Butcher's Broom (Ruscus aculeatus L.)
1. Identity, Botanical Description, and Natural Source
Ruscus aculeatus L. (butcher's broom) is a member of the Asparagaceae family and a perennial shrub native to the Mediterranean and Black Sea regions, naturalized in parts of Europe and North America. It is an evergreen shrub with rigid leaf-like structures that terminate in a single sharp spine. Common names include butcher's broom, box holly, knee holly, kneeholy, kneeholm, Jew's myrtle, sweet broom, pettigree, and Maeusedornwurzelstock (German). It is a low-growing, tough shrub with stiff, pointed leaf-like structures called cladodes, found throughout southern and western Europe, from the Mediterranean to the British Isles.
R. aculeatus was given its common name, butcher's broom, because its stiff twigs were bound together and used by butchers in Europe to keep their cutting boards clean. This plant belongs to the Asparagaceae family and usually grows up to 50 to 80 cm.
Medicinal part used: The medicinally active part is the root and rhizome (the underground stem). The root, the part used medicinally, is thick, typically 2 to 4 inches long, with many woody rootlets growing on its lower surface. The underground rhizome and root are harvested for medicinal purposes, though historical records also document use of young shoots (as food and medicine) and the aerial parts. Modern herbalism focuses almost exclusively on the rhizome, which contains the highest concentration of active compounds.
Common dosage forms and preparations: In recent decades, R. aculeatus extracts have been incorporated into numerous pharmaceutical and cosmetic preparations, particularly those intended to improve venous tone, reduce swelling, and alleviate symptoms of chronic venous disorders. Recognized herbal preparations include dried powdered root; dry extract (4.5–6.5:1; water); dry extract (5–8.5:1; 80% V/V ethanol); dry extract (6–9:1; 96% V/V ethanol); and dry extract (15–20:1; 60% V/V methanol). Today it is sold as a dietary supplement, most commonly in capsule or extract form, and is one of the few herbal remedies with formal recognition from European health authorities for venous complaints. External preparations include ointment preparations and suppositories for hemorrhoids.
2. Traditional and Historical Use
The plant has a long history of use. More than 2,000 years ago, it was noted as a laxative, diuretic, and a phlebotherapeutic (beneficial to veins) agent. Extracts, decoctions, and poultices have been used throughout the ages, but the medicinal use of this plant did not become common until the last century.
Dioscorides, a Greek physician, pharmacologist, and botanist from the first century AD, was an advocate for butcher's broom. He documented the herb's ability to promote urine flow, regulate menstrual bleeding, manage bladder stones, treat jaundice, and relieve headaches. Butcher's broom has been used in folk medicine as far back as the first century AD. In the past, it was used as a laxative and as a treatment for gout, jaundice, kidney stones, and broken bones. It was also used as a diuretic to reduce swelling in the hands and feet, and to reduce inflammation due to arthritis.
The Romans found utility in using butcher's broom to address issues like hemorrhoids and venous insufficiency. The herb was used since ancient Greece and Rome, where it was prescribed for urinary complaints, jaundice, and swelling in the legs. In European folk medicine, butcher's broom was a favored remedy for circulatory weakness, particularly varicose veins, hemorrhoids, and pelvic congestion. It was often included in remedies for "lazy veins" and chronic leg discomfort associated with prolonged standing or poor vascular tone.
A decoction of the roots of R. aculeatus is widely used internally as a diuretic and for the treatment of urinary system disorders in Turkey. In Palestinian folk medicine, a rhizome extract is used externally in skin diseases. In Italy, uses include treatment of warts and chilblains, colitis, diarrhea, inflammation, and arthritis.
According to reported folk knowledge, the aerial parts are mainly used as diuretics and the underground organs are used for the treatment of disorders of the urinary system and as a laxative. At one time, the plant was eaten as a vegetable in the United States. The seeds have been roasted and used as a coffee substitute.
Early investigations during the 1950s indicated that extracts of butcher's broom could induce vasoconstriction and therefore might have use in the treatment of circulatory diseases. The increasing popularity of natural and herbal remedies in Europe in the 1970s reaffirmed its position in modern medicine. Ruscus aculeatus has been used for over a decade as herbal substance or herbal preparations notably in France or Germany, since 1986 and 1978, respectively.
3. Key Chemical Constituents
3.1 Steroidal Saponins
Phytochemical investigations of R. aculeatus have revealed a complex chemical profile dominated by steroidal saponins of both the spirostanol and furostanol types. In general, steroidal saponins possess a C₂₇ carbon skeleton, usually derived from oxidized cholesterol, and contain one or more sugar residues attached at various positions. Spirostanol saponins are characterized by a bicyclic ketal structure at C-22, whereas furostanol saponins typically contain a hemiketal group at C-22 and an additional sugar moiety linked to C-26. The principal aglycone of the spirostanol saponins identified in R. aculeatus is ruscogenin.
The primary active ingredients of butcher's broom are the steroidal saponins ruscogenin and neoruscogenin (up to 6%). The plant also contains other steroidal sapogenins and saponins (such as ruscin and ruscoside), fatty acids, sterols, flavonoids, coumarins, sparteine, tyramine, and glycolic acid.
Ruscogenin is a steroidal saponin of the spirostan type. Its structure consists of two oxygen-containing heterocycles connected through a spiroacetal carbon atom located on the D ring of the steroid core, and the hydroxyl group at C-10 is glycosylated with a sugar chain.
A phytochemical investigation of the fresh underground parts of Ruscus aculeatus L. isolated two new furostanol saponins and three new sulphated glycosides from its methanolic extract, along with four known furostanol and one spirostanol glycosides. The composition of free sterols was also determined and campesterol, stigmasterol, and sitosterol were the major components.
3.2 Flavonoids and Phenolic Compounds
Nine phenolic compounds have been detected across extract preparations. Apigenin-C-hexoside-C-pentoside isomer II was the major compound in aqueous extracts, and in hydroethanolic extracts, quercetin-O-deoxyhexoside-hexoside was dominant, followed by apigenin-C-hexoside-C-pentoside isomer II.
Other constituents isolated from R. aculeatus include sterols, triterpenes, flavonoids, coumarins, sparteine, tyramine, and glycolic acid. The flavonoid content strengthens blood vessels, reduces capillary fragility, and helps maintain healthy circulation.
3.3 Variability of Constituent Concentrations
The variability in the concentration of these metabolites is influenced by several factors, including the plant's age, geographical origin, and extraction methods. Older plants often accumulate higher levels of steroidal saponins such as ruscogenin and neoruscogenin, which are key pharmacologically active compounds.
Recent studies have isolated new biphenyl derivatives from the rhizomes, demonstrating significant anti-inflammatory and antibacterial activities.
4. Mechanisms of Action
4.1 Alpha-Adrenergic Venotonic Activity
Ruscus aculeatus is an alpha-adrenergic agonist that causes venous constriction by directly activating postjunctional alpha1- and alpha2-receptors, in turn stimulating the release of noradrenaline at the level of the vascular wall. The ruscogenins act as potent agonists of the alpha-1 and alpha-2 adrenergic receptors located on the smooth muscle cells in the walls of veins. The stimulation of these receptors triggers a calcium-dependent contraction of the venous smooth muscle.
The effect being inhibited by phentolamine but persisting after chemical denervation with 6-hydroxodopamine suggests a direct effect on postjunctional α-adrenergic receptors of the smooth muscle cells. However, the release of norepinephrine stored in adrenergic nerve endings is also involved in the contractile effect of R. aculeatus extract.
R. aculeatus caused a dose-dependent constriction of the saphenous vein and potentiated the dose–response curve to local norepinephrine in anaesthetized dogs. These responses were antagonized by phentolamine, confirming that the venoconstriction caused by R. aculeatus is the result of α-adrenergic action.
Animal and in vitro studies show butcher's broom to have a vasoconstrictive effect. The mechanism of this effect remains somewhat unclear. Some studies indicate direct postjunctional alpha-1 and alpha-2 adrenergic receptor activation by its steroidal saponins; others indicate vasoconstriction is due to alpha-adrenergic blockade.
4.2 Venotonic and Vasoprotective Properties
Ruscus aculeatus also possesses venotonic properties: it reduces venous capacity and pooling of blood in the legs and exerts protective effects on capillaries, the vascular endothelium, and smooth muscle. Ruscus extract led to a decrease in the venous diameter of deep veins and at the same time to an increase in flow parameters.
When Ruscus extract is applied topically, a dose-dependent inhibition of the macromolecular permeability-increasing effect of histamine occurs. Ruscus extract given intravenously (5 mg/kg) inhibits the macromolecular permeability-increasing effect of bradykinin, leukotriene B4, and histamine.
4.3 Anti-Inflammatory Activity
The combined action of flavonoids, sterols, and proteolytic enzymes found in R. aculeatus root has reduced dextran- and carrageenan-induced rat paw edema in animal models, indicating the extract may have anti-inflammatory activity. The ruscogenins from butcher's broom showed remarkable anti-elastase activity in vitro but were inactive against hyaluronidase.
4.4 Orthostatic Hypotension: Mechanism
Ruscus aculeatus may prove useful for the treatment of orthostatic hypotension (OH) if denervation is not so advanced that it has compromised receptor activity at the venous wall. It is an alpha-adrenergic agonist that causes venous constriction by directly activating postjunctional alpha1- and alpha2-receptors, in turn stimulating the release of noradrenaline at the level of the vascular wall. Unlike most of the drug therapies used to treat OH, Ruscus aculeatus does not cause supine hypertension.
5. Scientific Evidence by Area of Use
5.1 Chronic Venous Insufficiency (CVI)
Chronic venous insufficiency (CVI) is the area in which butcher's broom has received the most rigorous clinical investigation.
Key Randomized Controlled Trial (Vanscheidt et al., 2002): Extracts from butcher's broom rhizome have been widely used in the oral treatment of lower leg edema in patients with CVI. A multi-center, double-blind, randomized, placebo-controlled trial confirmed the efficacy and safety of a ruscus extract (Fagorutin Ruscus Kapseln). 166 women suffering from CVI (Widmer grade I and II, CEAP 3–4) were included. There were significant differences between the treatment groups for the primary endpoint (area under baseline of leg volume changes over 12 weeks), for change of leg volume after 8 and 12 weeks of treatment (–16.5 ml and –20.5 ml), for changes in ankle and leg circumferences, and for changes in subjective symptoms, heavy tired legs and sensation of tension. A significant positive correlation between symptom changes and leg volume changes was shown. Overall assessment of efficacy was significantly better for ruscus extract compared to placebo. Overall tolerability for both treatments was assessed as good and very good.
Combination product trials (Cyclo 3 Fort): Clinical trials, including one double-blind trial, have confirmed the benefit of a combination of vitamin C, flavonoids, and butcher's broom for treatment of CVI. In a comparison study, a product combining butcher's broom extract, the flavonoid hesperidin, and vitamin C was more effective than a synthetic flavonoid product for treating CVI. A double-blind study in which butcher's broom alone was used also confirmed the beneficial effect of this herb in the treatment of CVI.
It was concluded that Ruscus extract combined with hesperidin methyl chalcone and ascorbic acid is effective and well tolerated in the treatment of patients with uncomplicated venous–lymphatic insufficiency of the lower limbs.
Regulatory recognition: The ESCOP herbal monograph lists the therapeutic indications as supportive therapy for symptoms of chronic venous insufficiency, such as painful, tired and heavy legs, tingling and swelling, and supportive therapy for symptoms of haemorrhoids, such as itching and burning. The Commission E monograph lists complaints of chronic venous insufficiency, pain and heaviness in the legs, nocturnal calf cramps, itching, and swelling, as well as itching and burning in haemorrhoids.
Limitations: Positive findings for vascular insufficiency and related conditions have been reported; however, clinical trials using R. aculeatus alone are generally lacking. Therefore, butcher's broom cannot be recommended as the sole treatment for any indication. Despite its widespread use, studies regarding R. aculeatus remain limited. Many clinical trials have used combination products, making it difficult to isolate the contribution of butcher's broom alone.
5.2 Hemorrhoids
Controlled clinical studies with butcher's broom demonstrated its therapeutic use in patients with chronic venous insufficiency and varicosis as well as in patients suffering from haemorrhoids. In one randomized study, patients taking a ruscogenin-based formulation experienced significant reductions in swelling, bleeding episodes, and their need for pain relievers compared to a placebo group. The European herbal monograph also notes the rhizome's traditional use in supporting hemorrhoid treatment.
No substantial studies have evaluated butcher's broom for hemorrhoids alone, but because hemorrhoids are similar to varicose veins, it is reasonable to suppose that butcher's broom might be helpful. The evidence base for hemorrhoids as a standalone indication therefore remains weaker than for CVI, relying substantially on its shared vascular mechanisms and on combination-product data.
5.3 Orthostatic Hypotension
A published review aimed to provide evidence for what appears to be an effective, safe, inexpensive botanical therapy for orthostatic hypotension (OH) and to encourage further studies on the efficacy of Ruscus for OH patients. The design involved a review of OH, currently available therapies, evaluation of the pharmacological properties of Ruscus aculeatus, and its mechanism of action.
With proven phlebotherapeutic properties, including vasoconstrictive action and venotonic properties, Ruscus aculeatus shows promise for ameliorating the symptoms of OH and improving the quality of life for large groups in the population.
The mechanism is theorized that butcher's broom, taken orally, might relieve orthostatic hypotension. In a single case report, a patient had relief of orthostatic hypotension while taking butcher's broom dried root 470 mg every hour while awake. The evidence for OH is currently limited to a pharmacological review and a single case report, making it preliminary. Controlled clinical trials in humans are needed before any firm conclusions can be drawn.
5.4 Lymphedema
Preliminary clinical research in women with arm lymphedema following breast cancer treatment shows that taking a specific combination of butcher's broom root extract 150 mg, hesperidin methyl chalcone 150 mg, and vitamin C 100 mg per capsule (Cyclo 3 Fort, Pierre Fabre Laboratories), in a dose of 3 capsules orally three times daily for 90 days, reduces swelling in the arms and improves mobility and heaviness. Edema was reduced by around 13% compared with placebo.
Various treatments used for venous insufficiency have also shown promise for treating arm swelling (lymphedema) following surgery for breast cancer. One study suggests that butcher's broom may also be helpful for this condition. However, this evidence comes from a single study using a multi-ingredient product; the independent contribution of butcher's broom cannot be determined, and the evidence remains preliminary.
5.5 Anti-Inflammatory Effects
Lab studies show that compounds in butcher's broom have anti-inflammatory effects. Beyond its vein-tightening effects, butcher's broom has notable anti-inflammatory activity. Saponins isolated from the rhizomes were tested in animal models of inflammation and showed potent results. Human clinical evidence specifically targeting inflammation as the primary endpoint is absent; anti-inflammatory activity has largely been demonstrated in preclinical (animal and in vitro) models.
5.6 Varicose Veins
Modern herbalists primarily use butcher's broom as supportive therapy for poor circulation, hemorrhoids, varicose vein syndrome, and other manifestations of leaky vein walls and poor venous blood return to the heart. Extracts are used internally and externally in Europe for treating varicose veins and hemorrhoids. Clinical data on varicose veins per se overlap substantially with those for CVI; no large, independent RCT focused exclusively on varicose veins using R. aculeatus as a sole agent has been published.
5.7 Areas With Insufficient Clinical Evidence
Butcher's broom is sometimes used by mouth for kidney stones, gallstones, atherosclerosis, and constipation, among other conditions. However, there is no good scientific research to support these uses. Evidence is lacking to support claims of relieving leg cramps, promoting urination, and treating hemorrhoids as standalone uses in rigorously designed trials.
6. Body Systems and Health Areas
- Venous and circulatory system: Chronic venous insufficiency, varicose veins, vascular stabilization; supported by Commission E, ESCOP, and EMA HMPC monographs.
- Lymphatic system: One clinical study showed that Cyclo 3 Fort, a butcher's broom product, reduced lymphedema in women who had undergone therapy for breast cancer.
- Anorectal system: Supportive therapy for symptoms of haemorrhoids, such as itching and burning.
- Autonomic/cardiovascular system: Orthostatic hypotension may also be aided by supplementation with butcher's broom. However, it is only recommended for mild cases and more human study is needed.
- Urinary system: The aerial parts are mainly used as diuretics and the underground organs for the treatment of disorders of the urinary system.
- Skin/Dermatological (topical): Dry extracts of butcher's broom are widely used in cosmetics and personal care for their vaso-protective and toning effects on the skin.
7. Dosage Forms and Reported Dosages
The European Scientific Cooperative on Phytotherapy (ESCOP) recommends a daily intake of Rusci rhizoma corresponding to a ruscogenins dose of 7 to 11 mg. For the treatment of chronic venous insufficiency, R. aculeatus has typically been used as part of a commercial combination product (e.g., Cyclo 3 Fort).
The ESCOP monograph specifies, for solid or liquid extracts used as supportive therapy for symptoms of chronic venous insufficiency and haemorrhoids, an adult oral dose of amounts corresponding to 7–11 mg of total ruscogenins, once a day.
Butcher's broom has been used in clinical trials for chronic venous insufficiency standardized to 7 to 11 mg of ruscogenin. Hesperidin methyl chalcone has also been used as a marker for standardization in the product Cyclo 3 Fort. Extracts have been dosed at 16 mg daily for chronic phlebopathy, while a topical cream formulation was used to apply 64 to 96 mg of extract daily.
A typical dose reported in studies is 36.0 to 37.5 mg twice daily of a methanol extract concentrated at a level of 15–20:1. This dosage supplies about 7 to 11 mg of ruscogenin daily.
Encapsulated butcher's broom extracts in the amount of 1,000 mg three times per day have also been reported for chronic venous insufficiency in clinical contexts.
For lymphedema (in the Cyclo 3 Fort trial), the specific dose was butcher's broom root extract 150 mg, hesperidin methyl chalcone 150 mg, and vitamin C 100 mg per capsule, taken as 3 capsules orally three times daily for 90 days.
For orthostatic hypotension, the single reported case used butcher's broom dried root 470 mg every hour while awake.
For hemorrhoids, butcher's broom is sometimes applied as an ointment or in the form of a suppository.
8. Safety Considerations and Drug Interactions
8.1 General Tolerability
When taken by mouth, butcher's broom is possibly safe when products containing the rhizome extract or root extract are used for up to 3 months. Side effects might include stomach upset, nausea, vomiting, diarrhea, and heartburn.
In a clinical trial in patients with chronic phlebopathy of the lower limbs (N=40), no adverse events were attributable to R. aculeatus therapy; however, reports of edema, nausea, and abdominal pain from multi-ingredient preparations exist.
8.2 Topical Use
When applied to the skin, there is not enough reliable information to confirm safety. Topical use may cause allergic reactions in some people. Allergic contact dermatitis has been reported with topical formulations, whereas oral administration has been associated with GI adverse effects including chronic diarrhea, lymphocytic colitis, and cytolytic hepatitis.
Diarrhea has been reported with the product Cyclo-3, but is less common with use of other formulations of butcher's broom.
8.3 Pregnancy and Lactation
There is not enough reliable information to know if butcher's broom is safe to use when pregnant or breast-feeding. Preparations have been studied in pregnancy-related varicosities; however, safety has not been established.
8.4 Drug Interactions
Butcher's broom might speed up the nervous system, increase blood pressure, and make the heart beat fast. By increasing blood pressure, butcher's broom might decrease the effectiveness of some medications used for high blood pressure. By increasing blood pressure, butcher's broom might decrease the effectiveness of antihypertensive medications. Some of these medications include doxazosin (Cardura), terazosin (Hytrin), and yohimbine.
Theoretically, interactions with alpha-adrenergic–stimulating agents are possible. Butcher's broom is used in various medicinal preparations and contains substances with alpha-adrenergic stimulating activity.
Anticoagulants and antiplatelets: butcher's broom may inhibit platelet activity; it contains coumarin and may potentiate anticoagulant response.
8.5 Populations Requiring Caution
Butcher's broom is not recommended for children or women who are pregnant or breastfeeding, as there is little research to support its safety in vulnerable populations. Butcher's broom might increase blood pressure. Taking butcher's broom might reduce the effects of blood pressure medications. Blood pressure should be monitored closely.
8.6 Contraindications
Formal contraindications have not yet been identified in the literature. Information regarding safety and efficacy in pregnancy and lactation is lacking.
9. Regulatory and Monograph Status
The German Commission E has approved oral use for supportive therapy for discomforts of chronic venous insufficiency and hemorrhoids. The ESCOP herbal monograph selects and summarises scientific studies and textbooks regarding efficacy, dosage, and safety to support the therapeutic uses of butcher's broom. By definition, the herbal drug consists of the dried, whole or fragmented underground parts of Ruscus aculeatus L. The European Medicines Agency's (EMA) Committee on Herbal Medicinal Products (HMPC) has also published a community herbal monograph and multiple assessment reports for Rusci aculeati rhizoma. According to the available monographs, Ruscus aculeatus is listed as "traditionally used in subjective symptoms of chronic insufficiency such as sensation of heavy legs" and "supportive therapy for symptoms of chronic venous insufficiency, such as painful, tired and heavy legs."
References
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