BPH Background
"Hormones from the testis may be the main factor. For example, as men age, the amount of active testosterone in the blood declines. Estrogen levels stay the same. BPH may occur when these hormone changes trigger prostate cell growth".
This 2021 study titled - "Relationship between serum total testosterone and prostate volume in aging men" (as many other studies before it) concludes: "The results of our study suggest that testosterone (TT) levels are negatively correlated with prostate volume, and BMI, waist circumference, and insulin are negatively correlated with PV (Prostate Volume) in older patients. In addition, men with low testosterone developed a larger prostate than men with normal testosterone. These findings will contribute to a better understanding of the role of TT in LUTS/BPH" (LUTS - Low Urinary Tract Symptoms).

Triggers For Testosterone Decline

• α1 - refers to adrenoceptors receptors. α1-adrenoceptors are highly expressed in the smooth muscle cells of the prostate gland, bladder neck, and urethra. At some point, these receptors act to increase the intracellular calcium concentrations leading to "smooth" cell and muscle contraction in the prostate, or prostate growth. When stimulated by α-adrenergic nerve fibers, these cells cause an increased levels of urethral resistance through the urethra (the pressure required to propel any given flow rate) (Akinaga and García-Sáinz, 2019).

• 5α-reductase (5-ARIs) enzyme and aromatase are enzymes involved in the conversion of androgens (such as testosterone) to estrogen (such as 17β-estradiol)."There is evidence that estrogens can directly modulate human prostate cell activity. It has also been shown that cultured human prostate cancer LNCaP can synthesize the active estrogen estradiol (E2)". "The most potent androgen, dihydrotestosterone (DHT), is produced from the major circulating androgen testosterone by 5α-reductase. There are two isoforms of the enzyme: 5α-reductase type I (SRD5A1) and type II (SRD5A2).

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• Aromatase enzyme - "Estrogens are generated mainly by the action of aromatase, which converts testosterone to estradiol and androstenedione to estrone (a female sex hormone)",

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• Aquaporins - Aquaporins (AQP) are integral membrane proteins that serve as channels in the transfer of water, and in some cases, small solutes across the prostate membrane. An accumulation of studies [1, 2, 3] in recent years has shown the link of BPH development and the abundance of various aquaporin proteins in prostate tissues. Expect improvement in BPH symptoms by a drastic reduction in the consumption of aquaporin containing foods (Corn, soybean, spinach leaf, and tomato) - watch this video with Dr. Gundry testifying from his own experience (min. 10:20).

Intuitive Option To Treat BPH 
If testosterone is the culprit, why not inject testosterone and solve the problem? This 2022 study concludes: "TT (testosterone) is an effective treatment for patients with hypogonadism (Hypogonadism is a medical term for decreased functional activity of the gonads). As for the fear that testosterone treatment may result in abnormal prostate growth and Pca (Prostate cancer) risk, however, our research shows that TT does not cause abnormal prostate growth, and may even reduce the risk of Pca". In the discussion section (section 4) of the above study the researchers write "In addition, it is unclear how different testosterone administrations affect prostate safety, and which testosterone preparations are better. Therefore, we conducted an indirect and direct comparison of the effects of different testosterone preparations on prostate safety in a network meta-analysis. As far as we know, this study is the first NMA to assess the impact of different testosterone preparations on prostate safety risk." Read here if you want to learn more about the direct administration of this treatment. 

Vitamin D3 - BPH Prevention And Therapy
Vitamin D3 is a Simple, safe and always beneficial supplement that is also effective for the BPH condition!
Role of vitamin D in common urological conditions - "Vitamin D deficiency is prevalent in the male population, with approximately one third of males having levels below 20 ng/mL (adequate vitamin D levels to be regarded above 20 ng/mL and low: below 12 ng/mL) (32). Low 25-hydroxyvitamin D (25-OH) levels have been found to be associated with prostatic enlargement and levels are inversely proportional to prostate volume (>40 grams) (33,34). Moreover, vitamin D levels have been inversely correlated not only with prostate volume but also with serum PSA (34)".
Furthermore, like many other studies on the subject of vitamin D3 supplementation to help reduce or even avoid the BPH/LUTS (Lower Urinary Tract Symptoms) problem, this 2023 study concludes: "In men with a vitamin D deficiency, supplementation of vitamin D suppressed the increase in the prostate volume. Improvements were noted in LUTS, such as a reduced postvoid residual urine volume and symptom questionnaire scores. Although there is no direct effect on serum testosterone levels, vitamin D supplementation helped improve hypogonadal symptoms."
Bottomline, vitamin D3 supplementation (5000-10,000 IU/day) is a good practice to help reduce or even avoid the BPH/LUTS problem! Read on this page more on the importance of vitamin D3.

Drugs Used For BPH Treatment 
As concluded in this most comprehensive review article, at this point in time (2020), there is no clear "winner" - a drug and/or artificial supplement that its benefit to the BPH problem clearly justifies its side effects and risks!. The two most common drugs used are α1 Adrenergic Antagonists (α1-Blockers), and inhibitors of Aromatase and 5α-Reductase. "The drugs used to treat BPH exhibit a wide range of clinical applications, pharmacological actions, and side effects. It is also possible that the efficacy and side effects of each BPH drug may vary within the same patient population, and that the sensitivity of different BPH patient populations to the same BPH drug may also vary. Consequently, there is no universal therapy for LUTS-BPH patients, and individualized treatment plans are required to ensure the judicious use of medical resources". 

α1-Blockers

"the alpha-1 adrenergic receptor antagonists (also called alpha-blockers) are a family of agents that bind to and inhibit type 1 alpha-adrenergic receptors and thus inhibit smooth muscle contraction". As far as BPH is concerned, α1-Blockers has shown to reduce IPSS (International Prostate Symptoms Score) by 50%, and to increase the maximum urinary flow rate (Q-max) by 40% (Michel et al., 1998; Djavan et al., 2004). α1-blockers can significantly improve the urinary symptoms of patients, including voiding symptoms and storage symptoms."

The α1-adrenoceptors can be classified into three different subtypes (α1a, α1b, and α1d); these subtypes are distributed across various anatomical sites (Akinaga and García-Sáinz, 2019).
Side effects - given the distribution of the α1-blockers subtypes, they can cause a range of side effects when used for the treatment of BPH, including postural hypotension, dizziness, asthenia, abnormal ejaculation, and intraoperative floppy iris syndrome (IFIS) (Andersson and Gratzke, 2007).

5α-Reductase And Aromatase Inhibitors

5α-Reductase inhibitors can inhibit the conversion of testosterone and reduce the levels of DHT, thereby shrinking an enlarged prostate and preventing the progression of the condition into BPH (Drobnis and Nangia, 2017). 5α-reductase can be divided into two subtypes - type I and type II with very different patterns of biodistribution. The type I 5α-reductases are widely expressed in the skin, sebaceous glands, liver, and prostate epithelial cells. Type II 5α-reductases are mainly expressed in the stromal cells of the prostate, and, to a lesser extent, the epithelial cells (Cilotti et al., 2001). There are two inhibitors of 5α-reductase: finasteride and dutasteride. Finasteride is specific to type II 5α-reductase, while dutasteride inhibits both type I and type II 5α-reductase (Drobnis and Nangia, 2017).
Side Effects - Effect of 5α-Reductase Inhibitors on Sexual Function: A Meta-Analysis and Systematic Review of Randomized Controlled Trials concludes "Evidence from the randomized controlled trials suggested that 5ARIs were associated with increased adverse effects on sexual function in men with BPH compared with placebo".

Aromatase inhibitors - "These data demonstrate that aromatase inhibition increases serum bioavailable and total testosterone levels to the youthful normal range in older men with mild hypogonadism" (hypogonadal in men - a condition in which the body does not produce enough of the testosterone hormone).
Another study - on the effects of aromatase inhibitors concludes: "Our results show statistically significant improvement in TT and ADAM scores in all 3 medications after treatment" . 
Side effects - "Unfortunately, this therapy leads to estrogen depletion in the body, which can lead to unpleasant side effects such as menopausal symptoms like hot flashes, insomnia, slightly increased risk of ischemic heart disease, accelerated bone loss leading to higher osteoporosis risk, and most significantly, arthralgias"

In conclusion - the use of drugs related to α1 blockers and 5α-Reductase and aromatase inhibitors is effective, but it comes with associated unpleasant side effects. 

In the following section we present alternative foods and supplements (additional  to the vitamin D3 as discussed above) that can help the testosterone producing body glands (gonads for men) in the production of that hormone.