Simon Mills, Herbal practitioner

Published in JHH14.3 – Men’s Health

Sixteen years ago, as a moderately prominent herbal practitioner, I published a paper for the Journal of the Royal Society of Medicine on natural approaches to the management of prostatic disease that predicted that plant constituents like beta-sitosterols and remedies like saw palmetto would become valuable adjuncts to treatment and that there was more herbal promise of this sort to come. Since then the evidence base has moved on considerably and the case for saw palmetto has been particularly dented. So by the time Kerry Bone and I updated our herbal textbook, Principles and Practice of Phytotherapy there was a substantial shift in emphasis.What we thought was the future had turned into the past. So now what is a man now to do? For many, prostatic problems can be the first big health fear. Here we look at how natural approaches can both help the three main chronic prostatic conditions and then actually unlock wider benefits for a healthy life.

Benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a progressive, benign growth of the prostate gland that gradually narrows the urethra leading to obstruction of the flow of urine. Urine remaining in the bladder stagnates, leaving the patient vulnerable to infections, bladder stones and kidney damage. Complicating many cases of BPH therefore is a linked range of lower urinary tract symptoms (LUTS). However, there is no exact correlation between the size of the prostate and the degree of LUTS, suggesting that other factors are involved.

Various theories have been proposed to explain BPH itself. Recent evidence downplays androgens, both testosterone and dihydrotestosterone; their role is now said to be permissive. A higher oestrogen/testosterone ratio could be a causative hormonal factor, and increased peripheral conversion of testosterone to oestradiol by aromatase could be at play (Roehrborn, 2008). There is, however, a strong link between BPH and chronic prostatitis (Sciarra, 2008) and one theory has proposed that BPH is an immune-mediated inflammatory disease caused by auto-immunity or possibly infection (Kramer, 2007). Another theory proposes that higher circulating insulin stimulates prostate growth, hence linking BPH to insulin resistance (Vikram, 2010), and an association with obesity has also been observed (Parsons, 2009). The sympathetic overactivity linked to obesity, metabolic syndrome and hypertension may specifically increase the risk of manifesting LUTS (Moul, 2010; Sarma, 2009). LUTS and meta[1]bolic syndrome have been shown to be comorbid, as has LUTS and erectile dysfunction. Improving testosterone can help symptoms of LUTS (Yassin, 2008) and inflammation may also play a role (insulin resistance is a pro-inflammatory condition); elevated serum C-reactive protein correlates well with severity of LUTS (Sarma, 2009).

Increased levels of physical activity have been associated with a decreased risk of BPH and LUTS in several large studies (Parsons, 2007; Sea, 2009). A low fat, low animal protein diet appears to be protective, modest alcohol consumption may protect against BPH, but it might increase LUTS (Parsons, 2009). High glycaemic foods appear to contribute to risk (Parsons, 2007; Ranjan, 2006), whereas consumption of fruit and vegetables appear protective (Barnard, 2009). It would seem likely that following a low-inflammatory diet replacing sugars and processed foods with vegetables, fruits and fish will be helpful in containing BPH.

In earlier times the association of the symptoms of prostatic enlargement with ageing led to the inevitable use of rejuvenating male tonics and promoters of male potency. Given the primal demand for such agents, it is not surprising that they feature in most traditions. There are obvious stimulants such as cola (Cola nitida) and yohimbe (Pausinystalia yohimbe) used in male virility ceremonies in west Africa, as well as more modest euphorics such as the central American plant damiana (Turnera aphrodisiaca) and the Asian ginseng (Panax ginseng). Although all have traditionally been used for BPH none has systematically been tested. The most notable remedy from the southern USA is saw palmetto (Serenoa serrulata), also initially used as a male tonic. However, the consensus view appears to be shifting against its efficacy in prostatic conditions. Positive 1998 and 2002 Cochrane reviews (Wilt, 2002) have been supplanted by a negative 2009 revision, which suggested that in a total of 26 studies there was no benefit above placebo (Tacklind, 2009) and a major robust clinical study showed no benefits in BPH (Barry, 2011). As well as saw palmetto urologists in Germany have widely prescribed nettle root (Urtica dioica) and pumpkin seed (Curcurbita pepo) for early symptoms of benign prostatic hyperplasia (Bombardelli, 1997). Pumpkin seed remains a good source of useful zinc and there is consistent evidence in double blind controlled studies in favour of nettle root (Safarinejad, 2005).

Chronic prostatitis

Unlike acute prostatitis overt infections are rarely involved in the painful and debilitating chronic disorder. It can affect up to 15% of men at some stage in their lives and between 2% and 10% of adult men suffer from prostatitis at any given time. Chronic prostatitis may be associated with an increased risk of prostate cancer as well as BPH (Krieger, 2004).

The main symptoms of chronic prostatitis are chronic genito-urinary pain or discomfort, with or without difficulties on urination. There is no known effective conventional treatment. Antibiotics are rarely effective. Feedback from patients is that prolonged sitting or riding a pushbike can make the condition worse, which suggests that poor circulation in the pelvic cavity is a factor. Many also complain that their pain flares up when they drink alcohol. Stress appears to be another factor (Mehik, 2001).

From the published research, chronic inflammation possibly linked to an auto-immune reaction is identified as an important factor. Men with chronic prostatitis have signs of significant inflammation in biopsy tissue, with T cells apparently driving this reaction (John, 2001).

Professional herbal approaches to this condition are likely to combine traditional male remedies like saw palmetto and damiana with echinacea, and urinary antiseptics such as buchu and the Ayurvedic herb varuna (Crataeva nurvala). A wider recourse to inflammatory modulators like tumeric, fish oils and boswellia may be helpful and any exercise that increases circulation to and from the pelvic cacity is recommended.

Prostate cancer

Older men are at increased risk of prostate cancer (PC), especially those with a family history and/or with a higher prostate specific antigen (PSA) level (Kell, 2010). The risk is low in Asia, but when Japanese men move to the US their risk increases (Patel, 2009). Infection and inflammation (prostatitis) also appear to be causative factors. Many men with PC also have prostatitis on biopsy and regular use of anti-inflammatory drugs lowers risk of developing PC. The role of androgens is unclear and controversial; 5-alpha reductase inhibitors may prevent the condition, but their value in studies might result from improved screening (Jacobs, 2005).

The phenomenon of ‘watchful waiting’ (active surveillance) for men with intermediate PSA and/or Gleason score readings provides an opportunity for conservative natural management of men with low-grade PC.

Plants that reduce NF-kappaB transcription can be considered for downregulating inflammatory pathways (Aggarwal, 2004) and here are promising research data for culinary items like rosemary, turmeric, ginger, green tea, and oregano (Capodice, 2009). Red wine, but not alcohol, has been linked to a significantly lower risk of PC (Schoonen, 2005). Grape seed extract inhibited advanced human prostate tumour growth (Singh, 2004).

There is also promising research on phyto-oestrogens such as isoflavones. Linseeds (30 gm a day) for an average of 30 days prior to surgery significantly reduced cellular proliferation rates in a controlled trial involving 161 men with PC (Demark-Wahnefried, 2008). There were no changes in testosterone or PSA. Metabolites of the linseed lignans (such as enterolactone) inhibit PC cell growth in vitro (McCann, 2008) and isoflavones appear to concentrate in prostate tissue after supplementation (Gardner, 2009). There is good evidence from a meta[1]analysis of 14 epidemiological studies that soya foods will lower the risk of PC by around 26%. Non-fermented sources of soya such as tofu or soya milk showed a higher degree of protection than fermented soya products such as miso (Yan, 2009).

Dean Ornish’s research team in the US has looked at the impact of diet in PC patients. In the first study a very low-fat vegan diet (12% dietary fat) plus supplements (soya, vitamin E, fish oil, selenium and vitamin C), exercise and stress management was compared to controls. PSA declined 4% over 12 months versus a 6% rise in the control arm. At follow-up two years later, 13 men in the control group had progressed to PC treatment versus just two in the intervention group. A second study with similar intervention examined prostate biopsies after three months. A low GI, moderate fat diet in four men for six weeks found favourable gene expression changes after radical prostatectomy compared with controls (Freedland, 2009; Van Patten, 2008).

In conclusion, prostatic disease need not be seen as a mysterious and untreatable series of conditions. Each may respond to basic health measures. If the shock of the diagnosis leads to a shift in lifestyle it may even help prevent other problems of ageing.

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