What kind of cruel joke is being played on aging men? Everything with our bodies gets smaller or shorter (muscles, height, penis) or thinner (hair, bones) with time except our stomachs and our prostate glands, which continue to grow bigger every year!
Benign prostatic hyperplasia (BPH) is the most common male-specific health condition in the United States, and while there are a ton of supplements out there that claim to be able to help, I believe the most successful ones work by simply lowering cholesterol, which improves your heart health, and because of a large placebo effect (33 to 50 percent in some studies!). As you’ll learn throughout this article, reducing your cardiovascular disease risk can make a difference with all kinds of health conditions, from BPH to varicose veins.
What is Benign Prostatic Hyperplasia?
BPH is a noncancerous enlargement of the prostate gland, a walnut-size organ that surrounds the urethra (the tube that carries urine from the bladder out through the penis) and secretes fluid that helps make up semen. BPH increases the risk of erectile dysfunction, but there is no relationship between BPH and the risk of prostate cancer. This is good news! Your age is directly related to your risk of BPH, though. You have a 40 percent risk in your forties, a 50 percent risk in your fifties, and so on. If you’re lucky enough to live to be 100, well, you’ll have to deal with BPH.
The incidence of BPH is on the rise thanks to the baby boomers. But it’s also due to heart-unhealthy lifestyle choices. Men who are obese, don’t exercise, or have high “bad” cholesterol, low “good” cholesterol, and high blood pressure also have a higher risk of BPH.
Because the gland surrounds the urethra, when it gets bigger, it can affect the flow of urine. That’s why common symptoms include frequent urination (especially at night), increased urgency, weak stream, dribbling, starting and stopping, and a feeling that your bladder hasn’t emptied. (These are sometimes referred to as lower urinary tract symptoms, or LUTS.) If you’re experiencing these, go online and download the American Urological Association (AUA)
Symptom Score or the International Prostate Symptom Score (I-PSS) questionnaire, fill it out, and take it to your primary care doctor or urologist. They’re both very short (they take less than 2 minutes), and the higher your score, the higher the chance that you have BPH. Your score also provides a baseline so that when you get treated, you can retake the test and see if you’ve improved. In addition to asking about the previous symptoms, the AUA Symptom Score questionnaire also inquires about how BPH symptoms affect your quality of life, which is hugely important.
Size does not always matter when it comes to BPH. Some men with tiny prostates have terrible symptoms of BPH, and others with gigantic prostates have few to no symptoms. What matters is whether the urethra is being pinched or squeezed.
Prescription BPH medications either relax the prostate (alpha-blockers) or shrink it (5-alpha-reductase inhibitors). Due to multiple side effects and cost, BPH prescriptions have wildly varying compliance rates, from 10 to 60 percent. The alpha-blockers can cause retrograde ejaculation (it goes up into the bladder instead of out the urethra—ouch!), orthostatic hypo-tension (you get dizzy when you stand up), and an increased risk of falls. The 5-alpha-reductase inhibitors can reduce libido and increase erectile dysfunction. So as you can see, there’s plenty of room (and need) for a safe, effective, over-the-counter, research-based dietary supplement.
Home Remedies For Benign Prostatic Hyperplasia
1. (tie) Beta-sitosterol and other plant sterols 60 to 195 milligrams a day in divided doses (or up to 2,000 to 3,000 milligrams a day in divided doses potentially)
Phytosterols, or plant sterols, are found in a variety of plants and plant oils, and this is the only way we can get them (we can’t make them ourselves). They block the uptake of cholesterol from dietary and bile sources in the intestinal tract. They also reduce LDL (bad) cholesterol, but do not impact HDL (good) and triglycerides. (This is somewhat similar to how some healthy dietary fats, such as those found in almonds or pistachios, may also reduce LDL.) The main phytosterols found in our diets are sitosterol, stigmasterol, campesterol, and beta-sitosterol.
Since plants arguably contain more beta-sitosterols than the other phytosterols, they’ve been the subject of many studies, but there are only four that I consider to be high quality. (No well-done studies have been published in the past 10 years, by the way.) One of the four showed beta-sitosterol did not work better than a placebo, but the other three showed a big improvement in urinary flow and frequency in patients with moderate BPH taking beta-sitosterol. These studies used higher dosages (20 to 65 milligrams three times a day, or 60 to 195 milligrams total) within a mixture of phytosterols.
The beta-sitosterol used in these studies is called Harzol, or Azuprostat, which is usually derived from South African star grass. Since it’s very tough to get these products in the United States today, you can look for beta-sitosterol as a stand-alone ingredient. The studies used products with at least a 50 percent concentration of beta- sitosterol and in the form nonglucosidic beta-sitosterol. (It’s interesting that the single study that did not work used a different form of beta-sitosterol.)
Overall, there were no differences in withdrawal rates in the beta-sitosterol group compared to the placebo group (both were around 8 percent). Gastrointestinal side effects were the most common complaint (1.6 percent) and erectile dysfunction was another side effect, but only in approximately 0.5 percent of men.
I’ve talked about making heart-healthy changes to impact BPH because improving cholesterol levels and exercising does improve symptoms in some men. There have been more than 50 clinical trials using phytosterols for lowering LDL cholesterol. As a result, plant sterols have even been added to some foods, including yogurt, margarine, orange juice, mayonnaise, olive oil, and milk. The typical phytosterol dose to reduce LDL by 6 to 15 percent, based on research, is 2,000 to 3,000 milligrams a day.
This is 10 times higher than the dose that worked in the BPH trials! But I have seen it work for BPH patients many times throughout my career, so taking this much plant sterol to reduce BPH could also reduce your cholesterol and may be an option if lower doses do not work. You can get it by taking one or two caplets twice a day with a glass of water right before your largest meals (so you can block cholesterol absorption). You can also just buy the enhanced food products. (For more information on supplements for lowering cholesterol, see the High Cholesterol section.)
1. (tie) Pygeum africanum 75 to 200 milligrams a day in divided doses
Most of the active substances in Pygeum africanum (bark of the African plum tree) are triterpenes, ferulic acid esters, and phytosterols, including beta- sitosterols, which could have anti-BPH properties, although beta-sitosterol is the most researched, as previously mentioned. Pygeum africanum has been used in Europe since 1969 for the treatment of mild to moderate BPH, and it arguably has the largest number of consistently positive clinical trials to date compared to almost any other dietary supplement product for BPH right now. Laboratory research suggests that it can lower some growth factors that could impact the prostate, and it may also have anti-inflammatory effects.
An analysis of 18 Pygeum africanum clinical trials involving 1,562 men suggested a potential benefit with this supplement. The majority of the studies looked at the effects of taking 75 to 200 milligrams a day (usually standardized to 14 percent sterol content or higher, which is what you should look for when you’re buying a product) divided into two doses.
The average age of participants was 66, and the average study duration was 64 days. Out of 13 placebo- controlled trials, 12 reported a positive impact on at least one measure of symptoms (such as flow rate or frequency) with Pygeum; men taking it were more than twice as likely to report an improvement in overall symptoms compared to the placebo groups. Nocturia, or getting up at night to pee, was reduced by almost one episode per night (this failed to reach statistical significance, but for most men this is still a big improvement!). The withdrawal rate was similar to the placebo (12 percent), as were side effects, which were usually GI-related.
However, there are two big problems with Pygeum. First, there has not been a well-done study in more than a decade (similar to beta-sitosterol). Second, it comes from an endangered tree and the demand, as you would expect, is high. Year after year, the supply appears to wane. (This is not the case with most other BPH nutraceuticals, such as pumpkin seed, which you’ll read about in the next column.)
As a result, there are quality-control issues. Whether companies are selling the actual Pygeum used in studies or a new or altered version of it usually isn’t clear from the packaging alone. So check with the manufacturer to find out where its Pygeum came from (the company is obligated to tell you).
2. (tie) Flaxseed and SDG 300 to 600 milligrams a day
I’m a big advocate of flaxseed for BPH simply because, if nothing else, it’s heart healthy and low cost. Not to mention, both preliminary clinical research and my own experience with it have been positive. In one clinical trial with 87 patients, 300 to 600 milligrams daily of a flaxseed-derived supplement called secoisolariciresinol diglucoside (SDG), made of purified lignan (phytoestrogen) extract, significantly improved urinary symptoms compared to the placebo.
Similar SDG products have also been found to significantly reduce cholesterol and glucose levels. Whether ingesting inexpensive ground flaxseed powder (2 to 3 tablespoons per day) will reduce BPH symptoms as well as an SDG supplement has not been well studied, but it should be. Preliminary research from Duke University suggests taking 3 tablespoons of ground flaxseed a day has an anti-inflammatory effect on BPH tissue, which could potentially improve flow and reduce frequency in some men.
2. (tie) Pumpkin seed (Cucurbita pepo) oil 320 milligrams a day
It’s used as a salad oil in countries such as Austria, and maybe we should take a cue from them! The majority of the fatty acids in pumpkin seeds are monounsaturated and polyunsaturated, both healthy fats. The seeds are also high in alpha- and gamma-tocopherol and tocotrienol (vitamin E), carotenoids (including lutein and zeaxanthin), and plant sterols. To sum up, they’re loaded with heart-healthy compounds, which might as well be prostate-healthy compounds.
There has been some preliminary lab data showing that pumpkin seed oil may slow BPH growth by reducing prostate weight, protein content, and prostatic acid phosphatase levels and by altering cholesterol metabolism.
This data also suggest, similar to beta-sitosterol and Pygeum, a potential preventive role for pumpkin seed oil when it comes to BPH. Clinical studies have been either small or not that well done, but they’re still impressive: One randomized, double-blind, placebo-controlled trial with 47 patients who had moderate to severe BPH saw improved flow and reduced frequency with 320 milligrams per day of pumpkin seed oil in pill form over 12 months. But if you have to take more than one or two pills daily, or if cost is an issue, then I’m not so excited about it.
Cernilton (a pollen extract mixture) is fairly well known for prostate health because it has been shown to significantly improve quality of life and reduce pain in men with chronic prostatitis/chronic pelvic pain syndrome (see the Chronic Prostatitis/Chronic Pelvic Pain Syndrome section).
Study results have suggested it has anti-inflammatory and muscle relaxation effects in the prostate and maybe even in the bladder and urethra, which may explain why it has shown preliminary positive results in BPH research.
In two past meta-analyses (which are essentially reviews of clinical studies), published in the Cochrane Database of Systematic Reviews and BJU International, that included 444 men from four different clinical trials, 63 milligrams of Cernilton twice daily improved self-rated symptoms, such as the number of times the subjects got up to urinate (about one less time); side effects were mild and rare.
In another study of 240 patients with moderate BPH, researchers compared two doses: 350 and 750 milligrams of Cernilton twice a day for 4 years. The higher dose group showed more rapid improvement as well as a more significant reduction of prostate size and urinary symptoms, including less urine left in the bladder after urinating and improved urinary flow rates. The high-dose subjects also required less surgery. However, there hasn’t been any good, positive research done recently, and there are quality control issues with Cernilton, so buyer beware.
What Are Useless For Treating Benign Prostatic Hyperplasia?
I’m rejecting the most popular dietary supplement for BPH in the world? Yes! I’m not a fan because of two very well-done US government– funded trials: STEP (Saw Palmetto for Treatment of Enlarged Prostates) and CAMUS (Complementary and Alternative Medicine for Urological Symptoms). Plus, patients I’ve worked with over the years tend to see minimal or reduced efficacy over time, which suggests more of a placebo effect. Anyhow, back to the research.
The STEP trial was one of the better herbal studies ever completed. It was funded by the National Institute of Diabetes and Digestive and Kidney Diseases and by the National Center for Complementary and Alternative Medicine. A total of 225 men with moderate to severe BPH symptoms were randomized to saw palmetto extract at a dosage of 160 milligrams twice a day (320 milligrams total) or a placebo. After 12 months of treatment, there was no difference between saw palmetto and the placebo. (The herbal extract used in this trial was one of the best.)
The CAMUS trial was a double-blind, multicenter, placebo-controlled randomized study conducted at 11 North American clinics with 369 patients. The CAMUS researchers found that low (320 milligrams), moderate (640 milligrams), and high doses (960 milligrams) of saw palmetto given over 72 weeks did not work better than a placebo for BPH or LUTS. Again, the saw palmetto used was outstanding quality.
By the way, these big trials were originally designed to compare supplements
to standard prescription drugs, but no companies offered up their drugs for testing! Makes you wonder.
Different parts of this plant have different effects. Apparently, the roots are used for BPH, but the bulk of the studies were completed long ago, they weren’t well designed, and the results weren’t impressive. Plus, there is potential for numerous diverse side effects.
High doses (80 to 100 milligrams or more) of this mineral have been associated with increased BPH severity and an increased risk of prostate cancer, respectively. One of the largest studies of zinc supplements showed that megadoses of zinc actually cause megaprostate problems!
What Lifestyle Changes Can Help With Benign Prostatic Hyperplasia?
Heart healthy = prostate healthy
Virtually any lifestyle change found to be heart healthy has been shown to reduce the risk or progression of BPH, including maintaining normal blood pressure, blood sugar, and cholesterol levels and a healthy weight or waist size, eating a healthy diet, and exercising. Alpha- blockers are the top-selling drug class used to treat BPH; they work by relaxing the prostate. They were originally derived from blood pressure–lowering medicines because men reported peeing better when their high blood pressure was reduced. Bam!
Drink in moderation
This has been consistently associated with a lower risk of BPH and reduced symptoms associated with BPH, probably due to the anti- inflammatory effects or the heart-healthy benefits of moderate alcohol consumption. Of course, this doesn’t mean you should start drinking if you don’t currently imbibe.
Work up a sweat
One of the best ways to prevent BPH or reduce the progression of it is to exercise regularly, about 30 minutes a day. In a famous Harvard study, regular physical activity was even associated with a lower risk of getting surgery for BPH! Patients tell me all the time that after a good, long aerobic workout, their urinary stream seems stronger, and this is further proof of how exercise relaxes the prostate and helps improve urinary function.