Do testosterone supplements help raise testosterone levels after use of Lupron with radiation?

[Godfather2]

trying to decide to decide between surgery and radiation w/Lupron as a treatment for prostate cancer. I’m particularly concerned with how long it takes to restore testerone levels after 6 months on Lupron. Does the use of testerone supplements help restore T levels more quickly?

[Godfather2]

This is helpful. Thanks!

[Tall_Allen]

A rule of thumb is that it may take as long for your T level to return to baseline as you have been on ADT - less time for men with higher baseline levels. It is best to let natural production resume.

Here are questions to ask yourself:

prostatecancer.news/2017/12...

[Godfather2 in reply to Tall_Allen]

Thanks.

[Godfather2 in reply to Tall_Allen]

Thanks.

[janebob99]

Here's a plot of % of men who recover their baseline T, versus time after stopping ADT, for different durations of ADT.

Tall_Allen is correct, the average recovery time is about the same as the Duration of ADT, for ADT durations 20 months, the recovery time is twice as long as the ADT duration.

Testosterone Recovery after Lupron ADT

[janebob99]

Here's a summary plot showing the T-recovery time for 50% of men who recover their baseline T after stopping ADT versus Duration of ADT. There is a linear portion for ADT duration 20 months.

As to your other question, does TRT supplementation help after stopping ADT, the answer is most likely it will (and it will be safe). See papers by Morgentaler from Harvard.

ADT duration time

[Godfather2 in reply to janebob99]

Thanks

[maley2711 in reply to janebob99]

Just to add this....I have read that age is a HUGE factor in successful recovery. BTW, I believe Docs consider full recovery when T= 300 or so.

As an aside, Doc seemed to wonder if my "high" T ( 580 at age 75) was not a bad thing for someone with PCa.....I think your work has shown that he may be wrong!! Thanks again!!!

[janebob99 in reply to maley2711]

You're welcome.😀

The effect of high vs low Testosterone depends on which group you are in: (1) pre-diagnosis, (2) hormone-sensitive , or (3) castration-resistant . High testosterone is better for groups (1) and (3), while very low testosterone is better for group (2). That's my working hypothesis, at least, and it seems to match the current data. Part of the explanation is related to Morgentaler's Saturation Model (where Androgen Receptors become saturated above T = 250 ng/dL).

Most docs only know about the second group, meaning that high testosterone is bad (which is correct). They don't know about groups (1) and (3), unless they spend a lot of time reading the current literature.

We're lucky that many of us have time to read and discuss/review the current literature. That's what is great about this forum.

About the age effect...older men naturally have lower testosterone levels (which is one of many reasons that older men are diagnosed more frequently with PCa). So, T-recovery (after stopping ADT) naturally occurs more slowly for older men. You are correct about that.

So, older men should consider doing testosterone replacement therapy (TRT) after ADT is over, to accelerate their T-recovery. It's a safe treatment (see many papers by Morgentaler from Harvard).

If you have a reference to the paper you read about the age effect on T-recovery, I'd love to get a link to that.

Some docs believe that optimum testosterone levels are > 1000 ng/dL. Mine does, and I'm at 1060 now on TRT.

My most recent PSA has dropped from 10.0 to 3.3 after 3 months of being on Dutasteride and no ADT. I'm delighted with that, since I was diagnosed with stage III PCa (T3a).

Dutasteride is working well for me. Perhaps a slight bit of increased gynecomastia because my estradiol level has gone up, though.

Thanks!

Bob

Morgentalers Saturation Model

[maley2711 in reply to janebob99]

Thanks again.......Bob??? Some engineering/scientific background?

Hmmm......I'd need to search again for thata recovery study...probably hidden away somewhere in my hundreds of Favorites!!! Often just easier to redo a search with Google! I'll try to remember and see if I can find for you.

I just read your bio...looks like you are almost ready to do ADT +RT?

Did your Doc suggest Dutasteride while you are in a holding period prior to RT? Or did you self-prescribe? Is Dutasteride generally SE free? Assume it is validates as helping with PCa growth/mutations..at least for some period of time. I think I do recall a now deceased PCa Doc and PCa victim....Snuffy Meyers I believe..who may have advocated Dutasteride?

[janebob99 in reply to maley2711]

Hi, Maley2711.

Yes, I am an engineer. Good catch !

Ph.D in Nuclear Engineering with 2 MS and 2 BS in mechanical and nuclear engineering from Illinois and Wisconsin. I've done a lot of computer modeling of time-dependent processes by numerically solving coupled partial differential equations. I worked at Sandia National Laboratories for 30 years doing magnetic fusion energy research. Now, I work as a Registered Patent Agent and I write patent applications for inventors from GM, Boeing, and NASA.

I love researching data, making a hypothesis, and then plotting the data to discover trends and relationships. I believe that if I can understand the underlying principles and mechanisms at work in prostate cancer, that I will be able to write a better treatment plan.

Case in point... When I read that PCa cells don't feed off of testosterone, but, instead they feed off of dihdrotestosterone (DHT), a light went off in my head and I asked my PCP to prescribe Dutasteride (which I had previously been on many years ago due to high DHT (for unknown reasons)). Three months after starting Dutasteride, my PSA has dropped from 10.0 to 3.3. (and no ADT.) I expect it to keep going down.

I have hypogonadism and I take Testosterone Replacement Therapy (TRT). My T is now high, T=1060 ng/dL, and estradiol is elevated.

The only side effect of Dutasteride is some loss of libido and some mild increased gynecomastia (due to an increase in estradiol levels).

I've heard reference to Snuffy Meyers, but didn't know he was deceased. Sounds like he was a great guy.

I've got a great PCP who is an alternative-type of doctor. If I show him some data and present a reasoned case, he will prescribe anything. He's a good family friend, and he trusts my intuition.

My treatment plan uses four different ways of fighting PCa (in addition to doing SBRT). The hormone treatment plan is: (1) continue taking Dutasteride, (2) stop doing TRT, (3) start estrogen patch/gel therapy, and (4) add Relugolix if I don't reach sub-castrate levels of T < 10 ng/dL. It's overkill...but I want the best cure. Plus, steps 1-3 are very low cost. The Estrogen will counteract most of the bad side effects of chemical castration.

What do you think of my plan?

Dr. Bob

[London441]

What was your testosterone at diagnosis? What’s your age? Any health issues? How’s your weight and body composition, if known? How much do you exercise and what kind?

Data is nice, but the ‘average’ man starting Lupron is not in good health except by the most perfunctory standards.

[janebob99 in reply to London441]

At diagnosis, my T was about 700 ng/dL because I take TRT for hypogonadism. I had just turned 69. I also have hypertension, hypothyroidism (Hashimoto's disease), depression, ADHD, chronic low back pain, pre-diabetes, Hyperprolactinemia, ED, [all of which are well treated now] and I'm overweight. I also take Xarelto for a pulmonary embolism that I had two years ago, likely due to high prolactin (I have a micro adenoma on my pituitary gland that likely causes the hypogonadism).

As my wife says (who is a RN), I'm a "walking chemistry set". 🙂

I go to the gym 3 days a week and lift weights, but don't walk much due to my back pain (I'm having my 5th back surgery soon to extend the existing fusion from L3-4-5 up to L2). I also do bike riding when the weather is nice.

What I've learned looking at all this data is there there is tremendous variability in the numbers, due to all of the things you have mentioned. But, with thousands of men typically in a given study, median and average values are statistically meaningful. The distributions have large standard deviations, though, and they are often skewed distributions...not normal Bell curves.

Bob

[Vynbal]

If your insurance or bank account will cover it, Orgovyx (in place of Lupron) will provide just as (or more) effective T control with (generally) much faster T recovery. In my (n=1) case, by 6 weeks after end-of-treatment T had recovered to 600+.

[janebob99 in reply to Vynbal]

Yes, I have heard that about Orgovyx (Relugolix). What were your side effects when on Orgovyx?

[Vynbal in reply to janebob99]

Primary sexual SE - ED & loss of libido - were delayed onset and exit. I.e. I was on O for about 3 months before these SE set in, and off for about 3-4 months before they abated.

Other SE included hand muscle cramps, fatigue, muscle loss, mood swings (depression) and some brain fog. I had just a few hot flashes. Also my triglycerides were elevated and my QT period lengthened, but neither reached dangerous levels.

[janebob99 in reply to Vynbal]

Very interesting. My MO wants to prescribe Orgovyx (Relugolix), so it's good to hear what I will be getting into.

Thanks!

Bob

[Mgtd]

No scientific study Just my experience. I am a study of one.

Age almost 79. T prior to Lupron was almost 700. I was in good physical condition.

I had 25 sessions of Radiation with Lupron for 6 months. My choice. Lupron was 2 months prior and 4 months post radiation. T during Lupron was zero. PSA was <.01 and continues there. Next lab work in 6 months.

Two months after stopping Lupron my T was 233 and PSA was <.01. T continues to rise and PSA remains the same.

You can actually feel the effects of the rising T - lack of fatigue, no hot flashes, normal sex life in words back to normal for me. It is very noticeable.

Am I an outliner? Maybe! But honestly you need to help the process of T recovery thru diet, exercise - resistance and aerobics. If you sit on your butt and do not help or stimulate the recovery do not expect results.

[janebob99 in reply to Mgtd]

Good post. Congratulations on your treatment and good recovery.

I think the higher the baseline-T level, the faster one recovers after stopping ADT, but I don't have a plot that shows that.

The rule of thumb (for ADT durations less than 20 months) is that the T-recovery time for 50% of men equals their length of ADT duration. So, for example, if your ADT was 6 months, 50% of men will recover their baseline T in about 6 months.

It will be interesting how your response compares to this simple rule.

Please let us know what your T-level is after 6 months. It should be much higher than 233, (according to the rule).

Bob

T-Recovery after stopping ADT

[Mgtd in reply to janebob99]

I am running into a roadblock when it comes to T testing. All my doctors - GP, MO and RO say there is really no need to track T anymore since I am very near that 250 number and have no symptoms. I will try one more time but not holding out much luck unless I can come up with some scientific rationale.

I have not found any scientific data that supports getting both ADT and T tests after T has recovered to that magic 250 range. If you have some fire away.

[janebob99 in reply to Mgtd]

I don't have any data to help you with your problem. Sorry about that.

You might want to read the book written by Dr. Abraham Morgentaler from Harvard Medical School about testosterone in men. The title is Testosterone for Life.

It's a shame that they won't measure T above 250.

It's interesting that you mention T= 250 ng/dL. That exactly matches the saturation point (roll-over point) on Morgentaler's Saturation Model (see plot). I think that's likely a coincidence, though, since not many doctors' are familiar with the Saturation Model concept.

My PCP wants all older men to have a T > 1000 ng/dL. You may want to search for an alternative doctor who does integrative medicine.

Bob

Saturation Model (Morgentaler)

[Mgtd in reply to janebob99]

Thanks for taking the time to respond. Other than that issue I am extremely happy with these doctors and besides in our small town the RO and MO are the only game in town and our family GP is worth her weight in gold.

I am not sure other than personal curiosity that it is really critical to my current treatment plan or they would be doing it.

They all seemed to be focused on my current and trending PSA values to see if the treatment plan is working correctly or if further scans are warranted.

[janebob99 in reply to Mgtd]

You're right that it's not critical to measure T at this point.

They are right to focus on PSA recurrance, as you said.

[sciaticaman in reply to Mgtd]

Dear Mdtd,

My case is very similar to yours except my RT was condensed to 5 sessions and I started my 6 months of ADT (Lupron) when the RT started. I do not have a baseline T reading but my T and PSA at the end of Lupron were 0 and 3 months later PSA=<.02 and T=180; 1year after Lupron PSA=.07 and T=490. The Lupron gave all the usual SEs hot flashes, loss of libido and loss of orgasms, and fatigue. I coped with all of those SEs pretty well. The main thing that Lupron did to me is that it atrophied my muscles even though I was hiking in the mountains around Albuquerque and doing upper body weight training. Apparently I should have been doing weights training on my legs and back (e.g. squats) because 4 months after stopping Lupron, I developed sciatica and knee pain. My doctors have suggested that the muscles in my back and legs atrophied from the ADT and made my knee and smaller back muscles (piriformis) venerable to injury. The problem with having pain in your knees and back is that it is hard to exercise those areas since I now have testosterone and the exercise may grow muscle. Bicycling is helping with my quads and I am doing leg exercises pinpointing certain other muscles. In retrospect I wished that I had done weight training for my legs besides walking and hiking. But I guess my problems are pretty minor when compared to those of many others on this site.

[Mgtd in reply to sciaticaman]

For what it is worth like you I neglected my legs in the beginning. One of the guys on the forum highlighted the need to incorporate weights for my legs. To start with I incorporated the rowing machine - slowly at first. 5 minutes now 15 minutes 2X a week.

I then transitioned to leg weight machines. You may have two options the horizontal and the vertical. He recommended that I use the vertical machine and that has been great. It is easier on the back. Be conservative with the amount of weight. My rule of thumb is to do a set weight for two weeks before I increase it and then slowly.

One other thought. I have now incorporated dumbbells into my chest work besides the bench press. I was getting a little flabby. What a huge difference they have made.

I got one of the gym rats to show me how. I find those young kids are more then willing to help a old man.

Like you I thought hiking/walking would be enough.

[Mgtd in reply to Mgtd]

Notice I changed the leg press machine from horizontal to vertical. Vertical is easier on the back.

[sciaticaman in reply to Mgtd]

Thanks for your exercise advice. I have been thinking about buying a weight apparatus (Smith machine, etc.) for my garage. I would miss out on the young guys in the gym telling me what to do but I think I would exercise more. If I can get over this knee problem and my PCa stays in remission, I will think of my time on Lupron as a “preview of coming attractions” for when I get into my 80’s and 90’s (I am 78) and naturally lose my testosterone, I will know what to expect and know that I need to build as much muscle now and keep weight training until the very end comes some day in the distant (hopefully) future.

[Mgtd in reply to sciaticaman]

Just one thought. The getting up and out to the gym is good for me. At the same age - 79 as you the social aspects of the gym environment is something to consider.

Many of these home gyms fall into lack of use so you may want to consider a second hand one. Also they tend to limit your future training expansion opportunities. Just something to consider.

[EdinBmore]

Also a N = 1 here. Lupron for 9 mos. Started prior to, during, and after IMRT and brachy. T prior to starting was in the 250 range; never been high. Dropped to 0. Bad side effects for me: name it, I experienced it. Last 3 mo injection was in May 2019. While T began to rise - very slowly in my opinion - in the Fall 2019, it took until May 2020 before it had risen to prior treatment level. It remains in 250-ish range. I considered T replacement but the docs were less than enthusiastic given the apparent inconclusive data regarding its impact and long term consequences. OTC testosterone? No idea.

Good luck to you with your decision.

EdinBaltimore

[janebob99 in reply to EdinBmore]

Thank you for N=1 data point. Your response fits the rule well, i.e. that 50% of men recover their baseline-T in a time period that is equal to what their length of ADT duration was.

So, in your case, your ADT was 9 months. The rule would say that it would take about 9 months for 50% of men to recover their baseline-T. So, the rule is roughly correct for you, because you recovered in 12 months...a bit longer than the simple rule, but within the scatter.

There is probably a factor of 2 spread in the data, due to many factors: age, baseline-T, and general health level/fitness. The data is an average for all men.

I don't have data to support this, but I imagine that men with lower initial baseline-T have a longer T-recovery time than men with average/normal baseline-T. Your data fits that hypothesis. Age is probably a factor, too. Older men naturally produce lower amounts of testosterone (perhaps because SHBG rises with age). So, their T-recovery time will likely be longer than younger men. That would be an interesting retrospective study to do...

How old are you?

Bob

T-recovery time vs ADT duration

[EdinBmore in reply to janebob99]

I began ADT in 2018 when I was 69 yrs old; 74 now. For whatever it's worth: dx in 2011; GS 3+3; PSA 4.3; no metastases. On AS until 2018 when Hopkins uro recommended treatment (btw, I think he waited too long to recommend treatment. GS became 3+4, and PSA rose to 23). While I had 7 yrs of treatment free side effects, the anxiety (when is the other shoe going to drop) put a damper on QOL Knowing what I know now, and if I had it to do over again, I would have begun treatment much earlier and in all likelihood, it would been either brachy or IMT (without ADT). But, we carry on, yes? FYI: most recent PSA was 0.04; nadir of 0.02.

Do we have data on men, treated for PCa, who tried TRT and then their cancer recurred? A correlation? Causation? How would we know? And, is it worth the risk? How does one assess that?

Thanks for your thorough and thoughtful input here.

EdinBaltimore

[janebob99 in reply to EdinBmore]

In hormone-sensitive men, lower testosterone levels are associated with improved survival outcomes. This is consistent with Morgentaler's saturation model, which shows a linear relationship between prostate cancer growth rates and testosterone level below the saturation point of T = 250 ng/dL. It predicts zero cancer growth at zero testosterone.

Here's a plot that supports that low testosterone predicts better outcomes for hormone-sensitive men. It shows the probability of becoming castrate-resistant versus time for three different levels of Testosterone nadir. Note that this plot is for men with advanced PCa who are still hormone-sensitive.

Above T = 250, increasing the level of testosterone doesn't increase the PCa growth rate very much...the saturation model curve becomes essentially flat above the roll-over T-level of 250 ng/dL. So, if you're going to do TRT, you might as well try to reach 1000 ng/dL, because the additional amount of PCa will be small in this saturation part of the curve.

Morgentaler (from Harvard) has published many papers that say TRT is safe for men with advanced PCa (who are most likely castrate-resistant). You may want to read his work, and/or watch his YouTube videos, which are very interesting. This regime may apply only to men in the castrate-resistant regime (i.e., rising PSA while on ADT). No one has explained why increasing T in this castrate-resistant regime is beneficial, however.

Of course, QoL is greatly improved when adding TRT for men with low-T, in general.

Alternatively, you can substitute estrogen patch/gel therapy for ADT, and get effective chemical castration with much fewer side effects.

Another data point is the successful use of the Bi-Polar Androgen (BAT) protocol, where they give castrate-resistant men shots of high-dose testosterone every few months, while continuously doing Lupron ADT. This BAT therapy successfully controls PSA rise in this cohort of men. The theory is that super-high T levels (in castrate-resistant men), resets their cancer cells to become hormone-sensitive again (at which point the Lupron ADT does it job). Dr. Sam Denmeade at Johns Hopkins discovered this seemingly-contradictive effect, which is becoming more commonly used.

Do you know if you're still hormone-sensitive, or are you castrate-resistant?

Bob

Castrate-Resistant PCa probability vs time for different testosterone nadir levels

[EdinBmore in reply to janebob99]

Not castrate resistant. No metastasis. Not sure what you mean by hormone sensitive. As I approach 5ys of low PSA, return to earlier T levels, and no evidence of PCa, I think that I'm considered "cured," yes?

[janebob99 in reply to EdinBmore]

Congratulations! Yes, it sounds like you are "cured "at this point.

"Hormone-sensitive" is the same as "non-castrate resistant PC, non-CPRC". It means that you haven't yet had a rise/recurrance in PSA after curative treatment, and that you are still could be effectively by ADT if needed (i.e. you're still sensitive to ADT anti-testosterone treatment).

I need to read up on how to determine the point where someone becomes "castrate resistant". I suppose it means that your PSA starts rising sigificantly (e.g., more than 2 units), and then observing that re-starting ADT doesn't bring the PSA back down. That would be "castration resistance".

Bob

[janebob99 in reply to EdinBmore]

I forgot to add that doing T-replacement (TRT) after stopping ADT is safe and effective. See Morgentaler's papers and YouTube lectures. Lot's of data support the safety of doing TRT after ADT.

I get my TRT from a compounding pharmacy (I have hypogonadism). You can go to one and ask them for the name(s) of doctors who prescribe compounded testosterone cream/gel. Then, contact that doctor and tell them you want TRT. Odds are they will prescribe it.

My PCP has a T-goal of > 1000 ng/dL for overall good health. I'm at 1060 now on TRT. My PSA has dropped from 10.0 to 3.3 after 3 months of Dutasteride, so I believe my PCa tumor has stopped growing, or is shrinking.

Bob

[conbio]

Data point - Age 65 when started 18 months of Lupron followed by EBRT and Brachy. Normal T was around 300. Dropped to 0 within a few months. Once treatment stopped returned to base in 5 months. While on Lupron - hot flashes, reduced hair on legs and elsewhere and gained 8 lbs despite lifting with a trainer once a week, lifting on my own, and continued to climb. Red blood cell and hemo was down as was my stamina. All great now.

[janebob99 in reply to conbio]

I thought I had replied to you, but now I don't see it...

Congratulations on your very fast recovery! You beat the rule of thumb by a very large margin. The rule says that it should have taken 18 months to recover your baseline T, on average. 5 months is really fast! It may have been be due to your relatively young age, and/or good fitness.

This plot doesn't show that there is large variability in the data, probably a factor of +/- 2X in the recovery-time data, with tails out to +/- 3X likely.

The original data plot predicts that at 5 months after stopping ADT, only about 15% of men have recovered their baseline T, for ADT = 18 months. You're one of those 15%.

Why do you think that your recovery was so fast?

Thanks!

T-recovery time vs ADT Duration