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Hormone Therapy

The information on this page comes from our Tool Kit fact sheet on hormone therapy. To order your own tailored copy of the Tool Kit, visit our publications page. You can also download and print a PDF version of this fact sheet.

This page is for men who are about to start, or are already receiving, hormone therapy to control their prostate cancer. It describes the different types of hormone therapy, how they are used and their possible side effects. We hope it will help you make decisions with your specialist team about your treatment. Each treatment centre will do things slightly differently so use this page as a general guide to what to expect and ask your specialist team for more details about the treatment you will have.

Who can have hormone therapy?

Hormone therapy is used in different ways depending on the stage of your cancer. Read our other treatment pages for information on other treatments mentioned here.

Localised prostate cancer

Cancer that has not spread outside the prostate gland may be monitored (active monitoring) or treated with radical prostatectomy, radiotherapy or brachytherapy. Your doctor may also offer you hormone therapy in the following situations:

  • If you are having radiotherapy or brachytherapy, you may have hormone therapy for around three months before your treatment starts. This shrinks the tumour and makes it easier to treat 1. Hormone therapy does not benefit men with localised disease who are having a radical prostatectomy.
  • If you are having radiotherapy, you may have hormone therapy at the same time. If there is a high risk of the cancer spreading, you may continue to have hormone therapy for between one and three years afterwards.
  • Hormone therapy can also be used as a second line of treatment if your first treatment is no longer controlling the cancer.

Locally advanced prostate cancer

Prostate cancer that has spread to the area just outside the gland, but has not spread to other parts of the body, is described as ‘locally advanced’. Because the cancer is not contained within the prostate gland, it is not possible to remove it completely with radical prostatectomy or radiotherapy. Hormone therapy treats prostate cancer wherever it is in the body and is the standard treatment for locally advanced prostate cancer.

Some men may benefit from radiotherapy alongside the standard hormone treatment, depending on the stage of their cancer. Speak to your specialist team about your individual treatment options.

Advanced prostate cancer

Prostate cancer that has spread (metastasised) to other parts of the body, such as the bone, is called advanced or metastatic disease. Hormone therapy treats prostate cancer wherever it is in the body. It cannot cure the cancer but it can keep it under control for many months or years.

You will usually be offered an LHRH (luteinizing hormone-releasing hormone) agonist or orchidectomy to begin with 2. Some specialists may also offer an anti-androgen 3.

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How does hormone therapy treat prostate cancer?

The male body produces a hormone called testosterone, which controls the development and growth of the sexual organs, including the prostate gland. Most (90-95%) of the testosterone in your body is produced by the testicles 4 , but a small amount comes from the adrenal glands which sit above your kidneys.

Normal levels of testosterone do not usually cause any problems but, if there are cancer cells in the prostate gland, testosterone can cause them to grow faster. In other words, testosterone ‘feeds’ the prostate cancer. If testosterone is taken away, the cancer cells shrink, wherever they are in the body.

Cancer specialists use hormone therapy to stop testosterone reaching the prostate cancer cells. To do this, they may offer you:

  • Surgery to remove the testicles, where testosterone is produced
  • Injections to stop the production of testosterone
  • Tablets to block the effect of testosterone

Surgery to remove the testicles

An operation, called an orchidectomy, is the oldest form of hormone therapy. It is equally effective at stopping testosterone production as injections. The surgeon will either remove the whole testicles, or just the parts that make the testosterone.

The operation may be done under local or general anaesthetic and you should be able to go home the same day. Short term side effects include swelling and bruising of the scrotum.

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Injections to stop the production of testosterone

Injections of a drug, called an LHRH agonist, work by stopping the brain from telling the testicles to produce testosterone.

LHRH agonists are given as an injection or implant, usually into your abdomen. There are several different LHRH agonist drugs made by different drug companies. Common ones include:

You may have the injections at your GP surgery or local hospital once every one or three months, depending on the dose you are having. Before you have your first injection, you will be given a short course of anti-androgen tablets. This is to prevent the body’s normal response to the first injection, which is to produce more testosterone. This rise in testosterone, known as ‘flare’, could cause the cancer to grow more quickly for a short time. The anti-androgen tablets help to prevent this flare from happening.

You will start taking the tablets a week or so before the first injection and continue taking them for a week or two afterwards. It is important that you take all of the tablets you have been given.

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Tablets to block the effects of testosterone

Anti-androgens

Anti-androgens are taken as tablets at least once a day. They can be used either on their own or together with orchidectomy or LHRH agonists. The most commonly used ones are:

Anti-androgens block the effect of testosterone. They do this by attaching to the areas of prostate cancer cells that attract testosterone from the passing blood stream. This stops the testosterone getting into the cancer cells. Without testosterone the prostate cancer cells are not able to grow.

Oestrogens

Oestrogens are hormones that control sexual development in women. For many years, doctors have used a man-made version of oestrogen called diethylstilbestrol (brand name Stilboestrol) to control the release of testosterone in men with prostate cancer. Diethylstilbestrol works in two ways:

  • It stops the brain from telling the testicles to release testosterone
  • It acts directly on cancer cells, slowing their growth and causing some cancer cells to die

Taking diethylstilbestrol tablets can increase your risk of circulation problems. Because of this, diethylstilbestrol is usually only used to treat advanced prostate cancer which is no longer responding to anti-androgens or LHRH agonists. If you have no history of heart disease or high blood pressure, you may be able to take diethylstilbestrol together with aspirin to reduce the risk 5 .

Skin patches are being studied as a new way of taking oestrogens. Clinical trials are currently looking at whether oestrogen patches are as effective as LHRH agonists at controlling prostate cancer. Researchers also aim to find out whether patches cause fewer side effects than diethylstilbestrol tablets. If you would like to find out more about clinical trials, read our Guide to Clinical Trials and speak to your doctor about trials going on in your area.

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What are the advantages and disadvantages?

Type of hormone therapy

Advantages

Disadvantages

Orchidectomy

It is a one-off treatment

The operation and the side effects are not reversible

It is equally effective at controlling prostate cancer as L HR H agonists

Side effects include erectile dysfunction and hot flushes

It is less likely to cause breast swelling than anti-androgens and oestrogens

Needs a local or general anaesthetic
     

L HR H agonists

If side effects are a problem, they may be improved by switching to a different drug or reversed by stopping treatment

There is a risk of ‘tumour flare' when treatment first starts

They are equally effective at controlling prostate cancer as orchidectomy

Side effects include erectile dysfunction and hot flushes

They are less likely to cause breast swelling than anti-androgens and oestrogens

Involves visits to the GP or hospital every month or every three months

Anti-androgens

If side effects are a problem, they may be improved by switching to a different drug or reversed by stopping treatment

You need to remember to take tablets every day

Because testosterone is still being produced, it may be possible to maintain erections

They cause breast swelling and some erectile dysfunction

They are less likely than L HR H agonists to cause osteoporosis

They are less effective than L HR H analogues at treating cancer that has spread to other parts of the body

Oestrogens

They are suitable for treating advanced prostate cancer if other hormone drugs are no longer effective

You need to remember to take tablets every day

They are less likely than L HR H agonists to cause osteoporosis and hot flushes

There is an increased risk of blood clots forming in the legs or lungs so they are not suitable for men with a history of heart or circulation problems

If side effects are a problem, they may be reversed by stopping treatment

They cause breast swelling and tenderness and erectile dysfunction

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What does the treatment involve?

Depending on which type of hormone therapy you have, you may visit the hospital or your GP surgery for treatment. You will have regular PSA tests and any side effects will be monitored.

Your specialist team may suggest different ways of using hormone therapy, such as ‘maximal androgen blockade’ and ‘intermittent hormone therapy’.

Maximal androgen blockade

This is also known as ‘combined androgen blockade’. The cancer is treated with both an LHRH agonist and an anti-androgen. The LHRH agonist stops the body producing 90% to 95% of its testosterone and the anti-androgen prevents the remaining 5% to 10% from reaching the cancer cells 6 .

Some specialists believe that maximal androgen blockade slightly improves survival in some men whose cancer has spread outside the prostate gland (advanced prostate cancer) 7 . However, it may also increase the risk of side effects so is usually only used if single hormone therapies stop being effective 4.

Intermittent hormone therapy

Intermittent hormone therapy involves stopping treatment when your PSA level is low and steady, and starting treatment again when your PSA starts to rise. This process is repeated for as long as it continues to work. Your doctor will advise you on when you will stop and start treatment.

The advantage of this method is that you avoid side effects during the times that you are not having hormone therapy. However it can take six to nine months for testosterone levels to rise and cause any side effects to wear off.

Researchers think that intermittent hormone therapy is just as effective as continuous treatment but this is still being tested in clinical trials 7 . We do not yet fully understand all of the benefits and risks of this treatment method.

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What happens afterwards?

Hormone therapy is usually a life-long treatment. Eventually the prostate cancer cells may become active again despite the lack of testosterone. This is described as ‘hormone resistant’ or ‘hormone refractory’ disease. We do not fully understand how or why this happens. If you are taking LHRH agonists, you are likely to continue taking them as they may have a ‘background effect’ even if the cancer becomes hormone resistant.

A persistent rise in PSA is usually the first clue that your prostate cancer has become hormone resistant. However, you may not get any symptoms for a long time, if at all. Your specialist team will explain your treatment options, which may include:

  • Continuing with your current treatment, only introducing further treatments if you get symptoms.
  • Starting anti-androgen treatment, if you are only taking an LHRH agonist at the moment.
  • If you are on maximal androgen blockade, stopping anti-androgen treatment for a little while to see if your PSA level falls. Around one in five men (20%) may find that this lowers their PSA level for a few months 8 . We do not fully understand what causes this ‘withdrawal response’.
  • Steroids. The aim of your hormone treatment was to reduce or block the effect of testosterone. However, there may still be some testosterone being produced by the adrenal glands. Adding a low dose of steroids to your hormone treatment will reduce this production. The most commonly used steroid is called dexamethasone. If you have steroid treatment, you will need to take the drugs as prescribed. Do not suddenly stop taking them unless your doctor tells you to as this could cause serious health problems. Your specialist team may give you a ‘steroid treatment card’ to carry with you. This gives details of the treatment you are having and information about what precautions you need to take. Always show this card to a health professional whenever you receive any kind of treatment, even if it is not related to your cancer.
  • Oestrogens. You may be able to use an oestrogen such as diethylstilbestrol to treat cancer that is no longer responding to LHRH agonists and anti-androgens.
  • Other treatments to consider include chemotherapy, bisphosphonates, and radiotherapy.
  • Clinical trials. You may be able to have a new type or method of treatment by taking part in a clinical trial. Ask your doctor which trials are taking place where you live.

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What are the side effects of hormone therapy?

All drugs and treatments carry a risk of side effects. The side effects of hormone therapy are often described as being similar to those experienced by women going through the menopause. Many of these side effects may be reversible if you stop or change your treatment. Testosterone levels rise again and cause the side effects to gradually reduce over the course of a few months. Orchidectomy cannot be reversed but there are drugs available that can help to reduce any symptoms.

The following information describes the most common side effects of hormone therapy. There is no way of knowing in advance which of these you will get or how bad they will be. The risk of getting each side effect depends on which hormone drug you are having.

If you are worried about any side effects or if you get any new symptoms while you are having treatment, speak to your doctor or call our confidential Helpline.

Loss of sex drive and erectile dysfunction

All types of hormone therapy are likely to cause you to lose your desire for sex (libido).

LHRH agonists, oestrogens and orchidectomy also cause problems with getting and keeping an erection (erectile dysfunction). If you stop LHRH agonist or oestrogen treatment, erections may return within a few months to a year. However this depends on how long you have been having hormone therapy and which type of treatment you had.

Anti-androgens are less likely to cause erectile dysfunction but do have other side effects, such as breast swelling.

Treatments for erectile dysfunction are available but these work best when sexual desire is still present.

Hormone therapy may affect your self esteem and sexual relationships. This can be difficult to come to terms with. Ask your specialist team for support if you need it. There may be a local support group or counselling service that they can refer you to. See the end of this page for details of other organisations who can help.

Hot flushes

Between five and eight out of every ten men (50% to 80%) taking hormone therapy will get hot flushes 9 . These give a sudden feeling of warmth in the upper body. Hot flushes can vary from a few seconds of feeling overheated to an hour of sweating that can stop you from sleeping or cause discomfort. They may happen suddenly without warning or they may be triggered by stress, a hot drink or a change in the air temperature.

You can help to prevent or reduce hot flushes by cutting back on smoking, alcohol and drinks that contain caffeine, such as tea and coffee. Using light bed sheets and wearing cotton clothes, especially at night, can also make you feel more comfortable.

Recent reports have suggested that eating soy may help to reduce hot flushes. If you would like to include soy in your diet, try natural forms such as soy beans, miso, tempeh, tofu and soy milk 10 .

Oestrogen patches have been found to help in some cases 11 . Tablets such as megestrol acetate and cyproterone acetate also help but they can affect your liver function so this will need to be monitored. A small number of studies have found that acupuncture reduces hot flushes in some men 12,13 .

Although there is no scientific evidence, some men have found that sage tea helps them to cope with hot flushes. Other complementary medicines that may help include evening primrose oil and red clover. Always tell your specialist team if you are thinking of taking herbal or complementary medicines because some of them cannot be taken alongside other medicines. Your pharmacist can also give you advice on this.

Mild symptoms may not need any treatment and some men find that their hot flushes get better with time. However, if your hot flushes are affecting your everyday life, please speak to a member of your specialist team.

Bone thinning

Long term treatment with LHRH agonists or orchidectomy can cause thinning of the bones, known as osteoporosis. Anti-androgens and oestrogens do not have this effect.

Testosterone helps to keep the bones strong so when hormone therapy reduces the amount of testosterone in the body, the bones may gradually lose their bulk. In some men the bone may fracture or break but we do not know whether this is caused by the hormone therapy or whether other factors, such as normal ageing, are responsible 14. You can help to reduce your risk of osteoporosis by:

  • Getting enough vitamin D and calcium in your diet Vitamin D and calcium may help to prevent bone thinning 15. Increase your intake of calcium by eating more spinach, breakfast cereals, beans, spring greens and fish with soft bones such as sardines. You can get vitamin D from fatty fish and from exposure to sunlight. If you would like to take supplements, aim for 400 to 800 IU of vitamin D and 1000 to 1500mg of calcium each day. Be careful not to take more calcium than this – some studies have shown that more than 2000mg of calcium a day increases the risk of prostate cancer in men. Your specialist team can advise you on your individual needs. You may also like to read our page on diet and prostate cancer.
  • Cutting down on alcohol 15
  • Stopping smoking 14
  • Exercising regularly
    Exercises that use the strength in your muscles, called resistance exercises, may help you to keep strong and prevent any falls which could result in a bone fracture 14. Examples of resistance exercises include swimming, Pilates or using the weights at the gym. Aim for 30 minutes to an hour of exercise two or three times a week.
  • Keeping a healthy weight
    Men who are underweight, with a Body Mass Index (BMI) of less than 19, have a higher risk of bone thinning 16 .

Tiredness

Hormone therapy can cause tiredness, lethargy and memory problems 17,18 . These effects may improve over time but many men find that regular resistance exercise gives them more energy and helps them to cope with treatment 19 . Try swimming or walking down stairs, or if you are not able to move about easily, ask your doctor whether there is a physiotherapist at your hospital who can give you some gentle exercises to do at home.

Breast swelling and tenderness

Anti-androgens and oestrogens may cause swelling (gynaecomastia) and tenderness in the breast area. This can affect one or both breasts and can range from mild sensitivity to ongoing pain.

Around half (50%) of men taking an anti-androgen will get some swelling and between a quarter and three quarters (25% - 75%) will get some degree of tenderness 20 . Most men taking a high dose of the anti-androgen bicalutamide for more than six months will get breast swelling. However it is less common in men who have had an orchidectomy or take an LHRH agonist together with anti-androgen therapy 21 .

If you are about to start taking anti-androgens or oestrogens, your doctor may recommend treating the breast area with radiotherapy or taking a drug called tamoxifen to prevent breast swelling.

A single low dose of radiation can reduce the risk of breast swelling and tenderness. It must be used within the first month of hormone treatment because it has no effect once swelling has already happened 9 . Side effects include reddening of the skin and irritation but this usually clears up in three to five weeks 21 .

Tamoxifen is better known as a treatment for breast cancer. However it is sometimes used to prevent breast swelling and tenderness in men taking anti-androgens 22 . You may not be able to have this treatment if you are taking oestrogens because it may stop the oestrogen from working properly 9 . We do not know how tamoxifen affects other hormone treatments in the long term.

Tamoxifen may also help to treat breast swelling and tenderness that has already developed after starting anti-androgen therapy 22 . Surgery may be a suitable option for men who have been treated with either anti-androgens or oestrogens. Surgery removes painful or swollen areas of the breast. However, this treatment carries a risk of damage to the nipple and a loss of feeling 21.

Weight gain and muscle loss

You may put on weight, particularly around the waist. Exercise and a healthy diet can help you keep to a healthy weight. It can take a long time to lose any weight that you may have put on during hormone therapy. If you are finding it difficult to lose weight, ask to be referred to a state registered dietitian.

Mood changes

Coping with a cancer diagnosis and going through treatment can put a strain on you and those close to you. Hormone therapy may also affect your mood. You may find that you feel more emotional than usual. Some men feel depressed or become worried about what is going to happen. Try to get help early on as this will help you cope better with treatment. Your medical team can answer any questions you may have and can be a good source of support. Talking to family and friends can also help. Anti-depressants are often very successfully used to treat hormone therapy-related depression.

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Questions to ask your specialist team

  • What is the aim of this treatment?
  • What type of hormone treatment are you recommending for me and why?
  • How long would it be before we know that the hormone treatment is working?
  • What side effects should I expect?
  • How often will you monitor my condition throughout this treatment?
  • What other treatments are available if the cancer starts to grow again?

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Links

The following organisations provide further information relevant to this page.

Cancerbackup
www.cancerbackup.org.uk
Produces an information booklet on coping with fatigue.

The Royal College of Psychiatrists
www.rcpsych.ac.uk
Provides information on their website on dealing with depression.

The Chartered Society of Physiotherapy
www.csp.org.uk
Gives details of how to find a physiotherapist.

Medicines and Healthcare products Regulatory Agency (MHRA)
www.mhra.gov.uk
Their website contains information on the safety of herbal medicines

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Reviewed by:

  • Dr John Graham, Lead Consultant Oncologist, Taunton & Somerset NHS Trust
  • Nicola James, Macmillan Nurse Consultant; Uro-oncology, Chesterfield NHS Foundation Trust
  • Dr Chris Parker, Senior Lecturer and Honorary Consultant in Clinical Oncology, Institute of Cancer Research and Royal Marsden Hospital
  • Lucy Powell, Uro-Oncology Clinical Nurse Specialist, Essex Rivers NHS Trust
  • The Prostate Cancer Charity Information Volunteers
  • The Prostate Cancer Charity Support & Information Specialist Nurses

Written and edited by:

The Prostate Cancer Charity Information Team

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References used in the production of this page.

1. Kumar S, Shelley M, Harrison C et al. Neo-adjuvant and adjuvant hormone therapy for localised and locally advanced prostate cancer. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD006019.

2. British Association of Urological Surgeons. 2004. Guidelines for the management of Metastatic prostate cancer (CD-ROM)

3. Augustovski F, Colantonion L, Pichon Riviere A. Androgen deprivation treatment (hormonal therapy) for the management of prostate cancer. Health Technology Assessment 2006, Report ITB No.30.

4. Schmitt B, Bennett C, Seidenfeld J et al. Maximal androgen blockade for advanced prostate cancer. Cochrane Database of Systematic Reviews 1999, Issue 2.

5. Burns-Cox N, Basketter V, Higgins B et al. Prospective randomised trial comparing diethylstilboestrol and flutamide in the treatment of hormone relapsed prostate cancer. International Journal of Urology 2002; 9(8): 431-434.

6. ASCO patient guide: hormone therapy for advanced prostate cancer. Clinical practice guidelines. 2007. Available from. www.asco.org [accessed April 2007]

7. Loblaw DA, Virgo KS, Nam R et al. Initial hormonal management of androgen-sensitive Metastatic, recurrent, or progressive prostate cancer – 2006 update of an American Society of Clinical Oncology practice guideline. Journal of Clinical Oncology 2007; 25(12): 1596-1605.

8. Small EJ, Vogelzang NJ. Second-line hormonal therapy for advanced prostate cancer: a shifting paradigm. J Clin Oncol. 1997; 15(1): 382-388.

9. Higano CS. Side effects of androgen deprivation therapy: monitoring and minimizing toxicity. Urology 2003; 61(Suppl 2A): 32-38.

10. Moyad MA. Complementary/alternative therapies for reducing hot flashes in prostate cancer patients: reevaluating the existing indirect data from studies of breast cancer and postmenopausal women. Urology 2002; 59 (Suppl 4A): 20–33.

11. Gerber, G. S., Zagaja, G. P., Ray, P. S. & Rukstalis, D. B. (2000) Transdermal estrogen in the treatment of hot flushes in men with prostate cancer. Urology, 55: 97-101.

12. Filshie J, Bolton T, Browne D, Ashley S. Acupuncture and self acupuncture for long-term treatment of vasomotor symptoms in cancer patients--audit and treatment algorithm. Acupunture Medicine 2005; 23(4):171-80.

13. Hammar M, Frisk J, Grimas O et al. Acupuncture treatment of vasomotor symptoms in men with Prostatic carcinoma: a pilot study. J Urol 1999; 161: 853-856.

14. Gomella LG. Contemporary use of hormonal therapy in prostate cancer: managing complications and addressing quality-of-life issues. BJU International 2007; 99 Supp.1: 25-29.

15. Drudge-Coates L. Bone health: the effect of androgen deprivation therapy in porstate cancer patients. International Journal of Urological Nursing 2007; 1(1): 18-26.

16. National Osteoporosis Socity. Osteoporosis: causes, prevention and treatment. 2001. Bath: NOS.

17. Shahinian VB, Kuo YF, Freeman JL, Goodwin JS. Risk of the androgen deprivation syndrome in men receiving androgen deprivation for prostate cancer. Archives of internal medicine 2006; 166(4): 465-71.

18. Stone P, Hardy J, Huddart R et al. Fatigue in patients with prostate cancer receiving hormone therapy. European journal of cancer 2000; 36(9): 1134-41.

19. Segal RJ, Reid RD, Courneya KS et al. Resistance training in men receiving androgen deprivation therapy for prostate cancer. Journal of Clinical Oncology 2003; 21: 1653-1659.

20. McLeod DG. Tolerability of nonsteroidal antiandrogens in the treatment of advanced prostate cancer. Oncologist 1997; 2: 18-27.

21. Di Lorenzo G, Autorino R, Perdona S et al. Management of gynaecomastia in patients with prostate cancer: a systematic review. Lancet Oncology 2005; 6: 972-79.

22. National Institute for Health and Clinical Excellence. 2008. Prostate cancer: diagnosis and treatment. Available at http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11924

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Page last updated: March 28th 2008