Hot Flushes/Flashes

Hot flashes occur in men receiving hormone therapy for the treatment of high-stage prostate cancer and in patients receiving neoadjuvant hormone therapy (hormone therapy administered before definitive treatment, e.g., radical prostatectomy or interstitial seeds to shrink the prostate cancer).

Approximately three-quarters (75%) of the men being treated with hormone therapy for prostate cancer report bothersome hot flashes that begin 1 to 12 months after starting hormone therapy and often persist for years. The hot flashes may vary in intensity and can last from a few seconds to an hour.

The cause of hot flashes and sweating (vasomotor symptoms) associated with hormone therapy (shots or orchiectomy) is not well known. The symptoms are similar to those that women experience while going through menopause, yet they are not typically experienced by men, whose testosterone level slowly declines with aging. The symptoms appear to be related to the sudden large decrease in the testosterone level and the effects that testosterone has on blood vessels. There are no identifiable factors that put one individual at higher risk for hot flashes than another.

There are many ways to treat hot flashes associated with hormone therapy, and different men respond to different treatments (Table 10). Some options include clonidine (a blood pressure medication), the hormone megestrol acetate (Megace), medroxyprogesterone acetate (Provera), estrogen patches, low-dose estrogen (DES), and medroxyprogesterone acetate (Depo-Provera). Oral estrogen has been effective in getting rid of the hot flashes; however, estrogen use carries the risk of heart problems, strokes, and blood clots. Low-dose megestrol acetate (Megace) has been used effectively to treat hot flashes and works in about 85% of people. However, it has been associated in rare cases with an increase in PSA that decreased with stopping the Megace and must be used cautiously. Another chemical, cyproterone acetate, has been used to treat hot flashes, but it is associated with cardiac side effects, is expensive, and is not approved for this use by the FDA. The hormone Provera, given orally or intramuscularly, has been effective in treating hot flashes, but it also may have

Table 10. Drugs Commonly Used in Treating Hot Flashes

Abbreviations: BID, twice a day; TID, three times a day; IM, intramuscularly; PO, orally; QD, every day.

Ellsworth, P. 100 Questions and Answers About Prostate Cancer, 2e. Jones and Bartlett Publishers, LLC, 2009.

some cardiovascular side effects. Clonidine patches have been helpful in decreasing the incidence and severity of hot flashes with natural or surgically-induced (hysterectomy and removal of the ovaries) menopause, but they do not appear to be as effective in men. Eating a serving of soy daily in addition to 800 IU of vitamin E in one study was shown to decrease the number and the severity of hot flashes to 50% (see Question 9). You should not take this amount of vitamin E without consulting your doctor first. Lastly, antidepressants such as gabapentin and venlafaxine have been shown to be useful in treating hot flashes. Limiting caffeine intake and avoiding strenuous exercise and very warm temperatures are also helpful in controlling hot flashes.

Breast Swelling and Tenderness (Gynecomastia)

Antiandrogens may cause swelling and tenderness in the breast area (gynecomastia). This can affect one or both breasts and can range from mild sensitivity to ongoing pain. About one-half of men taking antiandro-gens will develop breast swelling and between 25% and 75% will note some breast tenderness. Gynecomastia is not as common in men who have had an orchiectomy or in those who are on combination therapy (an LHRH agonist or antagonist and an anti-androgen). A single dose of radiation to the breasts can decrease the risk of developing gynecomastia but is only effective if the radiation is given the first month of the hormone therapy. If gynecomastia has already developed then radiation treatment is not helpful. Tamoxifen, a medication that is used to treat breast cancer, can help in treating gynecomastia in men taking antiandrogens. It can't be used in those men who are taking estrogens (DES) to treat prostate cancer as the tamoxifen stops the estrogens from working properly. Tamoxifen may help treat gynecomastia that has already developed in men after starting antiandrogens. Another option for the treatment of gynecomastia is surgical removal of the breast tissue. However, this has the risk of damage to the nipple and loss of feeling.

Hormone therapy can also cause weight gain and muscle loss. Exercise and diet regimens can help with these problems. Hormone therapy can also cause tiredness and lethargy, memory problems, and moodiness. The lethargy and tiredness may improve over time, but regular exercise can give men more energy and help them cope.

Anemia (lowering of the red blood cell count) may occur in men who are on hormone therapy. For men with advanced prostate cancer, use of an LHRH agonist/antagonist without the antiandrogen may be beneficial in limiting the anemia that is caused by complete androgen blockade (antiandrogen plus LHRH agonist or antagonist). Erythropoietin, iron preparations, and vitamin supplementation may be helpful in improving the anemia.