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• Inhibit 5-α-reductase. Like finasteride, saw palmetto extract can inhibit the action of the enzyme 5-α-reductase, reducing the conversion of testosterone to DHT, but it is thousands of times less potent than finasteride in this regard. The importance of 5-α-reductase inhibition in relieving symptoms of BPH is unclear, however. Some research suggests that reduction of DHT levels seems to occur only at doses of saw palmetto far higher than those typically used to treat BPH.2 Merck, of course, tries to paint finasteride's extremely high potency as a 5-α-reductase inhibitor as an advantage. As we discussed in the previous chapter, though, lots of excellent research disputes this.
  
  
• Block DHT binding to prostatic androgen receptors. According to the conventional medical wisdom, the binding of DHT to prostatic androgen receptors is the central event in the proliferation of prostate tissue. Studies show that extract of saw palmetto competes with DHT for androgenic receptors, effectively blocking the binding of DHT.3-6 Saw palmetto's anti-androgenic effects can be substantial. In one experiment, prepubertal rats and mice were castrated to remove the source of endogenous testosterone. The rats then received "testosterone" orally or by injection along with either saw palmetto extract or placebo for six to 12 days. Saw palmetto extract antagonized the prostate-stimulating effects of "testosterone," reducing prostate weight by 46%, compared with placebo.2 Finasteride has never been shown to affect DHT binding. All it can do is keep DHT levels low.
  
  
• Reduce prostatic edema (swelling) and inflammation. A too often overlooked clinical element in prostate enlargement is edema and inflammation, a condition called prostatitis. In animal and in vitro (test-tube) studies, saw palmetto extract has been shown to reduce edema and suppress inflammatory mediators.2, 7-9 Finasteride has no effect on prostate inflammation or edema.
  
  
• Inhibit the effects of estrogens. As noted in the previous chapter, it is becoming increasingly apparent that the potent estrogen estradiol can be a major stimulant for prostatic cell proliferation. The results of a double-blind, placebo-controlled Italian study have demonstrated that saw palmetto extract blocks estrogen receptors in the prostates of BPH patients, minimizing the growth-stimulating effects of estradiol.10
  
  
• Finasteride, of course, does not interfere with the actions of estradiol. In fact, according to Dr. Bruno de Lignieres, by blocking the conversion of testosterone to DHT, finasteride may make more testosterone available for aromatization, thus possibly increasing the amount of estradiol in the prostate. In the long run, this action might theoretically promote excess growth.11
  
  
• Antagonize a-adrenergic receptors. Stimulation of a-adrenergic receptors by noradrenaline causes smooth muscle cells all over the body, including the bladder and prostate, to contract.12 Blocking a-adrenoceptors is a therapeutic option for BPH because it can relax these muscles, dilating the urethra slightly, thus permitting a reduction in symptoms. Saw palmetto has recently been shown to block a-adrenergic activity in animal smooth muscle tissue, suggesting yet another avenue by which it may help relieve BPH symptoms.2