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A drug called finasteride acts by shrinking the prostate and decreasing the obstructive symptoms of BPH. But it may do more than simply ease the symptoms of BPH—it may halt its progression.

Finasteride works by thwarting a hormonal process without affecting levels of testosterone, the hormone responsible for a man’s libido and sexual function. Scientists have learned that the trouble in BPH starts after testosterone is converted by an enzyme called 5-alpha-reductase into a substance called DHT, which is the active form of male hormone within the prostate. Finasteride stops testosterone from changing to DHT by blocking this enzyme. So the amount of DHT in the bloodstream and prostate tissue drops; but because testosterone levels in the blood remain unchanged, impotence is not a problem for most men who take finasteride. The drug causes a significant reduction in the tissue surrounding the urethra, which is responsible for obstruction.

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This could mean a serious medical condition, such as bladder or prostate cancer. If you’re passing blood clots in your urine, you should seek treatment immediately But blood in the urine may also be related to BPH: In some men, there are big veins that cover the enlarged BPH tissue along the urethra; these veins may break open spontaneously. (Such bleeding tends to occur more frequently in men who regularly take aspirin.) Typically, men with BPH-related bleeding report that they pass a small clot when they begin to urinate, and also note bleeding during urination. This bleeding usually stops after several days but may require cystoscopy, so the bleeding vessels can be cauterized. Repeated episodes are usually a good indication for surgery. (Recently, doctors have reported some success with hormonal therapy as a treatment for bleeding.

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The major goal of hormone therapy is to reduce testosterone, which stimulates the prostate tumor. What’s the best approach? There are several good places to break this hormone chain—drugs that can target the hypothalamus (LHRH), the pituitary (LH), the adrenal gland (adrenal androgens), the testicles (testosterone) or the prostate (DHT).

The cheapest and easiest way to control testosterone is by a simple surgical procedure, castration (also called an orchiectomy). Castration works fast; it reduces the body’s amount of testosterone by 95 percent almost immediately, and permanently. Within about three hours after surgery, testosterone levels begin to plummet to a level called the “castrate range.”

Many men, for many reasons, don’t want to undergo surgical castration, so they opt for chemical castration—taking drugs that accomplish the same result. There are several options: One is a group of drugs called estrogens. DES, the main oral estrogen, targets the hypothalamus-pituitary connection, instead of the testicles. It works by blocking the release of LHRH—which, in turn, blocks LH and FSH, and this virtually shuts down the testosterone-making factories in the testicles. So testosterone drops to the castrate range. (Note: Men with a history of heart disease or thrombophlebitis should not use DES as their main form of treatment.)

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Remember the car trying to cross the border, and all the roadblocks set up to stop it at various points along the way? This is the key to how hormone therapy works. Each therapy targets a different link in the chain of hormonal interactions that affect the prostate.

This is a long and complicated chain; put together on paper, it’s a confusing jumble of letters, mostly consonants, that looks like alphabet soup. And if you’re like most men, just thinking about this muddle will make your eyes glaze over. But, stripped down to its essential steps, this code is not so tough to crack—you can do it! (And, you need to master this information, so you can not only understand what your doctor’s talking about, but help choose the treatment option that’s best for you.)

To understand this hormonal chain, let’s start at the beginning—the brain, where the hypothalamus makes, among other things, a substance called LHRH (luteinizing hormone-releasing hormone), which acts as a chemical signal. It’s dispatched in pulses, like Morse code or flashes of light, to the nearby pituitary gland. Its message? “Make LH and FSH” it tells the pituitary.

LH (luteinizing hormone) and FSH (follicle-stimulating hormone) are other chemical signals, and they bring us to the testicles, or testes, where LH motivates certain cells (called testicular Leydig cells) to make testosterone. (FSH has its major effect on sperm production.)

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How does an X-ray machine work? The simplest way to think of it is to imagine yourself getting a suntan. The difference here is that you can’t feel or see the X-ray energy hitting your body, and the “tan” occurs internally. (What happens is that the radiation particles destroy DNA, causing targeted cells to die.) The best way to get a good, even tan is in increments, not all at once. Similarly, the most effective radiation doses are spread out over several weeks, with each treatment lasting only a few minutes at a time. (The goal here, besides killing the prostate cancer, is to do as little harm as possible to the surrounding tissue—the rectum, bowel, bladder, bone, and skin.)

To help your radiation oncologists get a good picture of the terrain of the targeted area—the prostate and surrounding organs—you will probably be given a “treatment-planning” CT scan. Some doctors also use computer simulators to fine-tune the dose of radiation and fields of treatment for you—these can vary, depending on factors such as the stage and grade of your tumor, the contour of your pelvis, and your size (for some large or heavyset men, a different degree of energy works better).

For high-grade tumors (Gleason score 7 or higher) or malignancies greater than clinical stage T2b (B1), doctors make sure the field of treatment covers the prostate, seminal vesicles and surrounding tissue, including nearby lymph nodes, where the cancer may have spread after penetrating the prostate wall. Radiation is delivered to the front, back and each side of the patient. (The specific map of treatment can vary from man to man.) A major goal here is to safeguard as much of the surrounding territory—the cancer-free organs and tissue—as possible. Doctors particularly want to shield bone from radiation, to avoid harming key blood-forming cells that reside in the bone marrow. One way to protect cancer-free areas is to shield them with blocks of lead, which the radiation can’t penetrate. Other steps can also be taken—one way to protect the bowel, for instance, is for the patient to have a full bladder during treatment; this pushes the bowel away from the pelvis. Another technique is to have the patient lie on a hard pillow that pushes the bowel out of the way, into the upper abdomen.

To make treatment easier to tolerate (and thus minimize side effects), a “sandwich” approach—in which the radiation dose is split in two, with a break in between—may become more common. The purpose of this technique is to give the bowel and part of the bladder a “breather,” a window of opportunity to recover from the shock of the treatment. In men who have small (stage T1 or T2, or A and B), low-grade tumors—where the risk of cancer having spread beyond the prostate is minuscule—radiation is limited to the prostate alone.

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