Preventing Hormone Therapy Side Effects

BY MARK SCHOLZ, MD

Side effects vary from patient to patient and are influenced by types of testosterone inactivation pharmaceuticals (TIP) used, and by the duration of treatment. However, a number of interventions are available that can substantially reduce these adverse side effects.

Loss of Libido
Libido is an emotional attraction to the opposite sex (in most cases). Libido is not the same thing as potency, which is defined as the ability to get an erection. TIP causes loss of libido about 90% of the time.  Libido returns when TIP is stopped though some men say libido after TIP is chronically diminished. Loss of libido and the cessation of sexual activity has wide ranging ramifications far beyond the intended scope of this blog. Specialists in sexual counseling are available and can be of great assistance.

Erectile Atrophy
Whether or not couples continue to have sexual intercourse after treatment, we counsel men to induce daily erections to counteract the risk of penis shrinkage. Cialis or Viagra should be taken daily.  If this fails to restore the normal pattern of nighttime erections then either a vacuum pump or injection therapy should be considered.  

Muscle Atrophy
Muscle mass can be maintained with a strength training program. Walking, aerobics, and stretching are healthy but accomplish little toward building muscle mass. Strength training that is effective requires a program similar to that undertaken by body builders.  Ideally, strength training requires a minimum of two, one-hour sessions weekly during which all the major muscle groups are exercised: Pectorals, Deltoids, Biceps, Triceps, Latissimus dorsi, Upper and lower back muscles, Abdominals, Gluteus, Quadriceps, Hamstrings, and Calf muscles. Three sets of 10-12 repetitions should be undertaken with weight selected to result in muscle failure toward the end of the third set.

Fatigue and Lassitude

Tiredness and weakness from TIP are a direct result of muscle loss and reversible with strength training. Strength training is very effective for counteracting fatigue. Men who begin strength training when they initiate TIP will not only forestall tiredness, they can actually increase their strength.

Osteoporosis
TIP causes accelerated calcium loss from the bones, termed osteoporosis. Untreated bone loss can result in hip and spine fractures. Osteoporosis can be prevented with medications such as Prolia, Xgeva, Zometa, Boniva, Actonel and Fosamax which should be initiated when TIP is started.  See the booklet titled Osteoporosis available** soon at www.prostateoncology.com for further details.  

Hot Flashes
Hot flashes occur in about two-thirds of men on TIP. When severe, a progesterone injection (depo provera) can dramatically reduce hot flashes. Other prescription medications, which are effective about half the time, are low dose Effexor, a medication approved for the treatment of depression, and Neurontin, a medication approved to prevent seizures. Transdermal estrogen patches are very effective but sometimes cause breast enlargement or nipple tenderness.

Weight Gain
TIP slows metabolism causing weight gain. Keeping a stable weight is easier than trying to lose weight. It is wise to evaluate your diet at the time of starting TIP to see if fat and sugar intake can be reduced. See the brochure about diet from the PCRI for more details.

Breast Growth
Breast growth (even without estrogen patches) occurs frequently in men treated with Casodex monotherapy and less frequently, about one-third of the time, in men treated with other forms of TIP. If there is any evidence for breast growth or nipple tenderness, therapy with an estrogen blocking pill called Femara should be started immediately.  Alternatively, a short course of radiation to the nipples can be administered prior to starting TIP.  

Anemia
Blood is a mixture of red cells and "serum" (water). When the proportion of red cell is diminished it is termed anemia. Severe anemia can cause shortness of breath. Milder degrees cause fatigue. Anemia reverses when TIP is stopped. If anemia is severe, it can be corrected with a medication called Aranesp. Iron is not beneficial.

Arthritis
Joint pains particularly in the hands but sometimes in other joints are common and often improve with glucosamine, Motrin or Celebrex.

Liver Changes
Casodex and Flutamide occasionally cause serious liver problems. This is detected by blood tests that need to be done routinely after starting TIP. The problem is easily reversible if detected early and the medication is stopped.  

Mood Swings
Men on TIP occasionally mention increased intensity in their emotions. Some find this effect unpleasant whereas others enjoy it. For men with the former attitude, low doses of medications such as Zoloft or Paxil can reverse the unpleasant feelings.

Final Thoughts
My general impression after many years treating men with TIP is that treatment is quite tolerable if side effects are expertly managed. Preventative measures such as weight lifting and diet are critically important. Checking blood tests for anemia and liver function is essential. Side effects like joint pains, hot flashes, depression, emotional swings, breast enlargement and impotence can be greatly reduced with judicious medical care.

**email us to receive Osteoporsis booklet -- mail@prostateoncology.com

All Newly Diagnosed Men Should Be From Missouri. But There Are Limits . . .

BY RALPH BLUM

Missouri is known as the “Show Me State,”  a nickname made popular around 1899 by Congressman Willard Duncan Vandiver, who famously declared, "I'm from Missouri and you've got to show me." Appropriately enough, the state animal is a mule. Newly diagnosed men with prostate cancer, take heed. But also, know when to listen to the experts.

The newly diagnosed men I know who’ve had the best treatment results questioned everything related to the pros and cons of various treatment options. You need to develop the “I’m from Missouri” mindset, so that when an authority figure with a big reputation pronounces, “You need surgery. I’ve got space in my operating schedule next Thursday,” your automatic reaction is not “Whatever you say, doc.” It is “Well, I’m from Missouri and I need to know more before I make that decision.”

 Remember: 90% of us have the slow growing type of prostate cancer. Time is on our side. Second or even third opinions make sense. But—and I am here to tell you there’s a big “But…” Once you have chosen a treatment you had better pay attention to your doctor’s advice. I learned the hard way.

Back in 2002, when my PSA bumped up to 18.3, given my aversion to being sliced open, fried by radiation or poisoned by chemotherapy, it was only logical that I decided to pursue the minimally invasive treatment known as hormone blockade. The objective of hormone blockade is to reduce the production of testosterone—the hormone (androgen) in the blood credited with fueling the growth and spread of prostate cancer—as near as possible to castrate level. But there are some basic rules to follow once you opt for hormone blockage, and I soon began to wish I had taken Mark’s advice about how to avoid some of the adverse side effects that occur in the absence of testosterone. The most talked about one, of course, being no libido.

The protective measures are simple enough: You need to exercise in order to prevent weight gain and muscle wasting—even if, like me, exercise has not been part of your routine. Recommended: 45 minutes of weight training twice a week. Hate it, resent it, but do it. Otherwise? Somewhere down the line, chances are you’ll find your ability to lift, squeeze, steer and reach are all seriously compromised. The truth of “Use it or lose it” becomes painfully apparent. And the longer you wait, the greater the deficit, the harder to repair the damage.  

And then there’s my least favorite adverse side effect from injections of Lupron, which is breast enlargement.Official name gynecomastia. My options were: Either low dose radiation prior to the use of Lupron, or  taking the estrogen blocking drug Femara. I wasn’t keen on undergoing radiation unless it was of critical importance. And somehow I just never got around to taking Femara. Next thing I knew, there they were—my very own set of boobs. A souvenir of my trek through the libido-free zone.

So I’m a living example where ignoring instructions was mulish behavior of the wrong kind. If memory serves, this set of honkers is bigger than those of my first girlfriend. But on the bright side, after months of hormone blockade, my PSA had bottomed out at 0.05, only a breath away from the magic goal line marked “undetectable.” And nowadays, I am only from Missouri on carefully selected occasions.