How does hormone therapy work?

Hormone therapy works by either stopping your body from making testosterone, or by stopping testosterone from reaching the cancer cells.

Prostate cancer cells usually need testosterone to grow. Testosterone is a hormone that controls how the prostate grows and develops. It also controls other male characteristics, such as muscle strength, erections, and the size and function of the penis and testicles.

Most of the testosterone in your body is made by the testicles. A small amount also comes from the adrenal glands, which sit above your kidneys.

Testosterone doesn’t usually cause problems but, if you have prostate cancer, it can make the cancer cells grow faster. If testosterone is taken away, the cancer will usually shrink, even if it has spread to other parts of your body.

Hormone therapy on its own won’t cure your prostate cancer. If you have hormone therapy on its own, the treatment will aim to control your cancer and delay or manage any symptoms.

Hormone therapy can also be used with other treatments, such as radiotherapy, to make the treatment more effective.

Watch our video about hormone therapy to find out more:

Who can have hormone therapy?

Hormone therapy is an option for many people with prostate cancer, but it’s used in different ways depending on whether your cancer has spread.

Localised (early) prostate cancer

If your cancer hasn’t spread outside the prostate (localised prostate cancer), you might have hormone therapy alongside your main treatment. Hormone therapy can shrink the prostate and any cancer inside it, which makes the cancer easier to treat. It can also make your main treatment more effective. You might have hormone therapy:

Hormone therapy is not usually given to men having surgery to remove their prostate (radical prostatectomy).

Read more about localised prostate cancer.

Locally advanced prostate cancer

If your cancer has spread to the area just outside the prostate (locally advanced prostate cancer), you may have hormone therapy before, during and after radiotherapy. Hormone therapy can help shrink the prostate and any cancer that has spread, and make the treatment more effective.

You may be offered hormone therapy for up to six months before radiotherapy. And you may continue to have hormone therapy during and after your radiotherapy, for up to three years.

Some men might have hormone therapy on its own if radiotherapy or surgery aren’t suitable for them.

Read more about locally advanced prostate cancer.

Advanced (metastatic) prostate cancer

Hormone therapy will be a life-long treatment for most men with prostate cancer that has spread to other parts of the body (advanced or metastatic prostate cancer).

Hormone therapy shrinks the cancer and slows down its growth, wherever it has spread to in the body. It can’t cure the cancer, but it can keep it under control, sometimes for several years. It can also help manage symptoms of advanced cancer, such as bone pain.

How long it will control the cancer for varies from man to man. It may depend on how aggressive your cancer is and how far it has spread. It’s difficult for doctors to know exactly how long it will keep your cancer under control. Speak to your doctor or nurse about your own situation.

Read more about advanced prostate cancer.

Prostate cancer that has come back after treatment (recurrent prostate cancer)

If your cancer has come back after treatment for localised or locally advanced prostate cancer, hormone therapy will be one of the treatments available to you.

Read more about recurrent prostate cancer.

Unsure about your diagnosis and treatment options?

If you have any questions about your diagnosis at any time, ask your doctor or nurse. They can explain your test results and your treatment options. Make sure you have all the information you need. Read more about how prostate cancer is diagnosed.

Hormone therapy has kept my prostate cancer under control for seven years.

- A personal experience

What types of hormone therapy are there?

There are three main ways to have hormone therapy for prostate cancer. These are:

  • injections or implants
  • tablets
  • surgery to remove the testicles (orchidectomy).

The type of hormone therapy you have will depend on whether your cancer has spread, any other treatments you’re having, and your own personal choice. You may have more than one type of hormone therapy at the same time.

Injections or implants

These stop your body from making testosterone. They work by blocking the message from the brain that tells your testicles to make testosterone.

Injections or implants are as good at controlling prostate cancer as surgery to remove the testicles.

Ask your doctor or nurse whether you will have injections or implants. They are both given using a needle.

Injections use a needle to inject a small amount of liquid under the skin or into muscle. They may be given in your arm, abdomen (stomach area), thigh or bottom (buttock), depending on the type you’re having.

Implants may be given as a small pellet that is placed under the skin in the abdomen and slowly releases the drug.

You will have the injections or implants at your GP surgery or local hospital. How often you have them will vary, depending on the type you are having.

Some men have an injection or implant once a month, while others have an injection every three or six months.

LHRH agonists

LHRH agonists (luteinizing hormone-releasing hormone agonists) are the most common type of injection or implant. There are several available that all work in the same way, including:

  • goserelin (Zoladex®)
  • leuprorelin acetate (Prostap® or Lutrate®)
  • triptorelin (Decapeptyl® or Gonapeptyl Depot®)
  • buserelin acetate (Suprefact®).

LHRH agonists cause the body to produce more testosterone for a short time after the first injection. This usually happens about two or three days after you have the first injection.

This temporary surge in testosterone could cause the cancer to grow more quickly for a short time, which might make any symptoms you have worse for about a week – this is known as a flare.

If you’re having an LHRH agonist, you’ll be given a short course of anti-androgen tablets as well. This should stop any problems caused by this surge of testosterone.

You’ll usually start taking the anti-androgen tablets before your first injection or implant and keep taking them for a few weeks.

GnRH antagonists

GnRH antagonists (gonadotrophin-releasing hormone antagonists) are used less often than LHRH agonists. You may also hear them called GnRH blockers.

There’s one type available in the UK, called degarelix (Firmagon®). Degarelix can be used as a first treatment for advanced prostate cancer that has spread to the bones.

It may help to prevent metastatic spinal cord compression (MSCC), which can happen if cancer cells grow in or near the spine and press on the spinal cord.

When you start degarelix, you’ll have two injections on the same day – one on each side of your abdomen (stomach area). You will then have one injection every month, or some men switch to an LHRH agonist.

Unlike LHRH agonists, degarelix doesn’t cause a surge in testosterone with the first treatment, so you won’t need to take anti-androgen tablets.

Instead your testosterone levels will start to drop straight away, usually on the first day of having treatment. Symptoms such as bone pain should start to improve quickly.

Keeping track of your injections

If you’re having injections, it’s a good idea to record all the dates so that you don’t miss an appointment. There’s space to record details in our booklet, Living with hormone therapy: A guide for men with prostate cancer.

If your injection is a few days late, it shouldn’t be a problem. But if your injection is late by a couple of weeks or more, your body may start to produce more testosterone, which may cause the cancer to start growing again.

If you think you’ve missed an injection, tell your doctor or nurse as soon as possible.

Tablets

Anti-androgens

Anti-androgen tablets stop testosterone from reaching the cancer cells. They can be used:

  • on their own
  • before having injections or implants
  • together with injections or implants
  • after surgery to remove the testicles (orchidectomy).

There are different types of anti-androgen tablets, including:

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

Ask your doctor how long you’ll need to take anti-androgens for, and whether you’re having them with another treatment or on their own.

Anti-androgens taken on their own are less likely to cause sexual problems and bone thinning than other types of hormone therapy. But they may be more likely to cause breast swelling and tenderness.

If your cancer is advanced, anti-androgens will be less effective than other types of hormone therapy. So if you have advanced cancer, your doctor will usually recommend an LHRH agonist.

Abiraterone acetate (Zytiga®)

Abiraterone tablets are usually only given to men with advanced prostate cancer that’s stopped responding to standard hormone therapy.

But some hospitals now offer abiraterone as a first treatment for advanced cancer, for example if a man isn’t fit enough for chemotherapy. Find out more about abiraterone.

Surgery to remove the testicles (orchidectomy)

You may be offered an operation to remove the testicles, or the parts of the testicles that make testosterone. This is called an orchidectomy (or orchiectomy). It’s not used as often as other types of hormone therapy.

Surgery is very effective at reducing testosterone levels, which should drop to their lowest level very quickly – usually in less than 12 hours. It also means that you won’t need to have regular injections, so there’s no risk that you’ll miss an injection.

Surgery can’t be reversed, so it’s usually only offered to men who need long-term hormone therapy.

If you’re thinking about having surgery, your doctor may suggest trying injections or implants for a while first. This will give you and your doctor a chance to see how you deal with the side effects of low testosterone.

Short-term side effects of an orchidectomy include swelling and bruising of the scrotum (the skin containing the testicles).

Some men find the thought of having an orchidectomy upsetting and worry about how they’ll feel once their testicles are removed. Speak to your doctor if you have any concerns.

If you don’t want an orchidectomy, you can usually have a different type of hormone therapy instead.

What are the advantages and disadvantages of hormone therapy?

What may be important to one person might be less important to someone else. So speak to your doctor or nurse about your own situation.

Advantages

  • It’s an effective way to control prostate cancer, even if it has spread to other parts of your body.
  • It can be used alongside other treatments to make them more effective.
  • It can help to reduce some of the symptoms of advanced prostate cancer, such as urinary symptoms and bone pain.

Disadvantages

  • It can cause side effects that might have a big impact on your daily life.
  • It can’t cure your cancer when it’s used by itself, but it can help to keep the cancer under control, sometimes for many years.

What are the side effects of hormone therapy?

Like all treatments, hormone therapy can cause side effects. These are usually caused by low testosterone levels.

Hormone therapy affects men in different ways and you may not get all of the possible side effects. Some men only get a few side effects or don’t get any at all. This doesn’t mean that the treatment isn’t working.

Some men find their side effects improve or get easier to manage the longer they’re on hormone therapy. But if side effects don’t improve, there are usually ways to manage them.

Side effects will usually last for as long as you’re on hormone therapy. If you stop using it, the side effects should improve as your testosterone levels start to rise again.

Your side effects won’t stop straight away – it may take several months or years. For some men, the side effects may never go away completely.

The risk of getting each side effect depends on your type of hormone therapy and how long you take it for. If you have hormone therapy alongside another treatment, you may get side effects from that treatment as well.

Surgery to remove the testicles (orchidectomy) can’t be reversed, so the side effects will be permanent. But there are treatments to help manage them.

Discuss the possible side effects with your doctor or nurse before you start or change your hormone therapy, or call our Specialist Nurses. If you know what side effects you might get, it can be easier to manage them.

If you have any concerns about your side effects or get any new symptoms, such as bone pain, speak to your doctor or nurse, or call our Specialist Nurses.

We describe the most common side effects of hormone therapy below. Find out more about side effects of hormone therapy and how you can manage them.

Hot flushes

Hot flushes are a common side effect of hormone therapy. They are similar to the hot flushes women get when they’re going through the menopause.

They give you a sudden feeling of warmth in your body. You might feel very hot in your face, neck, chest or back. They can vary from a few seconds of feeling very hot to a few hours of sweating, which can be uncomfortable.

Some men find that their hot flushes get milder and happen less often over time, but other men continue to have hot flushes for as long as they have hormone therapy.

There are things that can help manage hot flushes, including lifestyle changes and medicines. Speak to your doctor if you get hot flushes.

Some men also use complementary therapies to manage hot flushes, such as acupuncture, cognitive behavioural therapy (CBT) and herbal remedies. But there isn’t any strong evidence that these work.

If you’re thinking about using any complementary therapies, make sure you tell your doctor or nurse as they might interfere with your cancer treatment. You should also tell your complementary therapist about any cancer treatments you’re having.

I have hot flushes through the night. I used to be angry but now I use the cooling off time to stretch and plan the next day.

- A personal experience

Extreme tiredness (fatigue)

Hormone therapy can make you feel extremely tired, which could affect your everyday life. Fatigue can come on quite suddenly and can affect your energy levels, motivation and emotions.

This may improve over time and there are things you can do to help manage fatigue.

These include being physically active and planning your day to make the most of when you have more energy. Read more about fatigue and prostate cancer.

Support for fatigue

Our fatigue support service is a 10-week telephone service delivered by our Specialist Nurses. It can help you make positive changes to your behaviour and lifestyle, which can improve your fatigue over time. For more information call our Specialist Nurses.

There are also lots of tips on how to manage fatigue in our interactive online guide.

Changes to your sex life

Hormone therapy can cause the following changes to your sex life:

  • less desire for sex (low libido)
  • problems getting or keeping an erection (erectile dysfunction)
  • producing less semen and having less intense orgasms
  • changes to the size of your penis and the size or shape of your testicles.

There are treatments and ways to manage changes to your sex life. Hormone therapy reduces your desire for sex. So treatments that only work when you have desire, such as tablets, are unlikely to work.

But injections, pellets, cream or a vacuum pump may still help you get an erection, even if your desire for sex is low.

Read more prostate cancer and your sex life.

Weight gain

Some people put on weight while they’re on hormone therapy, particularly around the waist. Some men find this hard to deal with, especially if they’ve never had problems with their weight in the past.

Physical activity and a healthy diet can help you stay a healthy weight.

Read more about diet and physical activity.

Strength and muscle loss

Testosterone plays an important part in the physical make up of men’s bodies. Hormone therapy can cause you to lose some muscle tissue. This can change the way your body looks and how physically strong you feel.

Regular gentle resistance exercise, such as lifting light weights or using elastic resistance bands, may help to prevent muscle loss and keep your muscles strong. Read more about diet and physical activity for men with prostate cancer.

Some men may also get aching muscles or joint pain while they’re on hormone therapy. This can happen when you lose muscle.

Talk to your doctor or nurse if you have any pain in your muscles or joints. They can talk to you about ways to manage it.

Memory and concentration

If you’re having hormone therapy you may find it difficult to concentrate or focus on certain tasks. Or you might struggle to remember things as well as you used to.

But we don’t know for sure whether any changes are caused by the hormone therapy or by something else, because the evidence isn’t very strong. For example, feeling tired, stressed, anxious or depressed can all affect your memory or ability to concentrate.

Memory problems can also happen naturally as you get older.

Whatever the cause, you may find problems with memory or concentration very frustrating. If you’re having problems with your memory, talk to your doctor or nurse. They will be able to suggest things that may help.

Breast swelling or tenderness

Hormone therapy may cause swelling (gynaecomastia) or tenderness in the chest area. The amount of swelling can vary from a small amount to noticeable breasts.

Tenderness can affect one or both sides of the chest and can range from mild sensitivity to long-lasting pain.

Breast swelling is more common in men who are taking anti-androgen on their own.

If you put on weight while you’re on hormone therapy, this can also lead to larger breasts.

There are ways to reduce your risk of breast swelling and tenderness, or help treat it. These include treating the breast area with a single dose of radiotherapy during your first six months on hormone therapy, taking tablets (such as tamoxifen), or sometimes having surgery to remove some of the breast tissue.

Loss of body hair

Some men lose their body hair while they are on hormone therapy. This is because testosterone plays a role in hair growth. So when testosterone is reduced, you might lose some of it. This can happen anywhere on your body, including your face, chest and pubic area. The hair should grow back if you stop hormone therapy.

Bone thinning

Testosterone helps to keep bones strong. Long-term hormone therapy can make your bones weaker and cause a condition called osteoporosis. This means you may be more likely to have broken bones (fractures).

Anti-androgens are less likely to cause bone thinning than other types of hormone therapy.

Your doctor may suggest you have a type of X-ray called a bone density or DEXA (dual energy X-ray absorptiometry) scan before you start hormone therapy. This will show any areas of weak bone.

You might also have a bone density scan after you’ve been on hormone therapy for a few years. This will check for any signs of bone thinning.

Lifestyle changes such as being more active and changes to your diet may help reduce your risk of bone thinning.

We don’t yet know whether exercise can help to prevent bone thinning in men who are on hormone therapy. But regular physical activity could help to keep you strong and prevent falls that could cause broken bones.

These types of exercise may be particularly helpful:

  • gentle resistance exercise, such as lifting light weights or using elastic resistance bands
  • weight-bearing exercise, where you’re standing up and have to support your own weight, such as walking, climbing stairs, tennis and dancing.

Risk of other health problems

Hormone therapy may slightly increase your chance of developing other health problems, including:

  • heart disease
  • stroke
  • type-2 diabetes
  • blood clots

Before you start hormone therapy, tell your doctor if you’ve ever had any of the problems listed above, or if you’re taking medicines to treat another health problem, such as high blood pressure (hypertension) or high levels of cholesterol (hypercholesterolaemia).

You can reduce your risk of many health problems by making lifestyle changes, such as eating a well-balanced diet, drinking less alcohol, being physically active and stopping smoking.

Read more about diet and physical activity for men with prostate cancer.

Changes to your mood

Hormone therapy can affect your mood. You may feel more emotional than usual or just ‘different’ to how you felt before. Some men find that they cry a lot. You may also get mood swings, such as feeling tearful then angry.

Just knowing that hormone therapy might be causing these feelings can help.

Some men experience low moods, anxiety or depression. This could be caused by the hormone therapy itself, or by dealing with your prostate cancer diagnosis. It could also be due to the impact that treatment is having on your life.

If your mood is often very low, you are losing interest in things, or your sleep pattern or appetite has changed a lot, speak to your doctor or nurse. These can be signs of depression, but there are things that can help.

Skin problems

If you are on degarelix, the skin around the area where you have the injections may feel red, hard, swollen and sore. This usually settles down after a few days and is often worse after the first injection than the later ones. Mild pain-relieving medicines, such as paracetamol, or using a cool pack on the area can help.

 

How will I know if my treatment is working?

You will have regular appointments to check how well your treatment is working and monitor any side effects. These will involve regular prostate specific antigen (PSA) blood tests to measure the amount of PSA in your blood.

PSA is a protein produced by cells in your prostate and also by prostate cancer cells, even if they have spread to other parts of your body. The PSA test is a good way to check how well your treatment is working.

How your treatment is monitored will depend on whether you’re having hormone therapy as part of treatment that aims to cure your prostate cancer, or having life-long hormone therapy to keep advanced prostate cancer under control.

You can contact your nurse at the hospital, or our Specialist Nurses, between appointments if you have any side effects or symptoms that you’d like to talk about.

What happens next?

If you’re having treatment that aims to cure your prostate cancer

If your PSA level falls and stays low, this usually suggests your treatment is working. How quickly your PSA level falls, and how low, will depend on the type of treatment you’ve had and will be different for everyone. Read more about follow-up after prostate cancer treatment.

At some hospitals, you may have fewer hospital appointments, and be encouraged to take greater control of your own health and wellbeing. You might hear this called self-management. Instead of going to the hospital, you may talk to your doctor or nurse over the telephone.

Men often prefer this type of follow-up, as it means you can avoid going to hospital appointments when you’re feeling well and don’t have any concerns. You, or your doctor or nurse, can arrange an appointment at any point if you have any questions or concerns.

Speak to your doctor or nurse about how long you will have hormone therapy for. After you stop having hormone therapy, you’ll continue to have regular follow-up appointments, including PSA tests.

If you’ve had radiotherapy, your PSA level may rise a little when you stop hormone therapy. If it continues to rise, this could mean that your prostate cancer has come back.

Your doctor might suggest that you have some scans to see if anything has changed. They will then be able to talk to you about further treatments, if you need them. Read more about recurrent prostate cancer.

If you’re having life-long hormone therapy for advanced prostate cancer

If you have advanced prostate cancer, it’s likely that you’ll have hormone therapy as a life-long treatment.

As well as regular PSA tests, your doctor will check for any changes in symptoms such as pain or weight loss. You may also have regular scans to keep an eye on your cancer.

If your PSA level starts to rise or your scans show changes, this may be the first sign that your hormone therapy is no longer working so well. If this happens, your doctor will talk to you about other possible treatment options.

You may be offered other types of hormone therapy, a combination of different hormone therapy drugs, or a different type of treatment.

Read more about other treatment options after you first hormone therapy.

Intermittent hormone therapy

If you’re on life-long hormone therapy and are finding the side effects difficult to manage, you might be able to have intermittent hormone therapy. This is where you stop hormone therapy when your PSA level is low and steady, and start it again if your symptoms get worse or your PSA rises to around 10 or higher.

Some of the side effects, such as hot flushes and sexual problems, may improve while you’re not having treatment. But it can take several months for side effects to improve, and some men never notice any improvement.

Read more about living with hormone therapy.

Questions to ask your doctor or nurse

  • What is the aim of treatment?
  • What type of hormone therapy are you recommending for me and why?
  • How often will I have my injections or implants?
  • How will my treatment be monitored?
  • How long will it be before we know if the hormone therapy is working?
  • What are the possible side effects, and how long will they last?
  • What will happen if I decide to stop my treatment?
  • Are there any clinical trials that I could take part in?

References

  • Full list of references  

    • Schmitt B, Bennett C, Seidenfeld J, Samson D, Wilt T. Maximal androgen blockade for advanced prostate cancer. Cochrane Database Syst Rev. 1999;2.
    • Isbarn H, Pinthus JH, Marks LS, Montorsi F, Morales A, Morgentaler A, et al. Testosterone and Prostate Cancer: Revisiting Old Paradigms. Eur Urol. 2009 Jul;56(1):48–56.
    • National Institute for Health and Care Excellence. Prostate cancer: diagnosis and management. NICE guideline 131. 2019.
    • Mottet N, Van den Bergh RCN, Briers E, Cornford P, De Santis M, Fanti S, et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer. European Association of Urology; 2019.
    • Schmidt-Hansen M, Hoskin P, Kirkbride P, Hasler E, Bromham N. Hormone and Radiotherapy versus Hormone or Radiotherapy Alone for Non-metastatic Prostate Cancer: A Systematic Review with Meta-analyses. Clin Oncol. 2014 Oct;26(10):e21–46.
    • Crouzet S, Chapelon JY, Rouvière O, Mege-Lechevallier F, Colombel M, Tonoli-Catez H, et al. Whole-gland Ablation of Localized Prostate Cancer with High-intensity Focused Ultrasound: Oncologic Outcomes and Morbidity in 1002 Patients. Eur Urol. 2014 May;65(5):907–14.
    • Bekelman JE, Mitra N, Handorf EA, Uzzo RG, Hahn SA, Polsky D, et al. Effectiveness of androgen-deprivation therapy and radiotherapy for older men with locally advanced prostate cancer. J Clin Oncol Off J Am Soc Clin Oncol. 2015 Mar 1;33(7):716–22.
    • Mason MD, Parulekar WR, Sydes MR, Brundage M, Kirkbride P, Gospodarowicz M, et al. Final Report of the Intergroup Randomized Study of Combined Androgen-Deprivation Therapy Plus Radiotherapy Versus Androgen-Deprivation Therapy Alone in Locally Advanced Prostate Cancer. J Clin Oncol [Internet]. 2015 Feb 17 [cited 2015 May 8]; Available from: jco.ascopubs.org/cgi/doi/10.1200/JCO.2014.57.7510
    • Warde P, Mason M, Ding K, Kirkbride P, Brundage M, Cowan R, et al. Combined androgen deprivation therapy and radiation therapy for locally advanced prostate cancer: a randomised, phase 3 trial. The Lancet. 2011 Dec;378(9809):2104–11.
    • Artibani W, Porcaro AB, De Marco V, Cerruto MA, Siracusano S. Management of Biochemical Recurrence after Primary Curative Treatment for Prostate Cancer: A Review. Urol Int. 2018;100(3):251–62.
    • Schröder F, Crawford ED, Axcrona K, Payne H, Keane TE. Androgen deprivation therapy: past, present and future. BJU Int. 2012 Jun;109 Suppl 6:1–12.
    • National Institute for Health and Care Excellence. Degarelix for treating advanced hormone-dependent prostate cancer. Technology appraisal guidance 404 [Internet]. 2016. Available from: www.nice.org.uk/guidance/TA404/chapter/1-Recommendations
    • Fang C, Wu C-L, Liu S-S, Ge L, Bai J-L. Efficacy, safety, and dose comparison of degarelix for the treatment of prostate cancer: A systematic review and meta-analysis. World J Meta-Anal. 2016 Jun 26;4(3):69–76.
    • Klotz L, Boccon-Gibod L, Shore ND, Andreou C, Persson B-E, Cantor P, et al. The efficacy and safety of degarelix: a 12-month, comparative, randomized, open-label, parallel-group phase III study in patients with prostate cancer. BJU Int. 2008 Dec;102(11):1531–8.
    • Shore ND, Abrahamsson P-A, Anderson J, Crawford ED, Lange P. New considerations for ADT in advanced prostate cancer and the emerging role of GnRH antagonists. Prostate Cancer Prostatic Dis. 2013;16(1):7–15.
    • Nguyen PL, Alibhai SMH, Basaria S, D’Amico AV, Kantoff PW, Keating NL, et al. Adverse Effects of Androgen Deprivation Therapy and Strategies to Mitigate Them. Eur Urol. 2015 May;67(5):825–36.
    • Kunath F, Grobe HR, Rücker G, Motschall E, Antes G, Dahm P, et al. Non-steroidal antiandrogen monotherapy compared with luteinising hormone-releasing hormone agonists or surgical castration monotherapy for advanced prostate cancer (review). Cochrane Database Syst Rev. 2014;(6).
    • Gruca D, Bacher P, Tunn U. Safety and tolerability of intermittent androgen deprivation therapy: A literature review: IAD therapy in prostate cancer. Int J Urol. 2012 Jul;19(7):614–25.
    • Mottet N, Prayer-Galetti T, Hammerer P, Kattan MW, Tunn U. Optimizing outcomes and quality of life in the hormonal treatment of prostate cancer. BJU Int. 2006 Jul;98(1):20–7.
    • Eziefula CU, Grunfeld EA, Hunter MS. ‘You know I’ve joined your club… I’m the hot flush boy’: a qualitative exploration of hot flushes and night sweats in men undergoing androgen deprivation therapy for prostate cancer. Psychooncology. 2013 Dec;22(12):2823–30.
    • Tombal B. A Holistic Approach to Androgen Deprivation Therapy: Treating the Cancer without Hurting the Patient. Urol Int. 2009;83(4):373–8.
    • Higano CS. Side effects of androgen deprivation therapy: monitoring and minimizing toxicity. Urology. 2003;61(2):32–38.
    • Kumar RJ. Adverse events associated with hormonal therapy for prostate cancer. Rev Urol. 2005;7(Suppl 5):S37.
    • Sountoulides P, Rountos T. Adverse Effects of Androgen Deprivation Therapy for Prostate Cancer: Prevention and Management. ISRN Urol [Internet]. 2013 Jul 25 [cited 2015 Nov 3];2013. Available from: www.ncbi.nlm.nih.gov/pmc/articles/PMC3747499/
    • Langston B, Armes J, Levy A, Tidey E, Ream E. The prevalence and severity of fatigue in men with prostate cancer: a systematic review of the literature. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. 2013 Jun;21(6):1761–71.
    • Gardner JR, Livingston PM, Fraser SF. Effects of Exercise on Treatment-Related Adverse Effects for Patients With Prostate Cancer Receiving Androgen-Deprivation Therapy: A Systematic Review. J Clin Oncol. 2014 Feb 1;32(4):335–46.
    • White ID, Wilson J, Aslet P, Baxter AB, Birtle A, Challacombe B, et al. Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer. Int J Clin Pract. 2015 Jan;69(1):106–23.
    • Haliloglu A, Baltaci S, Yaman O. Penile length changes in men treated with androgen suppression plus radiation therapy for local or locally advanced prostate cancer. J Urol. 2007 Jan;177(1):128–30.
    • Park KK, Lee SH, Chung BH. The Effects of Long‐Term Androgen Deprivation Therapy on Penile Length in Patients with Prostate Cancer: A Single‐Center, Prospective, Open‐Label, Observational Study. J Sex Med. 2011 Nov;8(11):3214–9.
    • Hwang TI-S, Lin Y-C, Lee MC-C, Juang G-D, Yeh C-H, Cheng Y-H, et al. The Effects of Medical Castration on Testes in Patients With Advanced Prostate Cancer. Urol Sci. 2010 Dec;21(4):169–74.
    • Sharifi N, Gulley JL, Dahut WL. An Update on Androgen Deprivation Therapy for Prostate Cancer. Endocr Relat Cancer. 2010 Dec;17(4):R305–15.
    • Owen PJ, Daly RM, Livingston PM, Fraser SF. Lifestyle guidelines for managing adverse effects on bone health and body composition in men treated with androgen deprivation therapy for prostate cancer: an update. Prostate Cancer Prostatic Dis. 2017 Jun;20(2):137–45.
    • Haseen F, Murray LJ, Cardwell CR, O’Sullivan JM, Cantwell MM. The effect of androgen deprivation therapy on body composition in men with prostate cancer: Systematic review and meta-analysis. J Cancer Surviv. 2010 Jun 1;4(2):128–39.
    • Keogh JWL, MacLeod RD. Body Composition, Physical Fitness, Functional Performance, Quality of Life, and Fatigue Benefits of Exercise for Prostate Cancer Patients: A Systematic Review. J Pain Symptom Manage. 2012 Jan;43(1):96–110.
    • Treanor CJ, Li J, Donnelly M. Cognitive impairment among prostate cancer patients: An overview of reviews. Eur J Cancer Care (Engl). 2017 Nov 1;26(6):e12642.
    • Wu LM, Tanenbaum ML, Dijkers MPJM, Amidi A, Hall SJ, Penedo FJ, et al. Cognitive and neurobehavioral symptoms in patients with non-metastatic prostate cancer treated with androgen deprivation therapy or observation: A mixed methods study. Soc Sci Med. 2016 May 1;156:80–9.
    • Gunlusoy B, Ceylan Y, Koskderelioglu A, Gedizlioglu M, Degirmenci T, Ortan P, et al. Cognitive Effects of Androgen Deprivation Therapy in Men With Advanced Prostate Cancer. Urology. 2017 May 1;103:167–72.
    • Nead KT, Sinha S, Nguyen PL. Androgen deprivation therapy for prostate cancer and dementia risk: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis. 2017 Sep;20(3):259–64.
    • Sun M, Cole AP, Hanna N, Mucci LA, Berry DL, Basaria S, et al. Cognitive Impairment in Men with Prostate Cancer Treated with Androgen Deprivation Therapy: A Systematic Review and Meta-Analysis. J Urol. 2018 Jun 1;199(6):1417–25.
    • Marzouk S, Naglie G, Tomlinson G, Duff Canning S, Breunis H, Timilshina N, et al. Impact of Androgen Deprivation Therapy on Self-Reported Cognitive Function in Men with Prostate Cancer. J Urol [Internet]. 2018 Mar 1 [cited 2018 Aug 10]; Available from: www.sciencedirect.com/science/article/pii/S0022534718393790
    • Murad MH, Johnson, Kermott. Gynecomastia - evaluation and current treatment options. Ther Clin Risk Manag. 2011 Mar;145.
    • Fagerlund A, Cormio L, Palangi L, Lewin R, Santanelli di Pompeo F, Elander A, et al. Gynecomastia in Patients with Prostate Cancer: A Systematic Review. PLoS ONE [Internet]. 2015 Aug 26 [cited 2018 Sep 12];10(8). Available from: www.ncbi.nlm.nih.gov/pmc/articles/PMC4550398/
    • Casey RG, Corcoran NM, Larry Goldenberg S. Quality of life issues in men undergoing androgen deprivation therapy: a review. Asian J Androl. 2012 Mar;14(2):226–31.
    • Serpa Neto A, Tobias-Machado M, Esteves MAP, Senra MD, Wroclawski ML, Fonseca FLA, et al. Bisphosphonate therapy in patients under androgen deprivation therapy for prostate cancer: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis. 2012;15(1):36–44.
    • Alibhai SMH, Gogov S, Allibhai Z. Long-term side effects of androgen deprivation therapy in men with non-metastatic prostate cancer: A systematic literature review. Crit Rev Oncol Hematol. 2006 Dec;60(3):201–15.
    • National Institute for Health and Clinical Excellence. Osteoporosis: assessing the risk of fragility fracture. Short clinical guideline. Clinical guideline 146 [Internet]. 2012 [cited 2015 Nov 16]. Available from: www.nice.org.uk/guidance/cg146/evidence/osteoporosis-fragility-fracture-full-guideline-186818365
    • Ahmadi H, Daneshmand S. Androgen deprivation therapy: evidence-based management of side effects. BJU Int. 2013 Apr;111(4):543–8.
    • Todenhöfer T, Stenzl A, Hofbauer LC, Rachner TD. Targeting Bone Metabolism in Patients with Advanced Prostate Cancer: Current Options and Controversies. Int J Endocrinol. 2015;2015:1–9.
    • Cormie P, Galvão DA, Spry N, Joseph D, Chee R, Taaffe DR, et al. Can supervised exercise prevent treatment toxicity in patients with prostate cancer initiating androgen-deprivation therapy: a randomised controlled trial. BJU Int. 2015;115(2):256–66.
    • Thorsen L, Courneya KS, Stevinson C, Fosså SD. A systematic review of physical activity in prostate cancer survivors: outcomes, prevalence, and determinants. Support Care Cancer. 2008 Feb 15;16(9):987–97.
    • Keilani M, Hasenoehrl T, Baumann L, Ristl R, Schwarz M, Marhold M, et al. Effects of resistance exercise in prostate cancer patients: a meta-analysis. Support Care Cancer. 2017 Jun 10;
    • Mohile SG, Mustian K, Bylow K, Hall W, Dale W. Management of complications of androgen deprivation therapy in the older man. Crit Rev Oncol Hematol. 2009 Jun;70(3):235–55.
    • Baumann FT, Zopf EM, Bloch W. Clinical exercise interventions in prostate cancer patients: a systematic review of randomized controlled trials. Support Care Cancer. 2012;20(2):221–33.
    • Azoulay L, Yin H, Benayoun S, Renoux C, Boivin J-F, Suissa S. Androgen-Deprivation Therapy and the Risk of Stroke in Patients With Prostate Cancer. Eur Urol. 2011 Dec;60(6):1244–50.
    • Crawley D, Garmo H, Rudman S, Stattin P, Häggström C, Zethelius B, et al. Association between duration and type of androgen deprivation therapy and risk of diabetes in men with prostate cancer. Int J Cancer. 2016;139(12):2698–704.
    • Jhan J-H, Yeh H-C, Chang Y-H, Guu S-J, Wu W-J, Chou Y-H, et al. New-onset diabetes after androgen-deprivation therapy for prostate cancer: A nationwide propensity score-matched four-year longitudinal cohort study. J Diabetes Complications. 2018 Jul;32(7):688–92.
    • Nead KT, Boldbaatar N, Yang DD, Sinha S, Nguyen PL. Association of Androgen Deprivation Therapy and Thromboembolic Events: a Systematic Review and Meta-Analysis. Urology [Internet]. 2018 Jan [cited 2018 Jan 29]; Available from: linkinghub.elsevier.com/retrieve/pii/S0090429518300165
    • Guo Z, Huang Y, Gong L, Gan S, Chan FL, Gu C, et al. Association of androgen deprivation therapy with thromboembolic events in patients with prostate cancer: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis. 2018 Jul 9;1.
    • Hicks BM, Klil-Drori AJ, Yin H, Campeau L, Azoulay L. Androgen Deprivation Therapy and the Risk of Anemia in Men with Prostate Cancer: Epidemiology. 2017 Sep;28(5):712–8.
    • Elliott S, Latini DM, Walker LM, Wassersug R, Robinson JW. Androgen Deprivation Therapy for Prostate Cancer: Recommendations to Improve Patient and Partner Quality of Life: Improving Life on ADT. J Sex Med. 2010 Sep;7(9):2996–3010.
    • Sharpley CF, Christie DRH, Bitsika V. Do hormone treatments for prostate cancer cause anxiety and depression? Int J Clin Oncol. 2014;19(3):523–30.
    • Nead KT, Sinha S, Yang DD, Nguyen PL. Association of androgen deprivation therapy and depression in the treatment of prostate cancer: A systematic review and meta-analysis. Urol Oncol Semin Orig Investig. 2017 Nov 1;35(11):664.e1-664.e9.
    • Gagliano-Jucá T, Travison TG, Nguyen PL, Kantoff PW, Taplin M-E, Kibel AS, et al. Effects of Androgen Deprivation Therapy on Pain Perception, Quality of Life, and Depression in Men With Prostate Cancer. J Pain Symptom Manage. 2018 Feb 1;55(2):307-317.e1.
    • Shahinian VB, Kuo Y-F, Freeman JL, Goodwin JS. Risk of the “androgen deprivation syndrome” in men receiving androgen deprivation for prostate cancer. Arch Intern Med. 2006;166(4):465–471.
    • Sciarra A, Fasulo A, Ciardi A, Petrangeli E, Gentilucci A, Maggi M, et al. A meta-analysis and systematic review of randomized controlled trials with degarelix versus gonadotropin-releasing hormone agonists for advanced prostate cancer: Medicine (Baltimore). 2016 Jul;95(27):e3845.
    • Electronic Medicines Compendium. Firmagon 80mg Injection - Summary of Product Characteristics [Internet]. 2013 [cited 2015 Oct 27]. Available from: www.medicines.org.uk/emc/medicine/21686/SPC/Firmagon+80mg+Injection/
    • Abrahamsson P-A. Intermittent androgen deprivation therapy in patients with prostate cancer: Connecting the dots. Asian J Urol. 2017 Oct;4(4):208–22.
    • Dong Z, Wang H, Xu M, Li Y, Hou M, Wei Y, et al. Intermittent hormone therapy versus continuous hormone therapy for locally advanced prostate cancer: a meta-analysis. Aging Male. 2015 Dec;18(4):233–7.
    • Magnan S, Zarychanski R, Pilote L, Bernier L, Shemilt M, Vigneault E, et al. Intermittent vs Continuous Androgen Deprivation Therapy for Prostate Cancer: A Systematic Review and Meta-analysis. JAMA Oncol. 2015 Sep 17;1–10.
    • Botrel TEA, Clark O, dos Reis RB, Pompeo ACL, Ferreira U, Sadi MV, et al. Intermittent versus continuous androgen deprivation for locally advanced, recurrent or metastatic prostate cancer: a systematic review and meta-analysis. BMC Urol. 2014;14:9.
    • Husson O, Mols F, Poll-Franse LV van de. The relation between information provision and health-related quality of life, anxiety and depression among cancer survivors: a systematic review. Ann Oncol. 2010 Sep 24;mdq413.
    • World Cancer Research Fund International. Continuous Update Project report: Diet, Nutrition, Physical Activity and Prostate Cancer [Internet]. 2014. Available from: www.wcrf.org/sites/default/files/Prostate-Cancer-2014-Report.pdf
    • Lin P-H, Aronson W, Freedland SJ. Nutrition, dietary interventions and prostate cancer: the latest evidence. BMC Med [Internet]. 2015 Dec [cited 2017 Oct 30];13(1). Available from: bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0234-y
    • Mohamad H, McNeill G, Haseen F, N’Dow J, Craig LCA, Heys SD. The Effect of Dietary and Exercise Interventions on Body Weight in Prostate Cancer Patients: A Systematic Review. Nutr Cancer. 2015 Jan 2;67(1):43–60.
    • Allott EH, Masko EM, Freedland SJ. Obesity and Prostate Cancer: Weighing the Evidence. Eur Urol. 2013 May;63(5):800–9.
    • Discacciati A, Orsini N, Wolk A. Body mass index and incidence of localized and advanced prostate cancer--a dose-response meta-analysis of prospective studies. Ann Oncol. 2012 Jan 6;23(7):1665–71.
    • Cao Y, Ma J. Body Mass Index, Prostate Cancer-Specific Mortality, and Biochemical Recurrence: a Systematic Review and Meta-analysis. Cancer Prev Res (Phila Pa). 2011 Jan 13;4(4):486–501.
    • Gerdtsson A, Poon JB, Thorek DL, Mucci LA, Evans MJ, Scardino P, et al. Anthropometric Measures at Multiple Times Throughout Life and Prostate Cancer Diagnosis, Metastasis, and Death. Eur Urol. 2015 Dec;68(6):1076–82.
    • Ho T, Gerber L, Aronson WJ, Terris MK, Presti JC, Kane CJ, et al. Obesity, Prostate-Specific Antigen Nadir, and Biochemical Recurrence After Radical Prostatectomy: Biology or Technique? Results from the SEARCH Database. Eur Urol. 2012 Nov;62(5):910–6.
    • Hu M-B, Xu H, Bai P-D, Jiang H-W, Ding Q. Obesity has multifaceted impact on biochemical recurrence of prostate cancer: a dose-response meta-analysis of 36,927 patients. Med Oncol Northwood Lond Engl. 2014 Feb;31(2):829.
    • Wang LS, Murphy CT, Ruth K, Zaorsky NG, Smaldone MC, Sobczak ML, et al. Impact of obesity on outcomes after definitive dose-escalated intensity-modulated radiotherapy for localized prostate cancer. Cancer. 2015 Sep 1;121(17):3010–7.
    • Keto CJ, Aronson WJ, Terris MK, Presti JC, Kane CJ, Amling CL, et al. Obesity is associated with castration-resistant disease and metastasis in men treated with androgen deprivation therapy after radical prostatectomy: results from the SEARCH database. BJU Int. 2011;110(4):492–8.
    • Pettersson A, Johansson B, Persson C, Berglund A, Turesson I. Effects of a dietary intervention on acute gastrointestinal side effects and other aspects of health-related quality of life: A randomized controlled trial in prostate cancer patients undergoing radiotherapy. Radiother Oncol. 2012 Jun;103(3):333–40.
    • Henson CC, Burden S, Davidson SE, Lal S. Nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy. Cochrane Database Syst Rev [Internet]. 2013 [cited 2014 Nov 18];(11). Available from: doi.wiley.com/10.1002/14651858.CD009896.pub2
    • Wedlake LJ, Shaw C, Whelan K, Andreyev HJN. Systematic review: the efficacy of nutritional interventions to counteract acute gastrointestinal toxicity during therapeutic pelvic radiotherapy. Aliment Pharmacol Ther. 2013 Jun;37(11):1046–56.
    • Hechtman LM. Clinical Naturopathic Medicine [Internet]. Harcourt Publishers Group (Australia); 2014 [cited 2015 Jul 21]. 1610 p. Available from: www.bookdepository.com/Clinical-Naturopathic-Medicine-Leah-Hechtman/9780729541923
    • Tillisch K. Complementary and alternative medicine for functional gastrointestinal disorders. Gut. 2006 May 1;55(5):593–6.
    • Wolin KY, Luly J, Sutcliffe S, Andriole GL, Kibel AS. Risk of Urinary Incontinence Following Prostatectomy: The Role of Physical Activity and Obesity. J Urol. 2010 Feb;183(2):629–33.
    • Menichetti J, Villa S, Magnani T, Avuzzi B, Bosetti D, Marenghi C, et al. Lifestyle interventions to improve the quality of life of men with prostate cancer: A systematic review of randomized controlled trials. Crit Rev Oncol Hematol. 2016 Dec;108:13–22.
    • Bourke L, Smith D, Steed L, Hooper R, Carter A, Catto J, et al. Exercise for Men with Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol. 2016 Apr;69(4):693–703.
    • Teleni L, Chan RJ, Chan A, Isenring EA, Vela I, Inder WJ, et al. Exercise improves quality of life in androgen deprivation therapy-treated prostate cancer: systematic review of randomised controlled trials. Endocr Relat Cancer. 2016 Feb 1;23(2):101–12.
    • Davies NJ, Batehup L, Thomas R. The role of diet and physical activity in breast, colorectal, and prostate cancer survivorship: a review of the literature. Br J Cancer. 2011 Nov 8;105:S52–73.
    • Richman EL, Kenfield SA, Stampfer MJ, Paciorek A, Carroll PR, Chan JM. Physical Activity after Diagnosis and Risk of Prostate Cancer Progression: Data from the Cancer of the Prostate Strategic Urologic Research Endeavor. Cancer Res. 2011 May 24;71(11):3889–95.
    • 94.     Larkin D, Lopez V, Aromataris E. Managing cancer-related fatigue in men with prostate cancer: A systematic review of non-pharmacological interventions. Int J Nurs Pract. 2014 Oct;20(5):549–60.