Too Fast, Too Furious

Too Fast, Too Furious

April 28, 2022   Return

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Assoc Prof Dr Christopher Ho Chee Kong   Consultant Urologist & Sexual Medicine Physician, Department of Surgery, Universiti Kebangsaan Malaysia Specialist Centre

How to Make Love All Night: and Drive a Woman Wild! The Way of the Superior Man! Make Her SCREAM: Last Longer, Come Harder and Be the Best She’s Ever Had!

These are just some of the actual book titles found on Amazon should you search for ‘premature ejaculation.’ Regardless of the content between the covers, these titles alone give the impression that a ‘real man’ (or to quote one of the book titles, a ‘superior man’) should be able to please his partner not just sexually, but also all through the night like the Energizer bunny, with the partner screaming and swooning from the ecstasy of it all.

The average man may flinch from the pressure (or try to rise to the challenge), but for someone with the problem of premature ejaculation (PE), the condition can be especially crippling to the self esteem. Furthermore, a lack of sexual fulfilment would eventually threaten the long-term happiness in any relationship.

HealthToday sits down with Assoc Prof Dr Christopher Ho, a consultant urologist and sexual medicine practitioner, to get down to the root of the condition known as PE, and the various treatment options available.

Not So Fast, Man!

Given how closely a man’s sexual performance is linked to his sense of confidence and self-esteem, it is little wonder that many men would prefer not to think about PE. If they do talk about it, it is usually during a ‘men’s only’ moment at the mamak stall, when ‘bros’ share notes and tips on bedroom matters.

Despite many men putting a lid on the problem, PE is actually quite common. While the estimated number of men with this problem can vary from one study to another, Dr Ho states that, generally, about 30% of men around the world have problems that can be defined as premature ejaculation.

How soon is too soon?

A US study found that the average man’s “lasting power” from the start of penetration to ejaculation is 5.4 minutes. If your arrival schedule is around this value, then you are perfectly normal.

“There are two types of PE – lifelong and acquired,” explains Dr Ho. Lifelong PE describes the condition that initially manifested during the man’s first sexual intercourse; the man has never experienced a ‘normal’ intercourse as a result. Acquired PE occurs when a man who has never suffered the condition before starts to show symptoms, often due to psychological factors (stress, anxiety or impatience, especially when the man has a new partner) or organic reasons such as an underlying medical condition.

  • For men with lifelong PE, the average ‘staying power’ is one minute or less.
  • For men with acquired PE, the average ‘staying power’ is three minutes or less.

Dr Ho goes on to explain that there are three typical signs of PE. One, the man experiences PE (1-3 minutes or less) consistently over a period of time. Two, he has problems controlling (or delaying) ejaculation nearly all the time. Three, his condition is causing emotional distress, and the man may even begin to avoid intimacy out of frustration or shame.

The Root of the Problem

There are several possible causes for PE, and it is possible that the causes for PE can be different from one man to another.

  • It’s psychological. Dr Ho says that strong emotions such as anxiety about his performance can cause a man to end things a little too soon in the bedroom. Other forms of stress such as external ones (from work and such) or unresolved interpersonal issues between the man and his partner could also be factors. 
  • It is also possible that early sexual behaviour could contribute to PE. For example, if a man is used to hurrying his climax in the past, he may experience problems slowing down the pace later on.
  • It’s biological. PE can arise when things go awry in the body. Some of the possible biological reasons for PE include:
    • Thyroid problems. There is a study which suggests that PE can be linked to an overactive thyroid (hyperthyroidism).
    • Abnormal levels of certain neurotransmitters (brain chemicals that transmit signals from nerve cells to brain). Unusually high levels of histamine, for example, can cause PE. 
    • Abnormal hormone levels. Like many other processes in our body, sexual arousal, stimulation and ejaculation are all carefully controlled and coordinated by interactions among various hormones. A little too much or too little here and there can cause the entire process to go haywire!

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Don’t Suffer in Silence – Get Help!

If you suffer from PE, the great news is that the condition is definitely manageable. There are ways to help you enjoy a healthy sex life with your partner.

Forget the many ‘special foods’ or ‘special exercises’ out there, all promising to improve one’s sexual prowess. The first step to managing PE is actually very simple.

“Talk to your doctor!” says Dr Ho.

“There is nothing to be ashamed of. The doctor will not judge or reveal your problems to other people. Therefore, there is no need to suffer in silence!” he adds. Some men get uncomfortable when the doctor asks probing questions related to intimacy, but this is a necessary step for the doctor to fully understand the extent of the problem. What is a little temporary discomfort or embarrassment, after all, compared to the promise of a healthy, fulfilling sex life?

Furthermore, sometimes PE may be a symptom of an undetected medical condition (such as thyroid condition, prostate disease, high blood pressure and diabetes), and may go away once the medical condition is treated. Getting treatment or management advice for those conditions do not just improve one’s sex life – it improves the overall health and quality of life!

“I know I have PE, so I can buy my own medications without seeing a doctor!”

Are you really sure that you have PE? While erectile dysfunction (ED) and PE are two very different conditions on paper, in reality, there are a number of men who cannot tell apart these two conditions. Dr Ho has encountered men with PE who believe that they have ED, and vice-versa. Since treatment methods for both conditions can be different, a diagnosis by a qualified healthcare professional is important, to ensure that you are getting the right kind of treatment. Another reason to visit your doctor, whether you have ED or PE!

Dr Ho goes on to share some of the most common methods for managing PE.

Hands-on Techniques

There are some techniques that your doctor can advise you to practice in the privacy of your home to help with PE. Dr Ho offers some examples:

  • The stop-and-start method. The man first masturbates on his own, stopping as he comes close to ejaculation. He will then relax until he has calmed down, before repeating this process several times until he cannot hold back any longer. Once he has become used to this, he can bring in his partner and they can initiate sexual activities without involving penetration. Essentially, this method helps the man learn how to control his arousal and delay his ejaculation over time.
  • The squeeze method.  A variation of the stop-and-start method, in which the man masturbates until he is close to achieving an orgasm. At that point, he squeezes the base of his penis to reduce his erection and delay ejaculation. Once the man has the hang of this, his partner can get involved and lend a helping hand, so to speak.
  • Try Kegel exercises. While there is not much evidence to conclusively prove that Kegel and other forms of pelvic floor exercises can help with PE, Dr Ho believes that there is no harm in adding these exercises into the daily routine of a man with PE. By strengthening the muscles in the pelvic region, the man may have better control over the delay of his ejaculation.
  • There are many other options, such as deep breathing techniques to help with focus during sex and the use of condoms to reduce stimulation on the penis. Your doctor would evaluate your case and suggest suitable solutions.
  • Dr Ho adds that these techniques are not “instant cures” – they only show results over time. Some men may get frustrated with  what they perceive to be slow progress and wish for a more “instant” solution, while others may get “distracted” while involving their partners in these techniques. For these men, medications may help tide the frustration.

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Medications for PE

Dr Ho explains that medications do not cure PE. Similar to pills for erectile dysfunction, they offer the man an opportunity to participate in sexual intercourse for a certain period of time after taking these medications.

Oral medications.

It may seem odd to many people, but medications normally given to people with depression can also help with PE. These medications can inhibit orgasm and delay ejaculation, usually considered unwanted side effects that, for men with PE, turn out to be favourable outcomes.

Of late, the medication of choice for many specialists is dapoxetine. Dr Ho explains that this is due to the studies that demonstrated its effectiveness on men with PE, as well as having fewer side effects compared to other medications offering similar benefits.

Aside from dapoxetine, other oral medications for PE include tramadol and other medications normally used for treating depression (eg, sertraline, paroxetine). All oral medications require prescriptions from a qualified healthcare professional.

Apply externally.

There are gels, creams, and sprays which work to reduce the sensations experienced in the penis that can bring about ejaculation. They typically contain analgesic or numbing ingredients such as lidocaine and lidocaine-prilocaine, and should be applied on the penis before sex. Because they work less specifically than oral medications, they may not be effective on some men with PE. There are also reports of some men’s partners experiencing discomfort or reduced sensation during sex.

The Lowdown on Dapoxetine

According to Dr Ho, in a normal male, a neurotransmitter called serotonin is involved in passing messages from one nerve cell to another. It is found that high levels of serotonin in the nervous system can lead to delayed ejaculation during sexual intercourse. For men with PE, this is obviously a good thing!

This is where dapoxetine comes in. It is a type of drug that helps to increase the concentration of serotonin at the junctions between nerve endings, hence allowing men with PE to last longer during sex.

It is taken “on demand”, from 1 to 3 hours before an anticipated sexual activity.

Side effects.

These include dizziness, nausea and headache. Fortunately, Dr Ho points out that fewer than 10% of men taking dapoxetine exhibit side effects.

Does it really work?

“Dapoxetine has been tested in robust trials involving thousands of men, and results point to it being effective and safe,” explains Dr Ho. This strong amount of research data is one advantage of dapoxetine over many other PE oral medications in the market.

Can someone with no PE still take dapoxetine to improve their ‘staying power’?

Besides the usual side effects caused by dapoxetine, there is no evidence suggesting that normal men taking this drug will experience health problems. However, Dr Ho also points out that there is no evidence to suggest that usage of dapoxetine can improve a man’s stamina in the bedroom. “Men often have unrealistic expectations when it comes to their stamina anyway,” Dr Ho says with a smile, “thanks to the frequently exaggerated portrayal of sex in popular media.”

Are there certain types of people who should not take dapoxetine?

“Men with severe heart and liver problems should avoid taking this medication,” cautions Dr Ho. Also, certain medications such as other selective serotonin reuptake inhibitors (SSRI, these are drugs that work similarly like dapoxetine to increase serotonin levels in the body), monoamine oxidase inhibitors (MAOIs), anti-fungal and anti-viral medications may cause unwanted side effects when taken along with dapoxetine, so consult your doctor if you are also on these medications.

The best of both worlds

According to Dr Ho, men with PE may be given medications while at the same time they are advised to put into practice the control techniques described earlier.

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Great News from the Man’s Cave!

Great News from the Man’s Cave!

April 28, 2022   Return

Mention “erectile dysfunction” (ED) and most men would blanch at the thought of it affecting them even for a second. Benign prostatic hyperplasia (BPH) may not be as familiar a term as ED, but this condition – in which a man’s prostate glands become enlarged – can cause complications, such as the frequent need to urinate – that can wreak havoc in a man’s efforts to be intimate with his partner.

Yet, many men will not admit that they have these problems if they can help it, several prominent and well-respected medical experts concurred during a very special “man cave” session at the PJ Live Arts Centre on 13 August, 2015.

The “man cave” was actually a stage decorated to resemble a den, representing a safe space in which a man feels confident and secure enough to bare his soul and confront his inner demons. Organized by Lilly Malaysia (Eli Lilly (Malaysia) Sdn Bhd), the “man’s cave” brought together Dr Teh Guan Chou (President of the Malaysian Urological Society and a Senior Consultant Urologist), and Dr George Lee (Clinical Associate Professor and Consultant Urological Surgeon). Joining them was Dr Prabhuram Krishnan, the Medical Director of Eli Lilly Malaysia.

ED is a common problem despite most men preferring to avoid addressing it. Dr Prabhuram pointed to a paper published in 2011 in the Malaysian Journal of Andrology, which stated that 20% of Malaysian men over 50 have ED, while the number doubles among men 40 to 60 years old. Worryingly, we are also seeing an increasing number of younger men with ED now!

ED does not just ruin a man’s effort to be intimate with his partner. Dr Lee pointed out that, among certain patients, ED has been linked to an increased risk of future health problems, including heart problems and strokes. “It can be scary if you don’t get it treated soon,” he said. Dr Teh always said that ED is a sign of a “broken heart”, and this can be true – literally!

Dr Teh, touching on BPH, mentioned that the prostate gland, for reasons yet to be determined, can become bigger with time. Due to its proximity to the bladder, its increased size can obstruct or constrict the bladder, slowing urine flow and increasing the time it takes to empty the bladder. Hence, a man with BPH needs to go to the toilet often. Up to about 60% of men aged 70 and above have BPH, Dr Teh claimed, and 80% of these men experience lower urinary tract symptoms such as the urge to urinate often.

All three speakers stress that seeing a doctor for ED and BPH is a far better course of action than turning to alternative remedies, which may not work and only prolong one’s misery.

The event closed with another excellent reason to see a doctor for ED and BPH woes: the launch of the new Cialis 5 mg Once Daily pill. Cialis is the only drug that is approved to treat both ED and the symptoms of BPH.

For men with ED, now they can take Cialis 5 mg Once Daily just once a day, and can engage in sexual activity any time of the day. Compared to the “on-demand” Cialis, which has to be taken before sexual activity can begin, the Once Daily pill offers spontaneity and convenience that would be welcomed by men who need this medication. 

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One Ring to Rue Them All

One Ring to Rue Them All

April 28, 2022   Return

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Assoc Prof Dr Christopher Ho Chee Kong   Consultant Urologist & Sexual Medicine Physician, Department of Surgery, Universiti Kebangsaan Malaysia Specialist Centre

Let us spare a thought for the man who made news in May when he landed in the hospital after having his scrotum stuck in a ring. While everyone probably had a chuckle over it, there was no doubt that his pain was intense and his condition could have taken a turn for the worse if not tended to.

Consultant urologist and sexual medicine physician, Assoc Prof Dr Christopher Ho is no stranger to patients with painful misadventures involving their little buddies. He recalled a similar case in which he had to borrow tools from the nearby fire department to remove a penile ring that was causing his patient great pain.

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Put a ring on it?

Dr Ho says that there are legitimate medical uses for penile rings and implants. Men with erectile dysfunction (ED) may use a vacuum pump to help them achieve an erection, and, a ring can be placed at the base of the shaft to sustain the erection.

“However, these rings should be used only upon the advice of a qualified healthcare professional, for specific reasons such as ED,” Dr Ho points out. Otherwise, there may be painful consequences – as seen in the case of that unfortunate person who ended up in the news. 

“The ring prevents blood from flowing out of the penis, which leads to engorgement and increase in girth,” says Dr Ho. For some men, especially those with ED, this sounds like a cause for celebration.

But if blood flow is obstructed for too long, the tissues of the penis become deprived of oxygen. Waste materials such as toxins will begin to accumulate, as the blood trapped in the penis is unable to leave and carry these wastes with them. Over time, these tissues may become damaged and even die, causing all kinds of problems such as ED and more.

A condition called priapism may also occur. This is a condition in which an erect penis cannot revert to its flaccid state after more than four hours. This is a painful condition, and in extreme cases, an amputation may be required. (Ouch!)

If you insist on wearing a penile ring, Dr Ho advises to limit its use to no more than 30 minutes.

Piercings and other “fashion statements”

There are men who subject their penises to other kinds of accessorising, often for aesthetic reasons or, because they believe that it would enhance their sexual prowess.

Dr Ho has come across several patients who tried to embed materials such as ball bearings into their penile shaft. “One tried to perform this procedure on his own, and ended up blocking the urethra – the passage through which urine and semen find their way out of the penis. He could not urinate, and had to be admitted under great pain.”

Piercing is another practice that has its share of painful pitfalls. Pierce the wrong part at the wrong place or even the wrong depth, and the tissues responsible for producing an erection may end up irreparably damaged. Dr Ho also points out that there is also a risk of infection, especially if the person does not exercise proper hygiene down there.

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The final call

Dr Ho admits that it is possible that rings, piercings and even the ball bearings may provide increased sexual pleasure to certain men and their partners, but the risks have to be seriously considered.

Complicating the issue further is the fact that selling sex toys is illegal in this country, and services such as piercing the penis are usually performed by untrained personnel. As a result, there is no testing done to ensure that those products or services are effective, and no guarantee that they are safe.

At the end of the day, it is a Wild, Wild West out there when it comes to all these devices and styles, so try them out at your own risk. If you love your friend down below, perhaps it is wiser – and safer – to stay accessory-free.

If you suffer from erectile dysfunction or other problems that affect your sexual performance, you should consult a qualified healthcare professional for safer options.

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Erectile Dysfunction Treatment for All

Erectile Dysfunction Treatment for All

April 28, 2022   Return

While erectile dysfunction (ED) is still considered a taboo topic in Malaysia, it is a condition that affects about 1.68 million men above the age of 40 years.

Speaking at a media session in August, Datuk Nancy Ho who is the President of the Malaysian Pharmaceutical Society pointed out that ED has a variety of possible causes, ranging from physical illnesses (heart problems, diabetes, Parkinson’s disease, etc) to risk factors (obesity, tobacco use, alcohol, substance abuse, etc). It can also be caused by stress, anxiety, depression, relationship problems and other mental issues.

Due to ED being a taboo topic, many people end up knowing little about the condition. As a result, they may turn to traditional and alternative treatments, many of which may not work. Many men who suffer from ED also feel embarrassed to seek treatment.

If ED is left untreated, Datuk Ho explained that the condition would negatively affect the sufferer’s relationship with his partner, and there may be subsequent spillover effects onto his relationships with friends and family members. Furthermore, ED can leave a big dent on a man’s self-esteem, confidence and overall morale.

She encourages men with ED to talk to a doctor or a pharmacist. Pharmacists, according to Datuk Ho, play an important value-adding role in the treatment of ED, as they are in a position to ensure that the patient will respond positively to the medications dispensed to them. Pharmacists are also well-equipped with the necessary knowledge and expertise to advise on the nature of ED, its medications and useful supplements.

For some men with ED, the cost of medication can be prohibitive. Fabio Sperandei, the Country Head of Sandoz Malaysia, had good news for them: there are several medical derivatives in the market that can be used for treating ED. These medical derivatives contain the same key active components as the currently available ED drugs – sildenafil, tadalafil or vardenafil.

“Sandoz, a division of Novartis, seeks to create healthier communities and make quality healthcare available to all,” said Sperandei. To that end, Sandoz is involved in efforts to educate the public on ED, so that men with ED will not suffer alone or opt for treatments and solutions that will not benefit them.

“Treatment for ailments like [ED] should not be regarded as a luxury, but rather a necessity,” he concluded. He added that quality, affordable treatment is readily available for men with ED – all they have to do is seek advice from a pharmacist or other healthcare practitioners.

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Quality Of Life, Uninterrupted!

Quality Of Life, Uninterrupted!

April 28, 2022   Return

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Assoc Prof Dr Ong Teng Aik      Consultant Urologist

Since 1998, the first-line therapy for ED consists of pills containing the phosphodiesterase-5 inhibitors (PDE5i). PDE5i improves blood flow to the penis. When a man anticipates or fantasizes about having sex, his brain is stimulated to send signals to his penis. With the aid of PDE5i, there is improved blood flow into the penis, allowing an erection to be achieved and maintained. After ejaculation, the penis will become soft again.

There are four main PDE5i medications, including sildenafil, vardenafil, tadalafil and udenafil. The half-life for sildenafil is about 4 hours so the effect will help the patient for about 12 hours. Vardenafil also lasts for about 12 hours. Tadalafil is the longest acting PDE5i – it has both the longest half-life (17 hours) and efficacy (36 hours). The choice of PDE5i depends on the individual’s needs. Some prefer short-acting PDE5i while others find the long-acting PDE5i more appropriate for their condition.

Leave the fatty food aside first

Fatty food affects the absorption of sildenafil and vardenafil. For example, sildenafil and vardenafil will not work so well after a meal of char kuey teow! So, stick to non-oily, low fat food for the ‘intimate’ dinners – it is also healthier this way. Incidentally, tadalafil is not affected by oily foods.

Just one pill a day?

The current practice of taking PDE5i is called ‘on demand’; which is to say, you only take PDE5i when you anticipate sexual activity within the next few hours.  It can be quite inconvenient for people who prefer spontaneity in their romantic encounters.

Now, there is a new concept – a daily dose of PDE5i. Studies show that taking low-dose tadalafil daily is effective and well-tolerated due to the long half-life of 17 hours. Another study shows that patients who were not satisfied with PDE5i on-demand were able to achieve normal erection by taking low-dose tadalafil once a day (OaD).

The 2015 European Association of Urology (EAU) guidelines say that this once a day tadalafil (or tadalafil OaD) is well tolerated and effective, and allows for spontaneous and frequent sexual activities.

In 2011, the US Food and Drug Administration approved tadalafil OaD for treating lower urinary tract symptoms (LUTS) – difficulty in passing urine, urinating frequently, waking up at night to pass urine. LUTS is caused by an enlarged prostate – a condition called benign prostatic hyperplasia (BPH).

When patients have prostate problems, they are either treated with medicine or surgery. If they don’t respond to medicine or have complications, they have to undergo surgery. There are two types of medicine available – alpha blockers (terazosin, doxazosin, alfuzosin and tamsulosin) to improve the urine flow and 5ARI (finasteride and dutasteride) to shrink the prostate.

A study has shown that tadalafil OaD allows patients with BPH to pass urine better and improves their sexual function as well. The 2015 EAU guidelines say tadalafil can be used on a daily basis to treat patients with both LUTS and BPH conditions. This is new information even for urologists.

The important thing is that tadalafil OaD keeps the flow going – just like the song River in you by Yiruma. So, you will have quality of life uninterrupted – that’s the concept of daily dose of PDE5I.

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Keeping the Dream of Fatherhood Alive

Keeping the Dream of Fatherhood Alive

 April 27, 2022   Return

WORDS LIM TECK CHOON

Men’s Health and Fertility with

Dr Agilan Arjunan

Consultant Gynaecologist & Fertility Specialist

 

KL Fertility CentreGoing through Father’s Day can be hard for men who experience difficulties conceiving a child with their loved one. If you are one of those men, don’t lose hope. Advances in fertility research and treatment have kept the door open even for men with low sperm count to become a father. This month, Dr Agilan Arjunan shares some insights on the options available to transform a man’s dream of fatherhood into reality.

Looking at the two men below, which one do you think has a sperm count issue? There is no way of telling, actually. A man can have every stereotypical element associated with masculinity — big strapping muscles, lots of body and facial hair, height, etc — but he can still have low sperm concentration.

Let’s have Dr Agilan explain the sperm production process to get a better idea of the big picture.

SPERM PRODUCTION

  1. The pituitary gland produces follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The hormones then travel to the testicles.
  2. FSH stimulates the Sertoli cells in the testicles to produce sperm cells. LH stimulates the Leydig cells in the testicles to produce the male sex hormone testosterone.
  3. As more sperm and testosterone are produced in the testicles, the Sertoli cells begin to produce another hormone called inhibin
  4. High levels of inhibin and testosterone cause the pituitary gland to reduce its production of FSH and LH. Subsequently, sperm cell production decreases.

Once sperm cells are produced, they will take around 72 days to reach maturation. Therefore, any changes made to improve sperm count and quality usually need about 3 months before any noticeable improvements are seen.

DOWN FOR THE COUNT

“The World Health Organization defines low sperm count as sperm concentration of below 15 million per millilitre of semen,” says Dr Agilan. Given the drop of fertility rate among men worldwide, he adds that this figure is expected to be redefined into a higher figure in the future.

How can a man have low sperm count? Basically, there are two possible reasons.

One, something affected the sperm production process. Dr Agilan reveals that about 15%of men with zero sperm count (azoospermia) are born with defects in their Y-chromosome. Hormonal imbalances can also affect sperm production — one common example is the use of anabolic steroids by men who want to improve their physique.

The other possible cause is that something is blocking sperm cells from being present in the man’s semen. Typically, this is due to past infections, previous surgery that led to obstructive scar tissues or trauma to the genitals.

However, there is hope! We only need one sperm cell to successfully fertilize a woman’s egg cell and create a child, and that’s the key. Now, we have the technology and expertise to retrieve sperm cells from the man’s genitalia, even if his sperm count is low.

THE TROUBLE WITH ANABOLIC STEROIDS

There are many different types of steroids. When people talk about the steroids used to build up muscles, they are referring to anabolic steroids. These steroids bind to muscle cells to promote growth.

Now, anabolic steroids are synthetic compounds that are based on testosterone. Therefore, when one uses anabolic steroids, Dr Agilan says that the body senses that there are already high levels of testosterone present, and as you can see in the previous page, high levels of testosterone will lead to reduced sperm cell production. Prolonged use of anabolic steroids can even lead to a complete shutdown of sperm production!

Thus, there is no other way about it. Don’t take steroids if you are concerned about your fertility!

But what if I’m already on anabolic steroids? Dr Agilan recommends visiting a fertility specialist for a proper assessment. Men whose sperm count is affected will have to halt taking the anabolic steroids for the time being; they will be given hormone therapy (usually human chorionic gonadotropin, along with FSH if necessary) in the meantime to stimulate sperm production.

Depending on how long they had been on anabolic steroids and the dosage they were taking, recovery may take place over a period of a few months or even a year or two.

OPENING THE DOOR TO FATHERHOOD

Dr Agilan shares that the fertility specialist will first run some tests to first determine the nature of the problem.

  • Sperm sample. Sperm samples will be needed to determine key details such as how much sperm is made, the shape of the sperm cells and how these cells move. The semen will also be analyzed to measure its volume, acidity and uniformity.
  • Blood tests. This will help determine whether there is any hormonal issue that affects sperm production. It also gives information about how ‘hard’ the brain is working to stimulate testicles to produce sperm.
  • Physical examination. This gives information about the size and consistency of testicles as well as the presence of vas deferens (the tube connecting the testicles to the penis).
  • Ultrasound examination may be useful to determine whether there is any issue with the man’s genitalia that can affect his fertility.
  • Biopsy. If necessary, a small piece of tissue may be obtained from the testicles to be further examined in a laboratory.

NEXT STAGE: HORMONE TREATMENT AND SPERM ANALYSIS

Based on the test results, the fertility specialist will prescribe the appropriate hormone treatment to improve the man’s sperm count. The man will provide his sperm sample at predetermined intervals (usually once every 4 to 8 weeks) for assessment.

IF GOOD IMPROVEMENTS ARE SEEN

The fertility specialist may recommend simple fertility treatments such as intrauterine insemination (IUI) to help the couple have a child.

IUI involves extracting the man’s sperms and placing them directly into the woman’s uterus. This is done in order to place the sperms nearer to the fallopian tube and hence increase the chance of fertilization of the egg cell by a sperm cell.

In most cases, though, the sperms would be frozen and used later for in-vitro fertilization (IVF). Dr Agilan strongly recommends that the man should take measures to improve his sperm quality prior to this, via healthy diet, regular physical activity, good stress management and healthy weight management. Cigarettes and alcohol should be avoided.

WHAT HAPPENS WHEN THE SPERM COUNT STILL REMAINS LOW?

Dr Agilan says that there are still options that can be explored.

ICSI-IVF. In normal IVF, a viable healthy egg obtained from the woman will be placed in a dish in the IVF laboratory and mixed with many sperms obtained from the man.

In ICSI-IVF (ICSI is short for intracytoplasmic sperm injection), the embryologist will directly inject a single sperm  cell into an egg cell using a thin hollow needle-like structure called a pipette. This procedure will be repeated for every egg harvested from the woman. This process improves the chances of a successful fertilization compared to IVF without ICSI, although

Dr Agilan notes that it does not guarantee a 100% chance of success. If the man is still unable to produce adequate sperm cells after hormone treatment, or if nearly all the sperm cells seen in provided samples are dead, then there is the option of PESA or TeSA.

Percutaneous epididymal sperm aspiration (PESA) is carried out if there is a blockage in the vas deferens preventing sperm cells from being present in the semen, or if the vas deferens is absent from birth.

Sperm produced in the testicles is stored in a tube-like structure called the epididymis. In PESA, a very fine needle will be

inserted into that structure to collect some epididymal fluid. The fluid will then be examined carefully under the microscope to locate healthy- looking sperm that can be used for ICSI-IVF or frozen for later use.

This process is performed under local anaesthesia, so there should be no pain, and there is no incision and hence no scar formation. The entire procedure doesn’t take too long, and the man can go back to his usual routine on the same day or the day after.

Testicular sperm aspiration (TeSA) is an option when there is no sperm cells observed in the man’s sperm sample. The procedure is nearly similar to PESA, only this time the fine needle is inserted directly into the testicular tissue instead of epididymis.

THE DOOR IS NEVER COMPLETELY CLOSED

Dr Agilan assures that there are many options these days that can help men with low sperm count. Many things that seemed impossible once upon a time are indeed possible today. Therefore, if you have always dreamed of being a father, but have troubles conceiving a child with your loved one, don’t feel embarrassed or emasculated. Talk to a fertility specialist (discretion is guaranteed) — it may just be the best gift you can give yourself, possibly opening the doors for future Father’s Day celebrations to cherish with a family you have always yearned for. HT

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What Men Should Know Before They Go For The Snip-Snip

What Men Should Know Before They Go For The Snip-Snip

 April 27, 2022   Return

WORDS LIM TECK CHOON

Professor Dr Christopher Ho Chee Kong

Consultant Urologist

Oriental Melaka Straits Medical Centre


GETTING THE SNIP

WHAT HAPPENS DURING A VASECTOMY?

To understand the procedure better, first let Prof Dr Chris Ho give an overview on the sperm production process. Sperm cells are made by cells called Sertoli cells in the testicles and are stored in the structure called epididymis. A tube called the vas deferens carries these sperm cells from the epididymis towards the urethra, and along the way, they are mixed with seminal fluids, produced by separate glands called seminal glands, to form ejaculate during sexual intercourse.

What happens during vasectomy is that the vas deferens is cut. As a result, sperm cells are unable to leave the testicles and pregnancy is no longer possible after sexual intercourse.

Because vasectomy does not affect the seminal glands, the man can still produce semen.

ASIDE FROM THE LACK OF SPERM CELLS IN THE SEMEN, WILL VASECTOMY CHANGE ANYTHING ELSE ABOUT ME?

Vasectomy does not affect the nerves in the penis or the blood supply to it, so Prof Dr Chris Ho states that there shouldn’t be any changes in the man’s ability to achieve an erection or attain sexual pleasure. There shouldn’t be any changes to the man’s semen either, aside from the absence of sperm cells.

Improperly done vasectomy, however, may damage blood supply to the testicles, which in turn can lead to reduced testosterone production. As a result, the man’s sexual performance may be affected, but such occurrence is very rare.

ANYTHING ELSE THAT I SHOULD KNOW?

“There is a failure rate of 0.3% to 9%, usually due to the surgeon’s technique or skill level,” says Prof Dr Chris Ho.

Also, sometimes the cut vas deferens may rejoin on their own, but this rarely happens.

CAN I CHANGE MY MIND AFTER THE SURGERY AND GET THE PROCEDURE REVERSED?

It’s possible. Prof Dr Chris Ho will explain more about this later. Still, he cautions that reversing a vasectomy is more complicated, and hence is an expensive procedure with a chance of failure, when compared to vasectomy.

Therefore, a man should be absolutely certain that he doesn’t want children before going for the snip!

HOW IS VASECTOMY DONE?

There are two methods, according to Prof Dr Chris Ho.

Conventional vasectomy will see the surgeon using a scalpel to make an incision on the skin of the scrotum to perform the snip.

No-scalpel vasectomy, on the other hand, sees the surgeon using a specialized surgical instrument, called the sharp haemostat, to puncture a small hole in the scrotum. Unlike the previous method, this method has a smaller risk of bleeding, infection and pain. The procedure also takes less time to perform compared to conventional vasectomy.

However, Prof Dr Chris Ho points out that the equipment needed for no-scalpel vasectomy may not be available at certain clinics and hospitals. Also, not every surgeon is capable of performing this type of vasectomy, as it requires a little bit more training and experience.

WHAT HAPPENS AFTER A VASECTOMY? WILL I NEED A LONG TIME TO RECOVER?

Prof Dr Chris Ho shares that one will need to rest for about 24 hours after the surgery, and he can perform light activities after 2 or 3 days. Sports, lifting and other heavy activities should be avoided for the first week or so, however. “Sexual intercourse can resume after about 1 week,” he says, adding that the man should use contraceptives such as condoms until follow-up medical appointments show that there are indeed no sperm cells in his semen.

FOLLOW-UP?

Oh yes. To determine whether a vasectomy is successful, the man will be asked to provide a semen sample for analysis at about 3 months or after 20 ejaculations (whichever is sooner) after the surgery.

While not common, post-vasectomy pain syndrome (PVPS) is a group of bothersome and even painful symptoms that can develop either immediately or later (sometimes even a few years) after a vasectomy. Symptoms can include ache in the testicles, discomfort during sex or after heavy activities and pain during ejaculation. There are ways to relieve these symptoms, but in some men, the symptoms may persist and become chronic—their best solution may be to reverse their vasectomy.

REVERSING THE SNIP

WHAT’S THE GOOD NEWS?

Prof Dr Chris Ho reveals that a vasectomy can be reversed, either by:

  • Reconnecting both ends of the cut vas deferens (vaso- vasotomy), or
  • Reconnecting the cut vas deferens to the epididymis (vaso-epididymostomy).

The choice of procedure is determined after an initial assessment of a fluid sample, called vas fluid, obtained from the vas deferens.

  • If healthy sperm cells are seen in the sample, then vaso- vasotomy will be carried out.
  • If no sperm cells are seen, or if the vas fluids aren’t of sufficient quality to be analyzed, then vaso- epididymostomy will be recommended instead.

SO, WHAT ARE THE NOT-SO-GOOD NEWS?

Vasectomy reversal is a far more complex procedure than vasectomy. It is best carried out by a well-trained surgeon, and even then, there are no guarantees of success.

Furthermore, Prof Dr Chris Ho explains that the vasectomy process itself may affect the man’s fertility even after a reversal has been carried out.

Epididymal blowout. After a vasectomy, the sperm cells in the epididymis has nowhere to go. As a result, there is mounting pressure in the epididymis, to the point that rupture of the epididymal structure may result.This affects sperm production and the quality of the sperm produced.

Anti-sperm antibodies. The body may produce antibodies that can either outright kill sperm cells or severely reduce the ability of the sperm cells to travel in the womb and seek out an egg cell to fertilize.

“The rate of a successful pregnancy after a reversal vasectomy is about 55% if the reversal is done less than 10 years after the initial vasectomy,” says Prof Dr Chris Ho. “This rate drops to 25% if the reversal is performed more than 20 years after the vasectomy.”

Even if the vasectomy reversal is successful, it may take up to a year before viable amounts of sperm cells are produced in some men.

DON’T BE DISCOURAGED BY THE NOT-SO-GOOD NEWS, THOUGH!

Prof Dr Chris Ho advises men who wish to have their vasectomies reversed to talk to a urologist. With advances in research and medical methodologies, there are many men who successfully become fathers despite having had vasectomies in their past. These days, there is always a possibility that the door to fatherhood is still open, so it is up to the man to make the first step and explore the options available to him. HT

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STOP! For goodness sake

STOP! For goodness sake

 April 25, 2022   Return

WORDS PANK JIT SIN

If you’re wondering what it is I’m asking you to stop, well, it’s smoking. I recently had a friend pass away from lung cancer. He had stopped smoking for 8 years by then and picked up healthy exercise habits. It wasn’t enough and after 3 years of battling the disease, he succumbed on 2nd August this year. Smoking is very much a man’s disease as many more men smoke compared to women. The World Health Organization (WHO) puts the number of smokers at 1 billion—800 million are men and 200 million are women. As November is Men’s Health Awareness month, let’s see what we can do to help smokers quit. HealthToday speaks to reader Keo Chia who managed to kick the addiction some years back. Smoking cessation comes with many benefits, among which are improvements in lung function, reduction of cardiovascular disease risk and reduction of cancer risk.1

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Keo during his interview.

It’s not you, it’s me

We asked Keo what his main driver was behind the decision to quit. Was it his children? Was it his wife? Or was it his health? He says, “I tried quitting cigarettes a few times before finally succeeding. Before that, I couldn’t last more than 1 or 2 days before the overwhelming urge to smoke took over.”

Things stayed the same with Keo trying to quit smoking once every few months due to nagging from his family or urging from friends. This constant trial-and-failure cycle is a typical trait of those looking to quit smoking. According to the US Centers for Disease Control and Prevention (CDC), a smoker tries to quit between eight and 10 times before succeeding. However, a 2016 Canadian study says it could take a smoker almost 30 trial-and-failure cycles before finally winning the fight against smoking.2

Things remained pretty much the same until one day, Keo got fed up of failing and told himself, “I WILL quit this time.” Instead of going cold turkey or cutting down on cigarettes like he did previously, Keo decided to use a nicotine patch. He approached a pharmacist near his home and received some counselling on how to use them.

The first time he put the patch on, Keo discovered he was feeling nauseous and dizzy. “I thought I was sick,” he says. However, the patch worked, and he didn’t feel the urge to smoke at all. The symptoms went away gradually over the next few days and he used the patch for 2 weeks.

After 2 weeks, Keo cut the patch into two, effectively halving his dose. This is not recommended, as suddenly halving the nicotine dose could trigger an urge to smoke. Ideally, he should have purchased the patch with a slightly lower dose to reduce the risk of smoking relapse. Luckily, Keo did not face this problem. Again, he wore the patch, this time closer to 3 weeks. When he felt he was ready, he again reduced the dose by half. At the end of 2 months, he could go without cigarettes and even without the patch!

It was the happiest he had been for a long time. There was a sense of achievement and overwhelming pride that he no longer needed to subject his new family (he had just settled down and had a baby by then) to secondhand smoke exposure. He says, “Remember, the decision to quit must come from yourself. Until you make that decision, the urging and nagging by others won’t work.”

It is an addiction

More evidence is emerging that a lot of our vices is the result of an imbalance in our brain’s chemicals. Cigarettes contain nicotine and many other chemical compounds. While we tend to think nicotine is the only addictive substance found in cigarettes, a 2007 study discovered that many additives in cigarettes enhance the addictive nature of nicotine and some mask the side effects, thus making it more pleasurable to the smoker.In the study, the scientists arrived at the conclusion that “documented cigarette additives have pharmacological actions that camouflage the odour of environmental tobacco smoke from cigarettes, enhance or maintain nicotine delivery, could increase addictiveness of cigarettes, and mask symptoms and illnesses associated with smoking behaviours.” 

It is, therefore, no wonder that smoking is so hard to quit once a person begins. Of course, one could say that smokers shouldn’t have started smoking in the first place, but we all make mistakes. The most important thing to do now is to focus on what can be done to help a smoker should they decide to stop.

While the nicotine patch is a commonly used smoking cessation tool, there are other options out there. Another example is the nicotine chewing gum. For some smokers, the action of putting cigarette into the mouth is a harder habit to break than the actual act of smoking. The act of chewing gum can help to attenuate this condition and also prevent the weight gain associated with this behaviour.

If both the patch and gum are not helping, there’s also the option of taking a pill known as varenicline. This is a prescription medicine and may affect the mood of the person. This is because it affects the reward pathways of the brain, preventing one from getting any pleasure from smoking. One should seek a doctor’s advice before embarking on this option.

Smoking and cancer are definitely linked

When a cigarette burns, it releases 5,000 to 7,000 chemicals, of which about 60 are known cancer-causing agents. Apart from nicotine, these include tar, ammonia, acetone, methanol, butane, and hexamine.3,4

We often think about lung cancer when talking about smoking. However, there are many other cancers which are linked to cigarette smoke. These include cancers of the mouth and throat; oesophagus, colon and rectum; bladder, kidney, stomach, and cervix. If we think about it, the chemicals from cigarette smoke stay in our mouth and as we swallow, they pass through the throat, into the stomach and come into contact with every part of our digestive system. Those of us who don’t smoke can always tell if the person using the toilet before us is a smoker based on the smell left behind after they urinate.5

Relapse

Just like any other addiction, a person who has quit smoking can relapse and pick up cigarettes again. Some people ‘slip’ during their journey to smoking cessation. This means the person sneaks a cigarette or a puff. This isn’t considered a relapse. Relapse refers to a return to regular smoking.7

It is important not to be judgmental about smokers who relapse. If you’re a smoker, remind yourself that this is a temporary setback and don’t look at yourself in a negative light. Remember that it is a battle with addiction and many battles will have to be fought before the war can be won. Even before a person starts his or her smoking cessation journey, it is helpful to know what happens should a ‘slip’ or relapse occur.

Did you know?

The nicotine patch does come with its own set of problems. Some side effects users often face include skin irritation, nausea, headache, vomiting, and diarrhoea. These symptoms are usually manageable and can be acceptable if the user is mentally prepared and properly counselled.

Did you know?

Lung cancer is the most common cancer occurring in men and the third most common in women. Approximately 2 million people were diagnosed with the disease in 2018.

Did you know?

Your risk of developing lung cancer takes many years to return to normal after stopping smoking? In total, it takes about 15 years before the risk of developing lung cancer drops to that of a person who has never smoked.HT

References:
1.https://www.who.int/tobacco/quitting/benefits/en/

2. Chaiton, M., et al. (2016). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open;6:e011045.

3. Cancer Research UK. What’s in a cigarette? Retrieved from https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-and-cancer/whats-in-a-cigarette-0.

4. Irish Cancer Society. What’s in a cigarette? Retrieved from https://www.cancer.ie/reduce-your-risk/smoking/health-risks/whats-in-cigarettes#sthash.zAwkOexD.dpbs.

5. Siegel, R.L., et al. (2015). Deaths Due to Cigarette Smoking for 12 Smoking-Related Cancers in the United States. JAMA Intern Med;175(9):1574–1576.

6. Rabinoff, M., et al. (2007). Pharmacological and chemical effects of cigarette additives. Am J Public Health;97(11):1981–1991.

7. Smokefree.gov. Slips & Relapses. Retrieved from https://smokefree.gov/stay-smokefree-good/stick-with-it/slips-relapses.

8. World Cancer Research Fund. Lung cancer statistics. Retrieved from https://www.wcrf.org/dietandcancer/cancer-trends/lung-cancer-statistics

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A Cancer Among Men

A Cancer Among Men

 April 25, 2022   Return

WORDS HANNAH MAY-LEE WONG

Dr-Hemanth-Kumar-Ram...

Dr Hemanth Kumar Ramasamy

Consultant Urologist & Laparoscopic Surgeon

Following this month’s theme and focus on men’s health, Dr Hemanth delves deep into the topic of prostate cancer, one of the most common types of cancer in men.

The prostate, an organ found exclusively in men, is roughly the size of a walnut. It is a gland that produces seminal fluid, which protects, nourishes and helps transport sperm. “The prostate makes 30% of semen. These fluids are essential for the sperm to survive when it is being sent to the female vagina. It’s got lots a minerals and nutrients for the health and wellbeing of the sperm,” Dr Hemanth explains.

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Although the prostate plays a vital role in male reproductive process, prostate cancer rates have been on the rise, and this is certainly an issue men should take note of. Dr Hemanth tells us more in detail.

How common is prostate cancer among men in Malaysia?

From a global perspective, prostate cancer rates are the lowest in South East Asia compared to the rest of the world. Prostate cancer is quite common in the UK, and very common in the US. It is also seen more frequently among the African and American black population.

“Prostate cancer has risen to become the 3rd most common cancer among men.”

In Malaysia, data from the 2007-2011 Malaysian National Cancer Registry Report showed that only six in 100,000 people developed prostate cancer, making it the 5th most common cancer among men at the time. It’s worth noting that in the past, there were fewer urologists, screening tools and overall less awareness on the disease. A recent study conducted by the  Malaysian  Prostate  Cancer Study Group (M-CaP) in 2018, found that prostate cancer has risen to become the 3rd most common cancer among men, occurring in every 12 per 100,000. The breakdown of demographics showed that prostate cancer is most common among the Chinese population, followed by Malays.

Urologists deduce that some of the reasons for the rising numbers could be attributed to: men in Malaysia living longer lives, our shifting diets towards a more western palette (the exact reason for this is still unknown, however studies have shown that a western or meaty diet increases the risk of developing prostate cancer). For example, Japan is a country where prostate cancer incidences are very low. But when we look at the Japanese that have migrated to the US (especially those who are 2nd generation migrants), we notice  that their incidences are higher than the Japanese men living in Japan. Therefore, prostate cancer risk could have lots to do with environmental factors.

What are the risk factors of prostate cancer?

The most common risk factor is age. 80% of prostate cancers are picked up after the age of 60, and prostate cancer in men below the age of 45 is rare.

Genetics could be a factor. Prostate cancer is more common in African Americans and Caucasians, and less common in the Asian population.

Family history is very important. If a man has a 1st degree relative who has prostate cancer (like dad or brother), his risk of developing prostate cancer may be higher, and familial prostate cancer tend to appear earlier.

What are the signs and symptoms of prostate cancer?

This depends on which stage of prostate cancer a man is in. In the  early stages, there could be no signs and symptoms. Some cases of prostate cancers are accidentally picked up during routine screening tests.

Some men may get symptoms of the lower urinary tract such as: difficulty in passing urine, having a burning sensation during urination, going to the toilet more often, dribbling after urination and so on. These could be the early indications of prostate cancer, but most of the time, these symptoms are associated with benign prostate hyperplasia (BPH)—an enlarged prostate, which is much more common in Malaysia.

For those with late stage prostate cancer where metastasis has occurred, they may get symptoms mainly associated with the bones, as the bones are commonly where the prostate cancer first spreads to. Prostate cancer lesions in the bone are very typical—they’re called sclerotic lesions and can be picked up relatively easily.

How often should men get their prostate checked? What are the tests available?

With the rising awareness of prostate cancer, screening is becoming more common. Usually, screening can be done in men who are above 50. Patients who have relatives with prostate cancer can opt to do screenings from as young as 45.

Screening is done via a prostate- specific antigen (PSA) test and rectal examination. When a screening programme is carried out, a couple of other tests are usually included, namely: the urine test, ultrasound and uroflow (to test urine flow for possible obstructions). Urologists also would take a detailed clinical history and may ask the patient to complete the International Prostate Symptom Score (IPSS) questionnaire.

What are the treatment options for prostate cancer?

A patient’s treatment plan would depend on several different factors including the patient’s age, the aggressiveness of his cancer and whether the cancer has spread. A trans-rectal ultrasound biopsy is usually done if the possibility of prostate cancer is picked up by a PSA test or rectal examination. It involves using a specialized probe which is put through the rectum, and biopsy samples may be taken through a needle. Small cuts of samples are taken from 12 different areas of the prostate, and these are sent to a pathologist for determining the aggressiveness (grade) of the cancer cells. Several other scans, such as bone scans, MRI or CT scans may be used to determine if the cancer has spread beyond the prostate.

Surveillance

For low-risk patients, doctors can offer patients active surveillance. Treating too early may result in complications of treatment such as erectile dysfunction, incontinence, issues with passing urine,  blood in the urine, etc. That’s why for patients in this category, doctors may try to delay treatment as much as possible. During active surveillance, the patient sees his doctors every 3 months for follow-up rectal examinations and blood tests. Every 1 year to 18 months, a urologist may perform another biopsy to monitor the cancer’s progress. If signs show that the cancer is progressing, the patient may opt for treatment.

Watchful waiting is another option, for patients with a less aggressive cancer or for those who are advanced in age.

Radiotherapy & Surgery

For intermediate and high-risk patients, definitive treatment options such as radiotherapy or surgery are available. Radiotherapy can be divided into external beam radiation and brachytherapy. With external beam radiation, radiation comes from outside the body and is directed to the prostate cancer. With brachytherapy (there’s a certain criteria for patients who are suited for it), radioactive seeds are placed into the prostate, and these seeds deliver low doses of radiation over time to kill cancer cells. The surgical option is called a radical prostatectomy. It can be done as open surgery or via robotic prostatic surgery.

Hormonal Therapy

For patients who have locally invasive and metastatic disease, they can consider hormonal therapy. Prostate cancer is fuelled by testosterone, and hormonal therapy is used to cut down testosterone levels in the body—in doing so, cancer cells may die off. Sometimes, hormonal therapy may be given to those with locally invasive disease, to shrink the tumour first, before going for radical surgery. If the newer hormonal therapies don’t work for patients with metastatic disease, they can choose to go for chemotherapy.

In summary, patients should work with their doctors to choose a treatment plan most suited to their condition. HT

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