ADT Side Effects & Management: Coping with Hormone Therapy

Common side effects of ADT – overview

Androgen deprivation therapy (ADT) lowers testosterone to castrate levels. While effective for prostate cancer, it causes significant side effects that impact quality of life:

• Hot flashes: 50-80% – most common
• Fatigue: 50-80%
• Erectile dysfunction and loss of libido: 80-90%
• Loss of muscle mass and weight gain: 30-50%
• Osteoporosis (bone loss): 20-40%
• Metabolic syndrome: Increased risk of diabetes, heart disease
• Depression and cognitive changes: 20-30%
• Gynecomastia (breast enlargement): 10-20%

Hot flashes management – medications and lifestyle

Hot flashes are the most common and bothersome side effect of ADT, affecting 50-80% of men.

Non-pharmacologic measures:

• Dress in layers
• Use fans or cooling devices
• Avoid triggers: caffeine, alcohol, spicy foods, hot beverages
• Maintain cool room temperature
• Deep, slow breathing at the start of a hot flash

Medications:

• SSRI/SNRI antidepressants: Venlafaxine (Effexor) 37.5-75 mg/day – most effective; paroxetine (Paxil), sertraline (Zoloft)
• Gabapentin: 300-900 mg/day – effective, causes drowsiness
• Megestrol acetate: 20-40 mg/day – effective but causes weight gain (use with caution)
• Clonidine: 0.1-0.2 mg/day – less effective, can cause dry mouth and hypotension

Fatigue management – exercise, sleep, energy conservation

Fatigue is the second most common side effect and can be debilitating.

Exercise (most effective):

• Aerobic exercise: Walking 30 minutes daily – reduces fatigue by 30-50%
• Resistance training: Weight lifting 2-3x/week – preserves muscle mass
• Combined program: Best results

Energy conservation:

• Prioritise activities
• Rest before you become exhausted
• Delegate tasks when possible

Sleep hygiene:

• Maintain regular sleep schedule
• Avoid caffeine and alcohol before bed
• Treat hot flashes (improves sleep quality)

Medications:

• Modafinil (Provigil) – limited evidence, possible benefit
• Methylphenidate (Ritalin) – limited evidence
• Treat anaemia (check CBC; iron supplementation if ferritin low)

Osteoporosis prevention – calcium, vitamin D, bisphosphonates

ADT accelerates bone loss (2-5% per year), increasing fracture risk by 2-3x.

Baseline assessment before starting ADT:

• Bone density scan (DEXA) – T-score
• Calcium and vitamin D levels

Prevention for all men on ADT:

• Calcium: 1,200 mg/day (diet + supplement)
• Vitamin D: 1,000-2,000 IU/day
• Weight-bearing exercise: Walking, jogging, resistance training
• Smoking cessation
• Limit alcohol

Pharmacologic treatment (for osteoporosis or high fracture risk):

• Denosumab (Prolia, Xgeva): 60 mg injection every 6 months – most effective
• Bisphosphonates (zoledronic acid): 4 mg IV annually
• Indicated for T-score < -2.5 or history of fragility fracture

Erectile dysfunction – PDE-5 inhibitors, vacuum devices

ADT causes loss of libido and erectile dysfunction in 80-90% of men.

Management options:

• PDE-5 inhibitors (sildenafil/Viagra, tadalafil/Cialis): May help but less effective on ADT than without ADT. Tadalafil 5 mg daily may improve spontaneous erections.
• Vacuum erection device (VED): Effective, no medication side effects
• Penile injections (alprostadil, Trimix): Very effective, but requires injection training
• Penile implant: For refractory ED

Libido (loss of sexual desire):

• Discuss with partner
• Focus on intimacy (touching, closeness) rather than intercourse
• Counselling or sex therapy

Metabolic syndrome – weight gain, diabetes, cardiovascular risk

ADT increases risk of insulin resistance, diabetes, and cardiovascular disease.

Metabolic changes on ADT:

• Weight gain (5-10 lbs average, primarily abdominal fat)
• Increased LDL cholesterol
• Increased triglycerides
• Insulin resistance → type 2 diabetes (risk increases 1.5-2x)

Prevention and management:

• Diet: Mediterranean diet, reduce refined carbohydrates and saturated fats
• Exercise: 150 minutes/week moderate activity + resistance training
• Monitor blood pressure, lipids, glucose: Every 3-6 months
• Statins: For elevated LDL cholesterol
• Metformin: For diabetes or prediabetes
• Aspirin: For secondary prevention (if high cardiovascular risk)

Cognitive changes – "brain fog" management

Some men experience cognitive changes on ADT: memory issues, trouble concentrating, word-finding difficulty ("brain fog").

Management strategies:

• Exercise: Aerobic exercise improves cognitive function
• Cognitive training: Brain games, puzzles, learning new skills
• Organisational tools: Calendars, lists, reminders
• Treat fatigue and depression: Often worsens cognitive symptoms
• Intermittent ADT: May reduce cognitive effects (if eligible)

Gynecomastia – prevention and treatment

Gynecomastia (breast enlargement/tenderness) occurs in 10-20% of men on ADT, especially with anti-androgens (bicalutamide).

Prevention:

• Prophylactic breast irradiation: Single dose of 8-12 Gy before starting bicalutamide – reduces risk by 70-80%

Treatment:

• Tamoxifen: 10-20 mg/day – reduces pain and size
• Anastrozole: Aromatase inhibitor – less effective
• Liposuction or surgical excision: For persistent, bothersome gynecomastia after ADT completion

Interactive FAQ – ADT side effects management

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Disclaimer: This information is for educational purposes. ADT side effects can be managed proactively. Discuss with a medical oncologist or urologist at Vivekananda Hospital.