Prostate cancer and hormonal symptoms
Prostate cancer is often treated with hormonal therapies that may be used on their own or combined with radiotherapy. These treatments can cause side effects, which are usually described as hormonal symptoms.
The symptoms can vary depending on the type of hormonal treatment you're having and will range from being mild to severe. This information is about these symptoms and gives you suggestions about how to cope with them.
Testosterone is a male sex hormone produced by the testicles. Hormones are substances that occur naturally in the body. They control the growth and activity of normal cells.
Testosterone is responsible for:
your sex drive (libido)
getting an erection
a low voice
facial and body hair
The testicles are stimulated to produce testosterone by another hormone called luteinising hormone (LH), which is produced by the pituitary gland in the brain.
Prostate cancer needs testosterone to grow. Hormonal therapies for prostate cancer work by lowering the level of testosterone in the body, or by preventing it from attaching to the cancer cells. This can help slow down or stop the growth of the prostate cancer cells.
Hormonal therapy treatments
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The levels of testosterone in the body can be lowered using hormonal therapy drugs (given either by injection or as tablets) or by a simple operation.
Hormonal therapy drugs
These are widely used in the treatment of prostate cancer.
Some drugs 'switch off' the production of testosterone by the testicles by reducing the levels of luteinising hormone produced by the pituitary gland. These drugs are called pituitary down-regulators, or GnRH (gonadotrophin-releasing hormone) analogues, and they're given by injecting a pellet or a liquid under the skin. The injections can be given monthly or every three months.
Commonly used GnRH analogues are:
Another type of hormonal therapy works by blocking the messages from the brain that tell the testicles to produce testosterone. These are known as GnRH (gonadotrophin-releasing hormone) antagonists. They’re also called GnRH blockers. The only GnRH blocker currently available is degarelix (Firmagon®), which is given as an injection under the skin once a month.
Other hormonal therapy drugs work by attaching themselves to proteins (receptors) inside the cancer cells. This blocks the action of testosterone on the cancer cells. They're called anti-androgens and are often given as tablets.
Commonly used anti-androgens are:
Oestrogen treatment (diethylstilbestrol) can also be used to reduce testosterone levels in some men but other hormonal therapies may be used first because of the increased risk of circulation problems, including blood clots. However, it may be suitable for men who have prostate cancer that is no longer responding to other hormonal therapy drugs.
Abiraterone acetate (Zytiga®)
A newer approach to hormonal treatment for prostate cancer is a drug called abiraterone acetate (Zytiga ®). It works by blocking an enzyme necessary for the body to make testosterone, and so stops the hormone being produced.
Surgery (subcapsular orchidectomy)
This operation removes the part of the testicles that produces testosterone. It's a simple operation that can be done as a day patient. Some men find the idea of this operation distressing but others don't find it a problem. It causes the same hormonal symptoms that treatment with hormonal therapies cause.
Reducing the level of testosterone can cause a number of symptoms. These may include:
erection difficulties and loss of sex drive
hot flushes and sweats
breast swelling and tenderness
loss of body hair
psychological effects and mood changes.
Managing hormonal symptoms
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There are a number of different ways in which hormonal symptoms can be managed. You may find some of the following suggestions helpful.
Erection difficulties and loss of sex drive
Hormonal therapies often cause the inability to have an erection, known as erectile dysfunction or ED, and loss of sex drive. This will continue for as long as the treatment is given.
If the treatment is stopped, sexual problems may improve after a period of time. However, some men find that these problems carry on after treatment is over. When men have both testicles removed ED is always permanent.
If you have problems getting or keeping an erection there are treatments that may help. However, they don't work for everyone and won't necessarily increase your desire to have sex (libido).
Tablets such as sildenafil (Viagra ®), vardenafil (Levitra ®) and tadalafil (Cialis ®) can help produce an erection by increasing the flow of blood to the penis. These tablets can be prescribed by your doctor. They may not be recommended for you if you have heart problems and/or are taking certain drugs, such as nitrates.
It's possible to buy these types of tablets on the internet, but this is not recommended. It can be unsafe to take these drugs without first being seen by a doctor who can check that they are suitable for you. It can also be difficult to know if a website selling these drugs is actually selling the correct drugs and not substitutes that look the same.
You may be able to buy Viagra tablets from certain high street stores or chemists that have specially trained pharmacists. Before they can give you Viagra you will need to have a health check and fill out a health questionnaire.
Sometimes a pellet can be inserted into the penis, or drugs injected into it (with a small needle), to help give an erection. These can be prescribed by your GP.
Vacuum pumps can be used to produce an erection by drawing blood into the penis. A ring is then placed around the base of the penis, trapping the blood, to help maintain an erection.
Coping with sexual difficulties can be distressing. Talk to your nurse or doctor if you're having problems. Many men find it difficult to talk about sexual issues because they feel embarrassed. But your doctor or nurse will be used to talking about this kind of thing and can give you information and support.
Hot flushes and sweats
Some men find the side effects that cause the most problems are hot flushes and sweats. The length of time they last for and their intensity can vary.
Hot flushes and sweats get easier to deal with after a period of time. They usually stop completely a few months after your treatment finishes.
It's difficult to stop hot flushes and sweats, but their frequency and intensity can often be reduced.
For some men, certain situations, drinks or foods may bring on a flush or sweat. Try to keep a note of anything that triggers flushes so that you can avoid them. Here are some other tips which may help you:
Wear several layers of light clothing (preferably cotton) that you can easily take off or put back on depending on your body temperature.
Cut down on alcohol, nicotine and hot drinks that contain caffeine, particularly coffee and tea.
Lukewarm baths and showers are less likely to trigger sweats than hot ones.
Flushes and sweats are often worse at night. Put a soft cotton towel on your bed that you can easily change if it gets wet during the night. Use light bed wear and cotton clothing to help you feel cooler at night.
Taking evening primrose oil, which you can buy in chemists and health food shops, may help some men, although there's no scientific evidence that it works.
Some men may find complementary therapies such as acupuncture or homeopathy helpful. Homeopathy uses tiny amounts of substances that would normally produce the symptoms being treated. There's no scientific proof that this works but some men may find it helpful. Your GP can give you details about having complementary therapies on the NHS. If you wish to find your own therapist, make sure they are properly qualified and registered. The British Complementary Medical Association has lists of registered practitioners throughout the UK.
A yoga breathing technique known as the 'cooling breath' or 'sheetali' can help reduce body temperature. Contact the British Wheel of Yoga to find a registered practitioner.
Hormones called progestogens and an anti-androgen drug called cyproterone acetate (Cyprostat®) may sometimes help reduce hot flushes and sweats. Your doctor can give you further advice.
Certain medicines used for other conditions may help to reduce hot flushes and sweats. An antidepressant drug called venlafaxine (Effexor ®) and an anti-epilepsy drug called gabapentin (Neurontin ®) are sometimes used. The medicines will need to be prescribed by your doctor.
Hormonal treatment can make you feel very tired, both mentally and physically. The tiredness gets better if the drug treatment is stopped. If you do get very tired, it can help to plan your day so that you have time to rest and do the things you want.
There may be things that you can't manage to do, such as housework or gardening. Ask others for help with tasks that you find too demanding. Exercise can also help relieve the symptoms of tiredness.
Exercise can help keep your weight stable if you have put on weight because of your hormonal therapy. Even regular short walks can help. It's also important to eat a healthy balanced diet. Your doctor or nurse can give you further advice about managing weight gain, or could refer you to a dietitian.
Bone thinning (osteoporosis)
Having both testicles removed, or being on long-term GnRH analogue treatment, will increase your risk of developing osteoporosis.
Regular weight-bearing exercises such as walking, dancing, hiking or gentle weight-lifting can help keep your bones healthy. Swimming is not so helpful, as your bones aren't supporting your weight.
It's important to make sure that you get enough calcium and vitamin D (which helps the body use calcium effectively) in your diet. Dairy products are a good source of calcium but you can get calcium from eggs, green leafy vegetables, nuts and fish such as whitebait, sardines and pilchards.
A well-balanced diet will normally give you all the calcium and vitamin D you need, but your doctor may advise you to take calcium and vitamin D supplements to help protect your bones. Cutting down on caffeine, alcohol and stopping smoking can also help lower your risk of osteoporosis.
Drugs called bisphosphonates can be used to treat osteoporosis. Your doctor can give you more information about them.
You could also try to reduce your chances of having a fall by making sure that your environment is safe.
The National Osteoporosis Society can give you more information about preventing and treating osteoporosis.
Warm baths can help to relax stiff, aching joints and regular exercise will keep your muscles supple. Let your doctor know if you have sore joints. They can prescribe you painkillers if needed.
Breast swelling or tenderness
Some drugs, most commonly flutamide and bicalutamide, may cause breast swelling and tenderness. The drug tamoxifen (a tablet) can help reduce this.
Giving a low dose of radiation to the breast tissue before or soon after the start of treatment may also help to avoid this. If you do have breast tenderness, your doctor can prescribe medicines to reduce any discomfort.
You may experience sleeplessness due to hot flushes, sweats or anxiety, which can make it harder to cope during the day.
The following tips may help you relax and sleep better:
Have a lukewarm bath to relax before bedtime.
A hot herbal or milk drink before bed can help you relax.
Techniques such as listening to relaxation CDs, relaxation exercises, visualisation, meditation or massage can help reduce anxiety and sleeplessness.
If you can't sleep, don't just lie in bed. Get up and read, listen to the radio or an audiobook, or watch TV until you feel sleepy.
Your GP can prescribe sleeping tablets for a short period of time to help you get back to a better sleeping pattern.
Loss of body hair
This can sometimes happen with hormonal therapies for prostate cancer. We have more information about coping with hair loss.
Psychological effects and mood changes
The psychological effects of hormonal symptoms can be hard to cope with when you may already be dealing with the physical and emotional effects of cancer.
The symptoms may be distressing for you and your partner (if you have one) to deal with. You may feel anxious, angry or frustrated at having more problems to cope with. You may also experience mood changes and feel emotional or anxious without knowing why.
Some men may find it helpful to talk about their feelings to their family and friends. Others may find it easier to get help from people outside of their situation. Talk to your doctor or nurse if you're having emotional difficulties. They can support you and, if appropriate, refer you to a specially trained counsellor.
We have more information about the emotional effects of cancer, which you may find helpful.
Intermittent hormonal therapy
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To reduce the risk of side effects, it may be possible to have the hormonal therapy for a few months and then stop for a time before restarting it some time later. This is known as intermittent therapy. A recent study has suggested that in some situations this is as effective as continuous hormone therapy.
British Complementary Medicine Association
The British Complementary Medicine Association is an umbrella organisation for complementary medicine organisations. Can provide contact details for practitioners and therapists in your area.
British Wheel of Yoga
The British Wheel of Yoga is the governing body of yoga in the UK. The BWY can provide a list of yoga teachers and classes in your area.
National Osteoporosis Society
The National Osteoporosis Society is an independent charity which offers advice and information to the general public and health care professionals. Provides support for people with osteoporosis via its helpline, resources and a network of local groups.
Prostate Cancer Charity
Prostate Cancer UK offers support and information to anyone affected by prostate cancer. The helpline is staffed by experienced nurses. Also funds research and can put men in touch with others affected by prostate cancer.
The information in this section has been compiled using a number of reliable sources, including:
Sweetman, et al. Martindale: The Complete Drug Reference. 37th edition. 2011. Pharmaceutical Press.
The National Institute for Health and Clinical Excellence. Prostate cancer: diagnosis and treatment. 2008. (NICE).
Brown J, Wright B. Use of gabapentin in patients experiencing hot flashes. Pharmacotherapy. 2009. 29(1): 74-81.
Thanks to Dr James Wylie, Consultant Clinical Oncologist, and all of the people affected by cancer who reviewed this information. You can help too when you join our Cancer Voices network