Fatigue and Hormone Therapy

Fatigue and Hormone Therapy

February 14, 2020 1 By Jose Scott


Hi, I’m Dr. Scholz. A common question we
get at the PCRI is “How do you counteract fatigue from hormone blockade?” Hormone blockade otherwise known as androgen
deprivation or we call it testosterone inactivating pharmaceuticals—these are medicines like
Lupron, Casodex, Zytiga, Xtandi—fatigue is far and away the most common complaint,
and this occurs primarily because low testosterone causes loss of muscle.
Think of muscles as the engines of your body. So if you’ve been driving around with a
V8 all your life and all of sudden they’ve put a 4-cylinder in your car, you’re going
to wonder why when you hit the gas nothing happens. There is a way to counteract muscle
weakness from hormone blockade and it takes a fanatical, diligent, consistent commitment
to exercise. And not just any kind of exercise; I’m not talking about running and stretching;
I’m talking about weightlifting. Weightlifting can compensate for the muscle loss that occurs
when testosterone levels are low. But this usually means visiting the gym 2 or 3 times
a week and really stressing the muscles so they become fatigued and sore. This will cause
them to increase in size and restore your normal strength. When testosterone levels
are low under therapy muscle loss can occur incredibly quickly—within a couple of weeks.
So people can diligently do exercise month after month after month, and feel reasonably
well and then take a two week holiday, and all of a sudden they feel horribly fatigued
because of all the rapid muscle loss. So not only does exercise need to be regular, it
needs to be totally consistent. There can’t be any holiday periods. In my experience,
regular fitness training like I’m describing will cause about an 80% reduction in the amount
of fatigue that men face when they’re on these treatments. There are a few other tricks that people can
consider as well. One, of course, is to realize that there are
other causes of fatigue beside the treatment. People can have low thyroid levels or low
B12 levels, and so a medical examination by a skilled doctor should be done to make sure
there’s not something else going on. If people are just told it’s always from the
Lupron, sometimes some of these other things are going to be missed. One medical condition
that is less common, but can also occur with low testosterone levels is the development
of anemia—low red blood cell counts. If anemia becomes severe then cardiorespiratory
reserve is reduced, and you’re left with getting shorter breath rather easily with
minimal exercise. Most of the anemia from low testosterone levels is mild and does not
need treatment, but if it becomes severe—which would probably be signaled by a hemoglobin
less than 10 or a hematocrit under 30%—pharmaceutical intervention with a medicine such as Aranesp
or Procrit can restore blood levels back up into an acceptable range. Transfusions are
not indicated. There is always some risk with transfusions, and unless the anemia was horribly
severe one would not consider giving transfusions just to correct the anemia of low testosterone. So what other tricks can people consider if
these measures don’t seem to be enough? Well, medicine such as Provigil, also called
modafinil, which is a medicine that has been FDA approved for the treatment of narcolepsy
seems to be a nice stimulant that can help people. Some men rely on caffeine—an extra
cup of coffee now and then. These measures have some benefit, but as is the case with
many pharmaceuticals continued successive use leads to less of a benefit over time.
It’s better to use these agents for certain special occasions or days that you need extra
energy and then allow your body acclimatized to the absence of these medicines so it reestablishes
their benefit when you use them again. Lastly, in men with ongoing hormone blockade
treatment (TIP Therapy, Androgen Deprivation) there’s always some flexibility in what
medicines are being used and how long the treatment is continued. Often times TIP is
giving for a four-month period for men with Teal, an 18 month period for men with Azure,
and maybe a 12 month period for men with Indigo, but when men are more elderly or perhaps they
have a milder form of disease, [then] shorter treatment periods should be discussed, especially
in men that are having a lot of serious fatigue. Another possibility is to use less intense
therapy. One medicine, in particular, Xtandi, is more associated with fatigue. Another competitor
called Zytiga is equally effective but less likely to cause fatigue. So you can talk about
switching the Xtandi to the Zytiga, and that may reduce the problem with the fatigue when
Xtandi is the cause. Another shift to consider when men are really hurting from Lupron (I
use Lupron sort of like the Kleenex of the prostate world. There’s Eligard, Firmagon,
and all these medicines can induce the fatigue of low testosterone) but Casodex, an oral
hormone blockade agent, is definitely associated with less fatigue than these other injectable
forms. Casodex is probably not quite as potent in its anti-cancer effects, so some of the
anti-cancer effect is probably being sacrificed by using Casodex instead of Lupron or one
of its analogs, but in severe cases, Casodex can be considered as a substitute for Lupron
to help people get some degree of treatment. In my own patients, I tend to use Casodex
in my elderly patients that in their 80s to extract some benefit from the testosterone
blockade therapy, but minimize the fatigue that comes from this type of treatment. So in summary, there’s a panoply of options
to help men who are suffering from fatigue. You need to put all this information into
context depending on how serious the disease and how serious the fatigue is different measures
can be implemented to try and reduce this troublesome side effect and improve a person’s
quality of life.