Monitoring TRT
Prior to instituting TRT and during its utilization, prostate evaluation is critical for men age 40 and older. Baseline evaluation should include a DRE, measurement of the serum PSA, and assessment of bladder outlet obstruction (BOO) with either the American Urological Association Symptom Score or the International Prostate Symptom Score questionnaire. The DRE, serum PSA, and BOO evaluation should be repeated at 3, 6, and 12 months and then every 6-12 months.38
PSA increases have been observed with TRT and have been reported in the range of 0.2-0.5, observed over 3-12 months, whereas other studies have demonstrated no such increase.39,40,41 PSA rises have been correlated with benign prostatic hyperplasia, however, and not with the development of overt cancer. Notably, multiple studies have not demonstrated worsening of voiding dysfunction in men on TRT, and complications such as urinary retention have not occurred at higher rates than in men receiving placebo.38 The subsequent rise in PSA and prostate volume have, in fact, been demonstrated to rise to the level of age-matched controls.41
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Serum testosterone levels should clearly be followed to evaluate the effectiveness of the TRT. The initial serum testosterone level should be checked 2-4 weeks after initiating therapy. The frequency of evaluating subsequent serum testosterone levels will be dependent on the mode of delivery of testosterone. Because one of the instigating factors for prescribing TRT is to manage the osteopenia and osteoporosis that develops in hypogonadal men, bone mineral density and a bone scan of the lumbar spine or femoral neck should be performed every 1-2 years. Elevated hematocrit can become problematic for men on TRT and should be checked at baseline, after three months of TRT, and then yearly. If the hematocrit is above 52%, the dose of TRT should be reduced or discontinued altogether.38
Conclusions
In the 70 years since its identification as a PCa growth promoter, testosterone has become inextricably associated with this disease. The paradigm of limiting the use of testosterone in patients at risk for or after treatment of PCa is changing.
The authors believe that with proper informed consent, testosterone may be offered to patients treated for PCa with the understanding that only small, non-randomized studies with short follow-up have shown no worse outcomes. Long-term, randomized trials will help further elucidate the safety and efficacy of this therapy. n
Kelly Chiles, MD is a resident in the Division of Urology at the University of Connecticut Health Center in Farmington, where Stanton Honig, MD, is Associate Clinical Professor of Surgery. Dr. Honig also practices at the Urology Center in New Haven, Conn. and is a member of the Renal & Urology News editorial advisory board.
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