What Happens During Hormone Treatment for Prostate Cancer

There are two approaches to hormone therapy: drug-based and surgical. Drug-based therapies are also called medical hormone therapy. The surgical approach is called orchiectomy. Here's how each approach works. 

Medical hormone treatment

For this treatment, you take antihormone drugs. Many men prefer this to surgical removal of the testicles. The drugs prevent the testicles from secreting male hormones such as testosterone or prevent the body from using them. Your doctor will recommend one or more of these three types of drugs:

• Luteinizing hormone-releasing hormone (LHRH) analogs. You’ll get a shot or an implant under the skin once a month, every three or four months, or yearly. It’s very important that you don’t skip the shots. If you do, your testosterone may go up and cause your cancer to grow. Examples of LHRH analogs include Lupron (leuprolide) and Zoladex (goserelin). They work about the same. Luteinizing hormone tells your testicles to produce testosterone. So when you start taking LHRH analogs, your testosterone levels go up briefly. But then your brain tells your testicles to stop producing testosterone. This process takes about five to eight days. This treatment can be expensive. You may receive LHRH analogs by themselves, or your doctor may recommend them with an antiandrogen.

• Luteinizing hormone-releasing hormone (LHRH) antagonists. These drugs also lower testosterone levels, but they may cause fewer problems than LHRH analogs because they don't raise testosterone levels when first given. The only LHRH antagonist used at this time is Firmagon (degarelix), which is given by injection under the skin once a month.

• Antiandrogens. These are usually pills in the United States. These drugs don’t lower testosterone production. They’re receptor blockers. They prevent hormones from acting on prostate cells. There are three commonly used antiandrogens. They are Casodex (bicalutamide), Eulexin (flutamide), and Nilandron (nilutamide). Usually doctors give them with LHRH analogs. When they are used together, it’s called total androgen blockade.

• CYP17 inhibitors. Even when the major sources of hormones are shut down, other cells in the body (including prostate cells) may still release small amounts of hormones. Drugs that block an enzyme called CYP17 help stop these cells from making hormones. The CYP17 inhibitor Zytiga (abiraterone) is taken as a pill once a day. It is most often used when other types of hormone therapy are no longer working.

Orchiectomy

This is a surgical approach to hormone therapy in which your surgeon removes both of your testicles. Without testicles, you can’t produce the male hormones that cause prostate cancer to grow.

This is a simple procedure. But many men opt for hormone treatment with drugs instead of surgery because either they don’t like the idea of losing their testicles or they sometimes want to go off of the hormone treatments. The advantage of this procedure is that it’s over in one treatment. It’s also less expensive than the shots. A disadvantage is that it can't be reversed once it's done. 

This surgery may be performed under local anesthesia. That means the area is numbed, but you aren’t put to sleep. Or it may be done with general anesthesia, where you are asleep during the surgery. Your urologist will make one or two cuts, called incisions, on each side of your scrotum. Your doctor ties off the blood vessels that supply your testes and sperm duct. Then he or she removes your testicles. The skin of your scrotum is still there. Some urologists remove just the center of your scrotum, leaving some fullness to it. Your surgeon closes the incisions with dissolvable stitches that don’t need to be removed. Usually you can go home the next day.

The empty feeling in their scrotum after having the testicles removed bothers some men. If that’s true for you, ask your doctor about testicular prostheses. These gel-filled plastic sacks are about the same size as adult testicles.