Butcher’s broom

Butcher’s broom is the common name for the medicinal plant Ruscus aculeatus. It is primarily anti-inflammatory, anti-oedematous, a venotonic, diuretic and diaphoretic (1,2). Butcher’s broom is a vascular tonic, specific for toning veins, reducing the swelling and inflammation associated with venous stagnation, varicose veins and haemorrhoids, and preventing blood clots (3,4). It is used as an internal and external treatment for venous insufficiency, causing pain and heaviness, leg cramping, itching, swelling, varicose veins, haemorrhoids, phlebitis (inflammation of a vein) and bruises (1). 

The anti-inflammatory and tonic actions on the vascular system specifically protect and strengthen the venous and capillary walls. This reduces capillary permeability which decreases oedema and tones the walls of the blood vessels to move congestion by supporting the return of blood from the periphery. This support for the blood vessel walls enhances elasticity, improves blood flow and venous return, which prevents the pooling of blood responsible for varicose veins and haemorrhoids. 

Butcher’s broom can be used to support other conditions affecting the circulatory system, including lymphedema, orthostatic hypotension as well as helping to support premenstrual symptoms. 

Butcher’ s broom can be taken internally as a decoction of the root, or used externally as an ointment, cream or balm, or as a suppository for haemorrhoids.

These actions and indications are similar to horse chestnut (Aesculus hippocastanum), and the two herbs are often used interchangeably (2,5). Although there is overlap in the actions and indications of both herbs, the constituents and mechanisms of action differ slightly, allowing them to complement each other and combine well together. 

The steroidal saponins (ruscogenins), the saponin glycosides (ruscosides), and the coumarins (esculin), are the main active constituents in butcher’s broom (6,7). A reduction in hyperpermeability of the epithelial cells has been linked to several of the steroidal saponins including deglucoruscin, ruscin, and esculin (8). The ruscogenins have an anti-inflammatory action by inhibiting leukocyte adhesion to the endothelial walls and, subsequently, the inflammatory cascade which would increase the permeability of the blood vessels (2). The decreased vascular permeability from butcher’s broom lowers the rate at which small proteins, electrolytes, and water are filtered into the surrounding tissue space. This affects the initial phase of inflammation by exerting a ‘sealing’ effect on capillaries and by reducing the number and diameter of capillary pores thereby also reducing vascular leakage, oedema, and swelling (9).

The ruscogenins also protect blood vessels by inhibiting the activity of liposomal enzymes, specifically elastase enzymes which break down the elasticity of the vascular walls (10). This anti-elastase activity protects the elasticity of the vascular walls and supports blood flow and venous return. 

Butcher’s broom also causes a vasoconstriction of the venules by activating smooth muscle receptors in the vascular walls (2). It has a direct effect on α-adrenergic receptors of the smooth muscle cells, initiating a contractile effect in venous and lymphatic vasculature (7). This contraction of the vessel walls increases the peripheral venous tone and raises the flow velocity in the veins and lymphatic vessels (11). This vasoconstriction, combined with the decreased permeability of the vessel walls improves the peripheral vascular tone and reduces venous swelling, oedema and varicosity.

Butcher’s broom extract increases fibrinolytic activity in the vein walls, the process where fibrin (a protein involved in blood clot formation) is broken down (2). This activity prevents or dissolves blood clots, ensuring proper blood flow in the veins.

One of the flavonoids in butchers broom, rutin, strengthens the capillaries and has a venotonic action (6). Flavonoids are recognised as having anti-inflammatory properties and the coumarin esculin is antioxidant, anti-inflammatory and acts as a tonic to the venous vessels (6). These actions all contribute to the therapeutic effect on varicose veins, spider veins, leg oedema and haemorrhoids (6). 

Energetically, butcher’s broom is cooling, drying, and slightly constricting (3).

Butcher’s broom was recommended by Dioscorides and the ancient physicians (50–80AD) as an aperient (cathartic, purgative), appetite stimulant, and diuretic used for dropsy (oedema), urinary obstructions and nephritic (kidney) ailments (12,13). 

Parkinson (1640) used butcher’s broom to protect meat, by erecting little hedges with the spiky leaves to prevent it from being eaten by vermin (4,12). He also reported its use to make sweeping brooms, by tying together a bundle of stalks (12). This was not only because of the stiffness and solidity of the stems, but also because of the essential oils with antibacterial properties (7). The combination of use for protecting meat and also making brooms explains the common name for the herb. 

Culpeper refers to Butcher’s broom in 1643 as “being of gallant, cleansing and opening quality” (14). A decoction of the root in wine was used to open obstructions, provoke urine, expel gravel and stones, clear yellow jaundice and associated headaches, and, clear the chest of phlegm and “clammy humours gathered within” (14).

As with the modern-day applications, the root was used externally, however Culpeper also refers to a poultice made from the berries and leaves to be effective for “knitting and consolidating broken bones or parts out of joint” (14). 

In 1812 when butcher’s broom began appearing in American Pharmacopoeias, John Hill regarded it as “an excellent medicine to remove obstructions. It works powerfully by urine, and is good in jaundices, and in stoppages of the menses, and excellent in the gravel” (15). 

In 1931, Grieve was recommending a decoction of the root for jaundice and gravel in the gallbladder and kidney, or combined with honey to clear the chest of phlegm and relieve breathing difficulties (12). As a decoction or infusion she recommended one ounce (~25 g) of the root or twigs per pint (~500 ml) of water. 

The modern day uses as a venous tonic for conditions arising from venous insufficiency only came to light following research in the 1950s by French researchers identifying the steroidal saponins in butcher’s broom root, and their actions on the circulatory system (16). 

Cardiovascular

Butcher’s broom is most commonly used to treat conditions arising from chronic venous insufficiency (CVI) and venous congestion, such as varicose veins and haemorrhoids, with clinical data to support these uses. CVI of the lower limbs is a major cause of morbidity and varicose veins in the western world (17). The German Commission E, which provides therapeutic guides for herbal medicine professionals, approves its use as a supportive therapy for symptoms of CVI, including pain and heaviness, leg cramps, itching, swelling, and haemorrhoids (18). 

The treatment of CVI attempts to both ameliorate the clinical symptoms and discomfort, as well as reduce the development of chronic venous disease (17). Butcher’s broom prevents degradation of the vascular walls and maintains vascular integrity, preventing the vascular hyperpermeability that causes oedema and swelling. The reduction in hyperpermeability of the epithelial cells has been linked to several of the steroidal saponins (ruscogenins) which inhibit the activity of enzymes that break down the elasticity of the vascular walls (8,10). Horse chestnut has a similar action, where the escin constituent prevents the activity of hyaluronidase enzymes from breaking down proteins in the vascular walls (11).

In chronic pathological vascular conditions such as CVI, phlebitis (vein inflammation), and varicosities, there is an increased activity of these enzymes which cause a breakdown of the capillary walls (19). Butcher’s broom lacks this action on hyaluronidase enzymes, which is why many herbalists combine the two herbs in formulas to protect and strengthen the vascular system (10). Horse chestnut and butcher’s broom also work by different mechanisms to stimulate vasoconstriction in the peripheral vasculature. The two herbs can be used interchangeably, however they complement each other well, with butcher’s broom primarily increasing the venous tone and elasticity of the vessels, and horse chestnut protecting the vascular structures and integrity. 

Butcher’s broom is most commonly prescribed for internal use as a tincture, combining well with:

• Horse chestnut
• Yarrow (Achillea millefolium) to stimulate the peripheral circulation
• Gotu kola (Centella asiatica) to support the connective tissues
• Bilberry (Vaccinium myrtillus) to further support the integrity of the microvasculature
• Prickly ash (Zanthoxylum americanum) as an analgesic which also stimulates the peripheral circulation

The Committee on Herbal Medicinal Products concluded that butcher’s broom preparations can be used to relieve discomfort and heaviness of legs related to minor problems of blood circulation, and to relieve itching and burning of haemorrhoids (7). Subsequently, the European Medicines Agency has approved the licensing of several internal and external products containing butcher’s broom extracts, in various countries across Europe (7).

Topical applications

Although butcher’s broom is often taken internally, the saponins in the whole herb extract can have low bioavailability across the gastrointestinal tract (GIT) (2). However, standardised extracts hydrolyse the saponins, yielding the aglycones (ruscogenin), which increases GIT absorption (7). The active constituents in whole-herb extracts are absorbed transdermally (through the skin) and butcher’s broom is often used concurrently in both internal and external formulas. The actions on the vessels in the peripheral circulatory system make butchers broom an excellent external treatment for varicose veins, spider veins, capillary fragility, haematomas, contusions, sprains, bruises, and haemorrhoids. It is applied as an ointment, cream or balm, or used in suppositories for haemorrhoids.

The additional benefit of external applications is the opportunity to massage the area of swelling and oedema. Rubbing a cream, balm or gel into the skin, massaging towards the centre of the body, provides an additional support to the blood flow back to the heart, as well as dissipating the oedema from the surrounding tissues. Other lifestyle advice to support CVI and varicose veins includes the use of compression stockings, avoiding standing for long periods, frequently walking around to support blood flow, and sleeping with the legs on a pillow or elevating the foot of the bed slightly.

Orthostatic hypotension

Orthostatic hypotension (OH) or postural hypotension is a disorder characterised by low blood pressure upon standing and the body’s inability to make rapid changes in response to the upright position (20). This is due to a combination of factors related to the neuronal signalling in the central nervous system, hemodynamic responses, sub-optimal venous tone and hormonal mechanisms (20). The condition results in a prolonged reduction in venous return to the heart, pooling of blood in the legs and symptoms of light-headedness, blurred vision, neck pain, fainting, nausea, fatigue, weakness, sleepiness, headaches, flushing, excessive sweating, oedema, and impaired mental capacity (20).

The vasoconstrictive and venotonic actions of butcher’s broom can counteract blood pooling in the lower limbs, which indicates its use to prevent or support orthostatic hypotension associated with many chronic cardiovascular conditions (2). Butcher’s broom combines well with horse chestnut for OH; a small case report demonstrated that the combination greatly ameliorated the patient’s symptoms and improved quality of life, with horse chestnut alone having negligible effects (20). 

Deep vein thrombosis

CVI, phlebitis (inflammation of veins) and varicose veins carry an increased risk of deep vein thrombosis (DVT), and butcher’s broom shows promise in reducing this risk (2,21).). A clinic trial which contained butchers broom extract (450 mg) in a combination formula found an increase in the breakdown of fibrin in blood vessels, a protein which causes blood clots (2). This fibrinolytic activity in the vein walls reduces the risk of blood clots and DVT in patients with venous insufficiency.

Butcher’s broom can be used both internally or externally before and during long flights to reduce oedema and for preventing thrombosis, particularly in patients with existing varicosities. Butcher’s broom can be used prophylactically before surgical treatment, for those at risk of DVT.

Lymphoedema 

Butcher’s broom increases the contractile properties and reduces the permeability of both veins and lymphatic vessels (7). Reductions in arm lymphoedema in post breast cancer patients has been clinically demonstrated with the use of butcher’s broom extract (2).

Blood lipids

Butchers broom can be used as part of a formula for hypercholesterolemia, arteriosclerosis and hypertension (19). The ruscosides in butcher’s broom can decrease the cholesterol content of the blood, reduce blood lipid deposits in the arteries, and lower liver arterial tension (19).

Diabetes 

Butcher’s broom, and specifically the ruscogenin constituent, reduces vascular permeability and can be used to improve symptoms of retinopathy in diabetic patients (8). Similarly, butcher’s broom can support the microcirculation in the skin in cases of diabetic neuropathy and diabetic ulcerated lesions.

Female reproductive system  

The circulatory action of butcher’s broom supports the removal of pelvic stagnation and is good for congested menstrual problems such as dysmenorrhea and menorrhagia (4). This can also help to reduce oedema associated with premenstrual fluid retention. Butcher’s broom has a mild hormone balancing action on oestrogen and progesterone, and is useful in premenstrual syndrome (PMS), menopause and cases of vaginal dryness (4). Clinical research has shown butcher’s broom to be effective in reducing symptoms of PMS including mastalgia, menstrual pain and low mood (22). 

Clinical data supports both internal and external use of butcher’s broom for CVI, varicose veins, haemorrhoids, varicose ulcers, lymphoedema, PMS, and diabetic retinopathy (2). Most research uses preparation of a butchers broom extract (150 mg), often in combination with hesperidin metylchalkone (150 mg), and ascorbic acid (100 mg), taken 2–3 times per day (Cyclo 3 Fort). Hesperidin methylchalcone and ascorbic acid both reduce capillary permeability and increase capillary integrity (2). There is a lack of clinical research exploring the efficacy of butchers broom alone, or as liquid/alcohol extracts of the whole plant, or use of the powdered root. 

Chronic venous insufficiency

Over 30 studies have assessed the effects of butcher’s broom extract in patients with CVI. 

A meta-analysis in 2003 reviewed the clinical studies up to that point to estimate the overall effect of butcher’s broom extract on the symptoms and severity of CVI (17). The study included a total of 31 trials, comprising: 20 placebo-controlled, randomised, double-blind studies; five randomised studies against a comparator drug; and six single arm studies with no placebo, all using the combination extract Cyclo 3 Fort, detailed above (17).

The butcher’s broom extract significantly reduced the severity of pain, cramps, heaviness, and paraesthesia, compared to placebo. There was also a significant reduction in venous capacity, although reductions in the severity of oedema, and calf and ankle circumference were not significantly different. The authors concluded the study provides a strong and objective demonstration of the clinical efficacy of butcher’s broom combination extract in treating patients with CVI, by reducing the severity of symptoms (17).

After the publication of the meta-analysis, another double-blind, randomised, placebo-controlled trial examined the efficacy and safety of a butcher’s broom extract (72 mg per day of a 20:1 extract), in 148 women with CVI (23). After 12 weeks of treatment the butcher’s broom extract group had a significant reduction in leg volume, ankle and leg circumference, and subjective symptoms of heavy tired legs and sensations of tension, compared to the placebo group.

The overall assessment of tolerability was very good, and the efficacy was significantly better for the butcher’s broom extract compared to placebo. The authors concluded that butchers broom extract, in the recommended daily dosage according to the German monograph, is a safe and effective treatment for patients suffering from CVI (23).

A observational, prospective study in 2009 assessed the effect of butcher’s broom combination extract (Cyto 3 Fort) on the quality of life (QoL) of 917 patients with chronic venous disorders (24). After 12 weeks of treatment the overall QoL scores significantly improved. There were significant sub-category improvements in lower limb heaviness (83% has improved),  lower limb pain (81.5%), lower limb swelling (68.5%), paraesthesia (72.8%), and cramps (66.8%). There was also a statistically significant decrease in ankle circumference after treatment. It should be noted that this was an observational study and the lack of a control group makes it difficult to rule out a placebo effect (24). 

The name ‘knee holly’ comes from its growth to the height of a man’s knee, and from the prickly, evergreen leaves, resembling true holly (Ilex aquifolium), although the two plants are unrelated (12).

Butcher’s broom is native to Great Britain; Central, Western and Southern Europe, from Mediterranean to Macaronesia, and North Africa (28). It has been introduced in Ireland, Germany and Mexico, and grows primarily in the temperate biome (28). It can be found in a range of habitats including woodlands, scrubland, coastal dunes, marine areas, grasslands, forests, rocky places, and moist areas (31).

The International Union for Conservation of Nature (IUCN) conducted a European assessment of butcher’s broom in 2011 and listed it as “Least Concern” (31). They state that the species population is stable with widespread distribution across Europe, and abundant in Spain, France and Hungary (31). There are currently no major threats or risk of extinction (28, 31). There is no CITES legislation for butcher’s broom (33). 

Habitat loss and over-harvesting from the wild are two of the biggest threats faced by medicinal plant species. There are an increasing number of well-known herbal medicines at risk of extinction. We must, therefore, ensure that we source our medicines with sustainability in mind.

The herb supplement industry is growing at a rapid rate and until recent years a vast majority of medicinal plant produce in global trade was of unknown origin. There are some very real and urgent issues surrounding sustainability in the herb industry. These include environmental factors that affect the medicinal viability of herbs, the safety of the habitats that they are taken from, as well as the welfare of workers in the trade.

The botanical supply chain efforts for improved visibility (transparency and traceability) into verifiably sustainable production sites around the world is now certificated through the emergence of credible international voluntary sustainability standards (VSS). 

Read our article on Herbal quality and safety: What to know before you buy and Sustainable sourcing of herbs to learn more about what to look for and questions to ask suppliers about sustainability.

Herbal medicines are often very safe to take; however, their safety and efficacy can be jeopardised by quality issues. So, it is important to buy herbal medicines from a reputable supplier, from sources known to test their herbs to ensure there is no contamination, adulteration or substitution with incorrect plant matter, as well as ensuring that recognised marker compounds are at appropriate levels in the herbs.

Some important quality assurances to look for are certified organic labelling, the correct scientific/botanical name, and the availability of information from the supplier about ingredient origins. A supplier should be able to tell you where the herbs have come from, what contaminants are not in the herb, and what the primary compounds are.

Propagation is by seed or root/rhizome division in autumn, which soon spreads into large clumps from the creeping rhizomes (12).  

Butcher’s broom is very hardy, thriving in most soil conditions. It is popular in gardens due to the unique flowers and berries, which remain attractive after the deciduous trees have shed their leaves (12). The shrub is maintained by cutting out dead stems to the base in spring (27).

Vein-soothing lotion*

Ingredients

• 250 g aloe vera gel or plain base cream
• 10 ml butchers broom root infused oil
• 10 ml calendula oil
• 10 ml butchers broom root tincture
• 10 ml horse chestnut seed tincture
• 10 ml yarrow tincture
• 10 ml witch hazel distilled water
• 20 ml peppermint or rosemary essential oil

Method

• Place the aloe vera or base cream in a bowl and gradually whisk in the oils, one teaspoon at a time. 
• Use the same method to gradually add the tincture, whisking thoroughly.
• Add the essential oil, then the witch hazel water
• Apply twice per day to varicose veins, thread veins or haemorrhoids.

* adapted from Chown and Walker (25)

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