Hi, I'm Dr. Scholz.
A common question we get at the PCRI is, "How do you manage hot flashes from hormonal therapy?"
Hot flashes from hormone therapy—hormone therapy being the most commonly used systemic
medicine for prostate cancer—are a very common problem. They're not universal though.
About a third of men that are on these hormonal medicines don't get hot flashes. About a third
get a mild low-grade issue that doesn't really concern them much, and about a third get full-blown
hot flashes. We're talking about waking up at night, sweating, these things can sometimes
cycle every 15 to 20 minutes and be really intrusive. One thing to realize is that they're
not dangerous although a hot flash is often accompanied by a sensation that something's
really wrong and it can really throw people off kilter. They're not dangerous even though
they feel that they are. So when we try and treat hot flashes, we're just treating symptoms
to improve quality of life and there's no perfect fix for them, but there are some effective
therapies and it's always a balance between "Are the side effects of the treatment worse
than the hot flashes?" So we'll just go through and cover some of the common things that are
used to counteract hot flashes.
The most effective medicine that I've come across for counteracting hot flashes is estrogen.
Estrogen will dramatically reduce the symptoms in over 80% of men. Estrogen has a few issues
though. You can't take estrogen pills because they cause blood clots, but interestingly,
transdermal estrogen in the form of a patch does not predispose men to blood clots. However,
estrogen can cause breast enlargement. When these estrogen patches are used, Vivelle Dot
is the most popular brand, the dose selected should be the smallest possible dose, and
most men will not develop a problem with breast enlargement. If breast enlargement is a major
concern, it is possible to undergo a brief course of radiation therapy to the nipples—three
or four treatments—to prevent that from happening. In most cases, I just tell men
to be on the lookout for these things, and if this problem develops, then to stop the
medicine and reconsider the therapy. There are other options.
So what are those other options?
There's basically two medicines. One is an antidepressant medicine called Effexor, used
in very small doses—say 37.5 milligrams, once a day. Or Neurontin, a medicine that
was originally approved to help reduce the incidence of seizures but in low-doses has
also been used to help people with numbness or tingling in their hands or feet, but it
also can reduce hot flashes just like Effexor. The effect is not as universal as it is with
estrogen. Maybe 50% of men respond to these medications. Both Neurontin and Effexor can
make people feel a little drowsy sometimes, and taking them at nighttime is probably the
best way to go.
There are studies showing that acupuncture can control hot flashes as well. Acupuncture
is not something I'm an expert in, but the studies showing its effectiveness are pretty
convincing. Finding people that really know what they're doing, of course, is part of
the protocol for getting a good result, and it's not going to work on everybody, but the
evidence is strong that acupuncture can counteract hot flashes.
Historically, progesterone has been a popular treatment for counteracting hot flashes. More
recently though, doctors are getting concerned because progesterone is a precursor to testosterone
and there has been some evidence that progesterone can enhance or stimulate the growth of prostate
cancer. Though historically progesterone was a popular and effective way to counteract
hot flashes, at this point we aren't recommending it.
Lastly, in terms of reducing side effects from hormone therapy, hot flashes included,
sometimes people overlook a milder medicine called Casodex—generic name, is Bicalutamide.
This is a pill rather than a shot, and the side effects from this medication are a little
bit less including a lower incidence of hot flashes. Casodex is not always an appropriate
thing to substitute because it's not quite as strong and its anti-cancer effects are
not as potent as Lupron's, but in certain situations, people can compromise the effectiveness
and achieve a better quality of life.
Hot flashes with hormonal therapy are common. There are things to reduce them. Thankfully,
they're not always so serious that they even require therapy, but if therapy is needed
effective treatment is available and thankfully there are other new medicines that are in
development that may be helpful as well.