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Some CRPC treatments are used only in men whose tumors have certain characteristics that make the therapy more likely to be effective. CRPC tumors continuously evolve resistance to treatments, necessitating several lines of therapy, each used in sequence to extend survival. Hormone therapy halts tumor growth in more than 95% of those treated, and PSA levels return to normal in up to 70%. For those with metastatic disease, the standard of care is androgen deprivation therapy (also called "chemical castration"), drugs that reduce levels of androgens (male sex hormones) which prostate cells require to grow. Those who elect to have therapy receive radiation therapy or a prostatectomy; these have similar rates of cancer control, but different side effects.
Nonetheless, LUTS are a set of subjective and objective symptoms, the causes of which are multifactorial and generally not disease specific. Another concept is an inflammatory cause of BPH, which has been known to directly or indirectly contribute to prostate enlargement since described by Kohnen and Drach29 in 1979. Through a retrospective review of publications from 1941 to 2008, Morgentaler and Traish26 have theorized a "saturation model" to explain the lack of effect of TRT on prostate volume or PSA in these men. This then leads to the AR-dependent transcription of specific target genes resulting in the production and secretion of peptide growth factors, including insulin-like growth factor 1, epidermal growth factor, fibroblast growth factor-related proteins, such as keratinocyte growth factor.3 Furthermore, after initial regression of BPH in older castrated dogs, BPH was restored following testosterone replacement.4 It is thought that the normal interactions between the epithelial and fibromuscular stromal components of the transitional zone prostate tissue are altered leading to a reduced epithelial/stromal ratio and thus micronodular remodeling that characterizes BPH.
Single sites of pain can be treated with external beam radiation therapy to shrink nearby tumors. The standard of care is the chemotherapy docetaxel along with antiandrogen drugs, namely the androgen receptor antagonists enzalutamide, apalutamide, and darolutamide, as well as the testosterone production inhibitor abiraterone acetate. Reducing testosterone can cause various side effects, including hot flashes, reduction in muscle mass and bone density, reduced sex drive, fatigue, personality changes, and an increased risk of diabetes, cardiovascular disease, and depression.
As of 2024update studies exploring the relationship between ejaculation frequency and prostate cancer risk are inconclusive and age, urinary health, and lifestyle are important factors to consider. Similarly, in human patients with primary hypogonadism, testosterone replacement allows the development of normal prostatic growth and BPH.5 It is also well-known that in men with diseases of the prostate (such as prostate cancer or BPH), castration or androgen deprivation treatments leads to decrease prostate size and improvement in urinary function in some patients.6 The frequency of prostate cancer screening during TRT should be determined by your doctor, based on your individual risk factors, including age, family history, and PSA levels. In the 1960s, large studies showed estrogen therapy to be as effective as surgical castration at treating prostate cancer, but that those on estrogen therapy were at increased risk of suffering blood clots.
With the right monitoring and communication, many men with BPH can still enjoy the benefits of testosterone therapy. In men with both low testosterone and BPH, these two specialists often work together to find the safest and most effective treatment plan. A urologist is a doctor who specializes in prostate and urinary problems. The AUA states that TRT should be used only when clear symptoms of low testosterone are present and confirmed by blood tests. Doctors may also ask for imaging of the prostate, such as an ultrasound or MRI, if the prostate feels large or if PSA levels are higher than expected.