*185/197/1*

And what does the Pill control? Certainly if taken correctly it does provide excellent fertility control. But at a deeper level, the Pill interferes with natural cycles. Does it matter that a couple loses touch with the moon and tides? No-one directly complained of this, but in many discussions there surfaced an agreement that nature was being interfered with. One man asked, ‘If she got pregnant on the Pill, would the child’s periods be affected later?’ As the child is mother to the adult, we want the child to have a natural, healthy start.

In talk of hormones, people mentioned steroids, hair growth, infertility, osteoporosis, cystic ovaries, baldness, libido changes and homosexuality. The word ‘hormone’ has become tainted because of its association with steroids and drugs. Men are cautious about what may be going on when their partner is on the Pill. Some felt that premenstrual tension was worse on the Pill, ‘even though she gets some break’. The tension was seen as a build up from the drugs over the 21 days of Pill taking.

*148/197/1*

In the contraceptive clinic plans and expectations about a family can be shared with the doctor very early when discussing contraception. A simple question like, ‘I wonder if you are considering a family at any stage?’, before writing out the repeat Pill prescription may well introduce another dimension to the routine demands of contraception, especially if the woman has been on the Pill for many years or is well into her 30s. The answer may be like any other answer, very vague – this year, next year, sometime, never – but it not only gives the doctor an opportunity of discussing possible problems that could arise, for both her and her partner if a pregnancy is not attempted until the woman is much older, but also may give some indication of her feelings about babies.

*111/197/1*

During her first tentative self-examination in the doctor’s presence she revealed her fantasies about her vagina. She thought her long painted finger nails would cut it. Immediately afterwards she started talking about her mother, not previously mentioned. ‘When I was very young there always seemed to be blood around and lots of men. I was with her because I hadn’t started school. When I was older she kept going away to have operations, female operations.’

Sharing these feelings about the potential of fingers and instruments to cut her precious, fragile vagina, and her painful recollections of her mother, helped Miss C. to sort things out in her mind, and she found this particularly helpful as she was thinking about having a baby and had been anxious about all the procedures.

*75/197/1*

In exactly the opposte way, many women dislike the sheath because they feel that this exciting wetting is missing.

Mrs A. strode into a busy family planning clinic. She had attended some years ago, when she had tried various Pills, expressing dissatisfaction with them all. The notes in the record sheet had become short and brusque, revealing perhaps the atmosphere of the consultations. Eventually, she had just stopped coming. Today she seemed tense and angry. With a frown, she looked at her watch, making the doctor feel guilty, and yet the clinic was not running late. The doctor found that she herself felt rushed and rather irritated.

*38/197/1*

Here’s how it works: LHRH, made in the brain by the hypothalamus, is dispatched in signal pulses—like Morse code or flashes of light—to the nearby pituitary gland. These pulses tell the pituitary to make LH. The powerful synthetic analogs called LHRH agonists work by providing prolonged stimulation—by turning on the light and keepingit on, for example, instead of just flashing the light. So these drugs trick the pituitary: Because the pituitary receives no flashes, or pulses, it thinks no signal is being sent. And it doesn’t make LH. It’s like a chess game, and LHRH agonists effectively put LH—and therefore, testosterone—in checkmate.

Why is it so important to stop production of testosterone? Testosterone, not in itself the prime culprit of BPH, represents just one step in a chain of chemical interactions involved in BPH—but it’s a big one. One of the most convincing demonstrations is the study in which scientists achieved a “chemical castration,” by suppressing testosterone in patients with BPH. They found that prostate size decreased by an average of 25 percent, reaching a plateau after about four months. When they reversed the chemical castration—by allowing testosterone production to resume—prostates returned to their former size.

That’s how LHRH agonists work, by shutting down testosterone. They do help BPH symptoms—in the above study, for example, one-third of the men had improved rates of urinary flow—and they may be an option for men who are not candidates for surgery. But as with any medication that must be taken regularly (as shots once a month), beginning this kind of therapy means assuming the cost of medication for years. Also, improvement is not immediate; it takes weeks or months before the prostate begins to shrink.

LHRH agonists are not standard therapy for BPH, mainly because in cutting the body’s levels of testosterone they cause impotence, hot flashes and weight gain. For BPH, such results are considered extreme and cause most men (except for those who are already impotent) and their doctors to wonder which is worse—the disease or the treatment. However, for an elderly man who has urinary retention and is not a candidate for other forms of treatment, an LHRH agonist may be successful and may act quicker than finasteride.

Of course, in prostate cancer—for which these drugs are mainly used—it’s a different story. Potency assumes a lower rung on the ladder of priorities in the face of a life-threatening disease.

*284\201\8*

If you’re planning your day around trips to the bathroom, consciously or not, it may be time to seek treatment. Once you’ve reached this point, here’s the next question: Do you want treatment badly enough to run the risk of side effects or complications? If your symptoms are mild or moderate and the answer is no, then watchful waiting (see below) is probably the way to go. But if the answer is yes, educate yourself. Learn as much as you can about these options and the risks involved. Talk to other men with BPH—those who have had treatment, and those who’ve decided to wait. And most importantly, talk to your doctor. Until fairly recently, the only treatments for BPH were surgical, and many men shied away from them. But now, so many options are available for managing BPH that more men are opting for treatment earlier in the course of the disease than ever before.

*245\201\8*

A drug called ketoconazole blocks production of testosterone by targeting the testicles. Also, the effects of testosterone on the prostate itself can be blocked by interfering with testosterone’s conversion to DHT—this is what a drug called finasteride does—or by blocking the effects of testosterone and DHT on the prostate cell by neutralizing their effect. This is what flutamide, an “anti-androgen” drug, does.

The standard forms of hormone therapy for men with prostate cancer are castration, estrogens, and LHRH agonists. All three achieve a similar effect—lowering testosterone to the crucial “castrate range.” There is no good evidence that another approach, called total androgen ablation, makes any significant difference in lengthening life expectancy. (The theory behind this approach is that even low levels of testosterone and DHT, produced by the adrenal gland, can stimulate cancer in the prostate, and that they must be stopped. This is done by combining a standard hormone treatment, such as castration, with flutamide.)

*206\201\8*

Testosterone in the blood circulates back to square one, the hypothalamus, which acts as a thermostat. It measures the level of testosterone and decides whether to boost or cut back on its LHRH production, and the cycle begins all over again (scientists call this a “feedback loop”).

Also, the adrenal glands, which sit on top of the kidneys, make weak male hormones called “adrenal androgens,” including androstenedione, dehydro-epiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEAS), plus small amounts of testosterone. These are minor players, believed to make up only 5 percent or less of the total androgen stimulation to the prostate. Their total effect on the prostate is a controversial issue (discussed in this chapter).

So there are several potential checkpoints in this chain of events. Currently, hormone therapy can target the hypothalamus (LHRH), the pituitary (LH, FSH), the adrenal gland (adrenal androgens), the testes (testosterone) and the prostate (DHT). They can be used individually or in combination.

Men on hormonal therapy should go back to their doctor every three to six months for a digital rectal exam, a PSA test, and a creatinine test, which tests for impaired kidney function. They also should get a bone scan once or twice a year if the PSA begins to rise.

*169\201\8*

What If I’ve Had a TUR Procedure for BPH?

Your predicament is just the same as that of men who have a radical prostatectomy—you’ve got to wait for the swelling and inflammation to go down, generally about eight to twelve weeks, before you can undergo any new treatment. This waiting period, though it may seem agonizingly slow, is critical—it helps minimize your risk of becoming incontinent or developing scar tissue around the urethra from radiation damage to not-yet-healed tissue. (Some men who have undergone a TUR procedure may be more likely to develop a urethral stricture, which is easily treatable).

*131\201\8*