.15, 0.68], p = 0.21), postvoid residual volume (PVR) (MD -4.23, 95% CI [-22.97, 14.44], p = 0.65), prostate-specific antigen (PSA) (MD 0.46, 95% CI [-0.06, 0.97], p = 0.08) with the exception of prostate volume (PV) (MD -0.29, 95% CI [-0.41, -0.17], p < 0.00001). For side effects, Serenoa repens was well tolerated compared with tamsulosin especially in ejaculation disorders (odds ratio [OR] = 12.56, 95% CI [3.83, 41.18], p < 0.0001) and decreased libido (OR = 5.40; 95% CI [1.17, 24.87]; p = 0.03). This study indicated that Serenoa repens had the same effect in treating BPH compared with tamsulosin in terms of IPSS, QoL, and PVR after at least 6-month treatment cycle, however, the latter had a greater improvement in PV compared with the former. And Serenoa repens did not increase the risk of adverse events especially with respect to ejaculation disorders and libido decrease.

Clinical Effects of Formulated Food of Peucedanum japonicum Extract and Saw Palmetto Extract in Male Patients with Lower Urinary Tract Symptoms

OBJECTIVES

To evaluate changes over time in subjective symptom scores and urination parameters before and after oral administration of formulated food containing a combination of Peucedanum japonicum (P. japonicum) extract and saw palmetto extract (SPE) in male patients with lower urinary tract symptoms (LUTS).

METHODS

This study was conducted in an open label manner on male patients with untreated LUTS. The urination state of patients was evaluated before and after administration of food formulated with P. japonicum extract and SPE for 4 weeks, based on urodynamic parameters and subjective symptom scores (International Prostate Symptom Score [IPSS and IPSS-QOL], Overactive Bladder Symptom Score [OABSS], Overactive Bladder Questionnaire [OAB-q], and International Index of Erectile Function [IIEF]).

RESULTS

After the administration of food formulated with these extracts, the following results were obtained: (i) Subjective findings: The IPSS-QOL score improved significantly; both parameters related to nocturia, i.e., frequency of nighttime urination and OABSS-2, improved significantly; other ratings for subjective symptoms slightly improved. (ii) Objective findings: Residual urine volume decreased significantly, and blood prostate specific antigen (PSA) and urinary 8-OHdG levels decreased slightly after the treatment. (iii) Other findings: Blood pressure decreased slightly. No adverse drug reactions were reported. (iv) Patient impressions: 75% of patients gave a rating of "Good" or higher, with 15 out of 20 patients wanting to continue treatment after the end of 4-week administration period.

CONCLUSIONS

Food formulated with P. japonicum extract and SPE may be useful to decrease frequency of nighttime urination and residual urine volume in male patients with LUTS.

Comparison of tamsulosin plus serenoa repens with tamsulosin in the treatment of benign prostatic hyperplasia in Korean men: 1-year randomized open label study

INTRODUCTION

In Korea, increasing attention has recently been given to the use of phytotherapeutic agents to alleviate the symptoms of BPH. Serenoa repens has been shown to have an equivalent efficacy to Finasteride or Tamsulosin in the treatment of BPH in previous studies. The present study was designed to compare the efficacy and safety of Serenoa repens plus tamsulosin with tamsulosin only over 12 months in men with LUTS secondary to BPH.

MATERIALS AND METHODS

One hundred forty men with symptomatic BPH (IPSS≥10) were recruited in our hospital for a 12-month, open-label, randomized trial. Patients were randomly assigned to either tamsulosin 0.2 mg/day plus Serenoa repens 320 mg/day (n=60) or tamsulosin 0.2 mg/day only (n=60). Prostate volume and PSA were measured at baseline and at end-point, whereas total IPSS, and its storage and voiding subscores, LUTS-related QoL, Qmax, and PVR were evaluated at baseline and later every 6 months.

RESULTS

Total 103 patients were finally available: 50 in the TAM+SR group and 53 in the TAM group. At 12 months, total IPSS decreased by 5.8 with TAM+SR and 5.5 with TAM (p=0.693); the storage symptoms improved significantly more with TAM+SR (-1.7 vs. -0.8 with TAM, p=0.024). This benefit with regard to storage symptom in the TAM+SR group lasts at 12 months (-1.9 vs. -0.9, p=0.024). The changes of voiding subscore, LUTS-related QoL, Qmax, PVR, PSA, and prostate volume showed no significant differences between the TAM+SR and TAM groups. During the treatment period, 8 patients (16.9%) with TAM and 10 (20%) with TAM+SR had drug-related adverse reactions, which included ejaculatory disorders, postural hypotension, dizziness, headache, gastro-intestinal disorders, rhinitis, fatigue and asthenia.

CONCLUSIONS

The combination treatment of Serenoa repens and tamsulosin was shown to be more effective than tamsulosin monotherapy in reducing storage symptoms in BPH patients after 6 months and up to 12 months of treatment.

Seidlitzia rosmarinus for lower urinary tract symptoms associated with benign prostatic hyperplasia: a pilot randomized controlled clinical trial

OBJECTIVE

This study was performed to investigate the effect of Seidlitzia rosmarinus on the clinical symptoms of benign prostatic hyperplasia.

METHODS

This single-blind clinical trial included 98 patients with voiding and storage symptoms in Shohada Ashayer Hospital of Khorramabad. The patients were randomly divided into two groups of treatment with prazosin 1mg/day plus Seidlitzia rosmarinus 3g/day and treatment with prazosin 1mg/day. The clinical symptoms were measured using the International Prostate Symptoms Score (IPSS) questionnaire. Serum prostate-specific antigen (PSA) level, prostate volume, and residual urine volume before and 2 months after the intervention were measured.

RESULTS

The results of the study before the intervention did not show significant differences between the prazosin and Seidlitzia rosmarinus plus prazosin groups for the scores of clinical symptoms, PSA level, prostate volume, and residual urine volume (p>0.05). However, significant differences were found between the two groups after the intervention for the mean change scores of clinical symptoms (6.8 scores in the Seidlitzia rosmarinus group vs. 2 scores in the control group) (p<0.001), while no significant differences were found for the mean change scores of PSA level, prostate volume, and residual urine volume (p>0.05).

CONCLUSION

The results of the study showed that the simultaneous consumption of Seidlitzia rosmarinus and prazosin, compared to the consumption of prazosin alone, results in significant improvements in the clinical symptoms of benign prostatic hyperplasia.

Alternative and antioxidant therapies used by a sample of infertile males in Jordan: a cross-sectional survey

Background

Complementary and alternative medicine (CAM) is frequently used in the Middle East, especially to treat chronic diseases such as infertility. We aimed to examine the prevalence, characteristics, and determinants of CAM use, particularly herbs and antioxidant therapies, among infertile males presenting for infertility evaluation in Jordan.

Methods

Demographic information, use of alternative and antioxidant therapies for infertility treatment, and patients’ belief in efficacy and safety of the therapies used were collected using a face-to-face questionnaire. Data were collected from 428 infertile male patients presenting at infertility clinics in Amman, the capital city of Jordan. The study was conducted between April 2013 and September 2013.

Results

Of the 428 men who completed the questionnaire, 184 (43%) used at least one of the alternative and antioxidant therapies specified in the questionnaire. Nutritional regime; vitamins, such as vitamins C and E; and medicinal herbs, such as ginger, saw palmetto, and ginseng were the most commonly used therapies reported. A correlation between the use of alternative and antioxidant therapies versus infertility duration was found. Additionally, the majority of males using CAM did not inform their health care providers about their usage.

Conclusions

The high prevalence of CAM use among infertile male patients underscores the urge to assimilate CAM into the education and training of health professionals, as well as to improve infertile patients’ knowledge of the safe use of CAM modalities.

Pharmacological characterization and chemical fractionation of a liposterolic extract of saw palmetto (Serenoa repens): effects on rat prostate contractility

ETHNOPHARMACOLOGICAL RELEVANCE

Saw palmetto (Serenoa repens) was first used medicinally by native American Indians to treat urological disorders. Nowadays, saw palmetto extracts are widely used in Europe and North America to treat the urinary symptoms associated with benign prostatic hyperplasia even though its mechanisms of action are poorly understood. This study aimed to characterize the bioactive constituents of a lipid extract of saw palmetto that are able to affect contractility of the rat prostate gland. The mechanism of action will also be investigated.

MATERIALS AND METHODS

A commercially available lipid extract of saw palmetto was subjected to fractionation using normal phase column chromatography. Composition of fractions was assessed by proton nuclear magnetic resonance spectroscopy ((1)H NMR) and mass spectrometry (MS). Contractile activities of these fractions were evaluated pharmacologically using isolated preparations of rat prostate gland and compared to the activity of the crude extract.

RESULTS

Saw palmetto extract inhibited contractions of the rat prostate gland which were consistent with smooth muscle relaxant activity. Only the ethyl acetate fraction resulting from chromatography inhibited contractions of isolated rat prostates similarly to the inhibition produced by the crude lipid extract. Comparison with authentic samples and analysis of NMR data revealed that this bioactivity was due to the fatty acid components present in the ethyl acetate fraction. Bioassay using various pharmacological tools identified multiple contractile mechanisms which were affected by the bioactive constituents.

CONCLUSION

A fatty acid component of saw palmetto extract causes inhibition of prostatic smooth muscle contractions via a non-specific mechanism.

The effect of increasing doses of saw palmetto fruit extract on serum prostate specific antigen: analysis of the CAMUS randomized trial

PURPOSE

Saw palmetto extracts are used to treat lower urinary tract symptoms in men despite level I evidence that saw palmetto is ineffective in reducing these lower urinary tract symptoms. We determined whether higher doses of saw palmetto as studied in the CAMUS (Complementary and Alternative Medicine for Urologic Symptoms) trial affect serum prostate specific antigen levels.

MATERIALS AND METHODS

The CAMUS trial was a randomized, placebo controlled, double-blind, multicenter, North American trial conducted between June 5, 2008 and October 10, 2012, in which 369 men older than 45 years with an AUA symptom score of 8 to 24 were randomly assigned to placebo or dose escalation of saw palmetto, which consisted of 320 mg for the first 24 weeks, 640 mg for the next 24 weeks and 960 mg for the last 24 weeks of this 72-week trial. Serum prostate specific antigen levels were obtained at baseline and at weeks 24, 48 and 72, and were compared between treatment groups using the pooled t test and Fisher's exact test.

RESULTS

Serum prostate specific antigen was similar at baseline for the placebo (mean ± SD 1.93 ± 1.59 ng/ml) and saw palmetto groups (2.20 ± 1.95, p = 0.16). Changes in prostate specific antigen during the study were similar, with a mean change in the placebo group of 0.16 ± 1.08 ng/ml and 0.23 ± 0.83 ng/ml in the saw palmetto group (p = 0.50). In addition, no differential effect on serum prostate specific antigen was observed between treatment arms when the groups were stratified by baseline prostate specific antigen.

CONCLUSIONS

Saw palmetto extract does not affect serum prostate specific antigen more than placebo, even at relatively high doses.

Effects of a nanocomposite containing Orbignya speciosa lipophilic extract on Benign Prostatic Hyperplasia

ETHNOPHARMACOLOGICAL RELEVANCE

Lower urinary tract symptoms (LUTS) are a common complaint among aging men and are usually caused by Benign Prostatic Hyperplasia (BPH). A number of medical treatments for LUTS/BPH exist, such as α-blockers, 5α-reductase inhibitors, phytotherapeutical drugs and combination therapies. Babassu is the common name of a Brazilian native palm tree called Orbignya speciosa, whose kernels are commonly used (eaten entirely or as a grounded powder), in parts of Brazil for the treatment of urinary disorders. This study investigates the effects of Orbignya speciosa nanoparticle extract, a newly developed phytotherapic formulation derived from the kernels of babassu, in the treatment of BPH.

MATERIALS AND METHODS

Orbignya speciosa extract was obtained from the kernels, a nanoparticulate system was developed and acute toxicity test was performed. BPH primary stromal cell and tissue cultures were established and treated with 300μg/mL Orbignya speciosa nanoparticle (NanoOse) extract in order to evaluate its effects on apoptosis induction, cytotoxicity, cell morphology and proliferation.

RESULTS

Our results indicated that NanoOSE shows no toxicity in animals and acts incisively by promoting morphological cell changes, reducing cell proliferation as well as inducing necrosis/apoptosis on BPH cells and tissues.

CONCLUSIONS

This study provided the first report of the successful use of NanoOSE on BPH treatment which corroborates with the popular use of the kernels of this plant. The results also suggest the potential of NanoOSE as a candidate new phytotherapeutic agent on the management of BPH.

Redesigning a large-scale clinical trial in response to negative external trial results: the CAMUS study of phytotherapy for benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH), a common condition among older men, confers its morbidity through potentially bothersome lower urinary tract symptoms. Treatments for BPH include drugs such as alpha-adrenergic receptor blockers and 5-alpha reductase inhibitors, minimally invasive therapies that use heat to damage or destroy prostate tissue, and surgery including transurethral resection of the prostate. Complementary and alternative medicines are gaining popularity in the US. Two phytotherapies commonly used for BPH are extracts of the fruit of Serenoa repens, the Saw palmetto dwarf palm that grows in the Southeastern US, and extracts of the bark of Pygeum africanum, the African plum tree.

PURPOSE

The objective of the Complementary and Alternative Medicines for Urological Symptoms (CAMUS) clinical trial is to determine if phytotherapy is superior to placebo in the treatment of BPH.

METHODS

CAMUS was originally designed as a 3300-participant, four-arm trial of S. repens, P. africanum, an alpha-adrenergic blocking drug, and placebo with time to clinical progression of BPH, a measure of long-term efficacy, as the primary endpoint. Before enrollment started, a randomized, double-blind, placebo-controlled, single institution clinical trial showed that S. repens at the usual dose did not demonstrate any benefit over placebo with respect to symptom relief at 1 year. Consequently, the focus of CAMUS shifted from evaluating long-term efficacy to determining if any short-term (6-18 months) symptom relief could be achieved with increasing doses of S. repens, the phytotherapy most commonly used in the US for BPH.

RESULTS

Results are anticipated in 2011.

CONCLUSIONS

Trial design occurs in an environment of continually evolving information. In this case, emerging results from another trial suggested that a study of long-term efficacy was premature, and that an effective dose and preparation of S. repens had to be established before proceeding to a long-term clinical trial.

Effects of dietary saw palmetto on the prostate of transgenic adenocarcinoma of the mouse prostate model (TRAMP)

BACKGROUND

Several of the proposed mechanisms for the actions of the liposterolic extract of saw palmetto (SPE) are exerted on known risk factors for prostate cancer (CaP). This study investigated whether SPE could prevent the progression of CaP in a transgenic adenocarcinoma of the mouse prostate (TRAMP) model.

METHODS

Two different doses of SPE designed to deliver 50 mg/kg/day SPE and 300 mg/kg/day SPE were administered in a custom diet to TRAMP mice for 12 or 24 weeks. Body and organ weights were used to evaluate toxicity, and radioimmunoassay was used to measure plasma and tissue androgen levels to monitor effects of SPE on 5alpha reductase activity. Prostate tissues were evaluated histologically to determine the effect of treatment on tumor grade, cell proliferation, and apoptosis.

RESULTS

Treatment with 300 mg/kg/day SPE from 4 to 24 weeks of age significantly reduced the concentration of 5alpha-dihydrotestosterone (DHT) in the prostate and resulted in a significant increase in apoptosis and significant decrease in pathological tumor grade and frank tumor incidence.

CONCLUSIONS

Dietary supplementation with SPE may be effective in controlling CaP tumorigenesis. SPE suppression of prostatic DHT levels lends support to the hypothesis that inhibition of the enzyme 5alpha-reductase is a mechanism of action of this substance.

Herbal Supplements: Facts and Myths—Talking to Your Patients About Herbal Supplements

The use of herbal supplements in the United States is steadily growing and raises concerns about safety, efficacy, and how they affect safe patient care. The direct health risks associated with herbal supplements include hypertension, prolonged bleeding, and the potential for drug-herb interactions. These potential drug interactions are of particular concern for patients undergoing anesthesia. This article provides a review of literature on the 10 most popular herbal supplements and addresses the herbal supplements' reported use, possible adverse effect(s), patient teaching, possible drug interaction(s), and recommendations regarding discontinuation before surgery.

Monotherapy versus combination drug therapy for the treatment of benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) is a medical condition occurring in older men (ie, those aged >60 years) resulting from enlargement of the prostate gland. Consequently, affected men may experience bother-some urinary tract symptoms and diminished quality of life. The risk of lower urinary tract symptoms and complications such as acute urinary retention (AUR) may increase if BPH is untreated. Currently, 2 classes of drugs-alpha-adrenergic blockers (alpha-blockers) and 5alpha-reductase inhibitors-are indicated for the treatment of BPH. Although the 2 classes are commonly used in combination, the evidence has frequently not been supportive of this practice. Results from the Medical Therapy of Prostatic Symptoms (MTOPS) trial, the largest and longest clinical trial on this topic to date, revisited the role of combination therapy in the treatment of BPH.

OBJECTIVE

This review presents published trials evaluating alpha-blockers or 5alpha-reductase inhibitors used alone or in combination for the treatment of BPH.

METHODS

A MEDLINE search was conducted (December 1974 to November 2004) using the MeSH term prostatic hyperplasia limited to the subheading of drug therapy. These results were cross-referenced with the MeSH term combination drug therapy. An additional search was conducted using the MeSH terms finasteride and adrenergic alpha-antagonists limited to adverse effects and therapeutic uses. These results were cross-referenced with prostatic hyperplasia and combination drug therapy. Review articles and meta-analyses were also used.

RESULTS

The Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group and the Prospective European Doxazosin and Combination Therapy studies were well-designed trials that failed to support the theory that combination therapy is preferred over alpha-blockers alone. Finasteride was also shown to be no better than placebo for the outcomes of symptom score and peak urinary flow rates. Other trials suggested that combination therapy (which included finasteride) was more effective at reducing symptom scores in men with enlarged prostates at 1 year and that alpha-blockers may be successfully discontinued once patients are stabilized on finasteride. Although it was a prespecified secondary end point, the incidence of surgery or AUR was reduced by 51% using finasteride over placebo. The additive benefit finasteride provides in reducing symptoms, risk of AUR, and invasive surgery was observed within the first year of treatment and correlated with larger prostate sizes (mean [SD], approximately 55 [26] mL). The MTOPS trial further demonstrated a relative risk reduction of 66% in clinical progression rates for the combination-therapy group versus 39% for the doxazosin group compared with placebo (P < 0.001); the doxazosin group was not statistically different from the finasteride monotherapy group. Improvements in symptom scores were greater in the combination-therapy group versus the doxazosin (P = 0.006) and finasteride monotherapy (P < 0.001) groups.

CONCLUSION

Based on the literature, combination therapy has been proven to relieve symptoms and delay progression of BPH in men with moderate to severe symptoms and moderately enlarged prostate glands.

Saw palmetto and finasteride in the treatment of category-III prostatitis/chronic pelvic pain syndrome

Chronic nonbacterial prostatitis/chronic pelvic pain syndrome is a common entity for which a standardized management has not been established. Patients often have a significant symptom complex and impact on quality of life, but very little is known about the efficacy of second- and third-line treatments, such as the use of herbal supplements. Many treatments studied in recent literature include antibiotics, alpha-blockade, anti-inflammatory agents, and cognitive behavioral interventions such as biofeedback and psychotherapy.

Evaluation and medical management of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is common among aging men. Untreated BPH may lead to complications including urinary tract infection, acute urinary retention, and obstructive nephropathy. Diagnosing BPH can be challenging because lower urinary tract symptoms are found in conditions other than BPH, and prostate size correlates poorly with symptoms of obstruction. Nonetheless, a careful medical history and physical examination, along with prudent use of diagnostic tests, can yield an accurate diagnosis. We review the evaluation of men with suspected BPH and indications for referral to a urologist for invasive therapy. We also review supporting evidence and treatment considerations for saw palmetto and the 2 major classes of prescription medications, alpha1-adrenergic antagonists and 5alpha-reductase inhibitors.

Is there a scientific basis for the therapeutic effects of serenoa repens in benign prostatic hyperplasia? Mechanisms of action

PURPOSE

The huge resurgence of interest in herbal remedies has spawned a global industry that now competes with conventional drugs as adjuncts and/or alternatives for various conditions. The medical treatment of benign prostatic hyperplasia (BPH) is no exception. Along with alpha-blockers and 5alpha-reductase inhibitors the extract of the American dwarf palm, Serenoa repens, is unquestionably the most widely used. Together with Pygeum africanum, an extract from the bark of the African plum tree, it is licensed in Germany, France and other European countries for symptomatic BPH. This review was done to analyze the large number of in vivo and in vitro laboratory studies that have been performed with extracts of Serenoa repens to elucidate mechanism(s) of action.

MATERIALS AND METHODS

A literature search (MEDLINE) revealed more than 30 publications relating to laboratory studies with extracts of Serenoa repens, addressing the question of a mechanism of action. It would appear that the n-hexane lipidosterolic extract of Serenoa repens, namely Permixon (Pierre Fabre Medicament, Boulogne, France), is a product that has uniquely been subjected to more scientific investigation than any other such preparation.

RESULTS

Placebo controlled and comparative clinical studies of Permixon indicate its efficacy for BPH/lower urinary tract symptoms. Numerous mechanisms of action have been proposed, including an antiandrogenic action, an anti-inflammatory effect and an antiproliferative influence through the inhibition of growth factors.

CONCLUSIONS

Set against the background of our current knowledge of the pathophysiology of the aging prostate, the results of these studies suggest a wide spectrum of activity. However, precise mechanism(s) of action remain obscure. Balance and caution are needed when extrapolating the results of in vitro laboratory studies to the complex human situation.

Barriers to planning and conducting a screening: prostate cancer

African American men participated in a screening initiative and completed the 22-item Barriers to Prostate Cancer Screening Checklist. Forty-three men received a digital rectal exam (DRE) and prostate specific antigen (PSA) laboratory test. The age of the males was M = 56.4 (range = 45-76) years; 47% were compliant with the American Cancer Society annual screening guidelines for high-risk individuals. Nineteen men from the screened group completed a 22-item Response to Barriers Checklist. The barrier ranked a "big problem" for not getting a prostate exam, and the highest by 32% (n = 6) of the sample was "Too many things going on in their lives." The lowest ranked problem by 100% of the participants was "Takes too long to get an appointment." Two individuals reported taking the over-the-counter supplement, saw palmetto. It is important that when planning a health screening in the community, both barriers and advantages be evaluated during the planning and before the implementation phase of the project.

Effect of permixon on human prostate cell growth: lack of apoptotic action

BACKGROUND

Permixon, a phytotherapeutic agent derived from the saw palmetto or Serenoa repens plant, is a lipid/sterol extract that is believed to interfere with 5alpha-reductase activity, thus inhibiting prostate growth. In this study, we investigated the magnitude and specificity of the effect of Permixon on cell proliferation and apoptosis in human prostate cancer cells.

METHODS

The effect of Permixon was examined in androgen-independent PC-3 prostate cancer cells, androgen-sensitive LNCaP prostate cancer cells, and MCF-7 breast cancer cells in vitro. Cell growth, apoptosis induction, and cell proliferation was studied after exposure to Permixon at two concentrations (10 and 100 microg/ml). Cell proliferation and cell cycle progression were determined after 24 hr on the basis of (3)[H]-thymidine incorporation assay and flowcytometric analysis, respectively. Apoptosis induction was evaluated in treated and untreated cultures using the Hoescht staining and caspase-3 activation.

RESULTS

Exposure of prostate and breast cancer cells to a high dose of Permixon (100 microg/ml) resulted in a significant decrease in the rate of cell growth; an effect that was not time-dependent and was not associated with cell cycle arrest. Permixon treatment (at either high or low dose) had no effect on apoptosis induction in prostate cancer cell lines (P > 0.6). Furthermore, in vitro Permixon was a weak inhibitor of 5alpha-reductase activity type 2 in prostatic homogenates.

CONCLUSIONS

The results indicate the ability of Permixon to affect prostate cancer cell growth without inducing apoptosis or cell cycle arrest. This effect was not prostate-specific and was only manifested at high concentrations of Permixon. Furthermore our findings indicate that Permixon is weak inhibitor of 5alpha-reductase compared to finasteride. This study challenges previous evidence on the anti-growth effect of Permixon in the prostate and its ability to inhibit 5alpha-reductase activity, while questioning apoptosis as a mechanism of action of this phytotherapeutic against prostate growth, a concept that may have therapeutic significance.

Saw palmetto extract suppresses insulin-like growth factor-I signaling and induces stress-activated protein kinase/c-Jun N-terminal kinase phosphorylation in human prostate epithelial cells

A common alternative therapy for benign prostatic hyperplasia (BPH) is the extract from the fruit of saw palmetto (SPE). BPH is caused by nonmalignant growth of epithelial and stromal elements of the prostate. IGF action is important for prostate growth and development, and changes in the IGF system have been documented in BPH tissues. The main signaling pathways activated by the binding of IGF-I to the IGF-I receptor (IGF-IR) are the ERK arm of the MAPK cascade and the phosphoinositol-3-kinase (PI3K)/protein kinase B (PKB/Akt) cascade. We tested the hypothesis that SPE suppresses growth and induces apoptosis in the P69 prostate epithelial cell line by inhibiting IGF-I signaling. Treatment with 150 microg/ml SPE for 24 h decreased IGF-I-induced proliferation of P69 cells and induced cleavage of the enzyme poly(ADP-ribose)polymerase (PARP), an index of apoptosis. Treatment of serum-starved P69 cells with 150 microg/ml SPE for 6 h reduced IGF-I-induced phosphorylation of Akt (assessed by Western blot) and Akt activity (assessed by an Akt kinase assay). Western blot analysis showed that SPE reduced IGF-I-induced phosphorylation of the adapter protein insulin receptor substrate-1 and decreased downstream effects of Akt activation, including increased cyclin D1 levels and phosphorylation of glycogen synthase kinase-3 and p70(s6k). There was no effect on IGF-I-induced phosphorylation of MAPK, IGF-IR, or Shc. Treatment of starved cells with SPE alone induced phosphorylation the proapoptotic protein JNK. SPE treatment may relieve symptoms of BPH, in part, by inhibiting specific components of the IGF-I signaling pathway and inducing JNK activation, thus mediating antiproliferative and proapoptotic effects on prostate epithelia.

Evaluation of the Clinical Benefit of Permixon and Tamsulosin in Severe BPH Patients—PERMAL Study Subset Analysis

OBJECTIVE

To compare the efficacy of the lipido-sterolic extract of Serenoa repens, Permixon, to that of the alpha-blocker, tamsulosin, in the treatment of severe low urinary tract symptoms (LUTS) of benign prostatic hyperplasia (BPH).

METHODS

In a 12-month, double-blind, randomized study that showed equivalent efficacy of Permixon 320 mg/day and tamsulosin 0.4 mg/day ("PERMAL study"), 685 BPH patients with IPSS > or =10 had been analyzed for efficacy. Of these, the 124 patients with severe LUTS (IPSS >19) at randomization were retained for this subset analysis. After a 4-week run-in period, 59 and 65 patients had been randomized to tamsulosin and Permixon groups, respectively. Both treatment groups were compared regarding the evolution from baseline of total IPSS and its irritative and obstructive subscores, LUTS-related QoL, prostate volume, Q(max) and MSF-4 (sexual activity questionnaire) at different time points over 1 year. An analysis of variance of changes from baseline to end point was performed for all the parameters. The over-time evolutions of total, irritative and obstructive IPSS were further compared using a variance analysis for repeated measurements.

RESULTS

At 12 months, total IPSS decreased by 7.8 with Permixon and 5.8 with tamsulosin (p=0.051); the irritative symptoms improved significantly more (p=0.049) with Permixon (-2.9 versus -1.9 with tamsulosin). The superiority of Permixon in reducing irritative symptoms appeared as soon as month 3 and was maintained up to month 12 (p=0.03).

CONCLUSION

Permixon 320 mg/day was shown to be slightly superior to tamsulosin 0.4 mg/day in reducing LUTS in severe BPH patients after 3 months and up to 12 months of treatment.

Use of alternative and hormonal therapies in male infertility

OBJECTIVES

To examine the patterns of use of alternative and hormonal therapies in men presenting for infertility evaluation.

METHODS

We administered a questionnaire on the use of alternative and hormonal therapies to 500 consecutive men presenting for infertility evaluation at our male infertility clinic. The questionnaire asked about the use of specific therapies (eg, vitamins, herbal medicine, or hormones), the monthly cost of these therapies, and whether the principal healthcare provider had been made aware of the use of therapies.

RESULTS

Of the 481 men who completed the questionnaire, 147 (31%) admitted to using one or more alternative therapies. Most of the men using alternative therapies (92 of 147, 63%) were taking one or more antioxidant vitamins or minerals (ie, vitamins C, E, selenium, zinc), and 18 men admitted to using herbal medicines. Of concern, 25 men reported using agents with clear hormonal activity (testosterone, clomiphene citrate), and 6 of these men had not informed their principal healthcare provider of this.

CONCLUSIONS

Our data suggest that a significant percentage ( approximately 30%) of men presenting for infertility evaluation do use alternative therapies. It is important to inquire about the use of these therapies because some of these treatments may be toxic to the gonads.

Herbs for benign prostatic hyperplasia

OBJECTIVE

To review and evaluate the literature relative to the use of herbal therapies in the treatment of benign prostatic hyperplasia.

DATA SOURCES

Literature was identified by MEDLINE, Embase, International Pharmaceutical Abstracts, and the International Bibliographic Information on Dietary Supplements searches and through cross-referencing of selected articles.

STUDY SELECTION/DATA EXTRACTION

All articles identified from the data sources were evaluated and all information deemed relevant was included in this review.

DATA SYNTHESIS

A large percentage of men >50 years old begin to experience signs and symptoms of benign prostatic hyperplasia (BPH). Herbs hold promise in the treatment of BPH. Serenoa repens, Pygeum africanum, Urtica dioica radix, and Cucurbita peponis semen are some of the botanical therapies used in the treatment of BPH.

CONCLUSIONS

There are many European studies examining efficacy, dose, and adverse effects of these plants in the treatment of BPH. However, numerous questions remain. These include issues concerning long-term beneficial and adverse effects of herbal therapy, prevention of complications, standardization of extracts, and concomitant use with "mainstream" medications. Based on the information available today, these botanical therapies can be used for treatment of a number of objective and subjective symptoms in patients with BPH, stages I and II.

Phytotherapy in the treatment of benign prostatic hyperplasia

There are numerous plant extracts that have been used for the treatment of benign prostatic hyperplasia and lower urinary tract symptoms. While some extracts show promise, their efficacy has not been adequately proven in long-term, double-blind placebo-controlled trials monitored by an outside agency.

Complementary and alternative therapies for advanced prostate cancer

This article reviews complementary and alternative therapies for advanced prostate cancer. This is not a comprehensive survey of nontraditional therapies for prostate cancer. Rather, this review focuses on alternative and complementary therapies with published studies to evaluate efficacy and safety. Three areas are addressed: alternative forms of hormonal therapy, management of side effects of hormonal therapy, and management of skeletal complications.

Tissue effects of saw palmetto and finasteride: use of biopsy cores for in situ quantification of prostatic androgens

OBJECTIVES

To determine the effects of a saw palmetto herbal blend (SPHB) compared with finasteride on prostatic tissue androgen levels and to evaluate needle biopsies as a source of tissue for such determinations.

METHODS

Prostate levels of testosterone and dihydrotestosterone (DHT) were measured on 5 to 10-mg biopsy specimens (18-gauge needle cores) in three groups of men with symptomatic benign prostatic hyperplasia: 15 men receiving chronic finasteride therapy versus 7 untreated controls; 4 men undergoing prostate adenomectomy to determine sampling variability (10 specimens each); and 40 men participating in a 6-month randomized trial of SPHB versus placebo, before and after treatment.

RESULTS

Prostatic tissue DHT levels were found to be several times higher than the levels of testosterone (5.01 versus 1.51 ng/g), that ratio becoming reversed (1.05 versus 3.63 ng/g) with chronic finasteride therapy. The finasteride effect was statistically significant for both androgens (P <0.01), and little overlap of individual values between finasteride-treated and control patients was seen. In the randomized trial, tissue DHT levels were reduced by 32% from 6.49 to 4.40 ng/g in the SPHB group (P <0.005), with no significant change in the placebo group.

CONCLUSIONS

For control versus finasteride-treated men, the tissue androgen values obtained with needle biopsy specimens were similar-both for absolute values and the percentage of change-to those previously reported using surgically excised volumes of prostatic tissue. The quantification of prostatic androgens by assay of needle biopsies is thus feasible and offers the possibility of serial studies in individual patients. The SPHB-induced suppression of prostatic DHT levels, modest but significant in a randomized trial, lends an element of support to the hypothesis that inhibition of the enzyme 5-alpha reductase is a mechanism of action of this substance.

Future concepts in the medical therapy of benign prostatic hyperplasia

The standard medical therapy for symptomatic benign prostatic hyperplasia is still alpha-blockers and 5alpha-reductase inhibitors. Ongoing studies demonstrate the long-term safety and efficacy of these two classes of therapeutic approaches. Although there have been no new Food and Drug Administration approved medical therapies for the treatment of benign prostatic hyperplasia over the past year, interest in and the use of phytotherapeutic agents continues to increase. In this review, we will discuss the developments that have occurred over the past year in the medical management of benign prostatic hyperplasia. In addition, we present ongoing efforts at our center to obtain a better understanding of and manipulate the apoptotic pathway as it pertains to the pathophysiology of benign prostatic hyperplasia.