Hormone Therapy

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Skate
Regular Member


Date Joined Oct 2010
Total Posts : 424
   Posted 10/30/2010 11:08 PM (GMT -6)   
Hi,
I had my prostate gland removed after a biopsy showed a gleason score of 7/8. Then 36 radiation treatments. PSA has risen to 1.6. Hormone Therapy is recommended. The side effects sound overwhelming, terrifying and seem like they will change who I am. Has anyone had or heard of anyone who has had Hormone Therapy for preostate cancer?

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/31/2010 12:00 AM (GMT -6)   
Hi principal,
You're going to find quite a bit of experience with hormone therapy here. Myself included. I did 28 months on it and I am on a break right now. Intermittent hormone therapy is very common and that is currently my protocol.

Ask anything you like. You can visit my website for my story about it.

BTW ~ welcome to HealingWell...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Don K.
Regular Member


Date Joined Jan 2010
Total Posts : 74
   Posted 10/31/2010 12:52 AM (GMT -6)   
Hi Principal:
Rule #1 of Prostate cancer  "There ARE no rules"
Rule #2 of Prostate cancer  "EVERY therapy has side effects".
 
Having said that, let me give you a bottom line on hormone therapy -
It sucks!
But it works!
 
You will be the same person you were before treatment (read - I will not have a sudden urge to go out and buy female underware)
 
Your urge to have sex will go to hell in a handbasket (but only until you are able to come off the treatment).
 
Other posters will fill you in shortly, but I just wanted to give you a quick bottom line on what to expect.
 
Hormone therapy is not fun, but you can do it as many of us have proven.
 
Don K.

Skate
Regular Member


Date Joined Oct 2010
Total Posts : 424
   Posted 10/31/2010 6:25 AM (GMT -6)   
Hi Tony and Don:

What side effects did you experience on HT and how did you cope with them? Do you know anything about anti androgen HP?

Jack

kbota
Regular Member


Date Joined Aug 2010
Total Posts : 486
   Posted 10/31/2010 9:29 AM (GMT -6)   
Hey Jack; Sorry for your diagnosis, and treatment dilemma. Trust me, I understand. I am currently in week three of lupron HT, and so far so good. I have experienced a few hot flashes, but they were relatively minor. My doc has me on effexor 75 which helps to minimize the hot flashes. Effexor is an antidepressant, but at this dosage level it has no anti depressant effect. From what I understand about the HT timeline, I am at the leading edge of the beginning of symptoms. My doc wants me on HT for the next two years. <yuck> As I move forward, I'm sure I will also have some questions about HT symptoms and how to treat them. Some of them may have to simply be endured.

You have found an outstanding web site with tons of information, and lots of guys with much experience and wisdom, which is a great combination.

Keep asking those questions, and you'll get tons of experiences and opinions.

I would also suggest you fill in your signature line so we know what your facing, and where you've been.

Good Luck, and God Bless

k
Age 57 at Dx
5/09 PSA 2.26
6/2010 PSA 3.07 FPSA 18% DRE +
6/2010 Bipsy, 7 of 12+, >60%, 4+5=9
7/21/2010 - RRP
Nodes neg,Ves neg
tumor contained, still 4+5=9
pni ext.
9/3, 2010 PSA - 0.04
9/3/2010, I'm 99% continent
10/14/10, PSA still 0.04, and lupron #1, now 99.9% continent
Total ED, 3 caverject failed, pump sux
10/20/10 OD'd on trimix, after 3hrs, neo synephrine shot

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/31/2010 11:01 AM (GMT -6)   
Jack,
I did well on them but it was no walk in the park. Hormone therapy (HT) was the right move however and I am enjoying a full remission right now. My side effects included:

1> Total loss of libido
2> Weight gain
3> Hot flashes (I called them personal summers. Mine weren't too bad)
4> Some depression
5> Fatigue (Together with depression it made it difficult to maintain a work out schedule but I did recover from both)
6> Loss of body hair


This list sounds huge but it was actually tolerable. When I stopped my HT almost all went away but it took some time for them to do so. I still have the weight gain issues which complicate my hypertension and can make me susceptible to diabetes. I am still working on that part.

Anti Androgens are a common combination to an LHRH Agonist like Lupron. The typical anti androgen is bicalutamide (Casodex).

Back on the LHRH Agonists. This is the primary testosterone stopper. LHRH Agonists include Lupron, Trelstar, Zoladex, Eligard or even others. They work by manipulating the pituitary gland which will stop the testicles from producing testosterone. Before you start HT I recommend that you get a testosterone count. This is your magic number when you finally stop the therapy. Get the T level and monitor it throughout the therapy. Some docs don't do this but I highly recommend that you do it by requesting that number at each shot. When I was on Lupron my T levels dipped to just 20 (Down from 350). This is what you want to see in the performance of HT. When I stopped it took close to 9 months to get my T levels above 250. But I sure felt better.

Peace to you, and don't be afraid of this therapy. If it's necessary it's good to know it is effective.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Skate
Regular Member


Date Joined Oct 2010
Total Posts : 424
   Posted 10/31/2010 11:04 AM (GMT -6)   

Finally got my signature line set up.  Thanks for the info on that! Thanks for sharing about HT.  Keep me posted as to the side effects and how you are handling them.  I am further investigating anti androgen HT as the testosterone apparently is only blocked from it rather than being suppressed.  After finally making some progress with ED,  this sounds feasible.  Any suggestions or insights.

Jack


Age 59 at Dx
01/08 PSA 4.17 with node on prostate(doubled in a year)
03/08 RP - PSA 0.0 for one year
Total ED / pump / pills no effect
09/09 RT PSA .14 / 36 treatments
Total ED / pump / pills no effect
08/10 PSA .6
10/10 PSA 1.67
HT recommended
11/10 Next PSA
ED somewhat improved / pump / somewhat helpful

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3747
   Posted 10/31/2010 11:09 AM (GMT -6)   
The idea behind ALL "hormone therapy" is to lower your testosterone level to as close to zero as they can.. This usually stops PC dead in it's tracks for a period of time. This period can be as short as two years or, in about 10% of PC patients, longer than 10 years depending on how aggressive the PC is and how long it takes to become "hormone refractory"..If you have not read Dr. Walsh's book, "Guide to surviving prostate cancer", The last two or three chapters explain in detail how advanced prostate cancer is treated and it spells out in detail what side effects to expect and how these side effects can be managed..

The latest and greatest HT drug is called "Firmagon" It performs the same function as Lupron / casodex but in a one shot, fast acting package. Being new, it's hard to get and expensive if you do find it...Best of luck to you....
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9

F8
Veteran Member


Date Joined Feb 2010
Total Posts : 3803
   Posted 10/31/2010 12:03 PM (GMT -6)   
i'm coming up on eight months on lupron.  according to my doctors the single best thing you can do to counteract side effects is exercise, which hasn't always been easy for me because i have also had two courses of radiation treatments (BT and IGRT) during this period.  my exercise program has evolved but i have continued to exercise several hours a week, even during those periods when all i could do was go through the motions.  i weight train and do aerobics. 
 
i also am taking a sub-clinical dose of celexa for hot flashes, which has been successful for me.  in the beginning the celexa also helped me with anxiety.  i strongly recommend celexa or some other anti-depressant.
 
a three-month shot of lupron doesn't affect me much for the first two or three weeks.  over the next six weeks i get the full brunt of side of the side effects, stiff joints, weakness, shortness of breath unmotivated, food cravings, intolerance to heat, nausea etc.  about the last month i start feeling better which tells me it's time for the next shot.  i also gained 20 pains due to overeating but i've talked to guys who gained weight on lupron even tho they did not eat more.  my sex drive has vanished.
 
please remember that some of my side effects have been aggravated by radiation treatments and drugs like flomax.
 
i know it sounds terrible but i've been through worse.  i've been able to work and function but i do have a light schedule that i can adjust. 
 
i see HT as a necessary evil but mostly as an inconvenience. and in my opinion it's not as bad as many would have you believe.
 
good luck.
 
ed
age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

Sancarlos
Regular Member


Date Joined Feb 2010
Total Posts : 242
   Posted 10/31/2010 12:18 PM (GMT -6)   
I have been on HT for 15 months, and the plan is to be on it for at least another nine months.

My side effects have been as follows.

1. Loss of libido. But not loss of ability to have an erection and orgasm. Not sure if this is common or uncommon with HT.
2. Bone density loss. Now taking Fosamax to counter.
3. Hot flashes, especially in the night.
4. Minor depression
5. Fatigue, but it turned out that I had become anemic. Now with iron and vitamin supplements I have regained most of the lost energy.
6. Some loss of body hair, mostly on legs and back.
7. Loss of strength due to lack of testosterone. Only way to counter this is to exercise as much as possible.

The most difficult time for me with HT has been during a week of three or four days after the Lupron injections. These shots leave me very sore at the point of the injection and with general muscle aches, and some depression. After a week or so I settle back to my condition immediately before the injection.

Overall HT has been more of an irritant than a major influence on my quality of life.

Sancarlos
Age 66, PC diagnosed 7/2009 at age 65
Stage: T2c, Gleason: 9 (4 + 5), 6 of 6 cores positive
Bone, CAT and MIR scans negative

Treatment: brachytherapy (103 palladium), 100 gy, 11/2010 + hormone therapy (Lupron + Casodex) + IMRT on Novalis, 45 gy, 3/2010.

PSA: 7/2009, At time of diagnosis -- 11.9
10/2009 -- 5.0
12/2009 -- 0.56
5/2010 -- 0.15
8/9/2010 -- 0.06

Skate
Regular Member


Date Joined Oct 2010
Total Posts : 424
   Posted 10/31/2010 12:20 PM (GMT -6)   
Thanks Ed for your very honest response.  What I am wrestling with right now is whether or not to go for HT.  My oncologist was very up front about treating only a number at this stage.  Recent MRI / bone san are negative.  I retrospect,  I wish that I would not have rushed into RT 
with a PSA of 0.14.  I think that maybe I should have waited to make a decision there.  After coming so far post surgery and 2 and 1/2 years later just starting to see some improvements with ED,  I wonder whether RT may have interrupted the healing process.  Was it needless art such an early stage and low PSA?  I have read about many who have not undergone follow up therapies until much higher PSA readings.  With Hormone therapy I really feel that I will be giving up the last part of manhood I can hold on to. Selfish I know but the last few years have caused me to proceed with caution.  Surgery?  I had no option and that was clear.  The rest I am beginning to question.
 
Jack
Age 59 at Dx
01/08 PSA 4.17 with node on prostate(doubled in a year)
03/08 RP - PSA 0.0 for one year
Total ED / pump / pills no effect
09/09 RT PSA .14 / 36 treatments
Total ED / pump / pills no effect
08/10 PSA .6
10/10 PSA 1.67
HT recommended
11/10 Next PSA
ED somewhat improved / pump / pills somewhat helpful

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 10/31/2010 12:38 PM (GMT -6)   
Principal,
All patients respond to Hormone therapy differently and you won't know your response untill you do it. For anyone doing Hormone therapy there are two MUST reads: "Beating Prostate Cancer: Hormone Therapy and Diet" by Dr Charles Sunffy Myers and " A Primer on Prostate Cancer" by Dr Stephen Strum. Also "Invasion of the Prostate Snatchers" by Dr Mark Scholz has an excellent chapter on HT. With all due respects Walsh's book is from a surgeon's view point and expresses the conventional wisdom of 10 or 15 years ago and a lot has changed. The PCRI web site has some excellent articles on side affects and how to eliminate some of them. There are tens of thousands of patients on Hormone therapy that are living normal productive lives for 10 to 15 years or longer. For the best possibe outcome have a medical ongologist specializing in PC direct your treatments, they can be done locally, but a good oncologist is worth his weight in gold. There is a list of medical oncologists that specialize in PC in the appendix of "Invasion of the Prostate Snatchers".

Good luck.
JohnT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

F8
Veteran Member


Date Joined Feb 2010
Total Posts : 3803
   Posted 10/31/2010 12:43 PM (GMT -6)   
Jack -- you're welcome. it's a no-brainer, my friend.  you can always try HT and then opt out if it doesn't work for you.  all the other stuff is just noise.  you are where you are at.  good luck to you!
 
ed
age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

Skate
Regular Member


Date Joined Oct 2010
Total Posts : 424
   Posted 10/31/2010 12:57 PM (GMT -6)   
Thanks again Ed as always.  Do you think I am being foolish. I am where I am at but...
 
JohnT
I'll look into the must reads you have suggested. Thank you,
 
Jack

F8
Veteran Member


Date Joined Feb 2010
Total Posts : 3803
   Posted 10/31/2010 5:45 PM (GMT -6)   

Jack -- lupron and the other HT drugs  are very serious drugs, and you have concerns and questions. my big worry was depression but i was suffering from anxiety back then. looking back i was freaked out about HT (and PC) because of all the stuff i read on the internet.  according to the doctors and medical staff that i talked to the biggest complaint with lupron is hot flashes. the flashes i get are very muted and a minor nuisance but i started celexa a week or so before my first shot of lupron.

ed


age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

Post Edited (F8) : 10/31/2010 5:53:57 PM (GMT-6)


Skate
Regular Member


Date Joined Oct 2010
Total Posts : 424
   Posted 10/31/2010 6:29 PM (GMT -6)   

Hi Guys:

Well I guess some big decisions will have to be made soon.  My next PSA test is scheduled at the clinic on November 23rd and my original urologist and surgeon will see me on November 30th.  Although he performed  the RP two and a half years ago,  he still wants to see me every three months on an ongoing basis.  I value the advice he offers and he is very helpful with my ED.  I will have another PSA on December 14th and then I will see my oncologist again on the 23rd of December.  This will be the fourth time in three months,  so I certainly feel that I am in good hands. At that time we will discuss options depending on the PSA pattern and any action needed.  It should be a very anxious two months. 

Happy Hallowe'en for now my friends.  I'll keep you posted.  In the meantime I enjoy receiving your ongoing input as your comments are helping me immensely when I finally do have to make some decisions.

Jack


Age 59 at Dx
01/08 PSA 4.17 with node on prostate(doubled in a year)
03/08 RP - PSA 0.0 for one year
Total ED / pump / pills no effect
09/09 RT PSA .14 / 36 treatments
Total ED / pump / pills no effect
08/10 PSA .6
10/10 PSA 1.67
HT recommended
11/10 Next PSA
ED somewhat improved / pump / pills somewhat helpful

Don K.
Regular Member


Date Joined Jan 2010
Total Posts : 74
   Posted 10/31/2010 10:27 PM (GMT -6)   
Mind vs matter
 
Hi Jack:
Appears that you are getting a good education on HT here. All above very good posts.
 
Aside to Sancarlos - Boy I hear you on pain at the injection site! First shot of lupron was just another shot in the butt. But third time I was so sore next day that I could not even get out of bed.
 
And Jack - I need to mention "Libido" to you just in case you didn't know. Hell, a lot of us guys don't even know we have a prostate until it starts acting up, not to even mention libido.
 
Since you have already had your prostate removed and then had radiation therapy, it is no wonder that you are having ED problems. But assuming that your Testosterone level is somewhere near normal, you still have the urge for sex. And this is libido.
 
The sexual drive called libido is a function of testosterone level. No testosterone = no libido. Simple as that.
 
The sole and only purpose of ADT drugs (Lupron, Etc) is to send a chemical message to the testes telling them to stop making testosterone.
 
So, if you go ahead with hormone therapy you can expect to have the urge for sex disappear. And in your case this could be a blessing. Instead of the constant need for sex that we men have, suddenly you won't even want it anymore.
 
Sounds awful on the face of it, but maybe better than the suffering of always wanting it but can't perform anyhow.
 
Then after stopping the hormone therapy you would be back to square one - Figuring a way around the ED problem.
 
Plus - You would still be alive.
 
Just something to think about.
 
Don K.

Skate
Regular Member


Date Joined Oct 2010
Total Posts : 424
   Posted 11/1/2010 6:13 AM (GMT -6)   

Don:

That certainly was a kick in the rear (or should I say shot in the rear).  I much appreciated your pointed wake up call.  Works for the present but we'll see as time goes by.

Jack


Age 59 at Dx
01/08 PSA 4.17 with node on prostate(doubled in a year)
03/08 RP - PSA 0.0 for one year
Total ED / pump / pills no effect
09/09 RT PSA .14 / 36 treatments
Total ED / pump / pills no effect
08/10 PSA .6
10/10 PSA 1.67
HT recommended
11/10 Next PSA
ED somewhat improved / pump / pills somewhat helpful

Don K.
Regular Member


Date Joined Jan 2010
Total Posts : 74
   Posted 11/1/2010 9:57 PM (GMT -6)   
Hi Jack:
 
Just want to make sure I didn't scare you with the report of big time pain at the injection site with Lupron.
 
Myself, Sancarlos and one other patient are the only ones I have heard complain about painful Lupron shots. And I check out several Pca sites.
 
So, just a few of us have that problem
 
Pca is ideed "A journey through a strange place".
 
Don K.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 11/1/2010 11:22 PM (GMT -6)   
Don K.
I forgive you and Sancarlos and one other patient for understating things on the injections. It starts out with the most careful nurse and everything goes well. A few days later you wonder if the license plate was imprinted down there. Then later on in therapy, Lord knows that they intentionally dull that harpoon before chucking it into us.

But I did it...pardon the pun.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Don K.
Regular Member


Date Joined Jan 2010
Total Posts : 74
   Posted 11/2/2010 12:00 AM (GMT -6)   
Tony:
 
You too?
 
Dang, that makes four of us.
Don K.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 11/2/2010 12:32 AM (GMT -6)   
Don I thought it was a secret handshake or something.

I have a much bigger list than you apparently...:-) Seriously it's tolerable but for some reason there's a week or two after the injection that you try to black out. I don't mean excruciating, but rather annoying...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Skate
Regular Member


Date Joined Oct 2010
Total Posts : 424
   Posted 11/2/2010 3:35 AM (GMT -6)   

tongue  Now now now! Let's not argue.  So it hurts and aches for a while, maybe endlessly.  That would be the least of my concerns with HT.  Although I do appreciate your sense of humour.  That is one thing we can hang on to I guess. Keep it coming friends!

Jack


Age 59 at Dx
01/08 PSA 4.17 with node on prostate(doubled in a year)
03/08 RP - PSA 0.0 for one year
Total ED / pump / pills no effect
09/09 RT PSA .14 / 36 treatments
Total ED / pump / pills no effect
08/10 PSA .6
10/10 PSA 1.67
HT recommended
11/10 Next PSA: ED somewhat improved / pump / pills somewhat helpful

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 11/2/2010 8:24 AM (GMT -6)   
Jack,
Don's description was accurate, I was just having some fun. It is tolerable but for a week or two it smarts. I guess I had 7 shots over 28 weeks. I switched side of the injections at the suggestion of the nurses who administered it. So one shot on the right then alternating. Some shots were worse than others, but none were intolerable.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Skate
Regular Member


Date Joined Oct 2010
Total Posts : 424
   Posted 11/3/2010 9:07 AM (GMT -6)   
Have read a lot about ED resulting from RP and RT. Hve tried the pump but will not retain the blood flow.  Good for therapy though.  Tried viagara and cialis with little effect.  Injections would be the next step from what I have read on this site.  Any supportive suggestions?
Age 59 at Dx
01/08 PSA 4.17 with node on prostate(doubled in a year)
03/08 RP - PSA 0.0 for one year
Total ED / pump / pills no effect
09/09 RT PSA .14 / 36 treatments
Total ED / pump / pills no effect
08/10 PSA .6
10/10 PSA 1.67
HT recommended
11/10 Next PSA: ED somewhat improved / pump / pills somewhat helpful
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