Some treatments for prostate and testicular cancer can cause hormonal symptoms. These symptoms may not always be severe but can cause a lot of discomfort, and lead to anxiety and a reduced quality of life for some men. This information is about the symptoms these treatments may cause and gives suggestions about how to cope with them.

Hormones are substances that occur naturally in the body. They control the growth and activity of normal cells. The male sex hormone, testosterone, is produced by the testicles and is involved in the development of male characteristics, such as beard growth, muscle strength and a deeper voice. Testosterone also stimulates sex drive and helps sperm to develop. The testicles are stimulated to produce testosterone by another hormone, luteinising hormone (LH), which is produced in the pituitary gland in the brain.

A reduction in the level of testosterone can cause a number of symptoms. These may include hot flushes and sweats, tiredness, a lower sex drive (reduced libido) and the inability to get an erection (impotence). Some men also experience sore joints, headaches, mood changes and sleeplessness. Not every man has every symptom, and the symptoms can range from very mild to more severe.

Testicular cancer

Surgical removal of one of the testicles (orchidectomy) is usually the first treatment for testicular cancer. Removing just one testicle will have little or no effect on the production of testosterone, as the remaining testicle will usually produce normal levels of the hormone. Sometimes, however, the remaining testicle is not able to produce enough testosterone. Occasionally both testicles may need to be removed. This is called a bilateral orchidectomy.

Prostate cancer

Cancer of the prostate is dependent on the hormone testosterone for its growth. By reducing the amount of testosterone in the body it is possible to slow down or stop the growth of the prostate cancer cells.

The levels of testosterone in the body can be lowered by removing the part of the testicles that produce testosterone (in an operation called a subcapsular orchidectomy), or by using hormonal therapy which is given either by injection or as tablets.

Hormonal therapy is widely used in the treatment of prostate cancer.

Some drugs 'switch off' the production of testosterone from the testicles by reducing the levels of luteinising hormone produced by the pituitary gland. These drugs are called pituitary down-regulators or GnRH (gonadotrophin releasing hormone) analogues and they are given by injecting a pellet or a liquid under the skin. The injections can be given monthly or every three months.

Commonly used GnRH analogues are:

• goserelin (Zoladex®)
• leuprorelin (Prostap®)
• buserelin (Suprefact®)
• triptorelin (De-capeptyl SR®).

Other hormonal therapy drugs work by attaching themselves to proteins (receptors) inside the cancer cells. This blocks the action of testosterone on the cancer cells. They are called anti-androgens and are often given as tablets.

Commonly used anti-androgens are:

• flutamide (Chimax®, Drogenil®)
• cyproterone acetate (Cyprostat®)
• bicalutamide (Casodex®).

Oestrogen treatment may be used to control the growth of the cancer for some men. The main drug used is a man-made oestrogen called diethylstilbestrol (DES). Oestrogen can cause nausea, indigestion and swelling and tenderness of the breasts. It can also increase the risk of developing blood clots.

Impotence

Most hormonal therapies often cause the inability to have an erection (sexual impotence) and loss of sexual desire. This will continue for as long as the treatment is given. If the treatment is stopped, the problem may disappear.

When both testicles are removed (bilateral orchidectomy) impotence is permanent. Most men who have one testicle removed for cancer will not have problems. If a man develops very low levels of testosterone (after surgery for testicular cancer) then it is possible to have hormone replacement therapy (HRT) but this is not often needed.

Medicines, pumps and injections to give an erection

If you have problems obtaining or maintaining an erection there are many options that may help. It's important to remember that, although these will give you a hard penis, they will not necessarily increase your arousal.

There are tablets that can help produce an erection by increasing the blood flow to the penis. These include sildenafil (Viagra®), vardenafil (Levitra®), and tadalafil (Cialis®).

Alprostadil (Caverject®, Viridal®) or papaverine are drugs that can be injected directly into the penis, using a small needle, to help cause an erection. The injections are prescribed by your GP.

Alprostadil pellets (MUSE®) can be inserted into the penis. The pellet melts into the area around, and, after some rubbing to distribute it into the nearby tissues, produces an erection.

Vacuum pumps can also be used to produce an erection. The pump is a simple device with a hollow tube that you put your penis into. The pump draws blood into the penis by creating a vacuum. The blood then gets caught in the penis by a rubber ring (placed around the base of the penis). This ring allows you to make love without losing the erection. Once you have finished making love the ring is taken off and the blood flows normally again.

If you think any of these options might be useful to you, your doctor can give more information.

Hot flushes and sweats

In about half the men who have hormonal therapy drugs, the side-effects which cause the most problems are hot flushes and sweating. Although it is difficult to stop these, their frequency or intensity usually wears off after a period of time and can often be controlled. Hot flushes and sweating will stop some months after the treatment ends.

Some tips to help you manage and reduce hot flushes and sweats are listed below:

• Wear several layers of light clothing (preferably cotton) that you can easily take off or put back on depending on your body temperature.
• Cut down on alcohol, nicotine and hot drinks that contain caffeine, particularly coffee and tea.
• Lukewarm baths and showers are less likely to trigger sweats than hot ones.
• Flushes and sweats are often worse at night. Put a soft cotton towel on your bed that you can easily change if it gets wet during the night.
• Cyproterone acetate (Cyprostat®) is an anti-androgen drug that can sometimes help to reduce hot flushes and sweats.
• Recent research suggests that progesterone or some antidepressants such as venlafaxine (Efexor®) may be helpful.
• Taking evening primrose oil may be helpful, although there is no scientific evidence that it works.
• Complementary therapies such as homeopathy or acupuncture may help. Your GP can give you details about having these on the NHS. If you wish to find your own therapist, make sure that they are properly qualified and registered. The British Complementary Medical Association has lists of registered practitioners throughout the UK.
• A yoga breathing technique, known as the 'cooling breath' or sheetali, can help to reduce the body temperature. Contact the British Wheel of Yoga to find a registered practitioner.

Breast swelling or tenderness

Some drugs (most commonly flutamide and bicalutamide) may cause breast swelling and tenderness. Often this can be avoided by giving a low dose of radiation to the breast tissue before or soon after the start of treatment.

A low dose of the drug tamoxifen (given as a tablet once a week) has been shown to help reduce breast swelling and tenderness. Your doctor can prescribe medicines to reduce any discomfort.

Weight gain

Exercise can help to keep your weight stable if you have put on weight because of your hormonal therapy. It is also important to eat a healthy balanced diet. Your doctor or nurse can give you further advice about managing weight gain, or could refer you to a dietitian.

Tiredness

Hormonal treatment can make you feel constantly tired (both mentally and physically). If you do get very tired, it can help to plan your day so that you have time to rest and do the things that you want. There may be things that you cannot manage to do, such as housework or gardening. Ask others to help you with tasks that you find too demanding. Exercise can also help to relieve the symptoms of tiredness. The tiredness gets better if the drug treatment is stopped.

Osteoporosis

Having both testicles removed, or being on long-term GnRH analogue treatment, will increase your risk of developing osteoporosis (brittle bones). Regular weight-bearing exercises help to maintain bone density. Walking is probably the best type of exercise. Swimming is less helpful as your bones are not supporting your weight. Be aware that smoking and alcohol can reduce your calcium levels. Calcium helps protect your bones.

You may wish to talk to your cancer specialist about using medicines such as bisphosphonates to try to prevent osteoporosis. Bisphosphonates might help to reduce bone deterioration, but they can have side effects. These drugs are taken as tablets on an empty stomach.

If you already have osteoporosis, you can talk to your doctor about taking calcium and vitamin D supplements. Warm baths can help to relax stiff joints and regular exercise will keep muscles supple. Be aware of dangers or trip hazards that could lead to falls.

The National Osteoporosis Society can give you more information about prevention of osteoporosis and can let you know more about helpful treatments.

Psychological effects

Some hormonal symptoms can be very difficult to deal with. These include a lower sex drive, hot flushes and sweats and tiredness. You may feel emotional and anxious without really knowing why. These symptoms may be quite distressing for you and your partner, if you have one. Sleeplessness due to sweats or anxiety may add to your problems. The following may help you to relax and sleep well, which can help you to feel more in control during the day:

• Have a lukewarm bath to relax before bedtime.
• A hot herbal or milk drink before bed can help you to relax.
• If you can't sleep, don't just lie in bed. Get up and read, listen to the radio or an audiobook on tape or CD, or watch TV until you feel sleepy.
• Occasionally your GP will prescribe sleeping tablets for a short period of time, which may help to re-establish a better pattern of sleep.
• Techniques such as listening to relaxation tapes, relaxation exercises, visualisation, massage or meditation can help to reduce anxiety and sleeplessness.

To reduce the risk of side effects, it may be possible to give the hormonal therapy for a few months and then stop for a time, before restarting it sometime later. This is known as intermittent therapy. At present it is not known whether this is as effective as continuous treatment, but it is being given as part of research studies (clinical trials).

This section based upon our Men's cancers and hormonal symptoms factsheet which been compiled using information from a number of reliable sources, including:

• Oxford Textbook of Oncology (2nd edition). Eds Souhami et al, Oxford University Press, 2002.
• Martindale: The Complete Drug Reference (35th edition). Eds. Sweetman et al, Pharmaceutical Press, 2007.

For further references, please see general bibliography.