Saw palmetto ( Serenoa repens/ S. serrulata, Sabal serrulata )

Saw palmetto ( Serenoa repens/ S. serrulata, Sabal serrulata )
| Practice points|
Saw palmetto may improve symptoms of benign prostatic hyperplasia (BPH) or chronic prostatitis
and may be used in conjunction with other medicines to improve benefits.
Inconsistent trial results may be due to differences in formulations. Saw palmetto extracts
standardised for fatty acids are likely to be more reliable.
Unlike other BPH medicines, saw palmetto does not suppress prostate specific antigen (PSA)
secretion therefore prostate cancer screening results are not affected.
| Key indications |
| Key actions11,12 |
Benign prostatic hyperplasia (BPH): In the past
Cochrane systematic reviews have reported that saw
palmetto improves urinary symptoms and flow in a
manner comparable to the 5-alpha-reductase inhibitor
finasteride,1 however, a 2012 update questioned this
finding.2 Since this time additional studies have been
published with conflicting results possibly due to
variations in methodology, product potency and dose.
Some of the positive findings include improvements in
International Prostate Symptom Scores (I-PSS), urinary
flow rate, post-void residual urine scores, sexual function
and quality of life (QoL).3,4
Anti-inflammatory
Long term use in BPH: Studies
using saw palmetto for 2-10 years
have reported improvements
in QoL, I-PSS scores, erectile
function, urinary flow, residual
urinary volume, rate of urination and
prostate volume.5,6
In combination for BPH: Some
trials have reported additional
benefits such as improved QoL
and storage symptoms, when saw
palmetto is combined with standard
BPH treatments (alpha1-blockers e.g. tamsulosin, and
5-alpha-reductase inhibitors e.g. finasteride).7,8
Chronic prostatitis: Saw palmetto alone or in
combination with selenium and lycopene may improve
symptoms of chronic prostatitis,9 and the addition of
saw palmetto to prulifloxacin improves the reduction in
prostatitis related pain and urinary symptoms.10
Anti-proliferative
5-alpha-reductase inhibition
Alpha-adrenergic antagonism
DHT and estrogen receptor inhibition
| Recommended Doses |
Saw palmetto berries are usually
administered in their crude form at
around 2-4 g/day. However, most
clinical trials use standardised
liposterolic extracts which
are a complex mixture of
free fatty acids (80%), their
esters (7%), as well as small
amounts of sterols and polyprenic
compounds.12
Liquid saw palmetto supplements contain
significantly higher concentrations of fatty
acids and phytosterols than powdered extracts, dried
berries and tinctures.13 Liquid liposterolic extracts are
available in capsule form for ease of dosing and patient
compliance.
BPH: The typical dose used in successful clinical trials
is 320mg saw palmetto extract daily.4-6 This would be
approximately 256 mg fatty acids.
| Adverse Effects |
Saw palmetto is generally well tolerated. The most
commonly reported effects include GIT upset,
constipation, nausea and abdominal pain which appear
to benefit from taking the herb with food.12
| Cautions/ Contraindications |
Medical advice should be sought if symptoms worsen,
blood is detected in the urine or acute urinary retention
occurs.12
Avoid during radiotherapy for prostate cancer as
experimental studies indicate that saw palmetto may
increase the radiosensitivity of normal prostate cells.12
There are anecdotal reports of increased bleeding risk
but a small human study reported no effect on platelet
function after 2 weeks of taking a commercial saw
palmetto product.14
Case reports have linked saw palmetto to intraoperative
floppy-iris syndrome which can cause complications
during cataract surgery.15
| Possible Interactions |
Finasteride: theoretical additive effect with potential
benefit12
REFERENCES
1. Wilt T, Ishani A, Mac Donald R. Serenoa repens for benign prostatic hyperplasia. Cochrane database of systematic reviews
2002(3):Cd001423.
2. Tacklind J, Macdonald R, Rutks I, et al. Serenoa repens for benign prostatic hyperplasia. Cochrane database of systematic reviews
2012;12:Cd001423.
3. Ju XB, Gu XJ, Zhang ZY, et al. [Efficacy and safety of Saw Palmetto Extract Capsules in the treatment of benign prostatic hyperplasia].
Zhonghua nan ke xue = National journal of andrology 2015;21(12):1098-101.
4. Suter A, Saller R, Riedi E, et al. Improving BPH symptoms and sexual dysfunctions with a saw palmetto preparation? Results from a pilot
trial. Phytotherapy research : PTR 2013;27(2):218-26.
5. Sinescu I, Geavlete P, Multescu R, et al. Long-term efficacy of Serenoa repens treatment in patients with mild and moderate symptomatic
benign prostatic hyperplasia. Urologia internationalis 2011;86(3):284-9.
6. Aliaev Iu G, Vinarov AZ, Demidko Iu L, et al. [The results of the 10-year study of efficacy and safety of Serenoa repens extract in patients
at risk of progression of benign prostatic hyperplasia]. Urologiia (Moscow, Russia : 1999) 2013(4):32-6.
7. Ryu YW, Lim SW, Kim JH, et al. Comparison of tamsulosin plus serenoa repens with tamsulosin in the treatment of benign prostatic
hyperplasia in Korean men: 1-year randomized open label study. Urologia internationalis 2015;94(2):187-93.
8. Alcaraz A, Carballido-Rodriguez J, Unda-Urzaiz M, et al. Quality of life in patients with lower urinary tract symptoms associated with BPH:
change over time in real-life practice according to treatment-the QUALIPROST study. International urology and nephrology 2016.
9. Morgia G, Mucciardi G, Gali A, et al. Treatment of chronic prostatitis/chronic pelvic pain syndrome category IIIA with Serenoa repens
plus selenium and lycopene (Profluss) versus S. repens alone: an Italian randomized multicenter-controlled study. Urologia internationalis
2010;84(4):400-6.
10. Stamatiou K, Pierris N. Serenoa repens extract additionally to quinolones in the treatment of chronic bacterial prostatitis. The preliminary
results of a long term observational study. Archivio italiano di urologia, andrologia : organo ufficiale [di] Societa italiana di ecografia
urologica e nefrologica / Associazione ricerche in urologia 2013;85(4):190-6.
11. Allkanjari O, Vitalone A. What do we know about phytotherapy of benign prostatic hyperplasia? Life sciences 2015;126:42-56.
12. Braun L, Cohen M. Saw palmetto. Herbs & natural supplements: an evidence based guide.[Vol. 2]. 4th ed. Australia: Elsevier; 2015.
p.875-80.
13. Penugonda K, Lindshield BL. Fatty acid and phytosterol content of commercial saw palmetto supplements. Nutrients 2013;5(9):3617-33.
14. Beckert BW, Concannon MJ, Henry SL, et al. The effect of herbal medicines on platelet function: an in vivo experiment and review of the
literature. Plast Reconstr Surg 2007;120(7):2044-50.
15. Yeu E, Grostern R. Saw palmetto and intraoperative floppy-iris syndrome. J Cataract Refract Surg 2007;33(5):927-8.
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