Hormonal therapy for advanced prostate cancer
Hormonal therapies lower testosterone levels or stop testosterone reaching the prostate cancer cells. Hormonal therapy may be given on its own, or in combination with other treatments.
On this page
-
What is hormonal therapy for advanced prostate cancer?
-
How hormonal therapy is given
-
Hormonal therapy injections and implants
-
Hormonal therapy as tablets
-
Other hormonal treatments for advanced prostate cancer
-
Steroids
-
Side effects of hormonal therapy
-
Related topics
-
About our information
-
How we can help
What is hormonal therapy for advanced prostate cancer?
Hormonal therapies lower testosterone levels or stop testosterone reaching the prostate cancer cells. Hormonal therapy is the main treatment for advanced prostate cancer. It can shrink the cancer, slow its growth and reduce symptoms.
Your doctor or nurse will talk to you about the type of hormonal therapy that is best for you. They will explain the different side effects and talk to you about your preferences.
Prostate cancer needs the hormone testosterone to grow. Testosterone is mainly made by the testicles. A small amount is made by the adrenal glands, above each kidney. Hormonal therapies reduce the amount of testosterone in the body, or stop it reaching the prostate cancer cells.
Testosterone is important for:
- sex drive (libido)
- getting an erection
- facial and body hair
- muscle development and bone strength.
Having lower testosterone levels means that some of these things can be affected.
Your doctor or nurse will check how well your hormonal therapy is working. They will ask about your symptoms, examine you and monitor your PSA (prostate specific antigen) level. Measuring your PSA level using a PSA test is usually a good guide to how well treatment is working. If it goes up, they may talk to you about having a different treatment.
Related pages
How hormonal therapy is given
Before you start hormonal therapy, you will have some blood tests, including for PSA level. Your doctor will also examine you and ask about your symptoms.
There are different types of hormonal therapy that may be used. Not all types of hormonal therapy are suitable for everyone. Your doctor or nurse will explain the drug that is most suitable for your situation. You may have treatment which involves having more than one type of treatment at a time.
You can have hormonal therapy as:
- injections
- implants
- a nasal spray
- tablets.
You might have a drug on its own or with another hormonal therapy.
Another way of lowering testosterone is to have an operation to remove the testicles. This is called an orchidectomy and is not commonly done.
You may have hormonal therapy with chemotherapy when you are first diagnosed with advanced prostate cancer. This may be more effective than hormonal therapy on its own. But there are more side effects to cope with. Your cancer doctor can tell you more about this.
Intermittent hormonal therapy
Instead of taking the drugs continuously, you may stop taking the drugs for a while and then start taking them again. This is called intermittent hormonal therapy. It means you get a break from any side effects. This is not suitable for everyone. It should only be done following your doctor’s advice.
Intermittent hormonal therapy may be helpful if certain side effects are difficult to cope with. Your doctor or nurse will explain the possible benefits and disadvantages. If your PSA level goes up or your symptoms get worse, your doctor will advise starting hormonal therapy again.
Hormonal therapy injections and implants
LHRH agonists
The pituitary gland in the brain makes a hormone called luteinising hormone (LH). This hormone tells the testicles to make testosterone.
LHRH agonists affect this hormone and stop the testicles making testosterone. These are the most common type of hormonal therapy. You have them as an implant injection or an injection under the skin.
The commonly used LHRH agonists are:
- buserelin ( Suprefact®)
- goserelin (Zoladex®, Novgos®)
- leuprorelin (Prostap®, Lutrate®)
- triptorelin (Decapeptyl®, Gonapeptyl Depot®).
A nurse or doctor at your GP practice or hospital can give you these drugs.
Tumour flare
The first time you have one of these drugs, it can cause an increase in testosterone for a short time. This can make any symptoms worse for a short time. This is sometimes called tumour flare.
To prevent this, your doctor usually asks you to take an anti-androgen drug. You take it for a short time before and after starting the LHRH agonist.
GnRH antagonists
These drugs block messages from the brain to the testicles telling them to make testosterone. They work quicker than LHRH agonists and do not cause tumour flare. They are usually given if:
- cancer has spread to certain parts of the body, such as the spine
- cancer has spread to the spine and there is a risk it could press on the spinal cord.
Currently, degarelix ( Firmagon®) is the only GnRH antagonist available. You have it as an injection under the skin (subcutaneously) of your tummy once a month. As well as hormonal side effects, it commonly causes skin reactions.
Hormonal therapy as tablets
If the cancer starts growing during treatment with an injection or implant, your doctor may advise also taking an anti-androgen tablet.
Having the 2 drugs together can help to slow down the growth of the cancer and how quickly it spreads. You will not usually have combined hormonal therapy as your first treatment. This is because you may have more side effects if you are taking 2 drugs. Your doctor or specialist nurse can explain more about this.
You may have newer hormonal therapy drugs called abiraterone (Zytiga®) or enzalutamide (Xtandi®) along with an injection or implant.
Anti-androgen drugs
These drugs stop testosterone from reaching the cancer cells. You take them as tablets. They may be given:
- for 1 or 2 weeks before and after starting injections or implants, to stop symptoms getting temporarily worse (tumour flare)
- on their own
- with hormonal injections or implants (combined hormonal therapy).
An anti-androgen on its own may cause fewer sexual side effects and less bone thinning. But it may not control the cancer as well as other hormonal therapies.
Anti-androgen drugs include:
- bicalutamide (Casodex®)
- cyproterone acetate (Cyprostat®)
- flutamide.
Bicalutamide and flutamide can cause breast swelling or tenderness. As well as hormonal side effects, these drugs have different side effects of their own.
If you have been taking an anti-androgen drug for some months or years, and the cancer begins to grow, your doctor may stop the drug. This may make the cancer shrink for a while. Doctors call this a withdrawal response.
Related pages
Enzalutamide and abiraterone
Enzalutamide and abiraterone are newer drugs for advanced prostate cancer. They are usually used when other hormonal therapies are no longer helping to control the cancer. This is when the prostate cancer cells need much lower levels of testosterone to grow. You may have these drugs earlier, when you are first diagnosed with advanced prostate cancer.
The drugs may be given before you need chemotherapy. This may happen if you have no symptoms or mild symptoms. If chemotherapy is no longer helping to control the cancer, they may be the first hormonal therapy drugs you have. You might have them with hormonal injections or implants, or on their own.
-
Abiraterone
You take abiraterone as tablets once a day, along with drugs called steroids. The steroids are given to lower the risk of some of the side effects. It may be given as a first treatment for advanced prostate, alongside other hormonal therapies.
If you have already had enzalutamide, you are unlikely to be offered abiraterone. This is because research suggests that men who have already had one of these drugs respond well to the other. Abiraterone is mainly given when other hormonal therapies are no longer controlling the cancer. Side effects of abiraterone can include high blood pressure and changes to your heartbeat. Your doctor or specialist nurse can give you more information.
-
Enzalutamide
Enzalutamide may be given as a first treatment for advanced prostate cancer, alongside other hormonal therapies You take enzalutamide as a capsule once a day. If you have already had abiraterone, you are unlikely to be offered enzalutamide.
Side effects of enzalutamide can include high blood pressure and, less commonly, an increased risk of infection. Your doctor or specialist nurse can give you more information.
Other hormonal treatments for advanced prostate cancer
Surgery to the testicles
Some people may have an operation to remove part or all of the testicles. This is called an orchidectomy. It is more common to use hormonal therapy drugs to reduce the amount of testosterone in the body. But it may be an option if you find it hard to have regular injections or to take tablets every day.
Orchidectomy is as effective as other hormonal treatments. You can have the operation as a day patient. The operation cannot be reversed, which may be upsetting. It causes most of the same side effects as other hormonal therapy drugs. It is important to talk with your doctor and nurse about this treatment.
Steroids
Sometimes steroid drugs such as prednisolone or dexamethasone are used to treat advanced prostate cancer. They work on the adrenal glands, to help reduce the amount of testosterone in the body.
They can be used on their own, but are usually given with abiraterone or chemotherapy. You may have dexamethasone along with a hormonal injection or implant drug. Side effects may include:
- increased appetite
- weight gain
- difficulty sleeping
- irritability.
Oestrogen
Treatment with the hormone oestrogen may help to reduce testosterone levels. It is sometimes used when other hormonal therapies are no longer working. The most commonly used drug is diethylstilbestrol (Stilboestrol®). You take it as a tablet.
The side effects are similar to other hormonal therapies. It can also increase the risk of getting a blood clot, so it may not be suitable for some people.
Side effects of hormonal therapy
Hormonal therapies have similar side effects because they all reduce the amount of testosterone in the body. But individual drugs do have different side effects. It is important to discuss these with your doctor or nurse before you start treatment, so you know what to expect.
-
Erection difficulties
Most hormonal therapies cause loss of sexual desire and erection difficulties (called erectile dysfunction, or ED). LHRH agonists usually completely stop erections during treatment. Anti-androgens stop erections in most people.
-
Hot flushes and sweats
These may happen less often as your body adjusts to treatment. Wearing layers of light clothing (such as cotton) can help. This means you can easily take off or put back on clothes as needed.
Having less alcohol, nicotine and hot drinks that contain caffeine can also help. If hot flushes are causing you difficultly, your doctor may give you a drug to help.
-
Tiredness (fatigue)
Tiredness is a common side effect. It can be made worse by hot flushes, which may make sleeping difficult. Pace yourself so you have more energy to do the things you want. Regular physical activity, such as walking, can help give you more energy. Ask your team for advice on the type of exercise that is suitable for your situation. If tiredness makes you feel sleepy, do not drive or operate machinery.
-
Breast swelling or tenderness
This is more common if you have flutamide or and bicalutamide over a longer period. Some people have low-dose radiotherapy to their chest before treatment to prevent breast swelling. If you are taking bicalutamide, another option is to take a hormonal drug called tamoxifen to reduce breast swelling.
-
Weight gain and loss of muscle strength
You may gain weight (often around the tummy) with hormonal therapy. Eating well and keeping active can help keep your weight stable. It also helps look after your muscles. Ask your doctor or nurse for advice.
-
Bone thinning
Hormonal therapy can cause bone thinning (osteoporosis). This can sometimes lead to tiny cracks in the bone (fractures). The risk increases if you are taking hormonal therapy for long periods. If you are starting long-term hormonal treatment, your doctors may arrange for you to have a DEXA (dual-energy x-ray absorptiometry) scan. This allows them to check your bones for any areas of weakness.
Weight-bearing exercises, such as walking, can help look after your bone health. Eating a healthy balanced diet can also help. If your bones are thinning, your doctor may advise you to take calcium and vitamin D tablets. They may also ask you to take bone-strengthening drugs called bisphosphonates or a drug called denosumab (Prolia®).
-
Mood changes
You may have mood changes and feel emotional or anxious. This can be a side effect of hormonal therapy, but it can also be because you are coping with advanced cancer. Tell your cancer doctor or nurse if these feelings are difficult to cope with. They can support you or refer you to a doctor or counsellor who specialises in emotional support. They may also prescribe drugs to help if needed.
Booklets and resources
About our information
-
References
Below is a sample of the sources used in our advanced prostate cancer information. If you would like more information about the sources we use, please contact us at cancerinformationteam@macmillan.org.uk
The National Institute for Health and Care Excellence (NICE) Prostate cancer: diagnosis and management. NICE guidelines. May 2019. Available at www.nice.org.uk/guidance/ng131
Horwich A et al. ESMO Consensus Guidelines: Prostate cancer. Annals of Oncology. 2012.
-
Reviewers
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Senior Medical Editor, Dr Lisa Pickering, Consultant Medical Oncologist.
Our cancer information has been awarded the PIF TICK. Created by the Patient Information Forum, this quality mark shows we meet PIF’s 10 criteria for trustworthy health information.
The language we use
We want everyone affected by cancer to feel our information is written for them.
We want our information to be as clear as possible. To do this, we try to:
- use plain English
- explain medical words
- use short sentences
- use illustrations to explain text
- structure the information clearly
- make sure important points are clear.
We use gender-inclusive language and talk to our readers as ‘you’ so that everyone feels included. Where clinically necessary we use the terms ‘men’ and ‘women’ or ‘male’ and ‘female’. For example, we do so when talking about parts of the body or mentioning statistics or research about who is affected.
You can read more about how we produce our information here.
Date reviewed
Our cancer information meets the PIF TICK quality mark.
This means it is easy to use, up-to-date and based on the latest evidence. Learn more about how we produce our information.