Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms in elderly men. The most commonly prescribed herbal preparation is the extract of the fruit or the saw palmetto dwarf palm tree. Prior studies have been mixed and a recent large trial published in 2006 in the New England Journal of Medicine showed no benefit over placebo in patients treated with saw palmetto. To determine whether higher doses may show greater efficacy, a large double-blind, multicenter, placebo-controlled, randomized trial at 11 centers across North America, was recently completed in over 300 patients treated for 72 weeks of with either escalating doses of saw palmetto or placebo.
Saw palmetto demonstrated no improvement over placebo in any measure of urine function. How does one explain the disconnect between recent results from controlled clinical trials and the knowledge that saw palmetto has been used for centuries to improve urinary symptoms? First and foremost, the disconnect is best explained in the methodology used in settings of clinical trials. In this case, the clinical trial randomized between saw palmetto as a single agent and placebo. When patients are seen by Western herbalists, they will typically be treated with combinations of remedies, most often also including stinging nettle and other extracts or herbs. Second, the positive effect of placebo is often difficult to beat, as is so often the case in pharmaceutical drug development. If the mind believes it is getting proper therapy and symptoms should improve, many patients will improve.
Yet, the lesson for me is on a different level. The use of single or combination remedies, whether herbal in nature or pharmaceutical, solely on the basis of symptoms, without an approach to delve into the level of the whole system, is fundamentally flawed. Ancient remedies were prescribed to shift physiology or energetics – whatever your preferred term is. Healers made diagnoses based on their understanding of each individual’s unique physiology and treatment of symptoms were based on this overall understanding. So, in olden times, no one would receive saw palmetto as a single agent. This is where integrative medicine offers serious advantages, but practitioners must become more aware of methods to better understand patterns of symptoms, patterns of disease, and begin treating based on a whole systems approach. If, as I believe, this is the future of medicine, then practitioners need to elevate their game and offer deeper insights into their patients than they can find routinely on the shelves of Whole Foods.