Short answer: Saw palmetto has the newer and stronger evidence, and it is negative: a 2023 Cochrane review found little to no benefit for urinary symptoms of BPH.1 Pygeum's 2002 Cochrane review found better symptoms than placebo, but in 18 small, short trials with varied doses.2 No trial has compared the two herbs.
| Saw palmetto | Pygeum | |
|---|---|---|
| Source | Berries of Serenoa repens, a small palm3 | Bark extract of the African prune tree2 |
| Latest Cochrane review | 2023: 27 studies, 4,656 men1 | 2002: 18 trials, 1,562 men2 |
| Main finding | Little to no difference in symptoms vs placebo (high-certainty evidence)1 | About twice as likely to report better overall symptoms vs placebo2 |
| Trial length | 3 to 17 months1 | Average 64 days2 |
| Compared with BPH drugs? | Not in the 2023 review (placebo only)1 | No trials vs alpha blockers or 5-alpha reductase inhibitors2 |
| Safety | Well tolerated up to 3 years; does not appear to affect PSA3 | Side effects mild and similar to placebo2 |
Saw palmetto has been studied in larger, more recent trials, including two NIH-funded ones. The 2023 Cochrane review, using only low-risk-of-bias studies for its main results, found little to no difference in symptoms or quality of life at 3 to 6 months and at 12 to 17 months.1 NCCIH concludes it is probably not helpful for BPH symptoms.3
Pygeum was last reviewed by Cochrane in 2002. Night-time urination fell by 19%, leftover urine by 24% and peak flow rose by 23% compared with placebo, but the reviewers warned the trials were small, short, used varied doses and preparations, and rarely used standard symptom scores.2
The two reviews differ in age, size and trial quality, so their results are not directly comparable.
NCCIH says saw palmetto has been used safely in studies for up to 3 years, with infrequent digestive upset, dizziness or headache, and does not appear to change PSA readings.3 In the pygeum trials, side effects were mild and similar to placebo.2
Urinary symptoms can have other causes, so see your clinician before treating them yourself. Neither is approved by FDA before sale.4 More detail: Saw palmetto vs finasteride: what do the trials show?, and the Saw Palmetto (Serenoa repens) and Pygeum (Pygeum africanum) guides.