Saw Palmetto is Not Effective for BPH
Saw palmetto should not be recommended for treating benign prostatic hyperplasia, as the highest quality evidence demonstrates it provides no benefit over placebo for improving urinary symptoms, flow rates, prostate size, or quality of life. 1
Evidence Against Saw Palmetto Efficacy
The definitive trial on this question was a rigorous, double-blind, placebo-controlled study of 225 men with moderate-to-severe BPH symptoms treated for one year. 1 This study found:
- No improvement in American Urological Association Symptom Index (AUASI) scores compared to placebo (mean difference 0.04 points) 1
- No improvement in maximal urinary flow rate (mean difference 0.43 ml/minute) 1
- No reduction in prostate size or post-void residual volume 1
- No improvement in quality of life measures 1
- No effect on PSA levels, even at doses up to 960 mg daily 2
Why Saw Palmetto Appears in Clinical Practice
Despite widespread use by over 2 million men in the United States, saw palmetto lacks FDA approval for BPH treatment. 1 The herb's continued popularity likely reflects:
- Profound placebo effects documented in BPH treatment trials, which makes rigorous placebo-controlled testing essential 3
- Inconsistent product formulations without standardized extracts, though hexane extracts with >80% free fatty acids show more consistent laboratory results 4
- Theoretical mechanisms (anti-androgenic, pro-apoptotic, anti-inflammatory effects) that have not translated to clinical benefit 4
Critical Consideration for Your Patient
For a male over 50 with elevated PSA, saw palmetto poses an additional concern: it may contain phytoestrogenic compounds that could theoretically affect PSA levels, though clinical studies show no significant PSA changes even at high doses. 5, 2 However, the exact composition of commercial herbal supplements remains poorly characterized. 5
Evidence-Based Alternatives
The AUA guidelines recommend proven treatments for BPH/LUTS instead:
- Alpha-blockers (alfuzosin, tamsulosin) for treating lower urinary tract symptoms 5
- 5-alpha reductase inhibitors (finasteride, dutasteride) for men with enlarged prostates and LUTS 5
- Combination therapy for appropriate candidates based on prostate size and symptom severity 5
Important Caveat About PSA Monitoring
Since your patient has elevated PSA, ensure proper evaluation per AUA guidelines: PSA should be offered to men with at least 10-year life expectancy when knowledge of prostate cancer would change management. 5 The elevated PSA requires appropriate workup including digital rectal examination and consideration of prostate biopsy based on PSA level, DRE findings, and risk factors. 5, 6
Bottom line: Direct your patient toward FDA-approved medications with proven efficacy rather than saw palmetto, which has been definitively shown to be no better than placebo. 1