Issues To Consider Regarding Vasectomy

October 12, 2014

Men who consider a vasectomy often ask questions about the risks involved. This blog will discuss the risks and the consequences of vasectomy and what every man needs to know before proceeding with the procedure.

There are three main concerns regarding the long-term consequences or general health hazards of vasectomy. These concerns have arisen mainly from isolated studies over the past 50 years. Remember that it is important to show that several things be true when trying to link two medical conditions: a) that the link makes physiological sense and that this is shown in either animal models or in humans, and b) there should be excellent evidence of this link in populations of humans.

Heart Disease Risk

In 1979 a study was published that suggested that atherosclerosis or coronary artery disease might occur prematurely after vasectomy in monkeys. In this small study, monkeys fed high cholesterol diets were found to have what appeared to be increased amounts of atherosclerosis following vasectomy. Subsequent animal studies did not agree with these initial findings, and large epidemiological studies, including an extensive study of U.S physicians followed for 259,000 person-years have concluded that neither early atherosclerosis nor heart attacks or strokes occur more frequently in men who have had vasectomies compared to men who have not.

It is true is that after vasectomy, approximately 60-70% of men develop a form of allergy to their sperm in the form of antisperm antibodies. The body, either during the vasectomy or after, is exposed to sperm proteins that it commonly does not see and antibodies against these proteins can be observed in some patients. However, it has not been shown conclusively that the presence of these antibodies has any significant effect on other organs.

Prostate Cancer Risk

There has been much discussion over the past 15 years about whether vasectomy is associated with the development of prostate cancer later in life. The Journal of the American Medical Association published 2 reports suggesting that men who have had a vasectomy may be at risk for developing prostate cancer. Both studies were coauthored by Dr. Edward Giovannucci. One study evaluated men married to female nurses: men with vasectomies were compared to men without. The second study evaluated men in the health professions (veterinarians, pharmacists etc) who had had a vasectomy, and, again compared them with other male health professionals who had not had vasectomies. In both studies, there appeared to be an increased risk of developing prostate cancer in men who had a vasectomy more than 20-22 years before. On the contrary, several other studies, including several in the U.S showed no statistically significant increase in the risk of prostate cancer following vasectomy. Indeed, it was suggested in the same JAMA issues that a true cause-and-effect relationship could occur by chance alone, or because of biases (selectivity) or other unaccounted variables in these two studies.

Concerns raised from these studies include the fact that the men in the study might not represent the larger population of all men who get vasectomies. This means that the study cannot be used with certainty to predict a similar occurrence in the general population. It is also possible that the men who had had vasectomies in these studies would be more likely to see a urologist rather than an internist or family practice physician for later evaluation of a urologic problem than the men who had not had vasectomies. Urologists are better at finding prostate abnormalities than other kinds of physicians and therefore cancer might have been detected earlier than it would have otherwise. This is called “detection bias.” It has also been suggested this study design makes it impossible to identify all of the factors that might contribute to this end result with two events (vasectomy and cancer) occurring several decades apart. A prospective study is really necessary here to answer the question. A prospective study evaluates groups of patients at the time they have the vasectomy and follows them regularly for years to see, if indeed, cancers do occur. This is the most powerful way to study this relationship, but was not used in the Giovannucci papers. In addition, no study has ever established that there is an increased risk of death after prostate cancer following vasectomy.

Because the question of a relationship between vasectomy and prostate cancer was raised, the American Urological Association first recommended that men who had a vasectomy more than 20 years ago or who were > 40 years of age at the time of vasectomy have an annual examination of their prostates as well as a blood test for prostate cancer (serum Prostate Specific Antigen or PSA). However, given the recent lack of support for this relationship between vasectomy and prostate cancer, this recommendation has been revoked. Finally, no mechanism is known, nor is there any animal model proof of the plausibility of the link between these conditions.

Dementia Risk

There is a recent, single, small paper that has linked vasectomy to the later development of a rare form of Alzheimer’s disease. The issue is that a researcher found that, among a group of patients suffering a form of dementia called primary progressive aphasia (PPA) that is often confused for Alzheimer’s disease, the men had a higher percentage of vasectomy than was thought normal. The study found that 40% of 47 men with PPA had had a vasectomy, while among another 57 men from the community without PPA there was a vasectomy rate of 16%. What this means is simply that the rate of vasectomy among PPA patients is a little over 2 fold higher than in otherwise healthy patients. This study did not find an increased rate of vasectomy in patients with Alzheimer’s.

The most common form of dementia caused by brain deterioration in individuals over age 65 is Alzheimer’s disease. A very unusual form of Alzheimer’s disease is called primary progressive aphasia. This condition robs people of their ability to speak and understand language, but they are still able to maintain their hobbies and perform other complicated tasks for a long time. By contrast, Alzheimer’s patients lose their memory, interest in hobbies, family life and become idle.

A “mechanism” for the association between PPA and vasectomy was also proposed in the study. It involves the fact that men can have antibodies form to sperm after having a vasectomy (see above risks) and these antibodies may somehow cross-react with the brain and cause PPA. There is no animal model data to support this theory, however.

Problems with this study are similar to that described for prostate cancer risk and vasectomy. How unique were these patients that they gathered from all over the US twice annually to participate in a support group with such rare disease? We really need a prospective study to show this relationship as retrospective studies have too much “bias” or too many uncontrolled issues that could produce the same result. In addition, the study groups were very small: fewer than 20 PPA patients had a vasectomy and fewer than 10 healthy patients had a vasectomy. It is hard to generalize at all from so few patients in a study. Also, the study methods were faulty in that the vasectomy condition should have been confirmed by reviewing the medical charts on the PPA patients, since their disease alters their ability to understand, hear and remember what has happened to them! Indeed, like the issue of prostate cancer and vasectomy, this issue will take at least a decade or two to confirm or disprove.

Bottom Line: Vasectomy remains an effective method of sterilization. Certainly there are risks with any procedure and the risks of prostate cancer, dementia, and heart disease need to be considered by every man who wishes to proceed with the vasectomy.

The Safety of Vasectomy Using No Scalpel, No-Needle Technique

October 12, 2014

Vasectomy remains one of the most effective and safest methods of contraception. The only technique that would be cheaper is the diaphragm and abstinence. Both of which have a high failure rate. The next few blogs will discuss the safety of vasectomy.

Besides the fact that a vasectomy is very popular, one must remember that there is no form of fertility control, except abstinence, which is completely free of potential complications. In all, vasectomy remains one of the safest and best forms of permanent contraception, provided that the patient is aware of and understands the potential risks associated with the procedure. The side effects and complications of vasectomy are divided into “early” and “late” categories, depending on when they occur. The risks and complications of the procedure, including potential vasectomy pain, are examined below in greater detail.

Vasectomy and Pain

Men worry about pain and discomfort during and after the procedure. In my practice less than 5% of respondents said they had pain, much lower than the well-recognized and commonly published rate. In addition, seldom do any of the men require post operative pain medication. I suggest bed rest and ice over the scrotum the day of the procedure and non-steroidal anti-inflammatory medication such as Tylenol or Aleve for post operative pain.

Early Complications

Shortly after the procedure there may be mild discomfort, and most men are able to return to work in 1-2 days. A small amount of oozing (light bleeding, less than the size of a quarter) and swelling in the area of the tiny opening are not unusual. This should subside within 72 hours. Occasionally, the skin of the scrotum and base of the penis turn black and blue. This is not painful, lasts only a few days, and goes away without treatment. For a period of 7 days following the vasectomy, sex should be avoided. Strenuous exercise (for example climbing, riding motorcycles or bicycles, playing tennis or racquetball) should also be avoided for 7 days, and nothing heavier than 8-10 pounds should be lifted after the procedure until day 7 when all activities including heavy lifting can begin.

Rarely (less than 1%), a small blood vessel may bleed into the scrotum and continue to bleed and form a clot of blood (hematoma). A small clot will be reabsorbed by the body with time, but a large one usually requires drainage through a surgical procedure.

Importantly, the vasectomy procedure is not always 100% effective in preventing pregnancy because, on rare occasions, the cut ends of the vas may rejoin. This occurs very infrequently; the published rate is about 1 in every 600 vasectomies. My vasectomy failure rate, defined as either persistent motile sperm in the ejaculate or a pregnancy after the procedure, is less than 1/1000 cases.

Since sperm can survive for several months in the vas deferens above the point where they were interrupted, it is very important that another form of contraceptive is used until sterility is assured. To determine whether the ejaculate is devoid of sperm, an ejaculate must be brought in for formal microscopic examination after the procedure. Since “clearing the tubes” through ejaculation is a relatively inefficient process, it make take 15 ejaculations to empty the system entirely of sperm. In terms of time after the procedure, roughly 90% of men will have no sperm in the ejaculate 3 months later. This is the reason we ask men to provide us with a semen sample after 15 ejaculations or 3 months after the vasectomy. Occasionally, it may take 6 months or longer after the procedure to flush out all the sperm. The semen specimen must demonstrate no sperm before unprotected intercourse is permitted.

Bottom Line: Vasectomy is a safe form of sterilization and there are few complications.  Each man who considers proceeding with a vasectomy needs to weigh the benefits vs. the risks and complications associated with the procedure.  Most men will find that the procedure is the best way to proceed with contraception.

Benign Prostate Enlargement (BPH) – Help Is Available

October 10, 2014

Millions of middle age men suffer from non-cancerous prostate gland enlargement. The cause is not known but is probably related to hormonal changes that occur normally in men after age 50.

The symptoms are going to the bathroom frequently, urgency of urination, poor stream, dribbling after urination. However, the most bothersome symptom that impacts a man’s quality of life is getting up multiple times during the night to go to the restroom.

Though the prostate continues to grow during most of a man’s life, the enlargement doesn’t usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties, and as many as 90% in their seventies and eighties, have some symptoms of BPH. Moreover, because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms but are less invasive than conventional surgery.

Thus, BPH is an age-related condition like many others, such as memory deficiency, reduced bones density and muscles flexibility.

As for natural treatment options, it has been noted Saw palmetto, a popular herbal therapy among men with prostate symptoms, is not effective and more and more scientific studies are showing that saw palmetto has no benefits in the treatment of BPH.

There are oral medications such as alpha-blockers such as Flomax and Rapaflo that relax the muscles in the prostate and make it easier for the bladder to empty the contents from the bladder. There are also medications that reduce the size of the prostate gland. These drugs, Proscar and Advodart, actually help decrease the size of the prostate thus decreasing the resistance to the flow of urine from the bladder to the outside of the body. Unfortunately, these drugs have mild side effects and since so many Americans are polymedicated, and alternative solutions are often more attractive to active middle aged men.

Minimally invasive treatments

Men with enlarged prostate glands have symptoms of going to the bathroom frequently, dribbling after urination, and getting up at night to go to the bathroom. The problem is usually caused by a benign enlargement of the prostate gland, which blocks the flow of urine from the bladder to the outside of the body. The cause of the benign enlargement is not known but is probably related to alternations in the hormones, testosterone, of middle aged and older men. Treatment usually consists of medications, alpha-blockers and medications to actually relax the muscles in the prostate gland but these are often ineffective especially if used for long period of time. The other options include minimally invasive procedures such as microwaves that can actually shrink the prostate gland. Now there’s a new treatment option that can be done in the doctor’s office under a local anesthetic.

What are some of the minimally invasive treatments available for BPH?

Laser vaporization: Anesthesia is usually required for this procedure, but patients can usually go home the same day. The technology involves placing a “cystoscope” (metal tube through which the visual lens and laser can be passed). A laser is used to burn and vaporize the obstructing or blocking prostatic tissue. Studies to date have shown limited long-term benefits.

Microwave thermotherapy of the prostate (TUMT): This is an office-based procedure performed with topical and oral pain medication and does not require a general anesthesia. Computer-regulated microwaves are sent through a catheter to heat portions of the prostate. A cooling system is required in some types for better tolerance. Traditionally, the best use of this procedure has been for patients who have too many medical problems for more invasive surgery or for patients who truly wish to avoid any type of anesthesia. Benefits are that there is no need for anesthesia and there is no blood loss or fluid absorption (these would be significant benefits in a person with a weak heart). Patients usually go home the same day. Men may need a catheter for one or two days after the procedure.

The UroLift system, made by NeoTract Inc. of Pleasanton, Calif., is the first permanent implant to relieve low or blocked urine flow in men age 50 and older with an enlarged prostate.

By pulling back prostate tissue that presses on the urethra, the system allows more natural urine flow.   This procedure is compared to pulling back the curtains with a sash. The procedure can be done in the doctor’s office under a local anesthetic and will actually open up the urethra to allow the flow of urine and reduce the urinary symptoms of frequency of urination, improve the force and caliber of the urine stream, and decrease the number of times a man needs to get up at night to empty his bladder.

Of course with any procedure there may be side effects and complications. Some b patients reported pain or burning during urination, increased urgency, decreased urine flow, incomplete bladder emptying, and blood in the urine. Most of these symptoms and side effects were temporary and resolved a few days or weeks after the UroLift was performed.

Bottom Line: Millions of American men suffer from symptoms as a result of an enlarged prostate gland. Certainly medications are a first line treatment option. However, the UroLift may be a permanent solution to this common problem and help men get a good night’s sleep!

Prostate Cancer: A New Test To Determine if Watchful Waiting is Appropriate

October 10, 2014

Prostate cancer affects 1 in 6 American men and causes over 25,000 deaths per year, making prostate cancer the second most common cause of death due to cancer in men (first is lung cancer).

Men who have a biopsy that is positive for prostate cancer are confronted with a decision regarding treatment. If the man has a life expectancy of greater than 10 years, he would be a candidate for surgical removal of the prostate gland, radiation therapy, or even a program of watchful waiting or referred to as active surveillance. So what is a man to do with a diagnosis of prostate cancer? Now there is a test, Prolaris, that will help men decide which cancers are aggressive and may require more aggressive treatment, i.e., surgery or radiation, and which cancers are indolent and the men may be candidates for watchful waiting.

Until now the only consideration for men with prostate cancer was the grade of the cancer and the stage of the cancer. However, there are men with low PSA levels and a low grade or Gleason score, who have an aggressive tumor as determined by the Prolaris test and perhaps should consider additional treatment.

How is the Prolaris test performed?

The doctor can submit your original prostate biopsy for analysis and this will look at several genetic markers to determine the Prolaris score. No additional blood test or biopsy is required. The Prolaris test provides an accurate assessment of the aggressiveness of your tumor.

The Prolaris score provides information that helps you and your doctor make the best treatment decision. For example a low risk Ca and low Prolaris score, may persuade you to consider watchful waiting and have close follow up with a digital rectal exam and a PSA test every 3-4 months. On the other hand, a high Prolaris score is suggestive of an aggressive tumor and more aggressive treatment may be selected.

Bottom Line: Until now no lab test or imaging study can determine the aggressiveness of your prostate cancer. Now you and your doctor can make a more informed decision about the potential of your cancer to remain slow growing and you would be a candidate for watchful waiting or the prostate cancer is more aggressive and more aggressive therapy is in order.

What Happens After A Vasectomy?

October 10, 2014

A vasectomy, using the no-scalpel, no needle technique takes just a few moments to accomplish in the doctor’s office. However, there are some precautions that are necessary after the procedure.

Most often, men are concerned about the pain involved in a vasectomy procedure as well as having a healthy, functional sex life afterwards. The no needle technique using a local anesthetic and the no-scalpel procedure which allows the procedure to be accomplished through a quarter inch opening without requiring an incision, causes minimal or no pain during or after the procedure.

Post Vasectomy Advice

  • The vasectomy procedure lasts anywhere from 10-12 minutes.
  • Patients do not require any general anesthesia and often take a Valium tablet before the procedure to remove the anxiety often associated with the procedure.
  • A bag of frozen peas or ice should be placed on top of the underwear over the scrotum to help reduce any swelling. Instead of frozen peas, you can place a few ice cubes in a zip lock bag and place this over the scrotum for a few hours after the procedure.
  • You may feel an ache in your testicles which is treated with extra strength Tylenol or Aleve.
  • You will need to have a ride home if you take the Valium.
  • It is recommended that vasectomy patients abstain from sex for 3 days.
  • You should have no activity the day of the procedure and minimal activity for 2-3 days after the procedure. You can resume all activity including heavy lifting and bike riding seven days after the procedure.
  • You will need to use some form of contraception until your semen is examined under the microscope to be certain that all sperm are absent from the ejaculate. I suggest that you have 15 ejaculations using contraception and then bring in a specimen for me to examine. If no sperm is seen, I will ask for a second specimen a few days later and if the second specimen is without sperm, you will be considered sterile and can stop using contraception.

Bottom Line: While pain tolerance varies from person to person, the pain following a vasectomy is generally a mild discomfort as long as instructions are followed. Avoid heavy lifting and strenuous exercise, take pain medication when necessary and place ice on the scrotum to speed up recovery time.   Finally, a vasectomy is not a protection against sexually transmitted diseases (STD).

Vasectomy For Male Contraception-What Are the Alternatives?

October 10, 2014

A vasectomy is a method of male birth control that should be considered carefully as it is, for the most part, a permanent form of sterilization. The procedure using the no-scalpel, no needle technique can be done in minutes. However, reversing the vasectomy takes several hours in the operating room and is usually not covered by insurance. Before you move forward with a vasectomy, it is important to review vasectomy alternatives that are available.  If you have any doubts about having children in the future, you should explore temporary birth control options.

Tubal ligation, commonly referred to as getting your ‘tubes tied,’ is a procedure used for female sterilization. The fallopian tubes, the small tubes that transport the egg or ovum from the ovary to the uterus, are closed off by various methods (severed, sealed or pinched) to block the eggs from reaching the uterus.

Essure

Essure is a permanent method of birth control where small metal coils are placed in the fallopian tubes. The coils cause scar tissue to form, which blocks the eggs from reaching the uterus. The coils are inserted vaginally during a hysteroscopy procedure. Unlike tubal ligation, there are no incisions or anesthesia used. Birth control is needed for several months after the procedure until the scar tissue has completely formed.

Bottom Line: Vasectomy should be considered a permanent form of contraception. If there is a possibility that you might want more children in the future, I suggest that you consider temporary forms of birth control that are non-surgical. There are a variety of options available including condoms, birth control pills, cervical cap, diaphragm and, yes, abstinence!

Patient Education About Healthcare Purchases Over the Internet: If It’s Too Good To Be True, It Probably Isn’t

October 1, 2014

Many of our patients are besieged with unsolicited Internet advertisements offering them unbelievable solutions and cures to most of mankind’s medical maladies. Patients come to and ask for advice about these promises to magically restore their health.

Since I receive so many request from patients to evaluate these offerings, I have put together five questions that patients should ask themselves before proceeding to buy from websites offering outlandish claims including restoring the fountain of youth!

  1. Does it claim to cure everything? Some of these ads offer to cure diabetes, arthritis, cancer, promote weight loss, prevent baldness and restore hair, remove wrinkles, increase sex drive and cure erectile dysfunction…just to name a few! Since the days of the traveling medicine man shows and snake oil salesmen, there have always been those that offer to sell the unwary elixirs, lotions, potions, monkeys paws and pills that will cure “all that ails ya”. Physicians know that there is not one single remedy that will cure everything.
  1. Are they trying to sell you something? Any website that reports a new discovery that requires the viewer to buy an E-book or pay for specialized treatments that are only available from their facility should be a red flag. Also any site that encourages you to encourage your friends to sign up as resellers, as in Amway pyramids, should make the buyer very cautious.
  1. Has this treatment already worked for thousands of anonymous people? The less reputable sites will post the outrageous benefits that have been received by unverifiable individuals who don’t give their name and city but only their initials.
  1. Is this the medical secret doctors don’t want you to know about? Of the country’s 600,000 physicians, I doubt if there any of them who are a part of a secret conspiracy to keep people sick so that the doctors’ appointment books and schedules remain full. Physicians are appalled and insulted at such a suggestion. People become doctors because they are interested in helping others.
  1. Are there any peer reviewed medical studies that can support their claims of curing so many maladies? It is difficult for the public and the media who are not trained in science and the scientific method to discern that a claim or a medical study is a well thought out evaluation that meets the criteria of a double blind study with placebo controls. So many of these unreasonable and dramatic claims suffer from confirmation bias which is giving more weight to an opinion or conclusion that supports those promoting or selling the products. This is the benefit of a peer review process for a scientific research report or article where multiple independent reviewers and scientists review the same study or research.

My advice to patients: If you answer yes to one or two of these questions, be cautious and ask the seller for more information. If you answer yes to three or more of these questions, shut down the site and don’t walk away, but run quickly and demand that they take you off of their mailing list!

I hope you have found this information useful and will help guide your patients on unsolicited Internet purchases. For more information about buying medical products over the Internet, encourage patients to speak to their physician. Final advice: Caveat emptor or let the buyer beware has never been more appropriate.

To Your Good Health. Give Me a High Fi-Ber!

September 30, 2014

We are trying to lead a healthy lifestyle. Doctors advise us to avoid processed food, take vitamins, and to exercise on a regular basis. Part of leading a healthy life style includes including plenty of fiber in our diets. Most men and women consume only 15gms of fiber a day. The daily recommendation for men is 35gms daily of fiber and for women the recommendation is 25gms. You can increase your fiber by 7gms a day by increasing vegetable and fruit consumption by two portions a day.

Good sources of fiber include what, rice, oats, barley and beans. Also fiber can be found in nuts and seeds, carrots, cauliflower, citrus fruits, strawberries and apples.

There’s no shortage of research showing how fiber may boost your health. Some of its top potential benefits include:

  • Blood sugar control: Soluble fiber may help to slow your body’s breakdown of carbohydrates and the absorption of sugar, helping with blood sugar control.
  • Heart health: An inverse association has been found between fiber intake and heart attack, and research shows that those eating a high-fiber diet have a 40 percent lower risk of heart disease.
  • Stroke: Researchers have found that for every seven-grams more fiber you consume on a daily basis, your stroke risk is decreased by 7 percent.
  • Weight loss and management: Fiber supplements have been shown to enhance weight loss among obese people,3 likely because fiber increases feelings of fullness.
  • Skin health: Fiber, particularly psyllium husk, may help move yeast and fungus out of your body, preventing them from being excreted through your skin where they could trigger acne or rashes.
  • Diverticulitis: Dietary fiber (especially insoluble) may reduce your risk of diverticulitis – an inflammation of polyps in your intestine – by 40 percent.
  • Hemorrhoids: A high-fiber diet may lower your risk of hemorrhoids.
  • Irritable bowel syndrome (IBS): Fiber may provide some relief from IBS.
  • Gallstones and kidney stones: A high-fiber diet may reduce the risk of gallstones and kidney stones, likely because of its ability to help regulate blood sugar.

Bottom Line: High-fiber foods are good for your health. But adding too much fiber too quickly can promote intestinal gas, abdominal bloating and cramping. Increase fiber in your diet gradually over a period of a few weeks. This allows the natural bacteria in your digestive system to adjust to the change. Finally, drink plenty of water. Fiber works best when it absorbs water, making your stool soft and bulky.

Modified from article by Dr. Maureen Hecker-Rodriguez from Touro Infirmary

Caffeine and Menopause-Say Adieu to the Brew

September 28, 2014

Menopause can cause uncomfortable and often incapacitating hot flashes. In most instances these are temporary and will subside without any treatment.

I suggest that if you are suffering from hot flashes, then limit your caffeine consumption. Higher caffeine intake could lead to more severe hot flashes and night sweats during the menopause.

A survey of more than 2,500 women who presented with menopause-related issues at the Mayo Clinic’s Women’s Health Clinic. Researchers then compared the data from those who used caffeine with those who did not.

The study shows that those who used caffeine were more likely to report more severe hot flashes and night sweats.

However, caffeine intake was also linked to experiencing fewer problems with mood, memory and concentration, indicating that it also has its benefits. Mayo Clinic said this could be because caffeine is known to enhance arousal, attention and mood.

Bottom line: While these findings are preliminary, our study suggests that limiting caffeine intake may be useful for those postmenopausal women who have bothersome hot flashes and night sweats.

Drug Treatment For Prostate Cancer

September 28, 2014

Many man will require drug treatment for prostate cancer.  Some of the drugs lose their effectiveness and need to have additional therapy.  This blog will discuss drugs that are used to stop the effect or the production of testosterone which is a necessary hormone for prostate cancer growth.

Drugs that stop androgens from working

Anti-androgens

Androgens have to bind to a protein in the cell called an androgen receptor in order to work. Anti-androgens stop androgens from working by binding to the receptors so the androgens can’t.

Drugs of this type, such as flutamide (Eulexin®), bicalutamide (Casodex®), and nilutamide (Nilandron®), are taken daily as pills.

Anti-androgens are not often used by themselves in this country. An anti-androgen may be added to treatment if orchiectomy, an LHRH analog, or LHRH antagonist is no longer working by itself. An anti-androgen is sometimes given for a few weeks when an LHRH analog is first started to prevent a tumor flare.

Anti-androgen treatment may be combined with orchiectomy or LHRH analogs as first-line hormone therapy. This is called combined androgen blockade (CAB). There is still some debate as to whether CAB is more effective in this setting than using orchiectomy or an LHRH analog alone. If there is a benefit, it appears to be small.

Some doctors are testing the use of anti-androgens instead of orchiectomy or LHRH analogs. Several recent studies have compared the effectiveness of anti-androgens alone with that of LHRH agonists. Most found no difference in survival rates, but a few found anti-androgens to be slightly less effective.

In some men, if hormone therapy including an anti-androgen stops working, the cancer will stop growing for a short time from simply stopping the anti-androgen. Doctors call this the anti-androgen withdrawal effect, although they are not sure why it happens.

Enzalutamide (Xtandi®)

This drug is a newer type of anti-androgen. When androgens bind to the androgen receptor, the receptor sends a signal for the cells to grow and divide. Enzalutamide (also known as MDV3100) blocks this signal from the androgen receptor to the cell.

In men with castrate-resistant prostate cancer, enzalutamide can lower PSA levels, shrink or slow the growth of tumors, and help the men live longer.

Enzalutamide is a pill, with the most common dose being 4 pills each day. In studies of this drug, men stayed on LHRH agonist treatment, so it isn’t clear how helpful this drug would be in men with non-castrate levels of testosterone.

Other androgen-suppressing drugs

Estrogens (female hormones) were once the main alternative to orchiectomy for men with advanced prostate cancer. Because of their possible side effects (including blood clots and breast enlargement), estrogens have been largely replaced by LHRH analogs and anti-androgens. Still, estrogens may be tried if androgen deprivation is no longer working.

Ketoconazole (Nizoral®), first used for treating fungal infections, blocks production of certain hormones, including androgens, similarly to abiraterone. It is most often used to treat men just diagnosed with advanced prostate cancer who have a lot of cancer in the body, as it offers a quick way to lower testosterone levels. It can also be tried if other forms of hormone therapy are no longer effective.

Ketoconazole can block the production of cortisol, an important steroid hormone in the body. People treated with ketoconazole often need to take a corticosteroid (like hydrocortisone) to prevent the side effects caused by low cortisol levels.

Possible side effects of hormone therapy

Orchiectomy, LHRH analogs, and LHRH antagonists can all cause similar side effects due to changes in the levels of hormones such as testosterone and estrogen. These side effects can include:

  • Reduced or absent libido (sexual desire)
  • Impotence (erectile dysfunction)
  • Shrinking of testicles and penis
  • Hot flashes, which may get better or even go away with time
  • Breast tenderness and growth of breast tissue
  • Osteoporosis (bone thinning), which can lead to broken bones
  • Anemia (low red blood cell counts)
  • Decreased mental sharpness
  • Loss of muscle mass
  • Weight gain
  • Fatigue
  • Increased cholesterol
  • Depression

Anti-androgens have similar side effects. The major difference from LHRH agonists and orchiectomy is that anti-androgens may have fewer sexual side effects. When these drugs are used alone, libido and potency can often be maintained. When these drugs are given to men already being treated with LHRH agonists, diarrhea is the major side effect. Nausea, liver problems, and tiredness can also occur.

Abiraterone does not usually cause major side effects, although it can cause joint or muscle pain, high blood pressure, fluid buildup in the body, hot flashes, upset stomach, and diarrhea.

Enzalutamide can cause diarrhea, fatigue, and worsening of hot flashes. This drug can also cause some neurologic side effects, including dizziness and, rarely, seizures. Men taking this drug are more likely to have problems with falls, which may lead to injuries.

Many side effects of hormone therapy can be prevented or treated. For example:

  • Hot flashes can often be helped by treatment with certain antidepressants or other drugs.
  • Brief radiation treatment to the breasts can help prevent their enlargement, but it is not effective once breast enlargement has occurred.
  • Several different drugs are available to help prevent and treat osteoporosis.
  • Depression can be treated by antidepressants and/or counseling.
  • Exercise can help reduce many side effects, including fatigue, weight gain, and the loss of bone and muscle mass.

There is growing concern that hormone therapy for prostate cancer may lead to problems with thinking, concentration, and/or memory. But this has not been studied well in men getting hormone therapy for prostate cancer. Studying the possible effects of hormone therapy on brain function is hard, because other factors may also change the way the brain works. A study has to take all of these factors into account. For example, both prostate cancer and memory problems become more common as men get older. Hormone therapy can also lead to anemia, fatigue, and depression – all of which can affect brain function. Still, hormone therapy does seem to lead to memory problems in some men. These problems are rarely severe, and most often affect only some types of memory. More studies are being done to look at this issue.

Bottom line: Many man experience recurrence of their prostate cancer after treatment. Hormone therapy is the most common treatment option for men in this situation.


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