I don't know if you want to give any general commentary, but I'm about to take you through some
quick side effects of androgen deprivation therapy when you're ready. Do you want to just do that?
Well, if we hadn't covered the exercise I'd start right there,
but we I think we covered that nicely, so jump right in.
Yeah so just keep in mind that if you put a checklist of every single side effect you can
experience on hormone therapy, the only thing that will cover most of the boxes, most of the checks,
on that list will be exercise, right? Whether it's cancer-related fatigue, whether it's
building up muscle because remember exercise is not just aerobic it's also resistance, it's also
flexibility. I always hear from the one naysayer every year that says well I'm not in a position to
do all those exercises. I don't even care if it's somebody wading in a pool or walking in
waist-high water, or just doing exercises within the pool and not moving. The body was meant to
move and to change position every once in a while, otherwise, it's a use it or lose it machinery.
it really is, and so is the brain. Quickly on your comment on anemia and hormone therapy.
Yeah, it's usually mild, the anemia of low testosterone doesn't usually translate into
the shortness of breath of severe anemias, and it's not — when people say I feel tired,
is it because of this mild anemia that the testosterone has caused—low testosterone
has caused. No, generally not. Usually, it's a lack of exercise, loss of muscle
that is causing the fatigue; not the anemia. So, it's something though to be aware of because
I do have patients who go to their family doctor, he says, "oh my god you're anemic;
I'm going to give you iron," and they're not iron deficient. They just have developed
a blood count that's similar to that of a woman because they don't have testosterone.
And what about in terms of the weight gain? I mean,
there's been lots of talk that some people experience extreme weight gain, some people
experience minimal weight gain, but how about androgen deprivation therapy and weight gain?
It's a big deal. If muscle mass goes down, your metabolic rate drops.
All you have to do is stay on the same diet that you ate for the last 20 years and you're getting
too many calories; it's got to go somewhere; it usually goes right to the tummy. If there isn't a
very you know targeted and thoughtful approach to eating, most men are going to gain weight,
and it's much easier to keep it off than to get it off later, so people that are starting hormone
therapy need to be thinking about their diet, "how am I going to cut back on my calories?"
Well said, well said. How about fatigue? I read this more than any other question in
the from the patient submissions: "I feel tired; I just I have no energy."
Well you know, that the — and if we talk about exercise all this whole time it'll
be useful for our patients. There are literal randomized studies looking at the degree of
fatigue in people that do weight training and those that just do a normal lifestyle,
and it's like night and day, and I see it in the clinic. Before we knew that exercise
could get rid of this fatigue that is so prevalent in men on lupron and other agents,
you know, we would warn them, "Okay, we're gonna give you a Lupron; we're so sorry; you're gonna
feel like a limp dish rag, and you're going to drag in here, but we're saving your life, so
no choice." And then later through the years, it became apparent that the men that would
do regular focus weight training—keep their muscles up—feel pretty darn normal. I mean,
it's like unbelievable difference, and so that's the that's the answer to fatigue.
Jama Oncology, a few years ago one of the largest reviews I had to review because every month I
review a different paper for doctors for the past 20 years then they get credit, so the one
the one I had to review last year was one of the most comprehensive reviews of people going
through cancer treatment and all the pharmacologic agents that could help combat fatigue and all the
supplements, and then the conclusion was basically this—if you look at the Jama Oncology article
that looked at cancer-related fatigue, the meta-analysis—it said, "we have nothing
better than exercise in clinical study. Have a nice day." That was the whole thing. Alright,
so what about hot flashes, and there was a lot of questions on using estrogen for hot flashes.
As you know, 10, 20 years ago there were all these drugs for hot flashes and they
all came with these catches and so what are people going to do about hot flashes today?
A lot of men that I talk to that have hot flashes—a lot of them—are a little hesitant to
take any more medicines because. they're already on a lot of medicines and many of them just suck
it up and and just live with them. I don't hesitate to provide some pharmaceuticals; you
mentioned estrogen which is clearly the best way to treat hot flashes. In the old days we used to
give a injection of progesterone and that became a little more problematic when it was realized
that that can be converted into testosterone, so we don't do that quite as liberally as we
would in the past because [estrogen] also works. Estrogen has to be given in a patch because the
oral forms cause blood clots, but the patches are safe, and they're very effective. if people are a
little nervous about estrogen, you mentioned that—I think when you're talking to Tia—about
things like venlafaxine which is a mild antidepressant, gabapentin which is a used
for nerve pain and seizures and whatnot. They can—they're not universally effective—but some
people they work really well. You're probably aware that acupuncture can help hot flashes.
Have you used that in any of your patients? Yeah, so acupuncture, well the data is really coming out
now, so we're we're instructing other physicians to—and healthcare professionals—to really start
considering that data because it used to be one, two studies and now it's 10, 11, and now the
these are very small studies but they've had they've had a now comparison in New York and
other places to sham acupuncture, so they actually do have a placebo group and they're still seeing
a potential benefit, and you know, you can go once a week, some people go twice a week. It also
helps — it can help with mood, it can help with pain, it can help with a lot of other things. So,
to find a qualified acupuncturist in your area or even acupressure for hot flashes the initial
investment is very small and the potential payoff to reduce hot flashes is massive,
right? It's also being studied in your area in chemotherapy induced peripheral neuropathy
or CIPN, so the multiple benefits of acupuncture — I get letters all the time, I talk to people all
the time about this who are going for it, and they're either getting little or they're getting
a lot, but they're getting something. So, I'm glad you mentioned that because I haven't even thought
about that for a long time, so the answer is yes, that's a great thing to potentially consider.
Where I'm not seeing a lot of help is the old days a lot of people would recommend supplements for
hot flashes and unless there's a major catch like someone's contaminated with estrogen or something,
I haven't seen much beyond a placebo. Although, I'm still a traditionalist, I still think
organic ground flaxseed helps a little bit. That was a Mayo Clinic study, it had a large impact.
They say it statistically didn't beat placebo, but clinically you could argue that it did help
a lot of people, and what I like about this is it costs pennies, you use two tablespoons, and
it's loaded with fiber, and what you always hear whether it's patients or someone in the public,
what you'll always hear is that if it works or it didn't work someone will go, "well god I'm regular
again, thank you" so, you know, it's first do no harm, right? You still get a potential benefit
even if you don't get the benefit you were looking for and some people get both.