What are the side effects of hormonal therapy?
Hormone therapy for prostate cancer, also known as androgen deprivation therapy (ADT), can have several side effects.
Androgen hormones, such as testosterone, stimulate the growth of prostate cancer cells. Hormone therapy aims to lower testosterone in the body, which can slow the growth of prostate cancer.
The side effects of hormone therapy for prostate cancer can vary depending on the specific treatment used, the duration of therapy, and the individual patient's health status. Some of the most common side effects of hormone therapy for prostate cancer include the following:
· Hot flushes
· Loss of libido (sexual desire),
· Change in the penis and testicle size
· Erectile dysfunction (difficulty achieving or maintaining an erection)
· Fatigue
· Weight gain
· Breast enlargement and tenderness
· Lower muscle mass and strength
· Mood changes, such as depression or irritability
· Reduced bone density and increased risk of fractures
· Increased risk of diabetes and cardiovascular disease
Does hormonal therapy cure prostate cancer?
The male hormone testosterone often fuels prostate cancer. Lowering the testosterone levels in the body slows the growth and spread of prostate cancer.
While hormone therapy can effectively control prostate cancer, it is generally not considered a cure because it does not eliminate all the prostate cancer cells.
Over time, some prostate cancer cells may become resistant to hormone therapy. They do so by starting to produce their supply. The cancer cells may begin to grow and spread again.
The gold standard of practice is combining hormone therapy with other treatments, such as radiation therapy, chemotherapy, or other novel antiandrogens, to improve the chances of curing cancer or extending survival.
However, hormone therapy can be used as a stand-alone treatment in men with metastatic prostate cancer who are not eligible or unfit for combination treatment.
Hot flushes
How common are hot flushes?
Hot flushes' exact frequency and severity can vary from patient to patient, but studies suggest that most men who receive hormone therapy experience hot flushes.
According to a study published in the Journal of Clinical Oncology, approximately 80 per cent of men who receive hormone therapy for prostate cancer experience hot flushes. Another study published in the Journal of Urology found that up to 70 per cent of men experience hot flushes during the first month of hormone therapy, and up to 50 per cent continue to experience hot flushes after six months of treatment.
How are hot flushes classified?
Mild: You feel slightly warmer and a bit uncomfortable. Typically, this lasts for less than three minutes.
Moderate: you feel so hot and slightly sweaty that you need to take off some clothing to cool down.
Severe: you feel very hot and sweaty (men must change their clothing or bedding). Some men become irritable, complain of discomfort, or feel sick.
Natural remedies to counteract hot flushes
Several natural remedies may alleviate hot flashes in men with prostate cancer who are undergoing hormonal therapy. These include
Lifestyle changes, avoiding triggers (spicy foods, caffeine, and alcohol), dressing in layers, and staying cool, can help reduce the frequency and severity of hot flashes.
Soy contains phytoestrogens that can mimic the effects of oestrogen in the body. There is a potential benefit that needs more scientific research.
Flaxseed contains lignans that can show oestrogen effects in the body. More research is needed to confirm flaxseed's role, but some men claim that it reduces the frequency and severity of hot flushes.
Regular exercise improves overall health and reduces the frequency and severity of hot flashes.
Mind-body techniques: mindfulness meditation, yoga, and deep breathing exercises may play a role as they lower our stress levels and improve our quality of life, which can, in turn, help reduce hot flashes.
Sage supplements: Some studies have suggested that sage extract may help reduce the frequency and severity of hot flushes, possibly by regulating hormones or affecting neurotransmitters in the brain. However, other studies have found little to no benefit of sage extract in reducing hot flushes. Additionally, there is limited information on sage extract's safety and long-term effects. While some people may find sage extract helpful for reducing hot flushes, the evidence is insufficient to recommend it as a first-line treatment.
Evening primrose oil (EPO): contains gamma-linolenic acid (GLA), an essential fatty acid that can help regulate hormones and reduce inflammation. Some studies have suggested that EPO may help reduce the frequency and severity of hot flashes in men undergoing hormone therapy for prostate cancer. The evidence is not solid. The positive effects that some men experience cannot be extrapolated to others. Further research is needed.
It is important to remember that natural remedies may not work for everyone, and in some cases, they may interact with other medications or supplements. Consult your NHS consultant, private urologist, or cancer nurse specialist.
What treatments reduce hot flushes?
There are several treatments available that can help reduce hot flashes. These treatments include:
Medications:
Cyproterone acetate (Androcur) is an antiandrogen medication. A study published in the Journal of Urology found that men who received cyproterone acetate had a significantly lower incidence of hot flushes than men who received a placebo.
However, cyproterone acetate has no side effects or risks and is not recommended for everyone. It can cause side effects such as decreased libido, erectile dysfunction, and breast tenderness, and it may increase the risk of blood clots and liver damage. Patients need to discuss the potential benefits and risks of cyproterone acetate with their healthcare provider to determine if it is an appropriate treatment option for them.
Other medications include antidepressants (e.g., venlafaxine) and anticonvulsants (e.g., gabapentin).
Acupuncture:
The exact mechanism by which acupuncture may reduce hot flushes is not fully understood.
One theory suggests that acupuncture may help regulate the hypothalamus, a brain region controlling body temperature and hormone production. By stimulating specific acupuncture points, it is thought that acupuncture may help rebalance the hypothalamus and reduce hot flashes.
Another theory suggests that acupuncture may help regulate the production and release of neurotransmitters, such as serotonin and endorphins, which can affect mood and body temperature. By promoting the release of these neurotransmitters, acupuncture may help reduce hot flashes and other menopausal symptoms.
The effectiveness of acupuncture may vary from person to person, and more research is needed to fully understand its potential benefits and limitations.
Fatigue
The exact cause of fatigue in men on hormone treatment is not fully understood, but it may be related to changes in hormone levels, disruption of sleep patterns, or other factors. Fatigue associated with hormone therapy can range from mild to severe and can affect a person's ability to perform daily activities.
Can power naps cure fatigue?
Power naps can effectively combat tiredness by providing a short burst of restorative sleep that can help boost energy levels and improve cognitive function. Here are a few ways that power naps can help combat fatigue:
Increases alertness: Taking a power nap can help increase alertness and reduce the feeling of sleepiness that often accompanies fatigue. Even a short rest of 20-30 minutes can help boost mental and physical energy levels, making it easier to concentrate and be productive.
Improves cognitive function: Power naps have been shown to improve cognitive function, including memory, attention, and problem-solving skills. Taking a short nap allows your brain to rest and reset, allowing you to think more clearly and effectively.
Reduces stress: Power naps can also help reduce stress levels, which can contribute to feelings of fatigue. When you nap, your body relaxes, which can help reduce the production of stress hormones like cortisol and adrenaline.
Boosts mood: Power naps have been shown to boost mood and reduce feelings of anxiety and depression. Taking a short rest gives your body a chance to recharge, which can improve your overall sense of well-being.
How does physical activity help to lower fatigue?
Physical activity can help lower fatigue in several ways:
Increases energy levels: Exercise releases endorphins, natural mood boosters that can help improve overall energy levels.
Improves sleeping pattern: Exercise regulates the sleep-wake cycle, making falling and staying asleep at night easier.
Reduces stress: Exercise is a natural stress reliever that can help reduce the production of stress hormones like cortisol and adrenaline, lowering fatigue and increasing overall energy levels.
Enhances cardiovascular function: Regular physical activity can improve cardiovascular function, which can help increase blood flow and oxygen to the body's tissues. This can help reduce feelings of fatigue and increase overall energy levels.
Boosts mood: Exercise has been shown to improve mood and reduce feelings of anxiety and depression. By boosting mood, physical activity can help improve overall energy levels and reduce feelings of fatigue.
How to address weight gain and loss of muscle mass and power?
Hormone therapy can cause loss of muscle tissue and more body fat deposits. Muscle aches or joint pain are common complaints by men on hormone therapy.
To address weight gain and loss of muscle mass and power, a combination of lifestyle changes, exercise, and medical treatment may be necessary, depending on the underlying cause of the symptoms. Here are some helpful strategies:
Regular Exercise: Combining aerobic and strength training exercises into your weekly physical activity can increase muscle mass and power—at least 150 minutes of moderate-intensity aerobic exercise and two strength training sessions per week.
Focus on Nutrition: Consuming a balanced diet of protein, complex carbohydrates, and healthy fats can promote muscle growth and maintenance. Avoiding processed foods and sugary drinks can also aid in weight management.
Manage Stress: High-stress levels can contribute to weight gain and loss of muscle mass and power. Implementing stress management techniques such as meditation, yoga, or other relaxation methods can be helpful.
Get Enough Sleep: Sufficient sleep is crucial for muscle recovery and growth. Aiming for 7-8 hours of sleep per night is recommended.
Bone Health
Does bone strength weaken when on hormone therapy?
In men, low testosterone levels due to hormone therapy can also lead to a loss of bone density and an increased risk of fractures. This is because testosterone helps to stimulate bone formation and maintain bone density in men.
What is the risk of men on hormone therapy developing osteoporosis?
A study published in the Journal of Clinical Oncology found that 22 per cent of men with prostate cancer who received androgen deprivation therapy for more than two years experienced bone fractures.
Another study published in the Journal of Bone and Mineral Research found that men on androgen deprivation therapy had a 4.4% higher risk of developing osteoporosis compared to men who did not receive hormone therapy.
However, not all individuals who undergo hormone therapy will experience bone loss. The risk of bone loss may depend on the type of hormone therapy used, the duration of treatment, and the individual's baseline bone density.
What lifestyle changes do men employ to prevent the risk of osteoporosis?
Regular exercise: Exercise can help to build and maintain bone density, as well as improve muscle strength and balance, which can reduce the risk of falls and fractures. Weight-bearing exercises like walking, jogging, and strength training are especially beneficial for bone health.
Adequate calcium intake: Calcium is an essential nutrient for bone health, as it helps to build and maintain bone density. Good sources of calcium include dairy products, leafy green vegetables, and fortified foods and beverages.
Adequate vitamin D intake: Vitamin D helps the body absorb calcium. Men on hormone therapy may be at an increased risk of vitamin D deficiency, which can contribute to bone loss. Vitamin D can be obtained through sun exposure, fortified foods (cereals, margarine), oily fish like sardines or mackerel, and supplements.
Avoid smoking and excessive alcohol consumption. Smoking and alcohol consumption can contribute to bone loss and increase the risk of fractures. As per guidelines, men should not regularly drink more than 14 units of alcohol a week.
Maintain a healthy body weight: Being underweight can increase the risk of osteoporosis while being overweight can increase the risk of other health problems. Men on hormone therapy should aim to maintain a healthy body weight through a balanced diet and regular exercise.
Should I have a DEXA scan?
A DEXA, or dual-energy x-ray absorptiometry scan, is a medical imaging test measuring bone mineral density (BMD). It is the standard gold test for diagnosing osteoporosis and osteopenia. A DEXA scan is a quick, non-invasive test that typically takes less than 20 minutes to complete.
All men on hormone therapy should have a DEXA scan before or at the beginning of hormone therapy.
The results of a DEXA scan are reported as a T-score, which compares an individual's bone density to that of a healthy young adult of the same sex.
· A T-score of -1 or above is considered normal.
· A T-score between -1 and -2.5 is classified as osteopenia.
· A T-score of -2.5 or below indicates osteoporosis.
What medications can I have if I have osteoporosis?
Denosumab (a monoclonal antibody) blocks the activity of a protein called RANK ligand, slowing down bone loss. Denosumab is typically given as an injection under the skin every six months.
Potential risks and side effects include low calcium levels in the blood, skin infections, and rare cases of jaw osteonecrosis (a condition in which bone tissue in the jaw dies and can lead to pain, swelling, and infection).
Bisphosphonates are a class of medications commonly used to treat osteoporosis in men. Bisphosphonates are available in both oral and intravenous forms. Oral bisphosphonates include alendronate and risedronate, while intravenous bisphosphonates include zoledronic acid. Potential side effects include nausea, vomiting, and abdominal pain. Rare but severe side effects such as jaw osteonecrosis and atypical femoral fractures.
Metabolic X Syndrome
How to lower the risk of diabetes and cardiovascular disease whilst on hormone therapy
Metabolic X syndrome is a cluster of conditions that includes high blood pressure, high blood sugar, excess body fat, and abnormal cholesterol or triglyceride levels. It can increase the risk of developing cardiovascular disease (stroke, heart attack) and type 2 diabetes.
Several lifestyle changes can help prevent metabolic syndrome while on hormone therapy:
Eat a healthy diet: A diet rich in fruits, vegetables, whole grains, lean protein, and healthy fats can help prevent metabolic syndrome. Avoid processed and sugary foods, and limit your intake of saturated and trans fats.
Exercise regularly: Brisk walking, cycling, or swimming can help prevent metabolic syndrome. Aim for at least 30 minutes of moderate-intensity exercise most days of the week.
Maintaining a healthy weight: Healthy eating and regular exercise can help prevent metabolic syndrome.
Monitor your blood pressure: Regular monitoring and managing blood pressure can help prevent metabolic syndrome.
Check your blood: The blood tests should be done twice yearly, looking at your sugar and cholesterol levels to monitor them closely.
Manage stress: High-stress levels can contribute to the development of metabolic syndrome. Meditation, yoga, or other relaxation techniques can be helpful.
Quit smoking: Improves overall health.
Loss of memory and concentration
Strategies to counteract forgetfulness and concentration
Exercise regularly
Get enough sleep
Manage stress
Stay mentally active: Keeping your mind busy with reading, puzzles, or learning new skills may help improve memory and concentration.
Maintain a healthy diet.
Consider cognitive training
It is essential to discuss any concerns about changes to memory and concentration with your healthcare provider.
Mood changes, such as depression or irritability
These changes may include depression, anxiety, irritability, or mood swings.
Strategies to address these negative feelings
Talk to your healthcare provider to help identify any underlying medical or psychological conditions contributing to your symptoms and develop an appropriate treatment plan.
Get support: Joining a support group or talking with a mental health professional can help manage mood changes. They can provide a safe space to discuss feelings and offer coping strategies.
Stay active: Regular exercise like walking or yoga can improve mood and reduce stress. The release of natural endorphins helps counteract the negative feelings building up. People who exercise regularly tend to sleep better.
Manage stress: Finding ways to manage stress, such as relaxation techniques, mindfulness, or hobbies, can be helpful.
Maintain a healthy diet: Support overall health, including mental health.
Medication: Antidepressants or anti-anxiety medications may be prescribed by your healthcare provider.
It is important to note that mood changes may be a side effect of hormone therapy and may improve over time. However, discussing concerns with your healthcare provider and seeking appropriate support is essential.
Intermittent Androgen Blockade
Intermittent androgen blockade (IAB) is a type of hormone therapy that involves cycling on and off androgen deprivation therapy (ADT).
In IAB, ADT is given for a period, typically several months to a year, followed by a period without treatment. This cycle is repeated several times to achieve similar outcomes to continuous ADT while minimizing side effects.
The idea behind IAB is that prostate cancer cells may develop resistance to continuous ADT over time, which can limit its effectiveness. Cycling on and off may prevent the development of resistance and potentially extend the effectiveness of the treatment.
IAB is inappropriate for all men with prostate cancer and should be discussed with a healthcare provider. It may be considered in men with a low risk of disease progression and those who experience side effects from continuous ADT, such as decreased bone density or sexual dysfunction.
It is important to note that IAB is still being studied, and its long-term effectiveness and safety are not yet fully known.
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