Hormonal therapies lower your testosterone levels or stop it reaching the prostate cancer cells. It may be given on its own, or in combination with other treatments.
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 lower your testosterone levels 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.
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 level. PSA is usually a good guide to how well treatment is working. If it goes up, they may talk to you about having a different hormonal therapy.
There are different types of hormonal therapy. You can have them as:
- a nasal spray
You might have a drug on its own or along with another hormonal therapy.
Another way of reducing testosterone in men with locally advanced or advanced prostate cancer is to have an operation to remove part or all of the testicles. This is called an orchidectomy and is not commonly done. It may be an option if you find it hard to have regular injections or to take tablets every day.
Hormonal therapy with radiotherapy for early and locally advanced prostate cancer
Doctors often advise having hormonal therapy along with radiotherapy (including brachytherapy), to make treatment more effective. This is usually if you have intermediate-risk or high-risk early prostate cancer. You may also have hormonal therapy before treatment with HIFU.
You may have hormonal therapy during radiotherapy and either:
- a few months before radiotherapy, to shrink the cancer and make treatment more effective (called neo-adjuvant treatment)
- after radiotherapy, to reduce the chance of the cancer coming back (called adjuvant treatment).
Your doctor will advise when and how long you should have the hormonal therapy for.
If you have intermediate-risk early prostate cancer, you may have hormonal therapy for up to a few months after treatment finishes.
If you have high-risk early or locally advanced prostate cancer, you may be advised to have hormonal therapy for 2 to 3 years after radiotherapy finishes.
Hormonal therapy on its own for early and locally advanced prostate cancer
If your doctors are using the watchful waiting approach and the cancer starts to grow, you may have hormonal therapy on its own.
Some men with early prostate cancer decide to have hormonal therapy on its own instead of with surgery or radiotherapy. Some men with locally advanced cancer decide to have hormonal therapy on its own instead of radiotherapy. Unlike these treatments, hormonal therapy on its own will not get rid of all the cancer cells. Doctors do not usually advise this. But it may be suitable if you:
- are not well enough to have surgery or radiotherapy
- do not want these treatments.
Hormonal therapy can slow down or stop the cancer cells growing for many years. Not having surgery or radiotherapy means you avoid the side effects of these treatments. Hormonal therapy can also cause side effects (see below). It is important to talk to your doctor or nurse about it before you decide.
Intermittent therapy for locally advanced and advanced prostate cancer
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 the side effects of hormonal therapy. This is not suitable for everyone. It should only be done following your doctor’s advice.
Intermittent hormonal therapy may be helpful when certain side effects are difficult to cope with. Your doctor or nurse will explain the possible advantages and disadvantages. If your PSA level begins to rise or your symptoms get worse, your doctor will advise starting hormonal therapy again.
Combined hormonal therapy for advanced prostate cancer
If the cancer starts growing during treatment with an injection or implant, your doctor may advise taking an anti-androgen tablet as well.
Having the two drugs together can help to slow the cancer from growing or spreading. 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 two drugs. Your doctor or specialist nurse can explain more about this.
There are different types of hormonal therapy that may be used. Your doctor or nurse will explain the drug that is most suitable for your situation.
The pituitary gland in the brain makes a hormone called luteinising hormone (LH). This hormone tells the testicles to make testosterone. LHRH agonists interfere with this action and stop the testicles making testosterone. You have them as an implant injection or an injection under the skin.
The commonly used LHRH agonists are:
- goserelin (Zoladex®, Novgos®)
- leuprorelin (Prostap®), Lutrate®)
- triptorelin (Decapeptyl®, Gonapeptyl Depot®)
- buserelin (Suprefact®) for advanced prostate cancer.
A nurse or doctor at your GP practice or hospital can give you these drugs.
The first time you have one of these drugs, it can cause a temporary increase in testosterone. 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.
These drugs stop testosterone from reaching the cancer cells. You take them as tablets.
Some men may have anti-androgen drugs with radiotherapy instead of having an LHRH agonist with radiotherapy. Or you may have an anti-androgen before and after the first injection of a LHRH agonist, to prevent any symptoms getting temporarily worse (tumour flare).
Anti-androgen drugs include:
GnRH antagonists for advanced prostate cancer
These drugs block messages from the brain to the testicles telling them to make testosterone. They work more quickly than LHRH agonists and do not cause tumour flare.
At the moment degarelix (Firmagon®) is the only GnRH antagonist available. You have it as an injection under the skin (subcutaneously) of your tummy once a month. It may be used for advanced prostate cancer that has spread to the spine (back). As well as hormonal side effects, it commonly causes skin reactions.
Newer hormonal therapy drugs for advanced prostate cancer
These drugs 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. Sometimes you may have these drugs earlier on, when you are first diagnosed.
Newer hormonal therapy drugs include:
These newer hormonal therapy drugs may be given before you need chemotherapy. This is if you have no symptoms or mild symptoms, or if chemotherapy is no longer helping to control the cancer.
Or they may sometimes be given as the first hormonal therapy you have. This may be with hormonal injections or implants, or on their own.
Sometimes steroid drugs such as prednisolone or dexamethasone are used to treat advanced prostate cancer. They work on the adrenal glands, to help reduce testosterone.
They are occasionally used on their own or given along with abiraterone. You may have dexamethasone along with a hormonal injection or implant drug. Side effects may include increased appetite, weight gain, difficulty sleeping and irritability.
Treatment with the hormone oestrogen may help to reduce testosterone levels. It is occasionally 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 men.
Reducing the level of testosterone can cause different side effects. There are different ways hormonal side effects can be managed or treated. Your doctor or nurse will explain these to you. Some side effects are only likely to affect you when you have hormonal therapy for over 6 months.
Common side effects include the following:
Erection difficulties and reduced sex drive
Hot flushes and sweats
Tiredness and difficulty sleeping
Different hormonal therapies have different side effects. It is important to discuss these with your doctor or nurse before treatment so you know what to expect.