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DEAR DR. ROACH: I’ll be 70 in August, and in 2012, I had prostate cancer. My prostate was removed. My PSA level was low but rose fast, so I guess it was an aggressive form of cancer. After the removal, they still found evidence of cancer, and I underwent 35 radiation treatments that were also completed in 2012.
Afterward, I had two Lupron shots to keep my testosterone low. I guess it’s been very low ever since. Beginning in 2017, I have been on GLP-1 agents for diabetes, and I’m now on Mounjaro. These meds have been great; I’ve lost 50 pounds, and all my numbers are perfect. Without testosterone, though, I’ve lost a lot of muscle.
I’d like to begin some testosterone therapy and weight work in order to start to regaining as much muscle as I can. Weights alone don’t seem to do much. The cancer doctor says that I’m crazy to want to start testosterone. What do you think? -- D.R.
ANSWER: This remains a controversial subject. On the face of it, your cancer doctor has a point. Your prostate cancer was stopped by preventing your body from making testosterone. It worked, and now you’re alive. Men with high-risk prostate cancer in particular have an increased risk that testosterone (your own or prescribed) could stimulate dormant cancer cells. Your cancer specialist has the relevant information about the pathology of your cancer, and if they’re recommending against it, I won’t urge you to do so.
Men with lower-risk prostate cancer (Gleason 6, or 3+3) who don‚Äôt have any evidence of the disease (a PSA score of 0) have only a very small risk of recurrent prostate cancer when they’re being treated with testosterone replacement therapy. Studies found recurrence rates to be between 0% and 7% in up to five years of follow-ups.
In my own practice, I discuss the risks and benefits with my patients, and if they’re interested, I have them discuss it with their expert -- usually a urologist but sometimes a medical oncologist. I understand why you’re interested in testosterone to build muscle and perhaps increase your energy and vigor; however, you don’t want to do this at the cost of a recurrence of life-threatening cancer.
DEAR DR. ROACH: I’ve been using a CPAP machine for about 25 years. My supplier keeps urging me to buy new face-mask cushions, disposal filters, tubing, headgear, and water chambers at very frequent intervals. For example, they tell me to buy face-mask cushions every month, tubing ever three months, and headgear and a water chamber every six months. This seems unnecessary. I suspect that it’s not medically necessary and instead a scheme for increasing supplier profits. Can you enlighten CPAP users on this issue? -- B.J.
ANSWER: When I read your letter, I was inclined to think that you were right, but some research shows that replacing the supplies leads to better compliance when using the machine. Specifically, people who regularly replace the mask cushions had about an hour of more device use per night and were much less likely (15% versus 32%) to stop using their machines, compared with people who didn’t replace it as often. Furthermore, worn-out masks can cause skin irritation, air leaks and reduced effectiveness.
I can’t say exactly what the optimum schedule is, but there are data to support the regular replacement of CPAP equipment.
DEAR DR. ROACH: I got vertigo for the first time; not knowing what was happening, I went to the hospital fearing that it could be an aneurysm or a stroke. The hospital told me it’s “just‚” vertigo, showed me the Epley maneuver, and prescribed meclizine for me to take for three days. A follow-up visit to my primary care doctor a couple days later confirmed the hospital’s diagnosis and treatment.
Since the hospital visit a month ago, I‚Äôve had vertigo two or three times a week. Some episodes are so severe that I get nauseated and vomit, and it often takes me out for a full day until the meds kick in. Another checkup with my doctor yielded the same reply: You just have to live with it and treat the symptoms with Epley and meds when they occur.-- I’m only 64 years old. Do I really have to live with this for another 20 or so years? -- E.C.
ANSWER: There are several causes for vertigo, including some that are potentially dangerous. The goal of an initial evaluation is to separate the potentially dangerous causes of vertigo (those originating from the brain itself called “central vertigo,” including strokes and poor blood flow) from the much more common “benign‚” causes (also called “uperipheral vertigo‚” -- those originating from the organ of balance or the nerve). A physical exam is usually sufficient to determine central vertigo from other vertigo causes.
The Epley maneuver is used when the diagnosis is benign paroxysmal peripheral vertigo (BPPV). This condition is vertigo that is caused by the crystals inside the semicircular canal in the organ of balance. This makes the brain unable to tell which way the head is moving, and we interpret this as vertigo — a sense of movement when we’re actually still.
The maneuver is intended to clear calcium crystals from the ear canal, which can provide immediate relief. Even without treatment, most people will recover from BPPV, although my experience is that recurrent attacks are common for a month, even up to several months. (The “benign‚” description isn’t always accurate, as this condition impairs a person’s quality of life and contributes to fall risk.)
Meclizine, by contrast, doesn’t improve a person’s recovery, and although it can help stop symptoms temporarily, it doesn’t promote recovery and can even hinder it. I’ve seen many people take meclizine for months or even years and never get better. I never prescribe meclizine for more than a day or two.
In the cases of BPPV that isn’t getting better in the few months after the initial bout, I have the luxury of referring my patients to vestibular rehabilitation, which requires special expertise and isn’t always available. But it’s the best long-term treatment to control the condition.
DEAR DR. ROACH: I read your recent column on low ferritin levels. Isn’t iron deficiency an absolute indication for a colonoscopy, regardless of whether the patient is “due‚” for screening? -- M.C., MD
ANSWER: I’d say that an unexplained iron deficiency is a strong indication for colonoscopy. In a person with a clear reason for low iron levels, a colonoscopy needn’t be performed if the person doesn’t meet criteria for screening.
In the recent column that you’re referring to, the person had been given four units of blood in eight months, which is enough to explain their low ferritin levels. Still, I agree that any person with an iron deficiency should be considered for an evaluation of their colon. But I wouldn’t say that it’s an “absolute‚” indication.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.