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SEXUAL HEALING IN MEN ON HORMONE THERAPY FOR PROSTATE CANCER
prostate biopsies. 5 Similarly, ED rates a year after diagnosis of
localized prostate cancer in 771 Norwegian men were 76% in
those on surveillance, 89% after radical prostatectomy, 83%
after radiotherapy, and 84% after combined radiotherapy
and hormone therapy. 6
Sexual and urinary function in men diagnosed with prostate
cancer were signifıcantly worse than in healthy controls
in the Prostate, Lung, Colorectal, and Ovarian Cancer
Screening Trial in the United States (p 0.001). 7,8 Side effects
persisted across 10 years of follow-up. More than 95% of
men in each cancer treatment group reported sexual dysfunction
and 50% had urinary or bowel dysfunction. Diagnosis
by prostate-specifıc antigen (PSA) screening
theoretically could downstage the cancer, but screening reduced
neither long-term mortality nor rates of sexual, urinary,
or bowel complications.
ANDROGEN DEPRIVATION FOR PROSTATE CANCER
AND ITS EFFECT ON SEXUAL FUNCTION
Androgen deprivation therapy has been used in a variety of
ways to treat patients with prostate cancer over the past 70
years, ever since the discovery that signaling from androgen
receptors in prostate cancer cells is responsible for at least
some of the proliferation and recurrence of disease. 9 However,
even when ADT succeeds in controlling cancer cells that are
sensitive to hormones, cancer progression may take place because
of clones of cells that are less dependent on androgens.
Second-line hormone treatment with drugs such as abiraterone
or the androgen blocker enzalutamide also has been shown to be
benefıcial even when fırst-line ADT has failed. 9
Androgen deprivation therapy, whether with bilateral orchiectomy,
luteinizing hormone-releasing hormone agonists
or antagonists, helps treat prostate cancer symptoms in men
KEY POINTS
Men with prostate cancer have a high prevalence of sexual
dysfunction because of age, comorbidities, and damage
from definitive treatment for localized disease.
Androgen deprivation therapy adds to the problem because
of the loss of hormone stimulation in the brain and direct
damage to the erectile tissue.
Men who have good sexual function at the time of prostate
cancer diagnosis and who are in a sexual relationship with
a partner who wants to stay active are more bothered by
the sexual dysfunction.
Preventing and treating problems may involve counseling
the man or couple on how to achieve more intense sexual
stimulation, how to improve sexual communication and
avoid performance anxiety, and how to decide whether to
try a treatment to restore better erections.
Men who have sex with men have some special issues,
including a greater emphasis on the sensual qualities of
semen at ejaculation and sometimes a need for a more
rigid erection to allow anal penetration.
with metastatic disease and may prolong survival, 10 but it
also increases the risks of cardiovascular disease, osteoporosis,
and sexual dysfunction. 10 It remains unclear if using ADT
as neoadjuvant treatment before radical prostatectomy prevents
recurrence in men with high-risk disease, although
benefıts in survival have been demonstrated from combining
ADT with external beam radiation therapy in this patient
subgroup. 10 It has become increasingly clear, however, that
ADT as a monotherapy is inferior to active surveillance in
older men with organ-confıned prostate cancer, causing
morbidity but not prolonging survival. 11,12
Rates of sexual problems are high among men on ADT.
These problems include a decreased desire for sex, diffıculty
getting and keeping erections, reduced semen volume, trouble
reaching orgasm, and distress about gynecomastia and
feminization of fat distribution. 13 Many men surveyed already
had defınitive local treatment with radical prostatectomy
or radiation therapy. Their sexual function was severely
damaged before the onset of ADT, making it diffıcult to attribute
additional problems to hormone therapy. 4,6,8,14-16
Nevertheless, sexual function is poorer in men who had past
or current ADT when compared to men only treated with
surgery or radiation therapy. 17-19 Even after 3 or 4 months of
ADT, damage to erectile function is likely to be permanent
because of alterations to the smooth muscle in the cavernous
bodies of the penis. During erection, despite adequate arterial
inflow of blood, the veins draining blood from the erectile
tissue are not occluded and penile rigidity cannot be maintained.
19 ADT also impairs nocturnal erections, which may
be important sources of oxygenated blood to the penis after
localized prostate cancer treatment by helping nerves to heal
and maintaining the health of endothelial cells in the erectile
tissue.
Men who rate their degree of distress or “bother” about
sexual dysfunction as greater also report more depression
and poorer quality of life. 16 Not surprisingly, men are more
bothered by sexual problems if they are younger and have
better sexual function when diagnosed with prostate cancer
or starting ADT, and if their relationship is more satisfying
(i.e., they have more to lose). 2,3,16 Distress about sexual problems
also is associated with more caregiving stress and poorer
quality of life in the spouses of men diagnosed 3 years previously
with prostate cancer. 20
Some men are given double-blockade therapy by adding an
androgen blocker to ADT. Although survival benefıts of double
blockade are dubious, 10,21 drugs such as fınasteride or bicalutamide
may directly damage the smooth muscle inside
the cavernous bodies, increasing the risk of venous leak and
irreversible erectile dysfunction. 22
INTERMITTENT ANDROGEN DEPRIVATION THERAPY
Another issue is whether intermittent hormone therapy is as
effective as continuous ADT in prolonging survival while
maintaining better quality of life, including recovery of sexual
function during time off ADT. 23 Two recent, large phase
III trials suggest that intermittent ADT is equivalent to con-
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