Testosterone replacement is a controversial topic, especially regarding its possible association with prostate cancer. Testosterone therapy does not increase the risk of developing the disease. No clinical study has proven that replacement causes new cases of prostate cancer. However, testosterone is contraindicated in men diagnosed with prostate cancer.
First, be careful with what you read…
Scientific studies show that testosterone replacement therapy, when used to correct low hormone levels and keep them within normal range, does not increase the risk of prostate cancer.
However, this safety cannot automatically be extended to testosterone supplementation in men without deficiency, a practice that has unfortunately become common. Since there are no good studies evaluating the effects of these supraphysiological doses on the prostate, it is not possible to say they are safe.
Where does the idea that testosterone causes prostate cancer come from?
In the 1940s, researchers observed that prostate cancer regressed when testosterone levels dropped. This led to the development of hormone blockade, still used today in the treatment of advanced tumors. The reverse logic seemed natural: if lack of testosterone slows the tumor, testosterone presence would cause the tumor.
Decades of research have not confirmed this hypothesis. Hormone blockade works because existing cancer depends on hormones to grow. This does not mean testosterone causes new tumors in a healthy prostate.
How does testosterone affect PSA?
The PSA (Prostate-Specific Antigen) is the test performed for early diagnosis of prostate cancer. When the PSA rises, the doctor may request additional tests, including MRI and prostate biopsy.
It is common to have a slight PSA elevation, usually less than 0.5 ng/mL, after starting testosterone replacement. This increase usually occurs in the first 12 months of treatment and PSA stabilizes afterward.
When is testosterone contraindicated?
Replacement is contraindicated in men diagnosed with prostate cancer. In tumors that have already spread throughout the body, testosterone can accelerate tumor cell growth. This is an absolute contraindication.
Other situations requiring caution include:
- Elevated PSA without investigation: prostate cancer must be ruled out before starting treatment.
- Abnormal digital rectal exam: nodules or hardened areas must be investigated with biopsy before prescription.
- Polycythemia: excessive increase in red blood cells, which can cause thrombosis.
In men who have successfully treated prostate cancer and maintain undetectable PSA for several years, the discussion about replacement can be revisited case by case, always with urological follow-up.
Which tests should be done before starting replacement?
Major medical guidelines recommend assessing the risk of prostate cancer before prescribing testosterone. The protocol includes:
- PSA measurement.
- Digital rectal exam.
- Evaluation of individual risk factors for prostate cancer, such as age and family history.
- Complete blood count to check red blood cell count.
- Cardiovascular evaluation when indicated.
After starting therapy, PSA should be monitoredregularly. An elevation above the expected level may indicate the need for prostate MRI and, when necessary, biopsy.
When is prostate biopsy indicated during replacement therapy?
If PSA rises beyond the expected level during replacement and MRI identifies a suspicious area in the prostate, biopsy is the next step to confirm or rule out prostate cancer. According to the European Society of Endocrinology guidelines, a PSA increase greater than 1.4 ng/mL in the first months after starting therapy should be investigated.
The most precise and safest technique available today is transperineal biopsy with image fusion. In this procedure, I collect samples through the perineum (the area between the scrotum and anus), without contact with feces, combining MRI images with real-time ultrasound. In this approach, the needle does not pass through the rectum, greatly reducing the risk of infection. Image fusion allows the needle to be directed exactly to the spot indicated by the MRI, increasing the chance of obtaining a definitive diagnosis.
Urological follow-up during testosterone replacement therapy in Manaus
In our office in Manaus, we see men who are considering or already undergoing testosterone replacement and need prostate evaluation. If you have concerns about the safety of the treatment, contact our dedicated assistant to schedule an evaluation.
