Women have menopause, characterized by a dramatic decline in levels of the hormone estrogen; men have andropause, in which testosterone levels are low. (This condition is also known as hypogonadism or androgen deficiency of the aging male.) While women typically experience a variety of symptoms during menopause, some of which can be quite life-changing, many men do not notice dramatic changes during their “change of life.” That’s largely because the decline in testosterone is low and steady, about 1 percent per year beginning when men hit their early 40s. Despite the drop in testosterone, many older men retain fairly normal levels of the hormone and experience few if any troublesome symptoms.
A decline in testosterone affects some men more than it does others, and they experience disturbing symptoms, such as reduced sex drive, erectile dysfunction, depression, loss of muscle mass, and a reduced sense of well-being. Although testosterone-replacement therapy may relieve many of the symptoms, the big question looms whenever testosterone therapy is mentioned: will it increase the risk of prostate cancer?
According to a Johns Hopkins Prostate Disorders Special Report, “Testosterone-Replacement Therapy: Does It Increase Prostate Cancer Risk?” the jury is still out on whether testosterone replacement therapy is safe when it is used for a prolonged time. Men who are considering testosterone supplements because they are experiencing symptoms associated with andropause need to consult their healthcare provider about the pros and cons. Most doctors are hesitant to prescribe testosterone supplements unless a man is experiencing symptoms and his blood test confirms a deficiency of testosterone. Although there is no figure that definitively identifies a testosterone deficiency, a level of 300 ng/dL is generally considered to be at the lower limit of normal for a healthy man.
When you begin taking testosterone, the prostate reacts very quickly and begins to grow. This increase in size usually stops after the first few months of treatment, so the prostate gland typically ends up being no larger than it was before the hormone level began to drop. Bottom line: the increase in prostate size is not sufficient to cause any of the urinary symptoms associated with benign prostatic hyperplasia.
If you already have prostate cancer, there is some concern that taking testosterone could make the cancer progress faster, or that the hormone could promote tumor growth. These worries are the reasons why many doctors will not prescribe testosterone therapy for men who have a history of prostate cancer. A University of Southern California study recently addressed this concern. (Leibowitz 2009) The researchers reviewed the records of 96 patients who had received testosterone replacement therapy after being treated for prostate cancer. Overall, 41 men had progression of their PSA levels while taking testosterone, but only seven showed radiographic progression of the disease. Fifty-six men stopped taking the testosterone because their PSA levels were rising, and in 59 percent of these men their PSA levels then declined with no additional intervention. A subset of 31 men were able to keep taking testosterone with no rise in PSA or evidence of disease progression for an average of 36 months.
The bottom line in this study was that PSA levels rose in most men while they were taking testosterone, stopping treatment typically caused the PSA levels to then decline. Nearly one-third of men were able to keep taking testosterone for several years. And those andropause symptoms? Testosterone supplementation relieved them in most cases.
In a Baylor College of Medicine study, investigators evaluated the changes in PSA and testosterone levels in patients who had andropause symptoms after they had undergone radical prostatectomy for cancer. (Khera 2009) A total of 57 men received testosterone supplementation for an average of 36 months after their surgery, and the men were followed for an average of 13 months after starting supplementation. Although mean testosterone levels rose in all the men (mean, 255 ng/dL before testosterone to 459 ng/dL after), there was no increase in PSA values after therapy started. So, testosterone replacement therapy caused hormone levels to rise, PSA values to remain the same, and symptoms to be relieved.
If you wonder why many doctors are reluctant to prescribe testosterone replacement therapy, you might recall what happened in the female camp. For years, postmenopausal women were prescribed hormone replacement therapy to relieve symptoms brought on by the dramatic decline in estrogen associated with menopause. Women were also encouraged when they were told that the therapy would also help prevent osteoporosis and reduce their risk of heart disease.
When the results of the Women’s Health Initiative were announced, it was learned that hormone-replacement therapy raised the risks of cardiovascular disease breast cancer, stroke, and blood clots. Today, hormone-replacement therapy is prescribed only for postmenopausal women who are experiencing distressing symptoms, and then for only a very short time.
Experts hope to avoid the same mistake with testosterone replacement therapy. It appears that testosterone replacement therapy can be useful and safe in some men who have testosterone deficiency and who have undergone treatment for prostate cancer. However, these men should be monitored very closely for any rise in PSA levels and/or return of their disease. That being said, men are encouraged to avoid synthetic testosterone and to ask their healthcare providers about bio-identical testosterone therapy, which mimics the activity of the testosterone naturally produced by the body. And most important of all, physicians need to balance testosterone with estradiol, as it is the proper ratio of testosterone to estradiol that is necessary for prostate (and overall) health.
Khera M et al. Testosterone replacement therapy following radical prostatectomy. J Sex Med 2009 Apr; 6(4): 1165-70.
Leibowitz RL et al. Testosterone replacement in prostate cancer survivors with hypogonadal symptoms. BJU Int 2009 Nov 5.