1. health and fitness
2. disease
3. cancer

Complementary and alternative approaches to men’s health
Continuing Education Module
Jacques Rossouw (DSc) and Timothy J. Maher (PhD)
Goal:
To briefly review the incidence, diagnostic techniques, pathophysiology, and psychosocial impact of
prostate related disorders prior to examining in greater depth the complementary and alternative medical
approaches aimed at their prevention, treatment, and management.
Objectives:
Following the successful completion of this module, the healthcare professional will be able to:
•
•
•
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Describe the incidence, pathophysiology and detection techniques, as well as the physical and
psychosocial impacts of prostate cancer;
List the available conventional therapies for treating prostate cancer as well as some of the
complementary/alternative medical treatments currently being used;
Describe the basic mechanisms of action for the more commonly used complementary/alternative
prostate cancer prevention and treatment approaches; and
Identify the major advantages and disadvantages of complementary/alternative medicine for treating
and managing prostate cancer, benign prostatic hyperplasia, prostatitis, and urinary retention.
1. Introduction
While the life-expectancy gap between men and women has decreased, it's no secret that men still need to
pay more attention to their bodies. Several things work against men - they tend to smoke and drink more than
women, and they don't seek medical help as often as women. Some men define themselves by their work,
which can add to stress.
There are also health issues that only affect men, such as prostate disorders and low testosterone levels.
Many of the major health risks that men face - like colon cancer, heart disease and prostate cancer - can be
prevented and treated with early diagnosis. Check-ups and screening tests can detect diseases early, when
they are easier to treat and manage.
2. Prostate disorders
The main disorders that will be discussed in this module include prostate cancer, benign prostatic hyperplasia
(BPH) and prostatitis.
2.1 The prostate
A pea-sized organ at birth, the prostate gland grows to the size and shape of a chestnut by the time a man is in
his early 20s. The prostate gland is situated between the bladder and the rectum and produces the thick fluid
that helps propel sperm in the form of semen through the urethra and out the penis during ejaculation. The
prostate also converts the hormone testosterone, largely produced in the testes, to the 100-times more potent
dihydrotestosterone via the enzyme 5 alpha-reductase. Normally, cells in the prostate continue to divide until
their plasma membranes touch, at which time growth stops. However, unchecked cell growth could indicate
prostate cancer. Humans and dogs appear to be the only species that spontaneously develop prostate
cancer.1
1
Prostate cancer, the most common form cancer in men after skin cancer, is quite rare among men younger
than 40, but its incidence increases steadily with age. By the age 70, 50% of South African men will have some
pathologically identified, but subclinical signs of prostatic tumors. Between the ages of 80 and 90, 90% of men
will have microscopic prostatic tumors. Thus, it is not surprising that prostate cancer is the third leading cause
of cancer deaths among men, trailing only behind lung and colorectal cancer.2 Despite the prevalence of
prostate cancer and its enormous impacts, research on this form of cancer lags seriously behind that of other
types.3
3. Signs and symptoms of prostate cancer
Unlike many other diseases, the early manifestations of prostate cancer typically do not result in recognizable
symptoms that alert patients to an underlying disorder. Only after the tumor on the prostate starts to grow will
symptoms be noticeable, and then they are typically similar to symptoms seen in other diseases.
Symptoms include urinary dysfunction such as difficulty in initiating or preventing urination, frequent and weak
urine flow, painful urination, blood in the urine or semen, and painful ejaculation. For instance, urinary flow of
less than 10 mL/minute is considered significantly below the normal 15 mL/minute. Additionally, a recurring
pain in the lower back, upper thighs or pelvis may be one of the earliest signs of prostate cancer. However, as
mentioned, there are many other causes of these same symptoms such as benign prostatic hypertrophy
(BPH), prostatitis caused by infection, prostatosis caused by excess fluid accumulation, and other systemic
infections.
BPH is quite common in aging men, so it is impossible to determine the cause of such symptoms without
appropriate diagnostic techniques. If BPH is left without treatment it increases the risk of urinary tract infections
(UTI), urinary bladder stones and urinary retention.
4. The diagnosis
The prostate gland, located in front of the rectum, is easy to examine manually. By inserting a lubricated,
gloved finger into the rectum, physicians can determine the prostate's relative size and screen for prostatic
cancer and BPH. In the mid 1980s, a blood test that identified prostate-specific antigen (PSA), a serine-specific
protease, became routine for screening prostate health.4 In general, PSA values below 4 ng/mL indicate
healthy prostatic function. Values between 4 and 10 ng/mL suggest the patient may be developing, or already
have prostate cancer. However, there are numerous conditions not related to prostate cancer that can also
elevate PSA values, including BPH, infections, and prostatitis. Very high PSA values - greater than 50 ng/mL indicate that the cancer has most likely spread from the prostate to other parts of the body (i.e., metastasized).
Those values represent total PSA; however, an improved method that measures free PSA may help refine the
diagnosis for patients whose values are between 4 and 10 ng/mL. Age-adjusted PSA values, which allow for
normal values as high as 6.5 ng/mL in a white male between the ages of 70 and 79, further improve this test's
usefulness. The ability to observe abnormalities in two of the physical characteristics of PSA, velocity and
density, may help improve the accuracy of the diagnostic techniques.
However, PSA tests are not without potential errors. Test results can be artificially elevated by several noncancerous factors, and values can vary between different test manufacturers.5 For instance, recent ejaculation
(within 48 hours) can transiently increase total PSA levels by at least 1 ng/mL.6 Additional testing to refine the
diagnosis may involve transrectal ultrasound (TRUS), which involves inserting an ultrasound probe into the
rectum to map the prostate. Other diagnostic tests include an intravenous pyelogram and a series of X-rays,
and cystoscopy, which requires inserting a thin illuminated tube through the urethra. If abnormal findings are
revealed during these visualisation techniques, a biopsy of the prostate using very fine sampling needles
inserted into the rectum is the only technique available to make a definitive prostate cancer diagnosis.
The American Urological Association and the American Cancer Society recommend that men older than 50
who have at least a 10-year life-expectancy be screened yearly for prostate cancer via digital rectal
2
examination and blood PSA.7 For patients with an increased prostate cancer risk, annual PSA tests should
begin at age 40. This is also the case for South Africa.
The emotional stresses associated with a prostate cancer diagnosis are substantial. By confiding in a partner
(if they have one), family member, or close friend, patients can help to dissipate some of the stress. However,
Helgason and colleagues found that one in three prostate cancer patients did not feel comfortable enough
even to confide in their partner regarding their illness.8 Not only is psychosocial morbidity very high among
patients with prostate cancer, it is also high in their partners.9 Psychological therapy should be considered for
every prostate cancer patient.
5. Stages of prostate cancer
Throughout the years there have been numerous staging or rating systems to describe the severity of a given
patient's prostate cancer. One of the more useful scales is TNM (Tumor, Node, Metastases). The least severe
is stage T1; microscopic tumor cells are detected following biopsy, usually prompted by abnormal PSA levels.
During this stage the digital rectal and ultrasound examinations are usually normal. In stage T2, the tumor has
enlarged to such an extent that a physician can detect the abnormal prostate by digital rectal and ultrasound
examinations. Stages T3 and T4 involve adjacent (e.g., seminal vesicles) and nearby (e.g., bladder) tissues,
respectively. At these stages the tumor is usually easily palpable or visualised with ultrasound. In stage N+ the
tumor has spread to the pelvic lymph nodes. Stage M+ is when distant organs such as bone are involved.
Another scoring system called the Gleason Score assigns a set of numbers from one to five that refer to the
aggressiveness of the tumor based on the cellular morphology obtained at biopsy. The higher the number, the
more severe is the tumor. Currently, many clinics use both scoring systems (staging and Gleason) in addition
to the PSA values to predict the prognosis of individual patients.
Survival following a prostate cancer diagnosis depends on the severity of the tumor. Patients with localised
tumors who are in otherwise good health generally can be expected to survive five or more years (in cancercure terms, five years constitutes a cure). Patients with tumors that have spread to adjacent tissues might be
expected to survive one to three years. When tumors have metastasized to distant tissues - a condition for
which none of the current therapies are effective - men typically die of prostate cancer. Since prostate cancer
is most common in elderly men, the chances of dying from causes other than prostate cancer increase with
age.
6. Risk factors for prostate cancer
Researchers have demonstrated that a genetic component may contribute to the risks associated with prostate
cancer development. An individual whose father or brother had prostate cancer is two to four times more likely
to develop the condition.10 Prostate cancer risk also increases slightly if the individual's mother or sister had
breast or ovarian cancer. There is still little known about which specific genes increase genetic risk.
Contrary to popular belief, neither vasectomy nor an active sex life increases the risk of prostate cancer.
Although many small, poorly designed studies initially reported these findings, subsequent well-designed
studies have failed to confirm increased risk.
In general, men in North America run a very high risk of developing prostate cancer. A similar risk is observed
in New Zealand and Northern Europe. Some of the lowest risks have been reported in Japan, Russia, and
Israel. The low prostate cancer rates among men living in Japan - estimated to be 1/30th the U.S. rates - have
been attributed in part to the diet. Japanese men eat a lot of soy, which contains weak estrogenic isoflavones.
In addition to their estrogenic anticancer actions in men, many of these isoflavones, such as genistein and
daidzein, are also potent antioxidants and have been shown to be effective against a number of experimental
cancers both in vitro and in vivo. When Japanese men move to the United States and adopt new eating habits
- usually much less soy and much more fat - their prostate cancer risk increases.11 Similar protective effects of
diet are seen with respect to Japanese women and breast cancer.12
3
Dietary fat in general and certain fatty acids in particular, are thought to contribute to prostate cancer
development. Fatty acids may be important in the overall approach to prostate cancer prevention and
treatment. Some researchers have suggested that the diet should include not more than 15% fat calories,
since excessive dietary fat can increase overall oxidative stress.13 Additionally, linoleic and α-linolenic acids,
which are common fats in the South African diet, promote PC-3 prostate cancer cell growth in culture.14 On the
other hand, omega-3 fatty acids, found in cold-water fatty fish, may suppress tumor cell growth. As a result of
their study, Newcomer and colleagues reported an elevation in the odds ratio of developing prostate cancer
among men with elevated linoleic, α-linolenic, and arachidonic acids.15
In the United States, African-American men have the highest prostate cancer risk. Their risk is almost 70%
greater than their Caucasian counterparts. Contrast this to the rate of prostate cancer among men living in
Africa, which tends to be extremely low. This observation indicates that the diet or other environmental factors
may contribute to the protection against or the sensitivity to developing this disease. Men of Native American
and Hispanic ancestry typically have the lowest disease risk.
Prostate cancer is the second most common malignancy in black men and the most common solid organ
malignancy in white men in South Africa (excluding skin cancer).73
7. Benign prostatic hyperplasia (BPH)
BPH is one of the most common diseases of the ageing male. As man passes the fifth decade of life, serum
testosterone levels fall and estrogens levels rise, which affect the number of androgen (DHT) receptors and
inhibits the metabolism by interfering with these receptors.41 The accumulation of dihydrotestosterone (DHT)
inhibits prostatic cell death and promotes proliferation that increases the size of the gland.42
BPH is characterized by an uncontrolled growth in the deep mucosal glands in the prostate and by proliferation
of some of the nearby stroma, hence there is a hyperplasia of both the glandular tissue and fibromuscular
stroma.41 About 50% of men at age 50 and 80% of men at age 70 develop BPH and this leads to urinary
retention, continuing dribbling of urine, urinary tract infections and kidney stones – due to the enlargement of
the prostate and contraction of smooth musculature that constrict the prostatic urethra.43 Factors that promote
the accumulation of DHT and estrogens contribute to the symptoms of BPH, obstruction of the lower urinary
tract and stimulation of the alpha-adrenergic system, which causes contraction of the smooth muscle fibres,
thus resulting in further flow restriction in an enlarged gland.42
Insulin resistance and truncal obesity have been shown to be additional components that cause prostatic
enlargement - elevations in insulin increase sympathetic nerve activity and also bind to insulin-like growth
factor (IGF) receptors that stimulate prostate cell growth. Excessive amounts of visceral fat also increase the
circulation of estradiol, further stimulating growth by rising DHT levels.42
8. Prostatitis
Prostatitis can be divided into the following categories: acute bacterial, chronic bacterial, chronic abacterial,
inflammatory (>10 WBC), non-inflammatory (<10 WBC) and asymptomatic inflammatory prostatitis.41 Bacterial
prostatitis is usually caused by manipulation of the urinary tract, unsafe sexual practices, and spasms of
muscular tissue in the bladder neck, prostatic urethra, and external urethral sphincter.42 Muscular spasms
induce prostatitis by interrupting the smooth flow of urine thus causing a reflux of urine into the ducts that
permeate the prostate.42 Chronic prostatitis may follow an acute episode but is often of insidious onset
characterized by ductal obstruction and chronic inflammation.
The prostate has the highest zinc concentration of any tissue in the body; men with chronic bacterial prostatitis
have extremely low concentrations of zinc within their prostates, even though their blood zinc levels are usually
normal.43 The immune system dispatches immune cells that either engulfs bacteria (monocytes) or poison
them with toxic substances such as hydrogen peroxide (lymphocytes and eosinophils) to prevent bacterial
prostatitis. The vast majority of men have nonbacterial prostatitis (also called chronic pelvic pain syndrome)
4
and has mainly been contributed to genetic factors, hormonal imbalance, aging, chemical irritants, fungal
infections and autoimmunity.42
9. Conventional treatments for prostate disorders
Conventional treatments for prostate cancer depend on the stage of the cancer (e.g., localized vs. metastatic)
and may include surgery, radiation therapy, chemotherapy, hormone therapy, and in some cases no therapy at
alI.16 For example, if the tumor has not spread beyond the prostate and the patient has a less than 10-year life
expectancy, the standard treatment options may introduce unacceptable risks.
Surgically removing the prostate (prostatectomy) is generally curative if the tumor is confined to the gland.
Impotence and incontinence are the most common side effects. Newer surgical techniques that spare the
nearby nerves help to decrease the incidence of these side effects. However, because of the prostate's role in
semen production, men who are spared impotence experience dry orgasms.
Radiation therapy involves exposing the prostate to high-energy radiation, which kills the tumor cells.
Radiation can be delivered externally or by a source inserted in the body. Brachytherapy is when radio-active
materials are placed in direct contact with the tissue being treated. Patients undergoing radiation therapy
typically experience diarrhea and painful urination. External radiation can also cause pelvic hair loss as well as
dry and tender skin in the radiated area. External radiation techniques tend to produce a greater incidence of
impotence than does internal radiation. Nausea and vomiting can also accompany radiation therapy.
Chemotherapy involves administering potent anticancer agents that typically do not differentiate between
normal and cancerous cells and, because of their systemic administration, affect many areas beyond the
prostate. These agents usually damage DNA, RNA, protein synthesis and result in lethal cellular outcomes.
Nausea, vomiting, bone marrow suppression, gastrointestinal erosion, and hair loss (alopecia) are common
adverse effects of most chemotherapeutic agents. Each individual agent, such as mitoxantrone, estramus (the
nitrogen mustard estramustine conjugated to estradiol), and doxorubicin, are also characterised by specific
adverse effects in addition to those listed above.
Hormone therapy involves removing the source of the male sex hormone, or administering agents that
antagonize this hormone's actions. Orchiectomy (the removal of the testes) almost completely eliminates
testosterone production in men and can help to prevent prostatic cancer cell growth. However, the side effects
associated with this procedure include impotence and gynecomastia (breast enlargement).
Estrogenic compounds, either estrogen itself or luteinizing hormone releasing hormone (LHRH) agonists,
antagonize the actions of testosterone and may help decrease tumor growth. Compounds that block
testosterone synthesis (5 alpha-reductase inhibitors) include finasteride. Although this compound is approved
for BPH and male pattern baldness, it is currently under investigation by the National Cancer Institute to
determine if treatment with this compound will act prophylactically to help prevent prostate cancer. Other
androgen antagonists that directly block the androgen receptor include the non-steroidal compounds
bicalutamide, flutamide, leuprolide, and nilutamide.17
10. Complementary approaches to prostate disorders
Complementary/alternative medicine has been defined in various terms, some more positive than others. The
National Institutes of Health Office of Alternative Medicine defines CAM as “…a broad range of philosophies
and approaches. Those treatments not taught widely in medical school, not generally used in hospitals and not
usually reimbursed by medical insurance. …”.18 From another perspective CAM is “... a broad domain of
healing resources other than those intrinsic to the politically dominant health care system”.19
There are many reasons why prostate cancer patients look beyond the mainstream treatment options in an
attempt to manage their disease. Sometimes it is the despair associated with a cancer diagnosis, or the
adverse effects of traditional radiation and chemotherapy. Plus, many patients think conventional therapies are
5
not efficacious. In fact, depending upon the severity of the disease, a number of the traditional allopathic
approaches are not very effective, and the side effects can be worse than the disease symptoms.
With the almost instant access to information via the internet, patients no longer rely entirely on their
physician’s advice regarding medical treatment options. Many patients will be armed with information about
their condition and its treatment when they meet with their physician. Some of the information they gather is
accurate and useful, but much is misleading or incorrect. Most patients are simply not trained to effectively
differentiate between good and bad medical information. In addition, the despair and stress associated with a
prostate cancer diagnosis probably increases the likelihood of being influenced by poor information. Whatever
their reasons, patients looking to CAM should be encouraged to use it in combination with allopathic
treatments.
While CAM continues to be investigated, it is being used either alone or in conjunction with conventional
cancer therapies. Cancer patients hope CAM can help improve their survival rate, reduce their disease
recurrence risk, relieve disease-related symptoms, and minimize side effects of conventional treatments.20
With a number of the approaches described below, evidence supports a beneficial effect, even if mild or
moderate, on improving quality of life issues, slowing tumor progression, and reducing recurrence rates.
Researchers reviewed 26 surveys from the literature and found that CAM use by cancer patients varied from 7
to 64% - the mean was approximately 30 percent.21 Studies have shown that patients with cancer in general,
and prostate cancer in particular, are more likely to use CAM than the general public.20,22 Such CAM
approaches include alternative and mind/body control methods such as diet, yoga, and meditation, or
nutritional supplements and herbal medicines that act as antioxidants, testosterone antagonists, estrogenic
agonists, and by a variety of other possible mechanisms. The one area that appears to provide the greatest
amount of potential in the short term is the use of antioxidants prophylactically and even following disease
diagnosis.
In 2007 a systematic review and meta-analysis of antioxidant supplements on mortality in randomized primary
and secondary prevention trials speculated that beta carotene, vitamin A, and vitamin E may increase
mortality.74 Experts from IADSA’s international scientific network however raised serious doubts about the
evidence to support the negative conclusions, and agreed that consumers could continue taking antioxidant
food supplements for the benefits they provide. It must however be cautioned that vitamin C may cause cancer
in smokers.
11. Oxidative stress and prostate disorders
There is ample evidence supporting the role of oxygen free radicals in initiating and promoting various
cancers.23 Many of the foods we eat contain potent antioxidant molecules that, in a variety of in vitro and in
vivo tests, have been associated with anticarcinogenic activity.24 Additionally, some foods also contain
beneficial compounds that don't function as antioxidants. The constituents in foods found to reduce cancer risk
in a variety of experimental settings include: allium (from garlic), carotenoids, dietary fiber, dithiolthiones,
flavonoids, glucosinolates, indoles, isothiocyanates, limolene, phenols, protease inhibitors, selenium, sterols,
and vitamins C and E.
Numerous compounds, some discussed below, are currently under investigation as potential anticancer
agents:
Indole-3-carbinol, a compound found in some cruciferous vegetables of the Brassica genus such as broccoli
and cabbage, appears to be effective at preventing free radical-mediated oxidative stress in a number of
experimental settings. In cancer cells grown in culture, indole-3-carbinol decreased cell growth and caused
cell-cycle arrest.25
Isoflavone phytoestrogens, found mostly in soybean products, have received much attention for preventing
and treating various cancers. It is well known that prostate cancer risk varies substantially throughout the
world, a fact some have attributed to differences in phytoestrogen consumption. In cell cultures, the
6
phytoestrogen genistein has been shown to consistently inhibit many types of tumor cell growth, especially
human prostate cancer cell lines.26
The mechanism that may partially explain the anticancer activity of isoflavones involves angiogenesis
inhibition. Angiogenesis, or new blood vessel growth, is required for tumor growth. Genistein can block that
process. Genistein and daidzein are classified as weak partial estrogen agonists. Acting as antioxidants, they
inhibit tyrosine kinase, an important intracellular enzyme in normal and cancerous cells involved in many
essential cell functions. Although interference with tyrosine kinase may help damage cancerous cells, it also
disrupts normal cell function and therefore may have side effects that are not dissimilar to the ones caused by
some of the traditional anticancer agents.
Mushrooms contain a number of compounds that have also shown significant antitumor activity in
experimental cancer models.27 Some mushrooms contain (1-3)-beta-D-glucans and other polysaccharides that
appear to mediate antitumor activity by working on T-cells and macrophages. While the exact mechanisms of
action and receptors involved in these responses are still unknown, results from numerous lines of
investigation suggest that the protective effects of mushrooms result from enhancing immune function.
Proanthocyanidins, present in certain fruits and vegetables, are a group of polyphenolic bioflavonoids known
to act as potent antioxidants.28 These compounds have been shown to prevent free radical-induced damage
such as the cytotoxic actions on DNA molecules and lipid peroxidation, as well as prevent cancer cell growth in
culture.29,30
The proanthocyanidins seem to decrease the proliferation of prostate cancer cells by inhibiting cell growth and
increasing cell death.44 The flavonoids appear to decrease superoxide production, thus contributing to the
antioxidant activity of grape seed extract. Grape seed extracts containing proanthocyanidins are more potent
antioxidants than vitamins C and E, and may offer some protection against oxidative stress-induced
carcinogenic changes.20
Pygeum extracts are used in the treatment of prostatitis, BPH and prostate cancer - inhibits the ligandactivated human androgen receptor that controls the growth of the prostate gland.45
The applicable part of pygeum is the bark and evidence suggests that pygeum extracts have antiproliferative
effects on prostatic fibroblasts and epithelial cells; it might also have an inhibitory effect on growth factors such
as basic fibroblast growth factor (bFGF), epidermal growth factor (EGF) and insulin-like growth factor (IGF),
which might inhibit prostate growth and cellular hyperplasia. Results have shown that taking pygeum orally
reduces functional symptoms of BPH: nocturia were decreased by 19%, peak urine flow increased by 23% and
residual urine volume reduced by 24%, making it an applicable treatment for BPH. The extract has shown to
play a significant role in regulation of prostate cancer both in vitro and in vivo and may therefore be useful for
people at high risk of developing prostate cancer.46
Lycopene is a predominant carotenoid with antioxidant properties. Lycopene intake might protect against
prostate cancer, especially advanced prostate cancer.42 According to one report, men who consumed tomato
products four times weekly reduced their prostate cancer risk by 20%, and those who had 10 or more helpings
weekly reduced their risk by 45%.42
Lycopene also appears to be a promising nutritional component for chemoprevention during prostate cancer
treatment. It inhibits the progression of prostate tumour growth, cell proliferation and remodelling in benign
prostate tissue.49
Quercetin is a flavonoid found in many commonly eaten vegetables and fruits. In fact, the average healthy diet
provides approximately 25 mg per day.31 Initially, researchers thought this flavonoid promoted carcinogenesis,
but subsequent studies have failed to confirm this finding. In fact, quercetin has consistently demonstrated a
potent antitumor effect. Quercetin acts as an antioxidant and a reverse transcriptase inhibitor; thus, it has been
shown to prevent numerous cancer cell line syntheses in vitro.32
7
Saw palmetto (Serenoa repens) has received the most attention regarding prostate cancer prevention and
treatment. The herb contains components that can inhibit 5 α-reductase, and thereby prevent testosterone
from converting to its much more active metabolite.33
Derived from the berries of the dwarf palmetto palm tree, saw palmetto induces apoptosis in the prostate
epithelial cells but does not reduce the size of the prostate gland and only shrinks the inner prostatic
epithelium. It has also been found to have an active role in reducing the number of estrogen and androgen
(DHT) receptors, combined with an anti-inflammatory effect on the prostate.42
Saw palmetto appears to have efficacy similar to that of finasteride, but it is better tolerated, less expensive
and less likely to decrease PSA levels, thus making it an effective treatment for symptoms of BPH.58 Multiple
clinical studies indicate that saw palmetto provides improvement in urinary symptoms such as frequent
urination, painful urination and perineal heaviness associated with BPH. It also decreases nocturia, improves
peak and mean urinary flow and lowers residual urine volume in patients with BPH.
In summary, saw palmetto has anti-androgenic, antiproliferative and anti-inflammatory properties that seem to
be responsible for improving symptoms of BPH.42 In combination with other herbs and minerals it might be
beneficial in the treatment of prostate cancer and chronic prostatitis.
Beta-sitosterol (one of the actives in amongst other saw palmetto) is one of the main components of a group
of plant sterols known as phytosterols - it inhibits the 5 alpha-reductase activity thus preventing the conversion
of testosterone to dihydrotestosterone (DHT). Research also suggests that it improves urological symptoms
and flow measures.48
Two randomized studies have shown β-sitosterol to be of benefit in treating BPH; it however does not reduce
the size of the prostate gland.47,48
PC-SPES, an herbal preparation that contains eight different herbs - chrysanthemum (Chrysanthemum
morifolium), the root fungus Ling Zhi (Ganoderma lucidium), Spanish licorice (Glycyrrhiza glabra), betasitosterol-containing indigo (Isatis indigotica), Siberian ginseng (Panax pseudoginseng), Rabdosia rucescens,
skullcap (Scutellaria baicalensis), and saw palmetto (Serenoa repens) - has gained attention after promising
results from studies in cell cultures and patients.34 In an in vitro study, researchers found that a 1:20 diluted
sample of the PC-SPES was as potent as 0.1nM estradiol with regard to estrogenic activity.
Many of the individual components in this mixture have demonstrated their ability to antagonize cancer cell
growth in vitro.35 The herbal combination effectively decreased growth of PC-3 and DU145 prostate cancer cell
lines while lowering PSA levels in 33 patients given three capsules daily (320 mg/capsule) for six months. The
subjects in this study were prostate cancer patients who had either refused convention therapies or for whom
those treatments failed. Side effects included nipple tenderness (6%) and leg clots requiring heparinization
(6%). Other reports in the literature describe individual beneficial effects of this herbal combination. For
instance, in one report an individual patient's PSA dropped from 8.8 ng/mL to undetectable levels following
treatment with nine 320-mg capsules of PC-SPES per day for eight weeks.36 Whether the reported beneficial
effects of PC-SPES are a result of the unique synergistic combination of herbs, or is attributable to one or two
of its ingredients remains unknown. Additional clinical studies are required to determine the usefulness of this
and other herbal products.
Pine bark extract - Pinus pinaster has anti-inflammatory and antioxidant constituents such as
proanthocyanidins (OPCs), polyphenolic monomers and procyanidins. In a study done on pine bark extract,
evidence has been provided that it exerts the anti-inflammatory effects by the inhibition of pro-inflammatory
gene expression.50
Stinging nettle (Urtica dioica) - the nettle roots’ polysaccharides inhibit inflammatory prostaglandins and
leukotriene molecules, thereby reducing prostatic pain, swelling and improving urinary flow.42 A study done on
the effects of stinging nettle root extracts and their steroidal components suggests that some hydrophobic
constituents in the nettle roots inhibit the membrane sodium and potassium ion-ATPase activity of the prostate,
8
which may subsequently suppress prostate cell metabolism and growth.51 A study by Safarinejad (2005)
concomitantly confirmed its value in the treatment of BPH.52
Selenium is another anticarcinogenic compound that has long been associated with cancer protection. As an
essential mineral for normal metabolism, the RDA is 55-70 µg; however, amounts between 200 and 500 µg per
day, much greater than what is found in the diet, are usually required to afford antitumor activity.37
Selenium may act as an antioxidant, alter carcinogen metabolism, enhance glutathione peroxidase activity,
inhibit protein synthesis, and stimulate apoptosis (programmed cell death).38
There is an inverse correlation between the mortality rates of certain cancers from various geographic areas
and environmental selenium levels. In areas where the selenium content of the soil is high, there are typically
lower rates of certain cancers.39 The relative high selenium content of soil results in a higher content of the
element in foods like mushrooms, garlic, onions, broccoli, asparagus, tomatoes, grains and seeds. When live
stock feeds on plant material high in selenium, substantially higher levels of selenium will be found in their
flesh, e.g. red meat, poultry, liver, kidney and egg yolks.
In a double blind cancer prevention trial the use of selenium significantly reduced the relative risk of developing
prostate cancer by 63% as compared to a placebo.53 However, in a more recent large scale clinical trial the
use of selenium resulted in a 60% reduction in prostate cancer risk, making it very beneficial for reducing
prostate cancer due to its potent antioxidant properties that controls free radicals and reactive oxygen
molecules associated with DNA damage. Selenium, and combinations of selenium, has been recognized as
one of the most efficacious chemopreventative agents against prostate cancer.54
Selenium is an essential component of the antioxidative enzyme glutathione peroxidase (GSH-Px), which is a
scavenger of hydrogen peroxide and lipid and phospholipid hydroperoxides in human cells. Seleno-enzymes
regulate hormone balance, electron transfer in the biosynthesis of nucleotides and redox status of vitamin C in
human and animal cells. It has also been shown that through its antioxidative function selenium can ameliorate
UV-B radiation damage in humans and experimental animals.40
Zinc is a cofactor in many biological processes including DNA, RNA and protein synthesis. About 30% of
cellular zinc is found within the nucleus; zinc plays a role in immune function, growth and development.42 The
high concentration of zinc in the prostate suggests that zinc may also play a role in prostate health.55
The correlation between zinc and citrate in the prostate have been indicative of an important role zinc plays in
the regulation of citrate metabolism in normal and malignant prostate epithelial cells - the prostate is
responsible for accumulating and secreting extraordinary high levels of citrate.56 In malignancy, the normal
zinc-accumulating citrate-producing epithelial cells are metabolically transformed to citrate-oxidizing cells that
lose the ability to accumulate zinc. The accumulation of zinc in citrate-producing epithelial cells is regulated by
testosterone and prolactin, which explains the beneficial effect that zinc has due to the inhibition of the 5 αreductase activity.56 It not only decreases the production of DHT but also inhibits binding of DHT to its
receptors, resulting in an anti-proliferative effect thus making it suitable for treatment of BPH.42
The inability of malignant prostate cells to accumulate high zinc levels results in increased citrate oxidation and
the coupled ATP production essential for the progression of malignancy – provides a compelling rational basis
for the expectation and concept that prostate zinc accumulation is an important factor in the development and
progression of prostate malignancy, and that zinc could be efficacious in the prevention and treatment of
prostate cancer.57
12. Urinary retention
If BPH is left without treatment it increases the risk of urinary tract infections (UTI), urinary bladder stones and
urinary retention. Other contributing factors for urinary retention include thyroid problems, high blood pressure,
kidney disease and seasonal changes.59
9
Acute water retention conditions (e.g. water retention due to sitting or standing for long periods of time) are
experienced by some men on a daily basis. Edema is usually treated with regular diuretics.60 However, these
can be habit-forming and the body may start relying on the diuretics to do the work.
Some men are opting for non-habit-forming natural remedies that contain herbs that can act as a
diuretic, treat indigestion and stomach discomfort and assists with urinary tract infections such as:61
Uva Ursi - has urinary antiseptic, astringent, diuretic, and anti-inflammatory effects in the genitourinary tract.62
The herb neutralizes acidity in the urine, increasing urine flow, therefore reducing bloating and water retention.
Uva Ursi contains allantoin which is well known for its soothing and tissue repairing properties. It contains
chemicals, primarily hydroquinone and hydroquinone derivatives, that make it potentially useful for urinary
conditions and is used to treat infections such as cystitis, urethritis and nephritis.62
The hydroquinone derivative arbutin is the chief active compound in Uva Ursi. During urination it acts on the
mucus membranes of the urinary tract to soothe irritation, reduce inflammation, and fight infection.
Interestingly, arbutin taken alone is not as effective as the whole Uva Ursi plant in controlling urinary tract
infections. That is because intestinal bacteria can break down arbutin, but they are less likely to do so in the
presence of other Uva Ursi compounds.
The leaves contain arbutin, which acts against E. coli and increases urination. Uva ursi also fights bacteria and
cleanses the urinary tract, promotes excretion, and deters water retention, supports the kidneys, and cools
inflammatory reactions (Frohne, 1970 as cited by Pizzorno and Murray, 2000: 990).63
The increased urine action of Uva Ursi is due to arbutin which is largely absorbed unchanged and is excreted
by the kidneys. During its excretion, arbutin exercises an antiseptic effect on the urinary mucous membrane. It
is therefore used in inflammatory diseases of the urinary tract, urethritis and cystitis.
Dandelion leaf and dandelion root - a diuretic high in potassium. Sesquiterpenes lactones are responsible
for the diuretic effect and may contribute to dandelion’s mild anti-inflammatory activity. According to Balch
(2004),64 dandelion is used as a diuretic to help to relieve fluid retention and counteract urine retention in
bladder infection.
Recent studies suggest that dandelion root extract inhibits production of the inflammatory cytokines interleukin
IL-6 and tumor necrosis factor (TNF) - alpha. Dandelion flower extract possesses bioactive photochemical with
the ability to scavenge ROS (reactive oxygen species) and prevent DNA from ROS-induced damages.
Juniper - a diuretic. Consist of alpha-pipene (29.17%), beta-pipene (17.84%), sabinene (13.55%), limonene
(5.52%) and micrene (0.33%). Juniper essential oil has bactericidal activities against gram-positive and gramnegative bacteria.65
The diuretic action of juniper has been attributed to the terpinen-4-ol. Stanic and co-workers (1998) suggested
that the diuretic effect is partly due to the essential oil and partly to hydrophilic constituents.66
Burdock - can help eliminate excess fluids in the body and stimulate the elimination of toxic waste materials,
which relieves liver disorder and improves digestion.64 Burdock root contains approximately 50% inulin, a fibre
widely distributed in fruits, vegetables and plants.
Several studies have confirmed that burdock seeds, roots and leaves exhibit antioxidant activities, as well as
an anti-inflammatory and an ability to inhibit the potent inflammation-causing chemical platelet activating
factor.67,68
Parsley powder - stimulant, diuretic, carminative and anti-inflammatory. The diuretic effect of the herb is
mediated through an increase in K+ retention in the lumen, and is mediated through an inhibition of the Na+ K+ pump that would lead to a reduction in Na+ and K+ re-absorption thus leading to an osmotic water flow in
10
the lumen and ultimately diuresis.69
Golden rod - used to counter inflammation (by inhibiting elastase) and irritation caused by bacterial infections.
The use of an herbal remedy such as goldenrod with a complex action spectrum (anti-inflammatory,
antimicrobial, diuretic, antispasmodic and analgesic) is especially recommended for the treatment of infection
and inflammation.70
Potassium, vitamin B6 and magnesium - many diuretics raise renal output of these solutes. Replacing these
essential electrolytes is thus important.
Potassium is an essential mineral needed to regulate water balance, levels of acidity and blood pressure.
Potassium (K) depletion usually is due to excessive losses of K in the urine or stool.71
Magnesium may also help to reduce symptoms such as abdominal bloating and fluid retention, whereas
vitamin B6 (pyridoxine) is thought to help in cases of mild fluid retention.72
13. Conclusions
While this discussion has been limited to some commonly used chemical complementary/alternative
approaches to treating prostate related disorders, there are many other phytochemical and non-phytochemical
agents available. There are also many non-chemical CAM approaches, such as prayer, meditation, exercise,
and stress management that are not discussed here.
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