Considering Testosterone Replacement Therapy? Think About Your Prostate Health

Tiredness. A lower libido, reduced strength. Feeling lower, more often. You turn 40 and something feels different for you, but you can’t figure out why. Many men brush these feelings off as the inevitable signs of aging, while some seek medical consultation for what they think is — a ‘midlife crisis’.

Similar to what women experience with menopause, men also encounter a natural decline in testosterone levels as they age. This is a phenomenon colloquially known as andropause.

After age 30, testosterone level in men starts to decline at a rate of 1% per year. By the age of 60, about 20% of men may start to experience symptoms of testosterone deficiency, increasing to 50% of men when they reach their 80s.

Apart from the symptoms above, some men may also have difficulty in gaining muscle while experiencing an increase in belly fat, mood swings or even erectile dysfunction — all of which are symbols of being “less youthful” and suffering a “masculinity crisis”.

Testosterone deficiency, medically known as hypogonadism, can be treated with testosterone replacement therapy (TRT). It can be administered in the form of pills, injections or gel application to restore testosterone levels in the body. Subsequently, it alleviates andropausal symptoms and enhances overall well-being.

Many men may believe testosterone therapy can help them regain their confidence and vitality, as often promised by advertisements. However, the relationship between TRT and prostate health has been a topic of considerable debate and scrutiny within the medical community.

Notably, as PSA production is dependent on testosterone, low testosterone can mask prostate cancer from being detected, by reducing the accuracy of the PSA test. The PSA test should therefore be interpreted after considering one’s testosterone levels.

There is growing concern about the potential association between TRT and an increased risk of prostate cancer. The male sex hormone is known to fuel the growth and progression of prostate cancer. However, there has not been concrete evidence showing that supplemental testosterone can initiate cancer development of prostate glands.

Nevertheless, testosterone therapy is contraindicated in men with a history of or suspected prostate cancer or benign prostatic hypertrophy symptoms. For this reason, a physical examination, consisting of a prostate-specific antigen (PSA) blood test and digital rectal examination, is needed before the prescription of TRT and after normalization of testosterone levels back to their typical range.

Supplemental testosterone used in TRT was initially approved by the US Food and Drug Administration (FDA) only for treating hypogonadism caused by specific medical conditions, such as genetic disorders or damage from chemotherapy.

However, a loophole in the regulations has allowed doctors to prescribe testosterone for men who claim they have “possible signs”.

"It's safe to say that the majority of that use is not for men with testicular cancer or true endocrine dysfunction, but rather in the situation of testosterone decline in older men” said Professor Peter Nelson, director of prostate cancer research at Fred Hutch Cancer Center.

According to a study on the US Continuous National Health and Nutrition Examination Survey, over a quarter of American men suffer from testosterone deficiency. In 2022, the TRT market was valued at over USD 1.8 billion, driven by “the rising awareness about the treatment of testosterone deficiency and erectile dysfunction”.

According to Dr Carl Pallais, an assistant professor of medicine at Harvard Medical School, "I can't tell you for certain that this raises your personal risk of heart problems and prostate cancer, or that it doesn't. I frequently discourage it, particularly if the man has borderline [testosterone] levels."

Before deciding on trying testosterone therapy, you should talk to your doctor about the risks and benefits you may face. They will be able to help advise you on the best solution to help you face and manage your issues, while prioritizing your health and well-being.