Introduction

Butcher’s broom (Ruscus aculeatus) is a bushy evergreen subshrub that grows to 3 feet in height, with flat, leaf-like branches, disproportionate red berries, and greenish-white flowers in late winter and spring.¹ It is native to the Mediterranean and Africa, from the Azores islands, west of Portugal, to Iran.² The rhizome, or root, is the most common part of the plant used today.

History and Cultural Significance

The common name “butcher’s broom” came from Europe, where butchers would bundle the shrub into a broom to sweep and cleanse their cutting blocks, due to the stiffness of the material.³ (It was later discovered that the essential oil in the plant is antibacterial.) Europeans have been using the shrub as a laxative and diuretic for almost 2,000 years.² Many cultures soaked the rootstock in water or wine to help alleviate abdominal complaints. In the first century CE, Greek physicians used butcher’s broom to treat kidney stones. In the 17^th century, the English herbalist Nicholas Culpepper used butcher’s broom to help the healing of fractured bones. He recommended that patients take a decoction of the root (made by boiling the plant’s woody parts) orally along with spreading a poultice of the berries over the fracture.²

The root of butcher’s broom contains ruscogenen and neoruscogenin, which have been found to have anti-inflammatory characteristics and to cause contraction of veins. These properties have led to the modern uses of the plant as supportive care for chronic venous insufficiency (CVI), hemorrhoids, and varicose veins.²

The German Commission E approved the use of butcher’s broom rhizome extract for discomforts of CVI, such as pain and heaviness, as well as for cramps in the legs, itching, and swelling, and for supportive therapy for complaints of hemorrhoids, such as itching and burning.⁴ Similarly, the European Scientific Cooperative on Phytotherapy (ESCOP) recommended solid or liquid extracts of the dried, whole or fragmented rhizome for supportive therapy for symptoms of CVI and hemorrhoids.⁵ The European Medicines Agency (EMEA) finalized its Community Herbal Monograph in 2008 for the registration of butcher’s broom products as traditional herbal medicines.⁶ Butcher’s broom medicinal products, in compliance with the quality standards set out by the European Pharmacopoeia,⁷ may be registered and labeled as traditional herbal medicinal products (THMPs) for the relief of symptoms of discomfort and heaviness of legs related to minor venous circulatory disturbances and symptomatic relief of itching and burning associated with hemorrhoids,⁶ with the noted limitation that such application is based solely on “long-standing use.”

Modern Research

Human studies have investigated formulations containing butcher’s broom for their effects on insufficient blood flow to the lower limbs, including in chronic venous disease (CVD) and/or CVI. CVD of the lower limbs can be recognized by symptoms such as varicose veins and venous ulcers, as well as edema, venous eczema, hyperpigmentation of the skin of the ankle, atrophie blanche (white scar tissue), and lipodermatosclerosis.⁸ CVD is often graded according to 7 classes of CEAP classification (e.g., clinical, etiologic, anatomical, and pathophysiological), which range from C₀ to C₆. The term CVD is applied to the full spectrum of symptoms from C₀ to C_6, whereas CVI is generally restricted to more severe disease (C₄ to C₆).

Studies include one in 1987 that studied butcher’s broom in combination with trimethylhesperidine chalcone and ascorbic acid _{for the treat}ment of lower limb venous disease,⁹ one in 1988 that investigated its ability to treat lower limb venous disease in patients with chronic phlebopathy (venous insufficiency) when taken in combination with hesperidin and ascorbic acid,¹⁰ one in 1989 that tested its effects on venous tone and capillary sealing when taken in combination with hesperidine methyl chalcone,¹¹ and two in 1999 that assessed the effect of a combination of Ruscus extract (150 mg) and hesperidin methyl chalcone (150 mg) and ascorbic acid (100 mg) (Cyclo 3 Fort®, Pierre Fabre Medicament, Paris, France) on uncomplicated venous insufficiency and superficial varicose veins.^12,13

Patients in a 2000 trial studying Cyclo 3 Fort for CVI experienced a significant reduction of symptoms and had a more favorable opinion of butcher’s broom than rutoside.¹⁴ Of the 80 participants, the treatment group took 2 capsules per day for 90 days, and the preparation was rated as excellent by 81.6% of the treating physicians.

In a 2007 study, 124 patients suffering from CVI were given 2 capsules of a combination product containing 150 mg butcher’s broom, 150 mg hesperidin methylchalcone (HMC) and 100 mg ascorbic acid (Fabroven®/Cyclo 3 Fort®; Pierre Fabre Ibérica; Barcelona, Spain) daily for 8 weeks.¹⁵ Improvement was seen in all patients, but the authors stated that although the early results were promising, symptom changes beyond the 8 weeks with treatment need to be clarified.

A 2008 study evaluated the effect of butcher’s broom, hesperidine methylchalcone (flavonoid), and vitamin C (Cirkan®, Pierre Fabre Santé; Boulogne, France) on women with CVD.¹⁶ After 4 weeks, the patients treated with Cirkan had experienced significant improvement in capillary morphology and capillary limb diameter, while the control group and the group treated only with elastic compression stockings did not.

A recent quality of life (QoL) study followed 917 Mexican patients (mostly women over 40 who were sedentary, overweight, or obese) suffering from CVD.¹⁷ Patients were given 1 capsule daily of Cyclo 3 Fort for 12 weeks. Evaluation of QoL using 2 auto-questionnaires showed that all symptoms improved, with lower limb heaviness and lower limb pain improving the most at 83% and 81%, respectively, and more so in older patients.

Studies on butcher’s broom alone for its effect on CVI are fewer in number. A long-term study published in 1991 studied 141 patients with CVI who took 3 capsules of Ruscus extract (type and manufacturer unspecified) twice daily for 4 weeks, then 2 capsules twice daily for 8 weeks.¹⁸ In all patients taking the extract, there was a decrease in foot and ankle volume after 13 weeks while the patients taking placebo experienced increased volume. The authors concluded that the reparation was a slow process and incomplete at the end of the study.

In 2003, 56 women suffering from CVI completed a study in which they were given 72-75 mg of a dry extract of butcher’s broom rhizome/root (Fagorutin^® Ruscus Kapseln, GlaxoSmithKline Consumer Healthcare GmbH, Herrenberg, Germany) daily for 12 weeks.¹⁹

Another 54 women were given placebo. Measurement of leg volume (indicative of edema) and symptoms were evaluated after 4, 8, and 12 weeks of treatment. All parameters improved in the butcher’s broom group and remained the same in general for the placebo group. The authors concluded that butcher’s broom was well tolerated and effective for CVI of Widmer grades I and II (mild to moderate stages).

Additionally, butcher’s broom has been studied for its potential vein-constricting action when applied locally. In a 1990 study, a Ruscus extract cream (specifics unknown) applied topically decreased the diameter of the femoral vein an average of 1.25 mm in 2.5 hours.²⁰ A 2003 study used a cream made of butcher’s broom and yellow sweet clover (Melilotus officinalis, Fabaceae), (formulation unknown, FLEBS Crema^®, Laboratoires Pierre Fabre, Castres Cedex, France) that, applied to both legs each day for 3 weeks, showed improvement in swelling, pain, and itching.²¹

A single small trial in 1996 suggested that butcher’s broom might be helpful in preventing diabetic retinopathy.²² Twenty patients, most suffering from non-insulin dependent diabetes (type 2) with non-proliferative diabetic retinopathy, were given 1 capsule of 0.0375 g of butcher’s broom dry extract 2 times a day (Fagorutin-Ruscus Kapseln®, GlaxoSmithKline Consumer Healthcare GmbH, Herrenberg, Germany) for 3 months. Regression of diabetic retinopathy was detected in 23.1% of patients and no cases of disease progression were seen.

In one randomized, double-blind trial in 1991, 20 women aged 18-50 years suffering from premenstrual syndrome were given 2 capsules per day for 90 days of Cyclo 3 Fort. The butcher’s broom group experienced reduced symptoms of premenstrual syndrome, including mastalgia, mood disorders, and ankle edema.²³

Butcher’s broom was shown to be efficacious in treating hemorrhoids in a study of 124 patients, in which the patients were given 6 capsules per day of Cyclo 3 Fort for 3 days, followed by 4 capsules per day for 4 days. Sixty-nine percent of the patients rated butcher’s broom as having a good or excellent effect, and 75% of the treating physicians rated it similarly.²⁴

Future Outlook

TRAFFIC, the wildlife trade monitoring network that is a joint program of the World Wildlife Fund (WWF) and the International Union for the Conservation of Nature (IUCN), stated in 1998 that wild collection of butcher’s broom in Turkey resulted in a harvest of 2,000 tons of fresh roots per year, or 400 tons of dried material, primarily for export.²⁵ The species had become locally extinct in certain areas of Turkey owing to over-collection and is among the 10 most threatened medicinal plants in trade in Turkey. At the time, the collection of the species was subject to restrictions in France, Bulgaria, Hungary, and Spain, indicating that the species is threatened in these countries also.²⁵ In Spain, this protection takes the form of limiting the amount that may be harvested.²⁶

In 2002, in a working group report, the International Plant Genetic Resources Institute stated that R. aculeatus was one of the plants sold on the Serbian market for which no cultivation information was available.²⁷ As of 2006, wild butcher’s broom was protected by law from collection in Romania as it is considered a “monument of nature.”²⁸

In Hungary, where butcher’s broom was once threatened by international trade, the situation has changed since that country joined CITES (The Convention on International Trade in Endangered Species) and protected the species.²⁹ Authorities have pledged to update the list of protected species regularly so the threats by trade can be addressed quickly.

The 9^th meeting of the Convention on Biological Diversity (May 19-30, 2008) produced a Global Strategy for Plant Conservation (GSPC) and recommended that parties develop strategies and action plans to achieve relevant biodiversity target and goals.³⁰ The GSPC target addressing butcher’s broom implemented action plans and disseminated methods to ensure that it not be endangered by trade within Europe.

—Gayle Engels

References

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