San Antonio Express-News (Sunday)
Meds for prostate cancer linked to hot flashes
Q: I’m a 76-year-old man who was treated for prostate cancer starting in summer 2017. Following radiation therapy, I was given Lupron injections every six months for two years. It’s been two years since my last injection, but I still experience hot flashes as a result. Will these hot flashes stay with me for the rest of my life? My urologist assured me the hot flashes would subside approximately a year after the final shot.
A: Leuprolide (Lupron) is a medicine that prevents the body from making testosterone. Back in 1941, depleting testosterone was proven to slow prostate cancer growth, but even in the first group of subjects, there were men with severe hot flashes. The sudden drop in testosterone causes “vasomotor instability,” meaning that the blood vessels in the skin suddenly dilate, causing an intense heat sensation. The whole body can cool down with this, leading sufferers to feel cold afterward.
I can’t predict how long these symptoms will last, but it does not shock me that they have continued for two years. Given that they seem to be quite bothersome, ask your urologist or oncologist about treatment. Just as with menopausal women who have hot flashes, treatments can reduce, though perhaps not eliminate, the number of hot flashes you get per day.
There are hormonal and nonhormonal treatments. Hormonal therapy (such as a progestin) carries the possibility of stimulating prostate cancer growth, so most experts prefer trying nonhormonal treatments first.
Both antidepressants and antiseizure medicines have been found to work, even though hot flashes are not related to depression or seizures.
Q: I just got my COVID-19 vaccination with the Moderna vaccine. I will have a booster in 28 days. Am I protected from the “new strain”? Or will I need yet another type of vaccination?
A: At the time of this writing, most experts agree that both the Pfizer and Moderna vaccines provide a high degree of protection against the currently predominant strains. There is less protection against the South African variant.
Some variants, such as the UK B.1.1.7, seem to be more likely to transmit from person to person
compared with those previously circulating, and they may even be more likely to cause serious disease or death in an infected person.
Despite the reassurance about protection, it is possible that future mutations in the virus could lead to a large enough structural change in the spike protein that the vaccine will be significantly less effective.
The best way to prevent this is to get control over the pandemic as fast as possible. The more people that are infected with COVID-19, the more chances the virus has of developing a resistant variant. If that happens, a new vaccine would indeed be needed, although vaccine development would be much easier due to the immense amount of work already done.
It is not clear whether yearly (or some other frequency) boosters will be required. Immunity might wear off, or new variants may continue to emerge that require new vaccines. This is similar to what is seen with seasonal flu. This is all speculative until we have more information.
Q: About two weeks ago, I received the vaccine for
COVID-19. By the next day I had a great deal of pain in the shoulder area where the vaccine was administered. For about five days, I could barely lift my arm. It is still sore but the pain is subsiding, and I can now fully raise my arm. If the vaccine got into the bursa (as described in a recent column), would it still have been absorbed into my bloodstream so that I could get immunity?
A: Shoulder injury related to vaccine administration, or SIRVA, is a seldom-reported — but probably more prevalent than thought — adverse vaccine event. It happens when the vaccine is injected not into the muscle, as it should be, but into the bursa space below the muscle. This results when the injection site is too low or the needle is placed too deeply.
Vaccines are intended to cause a response by the body, but doing so in the bursa will cause weeks of poor shoulder function. It is treated with physical therapy and sometimes steroid injection.
Vaccines do not go into the bloodstream. Both the Moderna and the Pfizer COVID-19 vaccines are an mRNA vaccine. The mRNA is taken up by the muscle
cells, and the muscle cells use the information in the mRNA to start making a COVID-19 protein. It’s not the whole virus, so it is impossible to get COVID-19 from the vaccine. The mRNA is then destroyed, but not before the muscle cells have made enough COVID-19 protein that the body has learned how to fight it off.
While it is possible that the cells around the bursa could express some COVID-19 protein, I recommend that a person who developed SIRVA after COVID-19 vaccination restart the two-dose vaccine series.
The fact that you are getting better after five days makes me think you do not have SIRVA. Five days is longer than most people have arm pain as a side effect, but it’s nothing like the six weeks of shoulder motion restriction seen with SIRVA.
Q: My husband is 85 years old and his hands shake. Doctors say it’s not Parkinson’s disease but some kind of tremor. It embarrasses him. One time he spilled a plate of spaghetti on himself. He drops dirty dishes on the way to the sink. I read about medicines that could cause tremors.
Could this be the problem?
A: Although some medicines can cause or worsen tremors — especially antidepression drugs, antiepilepsy drugs, asthma inhalers and steroids — I did not see any on the list you sent, and I think it is much more likely that your husband has essential tremor. “Essential” just means we don’t know what causes it. It is more common as we get older and typically runs in families.
The diagnosis can usually be confirmed by a physical exam, but a neurologist, especially one who specializes in movement disorders, may be helpful to be sure. A neurologist is certainly the expert in managing this condition. There are several medications commonly used for firstline treatment. A deep brain stimulator, or even surgery, is considered in severe cases that do not respond to medication.
Dr. Roach regrets that he is unable to answer individual letters, but he will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell. edu or send mail to 628 Virginia Dr., Orlando, FL 32803.