Cancer of the testicles, also known as testicular cancer, is one of the less common cancers. It usually affects younger men between the ages of 15 and 44.
The most common symptom is a painless lump or swelling in the testicles. Other symptoms can include:
- a dull ache in the scrotum (the sac of skin that hangs underneath the penis and contains the testicles)
- a feeling of heaviness in the scrotum
Read more about the symptoms of testicular cancer.
The testicles are the two oval-shaped male sex organs that sit inside the scrotum on either side of the penis.
The testicles are an important part of the male reproductive system because they produce sperm and the hormone testosterone, which plays a major role in male sexual development.
Types of testicular cancer
The different types of testicular cancer are classified by the type of cells the cancer first begins in.
The most common type of testicular cancer is known as ‘germ cell testicular cancer’, which accounts for around 95% of all cases. Germ cells are a type of cell that the body uses to help create sperm.
There are two main subtypes of germ cell testicular cancer. They are:
- seminomas, which account for around 40% of all germ cell testicular cancers
- non-seminomas, which account for around 60% of all germ cell testicular cancers
Seminomas and non-seminomas tend to respond well to chemotherapy, a treatment that uses medication given directly into the bloodstream to kill cancer cells.
Less common types of testicular cancer include:
- Leydig cell tumours, which account for around 1-3% of cases
- Sertoli cell tumours, which account for around 1% of cases
This article focuses on germ cell testicular cancer. The Macmillan website has more information about Leydig cell tumour and Sertoli cell tumour.
How common is testicular cancer?
Testicular cancer is relatively uncommon, accounting for just 1% of all cancers that occur in men.
Each year in the UK around 2,090 men are diagnosed with testicular cancer, according to Cancer Research UK.
Testicular cancer is unusual compared to other cancers because it tends to affect younger men. As a result, although relatively uncommon overall, testicular cancer is the most common type of cancer to affect men between the ages of 15 and 44.
Rates of testicular cancer are five times higher in white men than in black men. The reasons for this are unclear.
The number of cases of testicular cancer that are diagnosed each year in the UK has roughly doubled since the mid-1970s. Again, the reasons for this are unclear.
Causes of testicular cancer
The cause or causes of testicular cancer are unknown, but a number of things have been identified that increase the chance of developing the condition. These include:
- having a family history of testicular cancer
- being born with undescended testicles (cryptorchidism). About 3-5% of boys are born with their testicles located inside their abdomen, which usually descend into the scrotum during the first four months of life
Read more about the causes of testicular cancer.
Testicular cancer is one of the most treatable types of cancer. Over 95% of men with early stage testicular cancer will be completely cured.
Even cases of more advanced testicular cancer, where the cancer has spread outside the testicles to nearby tissue, have an 80% chance of being cured.
Compared to other cancers, deaths from testicular cancer are rare. Cancer Research UK say that around 70 men die from testicular cancer every year in the UK.
Treatment for testicular cancer includes the surgical removal of the affected testicle (which should not affect fertility or the ability to have sex), and chemotherapy. Less commonly radiotherapy, a treatment that uses radiation to kill cancer cells, may be used for seminomas.
Read more about treating testicular cancer.
Benign Benign refers to a condition that should not become life threatening. In relation to tumours, benign means not cancerous. Malignant Malignant is a term used to describe a life threatening or worsening condition. In the case of tumours, malignant means cancerous. Testicles Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones. Testosterone Testosterone is a male sex hormone that is involved in making sperm and sexual characteristics, such as the development of a deeper voice. Testosterone is also found in small amounts in women.
The most common symptom of testicular cancer is a lump or swelling in one of your testicles.
The lump or swelling can be about the size of a pea, but may be larger.
Most testicular lumps or swellings are not a sign of cancer. But they should never be ignored. You should visit your doctor as soon as you notice a lump or swelling in one of your testicles.
Testicular cancer can also cause other symptoms including:
- a dull ache or sharp pain in your testicles or scrotum, which may come and go
- a feeling of heaviness in your scrotum
- a dull ache in your lower abdomen (stomach area)
- a sudden collection of fluid in your scrotum (hydrocele)
- a general feeling of being unwell
When to see your doctor
It is very important to visit your doctor as soon as you notice any lump or swelling on your testicle.
Your doctor will examine your testicles to help determine whether or not the lump is cancerous.
Research has shown that less than 4% of testicular lumps are cancerous. For example, varicoceles (swollen blood vessels) are a common cause of testicular lumps. For more information about varicoceles, read more about testicular lumps and swellings.
In the unlikely event that you do have testicular cancer, the sooner treatment begins, the greater the likelihood you will be completely cured.
If you do not feel comfortable visiting your doctor, you can go to your local sexual health clinic, where a healthcare professional will be able to examine you. You can find your local clinic by visiting the Family Planning Association (FPA) website.
If testicular cancer has spread to other parts of your body, you may also experience other symptoms. Cancer that has spread to other parts of the body is known as metastatic cancer.
Around 5% of people with testicular cancer will experience symptoms of metastatic cancer.
The most common place for testicular cancer to spread is to nearby lymph nodes in your abdomen or lungs. Lymph nodes are glands that make up your immune system. Less commonly, the cancer can spread to your liver, brain or bones.
Symptoms of metastatic testicular cancer can include:
- a persistent cough
- coughing or spitting up blood
- shortness of breath
- swelling and enlargement of male breasts
- a lump or swelling in your neck
- lower back pain
The causes of testicular cancer are not fully understood.
However, we do know about several things which increase your risk of developing the condition.
Some risk factors for testicular cancer are outlined below.
The most significant is undescended testicles.
When male babies grow in the womb, their testicles develop inside their abdomen. The testicles then normally move down into the scrotum when the baby is born or during their first year of life.
However, for some children, the testicles fail to descend. The medical name for undescended testicles is cryptorchidism.
Surgery is usually required to move the testicles down. If you have had surgery to move your testicles down into your scrotum, your risk of developing testicular cancer may be increased.
One study found if surgery is performed before the child is 13 years of age, their risk of later developing testicular cancer is approximately double that of the rest of the population. However, if the operation is carried out after the boy is 13 years of age, the risk of developing testicular cancer is five times greater than that of the rest of the population.
Age and race
Unlike most other types of cancer, testicular cancer is more common in young and middle-aged men affecting those between 20 and 44 years of age, with 90% of cases affecting men under the age of 55.
Testicular cancer is more common in white men than other ethnic groups. It is also more common in northern and western Europe compared with other parts of the world.
Having a close relative with a history of testicular cancer increases your risk of developing it.
If your father had testicular cancer, you are four to six times more likely to develop it than a person with no family history of the condition. If your brother had testicular cancer, you are eight to ten times more likely to develop it (having an identical twin with testicular cancer means that you are 75 times more likely to develop it).
The fact that testicular cancer appears to run in families has led researchers to speculate that there may be one or more genetic mutations (abnormal changes to the instructions that control cell activity) that make a person more likely to develop testicular cancer.
A promising piece of research carried out in 2009 identified mutations in two genes (known as the KITLG and SPRY4 genes) that appear to increase the risk of a person developing testicular cancer.
Examples of endocrine disruptors include:
- some types of pesticide
- polychlorinated biphenyls (PCBs), chemical compounds used as a coolant
- dibutyl phthalate, a chemical used to manufacture cosmetics, such as nail polish
In most countries, including the UK, many endocrine disruptors, such as PCBs, have been withdrawn as a result of their link to health problems. However, there is a concern that exposure to endocrine disruptors may still occur due to contamination of the food chain.
However, as yet, there is not yet enough evidence to prove a definite link between indirect exposure to low levels of endocrine disruptors and health problems. Indirect exposure is the type of exposure that would occur if the food chain was contaminated.
Men who are infertile are three times more likely to develop testicular cancer than fertile men.
The reasons for this are not clear.
Research has found that long-term smokers (people who have been smoking a pack of 20 cigarettes a day for 12 years or 10 cigarettes a day for 24 years) are twice as likely to develop testicular cancer than non-smokers.
HIV and AIDS
Studies show that men with HIV or AIDS have an increased risk of testicular cancer.
A study that was carried out in 2008 found that a man’s height affects his chances of developing testicular cancer.
Men who are 190-194cm (6.1-6.3ft) tall are twice as likely to develop testicular cancer than men of average height. Very tall men, who are 195cm (6.4 ft) or above, are three times more likely to develop testicular cancer than men of average height.
Being shorter, less than 170cm (5.6ft) tall, decreases your risk of getting testicular cancer by around 20%.
Researchers who conducted the study think the link between height and cancer risk may be caused by diet. Taller children often require a higher-calorie diet as they are growing up, and it may be the effects of such a diet that leads to the increase in cancer risk.
See your doctor if you notice a lump or abnormality on or in your testicles.
Most testicular lumps are not cancerous, but it is important you have the abnormality checked as treatment for testicular cancer is much more effective when started earlier.
As well as asking you about your symptoms and consulting your medical history, your doctor will usually need to carry out a physical examination of your testicles.
Your doctor may hold a small light or torch against the lump in your testicle to see whether light passes through it. Cancerous lumps tend to be solid, which means light is unable to pass through.
Tests for testicular cancer
If your doctor suspects the lump in your testicle may be cancerous, you will be referred for further testing at a hospital. Some tests you may have are outlined below.
A scrotal ultrasound scan is a painless procedure that uses high-frequency sound waves to produce an image of the inside of your testicle. This is one of the main ways your health professional will be able to determine whether or not your lump is cancerous (malignant) or non-cancerous (benign).
During a scrotal ultrasound, your specialist will be able to determine the position and size of the abnormality in your testicle.
It will also give a clear indication of whether the lump is solid or filled with fluid. A lump filled with fluid is known as a cyst and usually harmless. A more solid lump may be a sign the swelling is cancerous.
To help confirm your diagnosis, you may need a series of blood tests to detect certain hormones in your blood, which are known as 'markers'. Testicular cancer often produces these markers, so having them in your blood may be an indication you have the condition.
Markers in your blood that will be tested for include:
- AFP (alpha feta protein)
- HCG (human chorionic gonadotrophin)
- LDH (lactate dehydrogenate)
Not all forms of testicular cancer produce these markers. There may still be a chance you have testicular cancer even if your blood test results come back normal.
The only way to definitively confirm a case of testicular cancer is to have a biopsy of the tumour taken. The cells from the tumour can be examined in a laboratory to determine whether it is cancerous.
For most cases the only way to safely take a biopsy is to remove the affected testicle completely. This is because specialists often think the risk of the cancer spreading is too high for a conventional biopsy to be taken.
Your specialist will only recommend removing your testicle if they are relatively certain your lump is cancerous. Losing a testicle will not affect your sex life or ability to have children.
The removal of a testicle is known as an orchidectomy. The main form of treatment for testicular cancer is removing the affected testicle, so if you have testicular cancer it is likely you will need an orchidectomy.
See Cancer of the testicles - treatment for more information about the procedure.
If your specialist feels it is necessary, you may require further tests to check whether testicular cancer has spread. When cancer of the testicle spreads, it most commonly affects the lymph nodes and lungs.
Therefore, you may require a chest X-ray to check for signs of a tumour. You may also require a scan of your entire body, such as a magnetic resonance imaging (MRI) scan or a computerised tomography (CT) scan to check for signs of the cancer spreading.
Stages of testicular cancer
Once these tests have been completed, it is usually possible to determine the stage of your cancer.
There are two ways the staging of testicular cancer can be categorised. The first is known as the TNM staging system:
- T indicates the size of the tumour.
- N indicates whether the cancer has spread to nearby lymph nodes.
- M indicates whether the cancer has spread to other parts of the body (metastasis).
See the Macmillan website for more information about TNM staging for testicular cancer.
Testicular cancer is also staged numerically. There are four stages:
- Stage 1: the cancer is contained inside your testicles.
- Stage 2: the cancer has spread from the testicles into the lymph nodes in your abdomen and pelvis.
- Stage 3: the cancer has spread into the lymph nodes in your upper chest.
- Stage 4: the cancer has spread into another organ, such as your lungs.
Benign refers to a condition that should not become life threatening. In relation to tumours, benign means not cancerous.
A biopsy is a test that involves taking a small sample of tissue from the body so it can be examined.
An incision is a cut made in the body with a surgical instrument during an operation.
Lungs are a pair of organs in the chest that control breathing. They remove carbon dioxide from the blood and replace it with oxygen.
Lymph nodes are small oval tissues that remove unwanted bacteria and particles from the body. They are part of the immune system.
Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones.
An X-ray is a painless way of producing pictures of inside the body using radiation.
If you have testicular cancer, your recommended treatment plan will depend on two factors:
- whether you have seminomas or non-seminomas testicular cancer
- the stage of your cancer (see Cancer of the testicles - diagnosis for more information about staging)
The first treatment option for all cases of testicular cancer, whatever the stage, is to surgically remove the affected testicle (an orchidectomy).
In cases of stage one seminomas testicular cancer, after the testicle has been removed, a single dose of chemotherapy is usually given to help prevent the cancer returning. Sometimes a short course of radiotherapy is recommended.
In stage one non-seminomas close follow-up (called surveillance) may be recommended, or a short course of chemotherapy using a combination of different medications.
In cases of stage two and stage three cancer, three to four cycles of chemotherapy are given using a combination of different medications. Further surgery may sometimes be needed after chemotherapy to remove any affected lymph nodes.
A similar treatment plan is used to treat stage four cancer. Additional surgery may also be required to remove tumours from other parts of the body, such as the lungs.
Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.
Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out advantages and disadvantages of particular treatments.
An orchidectomy is the medical name for the surgical removal of a testicle. If you have testicular cancer, it is necessary to remove the whole testicle because only removing the tumour may lead to the cancer spreading. By removing the entire testicle, your chances of a full recovery are greatly improved. Your sex life and ability to father children will not be affected.
If you have testicular cancer that is detected in its very early stages, an orchidectomy may be the only treatment you require.
The operation is performed under general anaesthetic. A small incision (cut) is made in your groin and the whole testicle is removed through the incision. If you want, you can have an artificial (prosthetic) testicle inserted into your scrotum so that the appearance of your testicles is not greatly affected. The artificial testicle is usually made from silicone (a soft type of plastic).
After an orchidectomy, you will need to stay in hospital for a few days. If you only have one testicle removed, there should not be any lasting side effects.
If you have both testicles removed (a bi-lateral orchidectomy), you will be infertile. However, it is only necessary to remove both testicles in 1 in every 100 cases.
You may be able to bank your sperm before having a bi-lateral orchidectomy to allow you to father children if you decide to. See the box to the left for more information about sperm banking.
Testosterone replacement therapy
Having both testicles removed will also stop you producing testosterone. This means you will have a low libido (a decreased sex drive) and will not be able to achieve or maintain an erection. In this case, you will require testosterone replacement therapy.
Testosterone replacement therapy is where you are given a synthetic version of the testosterone hormone to compensate for the fact that your testicles will no longer produce the natural version.
Testosterone is usually given either as injections or skin patches. If you have injections, you will usually need to have them every two to three weeks. If you have testosterone replacement therapy, you will be able to maintain an erection and sex drive.
Side effects of testosterone replacement therapy are uncommon and usually mild. They include:
- oily skin, which can sometimes trigger the onset of acne
- enlargement and swelling of your breasts
- a change in normal urinary patterns, such as needing to urinate more frequently or having problems passing urine (caused by an enlarged prostate gland which puts pressure on your bladder)
Lymph node surgery
If your testicular cancer is more advanced, it may spread to your lymph nodes. Your lymph nodes are part of your body's immune system, which help to protect it against illness and infection.
Lymph node surgery is carried out under general anaesthetic. The lymph nodes in your abdomen are the most likely nodes that will need to be removed.
In some cases, the nerves near to the lymph nodes can become damaged, which means that rather than ejaculating semen out of your penis during sex or masturbation, the semen instead travels back into your bladder. This is known as retrograde ejaculation.
If you have retrograde ejaculation, you will still experience the sensation of having an orgasm during ejaculation, but you will not be able to father a child.
As with an orchidectomy, you may wish to bank your sperm before your operation, in case you become infertile.
Nerve-sparing retroperitoneal lymph node dissection
A new type of lymph node surgery, called nerve sparing retroperitoneal lymph node dissection (RPLND), is increasingly being used because it carries a lower risk of causing retrograde ejaculation and infertility.
In nerve-sparing RPLND, the site of the operation is limited to a much smaller area. The advantage of limiting the site of the operation is that there is less chance of nerve damage occurring. The disadvantage is that the surgery is more technically demanding. Due to this, nerve-sparing RPLND is currently only available at specialist centres that employ surgeons with the required training.
There may be a long waiting list for nerve-sparing RPLND. However, in many cases, it may be too dangerous to delay surgery and ‘traditional lymph node surgery’ may be required.
Laparoscopic retroperitoneal lymph node dissection
Laparoscopic retroperitoneal lymph node dissection (LRPLND) is a new type of ‘keyhole’ surgery that can be used to remove the lymph nodes. During LRPLND, the surgeon will make a number of small incisions (cuts) in your abdomen.
A special instrument called an endoscope is inserted into one of the incisions. An endoscope is a thin, long, flexible tube that has a light source and a video camera at one end, enabling images of the inside of your body to be relayed to an external television monitor.
Small, surgical instruments are passed down the endoscope and can be used to remove the affected lymph nodes.
The advantage of LRPLND is that there is less post-operative pain and a faster recovery time. Also, as with nerve-sparing RPLND, in LRPLND there is a smaller chance that nerve damage will lead to retrograde ejaculation.
However, as LRPLND is a new technique, there is little available evidence regarding the procedure’s long-term safety and effectiveness. If you are considering LRPLND, you should understand there are still uncertainties about the safety and effectiveness of the procedure.
Radiotherapy uses high-energy beams of radiation to help destroy cancer cells. Sometimes, seminomas may require radiotherapy after surgery, to help prevent the cancer from returning.
If your testicular cancer has spread to your lymph nodes, you may require radiotherapy after a course of chemotherapy.
Side effects can include:
- reddening and soreness of the skin, which is similar to sunburn
These side effects are usually only temporary and should improve on completion of your treatment.
Read more about Radiotherapy for more information.
Chemotherapy uses anti-cancer medicines to kill the malignant (cancerous) cells in your body or stop them multiplying.
If you have advanced testicular cancer or it has spread within your body, you may require chemotherapy. It is also used to help prevent the cancer returning. Chemotherapy is most commonly used to treat non-seminoma tumours.
Chemotherapy medicines are usually injected or given orally (by mouth). Sometimes, chemotherapy medicines can attack your body’s normal, healthy cells. This is why chemotherapy can have many different side effects. The most common include:
- hair loss
- sore mouth
- loss of appetite
- infertility (usually temporary)
- ringing in your ears (tinnitus)
- skin that bleeds or bruises easily
- increased vulnerability to infection
- numbness and tingling (pins and needles) in your hands and feet
These side effects are usually only temporary and should improve after you have completed your treatment.
You should not father children while you are receiving chemotherapy and for a year after treatment has finished. Chemotherapy medications can temporarily damage your sperm, increasing your risk of fathering a baby with serious birth defects. Therefore, you will need to use a reliable method of contraception, such as a condom, during this time.
Condoms should also be used during the first 48 hours after having a course of chemotherapy. This is to protect your partner from any potential harmful effects of the chemotherapy medication in your sperm.
Read more about Chemotherapy for more information.
Even if your cancer has been completely cured, there is a risk that it will later return. Around 25-30% of people experience a return of the cancer, usually within the first two years after their treatment has finished.
Due to this risk, you will require regular tests to check if the cancer has returned. These include:
- a physical examination
- blood tests
- chest X-ray
- computerised tomography (CT) scan
Testing is usually recommended every three months during the first year after treatment. After the first year, tests will decrease to two a year, and then annually.
If the cancer does return and is diagnosed at an early stage, it will usually be possible to cure it using chemotherapy and possibly also radiotherapy. Some types of recurring testicular cancer have a cure rate of almost 100%.
Chemotherapy Chemotherapy is a treatment of an illness or disease with a chemical substance, such as in the treatment of cancer. Hormone replacement therapy Hormone replacement therapy or HRT involves giving hormones to women when the menopause starts, to replace those the body no longer produces. Lymph nodes Lymph nodes are small oval tissues that remove unwanted bacteria and particles from the body. They are part of the immune system. Radiotherapy Radiation therapy uses X-rays to treat disease, especially cancer. Testicle Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones. Testosterone Testosterone is a male sex hormone, which is involved in making sperm and sexual characteristics such as the voice getting deeper. Testosterone is also found in small amounts in women.
Testicular cancer cannot usually be prevented. But it is important to check your testicles regularly. See your doctor if you notice any lumps or abnormalities.
Cancer is easier to treat when diagnosed early. If you regularly examine your testicles, you are more likely to notice any swelling or abnormalities at an early stage of development.
Checking your testicles
The best time to check your testicles is after a warm shower or bath, because this is when your scrotal skin will be most relaxed.
Hold your scrotum in the palms of your hands, and use your fingers and thumbs to examine your testicles. You should first feel the size and weight of your testicles. A lot of men have one testicle which is larger than the other. You may also have one testicle that hangs slightly lower than the other.
As well as feeling the size and weight of your testicles, gently feel each individually.
They should feel smooth with no lumps or swellings with a soft, tube-like section at the top and back of each testicle. This is your epididymis, which is used to store sperm. It may feel slightly tender, which is normal.
It is very rare to develop cancer in both testicles. If you are unsure about what your testicle should feel like, try comparing it to your other one.
If you find a lump or swelling, visit your doctor as soon as possible.
Of all of the known risk factors for testicular cancer, smoking is the most significant risk factor you can address.
If you smoke, giving up will half your risk of developing testicular cancer, as well as reducing your risk of getting many other serious health conditions, such as lung cancer and heart disease.
If you are committed to giving up smoking but do not want to be referred to a stop smoking service, your doctor should be able to prescribe medical treatment to help with withdrawal symptoms you may have.
See the Health A-Z topic about Smoking - treatment and the Live Well section about how to [stop smoking] for more information.
Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones.
Jack and Mark's stories
Two men who have had testicular cancer talk about their experience and the importance of checking for early warning signs, plus advice from an expert.
Surviving testicular cancer gave Mark Adams a new lease of life. Trekking through Peru and visiting the Great Wall of China, he admits, just wouldn’t have been on his to-do list before.
“It was the middle of 2003 when I noticed a lump in my testicle, while in the shower. It was a complete chance finding. I’d heard about cysts so I didn’t think much of it until about mid-September, when I thought it wasn’t right and I should do something about it.
“So I saw my doctor and was referred to a specialist for an ultrasound, which showed it was cancer. I felt like I’d been hit by a freight train. I thought, ‘What if this is the beginning of the end?’
“It was quite hard concentrating and taking in what the doctor was saying, because I was so upset. I had to try hard to put these feelings aside and to understand what they were telling me.
“That evening, I had to decide who I should tell. I told my parents over the phone and they reacted very well. I then went to the Cancer Research UK website to do some research about testicular cancer.
“After surgery to remove the testicle, I went to see a consultant at the Royal Marsden Hospital. I had two weeks of radiotherapy, which was pretty straightforward, although it does affect you. I had the radiotherapy on my pelvis and stomach, so mealtimes became hard. I didn’t eat much during those two weeks. A couple of nights I felt nauseous and stayed in bed for the whole day.
“One thing I felt was guilt. When you’re waiting for your radiotherapy, you’re surrounded by a lot of people in a much worse situation than yourself. They might be going through chemotherapy, losing their hair and looking really ill, whereas you feel OK.
“Three years later, I could breathe a sigh of relief. Since the cancer was treated, I’ve been physically healthy and have upped my game. I’ve done some charity events in China and been to Peru on a BBC documentary, through Cancer Research UK. I've also run the London Marathon.
“No one can ever underestimate the psychological impact of being diagnosed with cancer. But on a positive note, taking myself to the Andes and the Great Wall of China aren’t necessarily things I’d have done before. I want to give something back to the charity and do something worthwhile."
This case study was provided by Cancer Research UK.
Caring for someone can be a varied and demanding job. This is because of the broad range of medical, personal and emotional needs a person can have.
If you are caring for a family member, you may not consider yourself a carer because you are just doing what needs to be done. You may feel you have no other option. This can be stressful and you may feel resentful towards the person you are caring for, which can leave you feeling guilty. You may have been forced to leave your job, give up hobbies and stop socialising, which can be very isolating.