Types of hormonal therapy

Hormone therapy is the main treatment for advanced prostate cancer. There are different types of hormone therapy. You may be given hormone therapy on its own or with another type. You may be given hormone therapy as:

  • Injections - these are injections of drugs that stop the testicles making testosterone. They are often the first drugs used. You have them as an implant injection or an injection under the skin.
  • Tablets - these drugs block testosterone from reaching the cancer cells. You may have them on their own or with hormone therapy injections (combined therapy). Some men may have them before or after they have injections to reduce symptoms becoming temporarily worse.

Some men may have steroid drugs with hormone therapy or they may be offered newer hormone therapy drugs such as abiraterone and enzalutamide.

These drugs are usually used when other hormonal therapies are no longer helping to control the cancer. But some men may have them as their first treatment or given in combination with other types of hormone therapy.

Types of hormonal therapy

There are different types of hormonal therapies that may be used. 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 therapy at a time.

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 interfere with this action and stop the testicles making testosterone. These are often the first drugs used. You have them as an implant injection or an injection under the skin.

The commonly used LHRH agonists are:

A nurse or doctor at your GP practice or hospital can give you these drugs.

  • Buserelin is given as an injection under the skin 3 times a day for a week. After this you take it as a nasal spray 6 times a day.
  • Goserelin is given as an injection of a small pellet (implant) under the skin of the tummy (abdomen). The drug is released slowly as the pellet dissolves. You have it every 4 weeks. You can also have it as a longer-acting injection every 12 weeks.
  • Leuprorelin and triptorelin are given as an injection under the skin or into a muscle. You have these monthly, or every 3 to 6 months.

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.

GnRH antagonists

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.


Surgery to the testicles

Occasionally, men have an operation to remove part or all of the testicles. This is called an orchidectomy. It is not commonly done. It is more common to use hormonal therapy drugs to lower testosterone. But it may be an option if you find it hard to have regular injections or to take tablets every day. It 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 you get with other hormonal therapy drugs. It is important to talk it over carefully with your doctor and nurse.


Combined hormonal therapy

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.

Some men may have newer hormonal therapy drugs called abiraterone (Zytiga®) or enzalutamide (Xtandi®) along with an injection or implant.

Anti-androgen drugs

These drugs block 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. But it may not be as effective in controlling the cancer as other hormonal therapies.

Anti-androgen drugs include:

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 the cancer begins to grow after you have been taking an anti-androgen drug for months or years, your doctor may stop the drug. This may make the cancer shrink for a while. Doctors call this a withdrawal response.



Newer hormonal therapy drugs

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.

Abiraterone

You take abiraterone as tablets once a day along with drugs called steroids.

If you have already had enzalutamide you may not always be able to have abiraterone. Side effects of abiraterone can include high blood pressure and changes to your heartbeat. Your doctor or specialist nurse can give you more information.

Adding abiraterone to standard hormonal therapy as a first hormonal treatment may help men with advanced prostate cancer to live for longer. But this is not standard treatment.

Doctors still need to know if the benefits outweigh the side effects of this combined treatment. However, trial results are promising and the NHS is looking at how effective this is for the cost involved. Your doctor can talk to you about the benefits and disadvantages of this treatment in your situation.

Enzalutamide

You take enzalutamide as a capsule once a day. If you have already had abiraterone you may not always be able to have enzalutamide. Side effects 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

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 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.

Oestrogen

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.

Back to Hormonal therapies explained

Side effects of hormonal therapy

There are different side effects to hormone therapy but there are ways to manage these. Your doctor or nurse can tell you more.