Testosterone supplementation after prostate cancer?

Two experts examine the pros and cons of this controversial practice

At some point in their 40s, men’s testosterone production begins to slow. By some estimates, levels of this hormone drop by about 1% a year. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone. These include reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, lower muscle mass and bone density, and anemia. When severe, these signs and symptoms characterize a condition called hypogonadism.

Researchers estimate that hypogonadism affects two to six million men in the United States. Yet it is an underdiagnosed problem, with only about 5% of those affected receiving treatment, according to the FDA. Deciding which patients should receive testosterone supplementation has proved tricky, however. For example, little consensus exists on what constitutes low testosterone. (The Endocrine Society considers a man to have low testosterone if the blood level is less than 300 ng/dl; some physicians set higher or lower benchmarks.) In addition, some men may have low blood levels of testosterone but not experience any symptoms. And few large, randomized studies on the long-term risks or benefits of testosterone supplementation have been completed.

One of the most heated debates centers on whether testosterone fuels prostate cancer. If that’s true, say some experts, then why do men develop prostate cancer when they are older, at the same time their testosterone levels are dropping? (See Figure 1.) Others point to the fact that many men with prostate cancer, especially those with advanced or metastatic cancers, take hormone therapy that nearly stops the production of testosterone to tamp down the disease. Under the influence of hormone therapy, tumors regress. So wouldn’t the opposite be true — that giving a man testosterone will accelerate or promote tumor growth?

Figure 1: Prostate cancer prevalence versus testosterone levels

Prostate cancer prevalence versus testosterone levels

SOURCE: Morgentaler A. Testosterone and Prostate Cancer: An Historical Perspective on a Modern Myth. European Urology 2006;50: 935–39. PMID: 16875775.

Abraham Morgentaler, M.D., an associate clinical professor of surgery at Harvard Medical School and the director of Men’s Health Boston, specializes in treating male sexual and reproductive difficulties.* In his book, Testosterone for Life, he touts the benefits of testosterone supplementation, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. He also argues in the book, an excerpt of which follows, that some men who have had prostate cancer can take testosterone without upping their risk of cancer recurrence.

*Editor’s note: Dr. Morgentaler has received support from companies that make testosterone therapies.

Many well-respected experts advocate a more conservative approach: prescribing testosterone sparingly until more evidence convincingly shows a lack of harm in the long run, and until studies demonstrate which patients are most likely to reap significant benefits. One is Ian Thompson, M.D., chairman of the Department of Urology at the University of Texas Health Sciences Center at San Antonio and a principal investigator for the Prostate Cancer Prevention Trial (PCPT).* He shares his views on testosterone supplementation with Harvard editors following the book excerpt.

*Editor’s note: Dr. Thompson has received support from a company that makes drugs that affect testosterone levels in the prostate and a company that makes diagnostic tests for prostate cancer.

An excerpt from Testosterone for Life

The oldest and most strongly held prohibition against testosterone therapy is its use in men previously diagnosed with prostate cancer. The fear has been that even in men who have been successfully treated for prostate cancer, raising testosterone levels will potentially make dormant, or sleeping, cancer cells wake up and start growing at a rapid rate. Thus, the FDA requires all testosterone products to include the warning that T [testosterone] therapy is contraindicated in men with a prior history of prostate cancer.

However, attitudes about this are changing — and changing rapidly — over just the last few years. The reasons for this are several, including the ongoing re-evaluation of the old belief that raising the concentration of testosterone is to prostate cancer like pouring gasoline on a fire or feeding a hungry tumor. In addition, there is growing recognition that T therapy can provide important benefits to a man’s quality of life, so the delicate medical balancing act between potential risk and possible benefit is shifting.

A major push for consideration of T therapy in symptomatic men with a history of prostate cancer has come from the large population of men who have been treated for prostate cancer over the last 25 years. Many of these men had small or low-grade cancers and, after treatment, were assured that they were cured and had no trace of any remaining cancer in their body. Despite having been given a clean bill of health, they were then told that they could not receive T therapy. As these prostate cancer survivors have questioned the basis for the T therapy prohibition, many physicians have been forced to reconsider whether the old arguments learned from their former teachers still make sense.

* * *

A number of physicians have told me that they have treated occasional patients with testosterone despite the fact that they’d been treated for prostate cancer in the past. The first people to publish their experience with doing this were Drs. Joel Kaufman and James Graydon, whose article appeared in the Journal of Urology in 2004.

In this article, Drs. Kaufman and Graydon described their experience in treating seven men with T therapy some time after these men had undergone radical prostatectomy as treatment for prostate cancer, with the longest follow-up being 12 years. None of the men had developed a recurrence of his cancer. Soon afterward, there was another paper by a group from Case Western Reserve University School of Medicine describing a similar experience in 10 men with an average follow-up of approximately 19 months. Then another group from Baylor College of Medicine reported the same results in 21 men.

In all these reports, not a single man out of the 38 treated with testosterone developed a cancer recurrence. It is important to emphasize that all these reports included only men who were considered good candidates because they were at low risk of recurrence anyway. And in some cases, the duration of time the men received T therapy was relatively short. But it was reassuring that none of the 38 men who had suffered from prostate cancer in the past and who were treated for years with testosterone had developed a recurrence of prostate cancer.

This reassuring experience was bolstered by the published experience of Dr. Michael Sarosdy, who reported the results of T therapy in a group of 31 men who had received prostate cancer treatment in the form of radioactive seeds, called brachytherapy. This less-invasive form of treatment does not remove the prostate, so theoretically there is the possibility that a spot of residual cancer might still be present. With an average of five years of follow-up in these men, none of the 31 men had evidence of cancer recurrence.

The total number of men treated in these reports is still very small — much too small for anyone to be able to stand up and declare definitively, “Testosterone therapy is safe in men who have been treated for prostate cancer.” But these reports have at least given us some perspective on the degree of risk of T therapy in men treated for prostate cancer. At a minimum, it is now possible to say that there is evidence from a number of small studies that T therapy in men who have been successfully treated for prostate cancer does not appear to be associated with a substantial risk of cancer recurrence over the first several years of treatment.

* * *

I’d like to make a few final points to give some perspective on this story. First, it has become obvious that raising testosterone levels in a man with a history of prostate cancer is not like pouring gasoline on a fire. In fact, with the important exception of men who have undergone hormonal treatment to bring down their T levels to castrate levels, the limited evidence suggests that raising T levels does very little to the growth of prostate cancer.

Of course, one day new studies may suggest that there is a risk. However, no such study is likely to appear for at least five to 10 years because it takes at least that long to judge whether a treatment has stimulated the growth of a cancer. Until then, we have to make decisions based on the available evidence, supported by logic and experience. For the moment, I am comfortable explaining to my patients that the use of T therapy in men with a history of prostate cancer entails an “unknown degree of risk” but that my assessment is that this degree of risk is small.

Second, it is important to recognize that even if you have low levels of testosterone as well as the symptoms of chronic fatigue, decreased libido, and erectile dysfunction, there is no certainty that raising T levels will alleviate your symptoms. There may be other reasons you are feeling this way. Moreover, there is no known benefit to T therapy if T levels are not truly low. Thus, the decision about whether to try T therapy requires balancing possible benefits with possible risks. This decision will be different for every man.

Third, T therapy is not itself a treatment for prostate cancer. Even though [one patient’s] PSA dropped with T therapy, fluctuations in PSA values are common and no conclusions should be drawn from any one case.

Finally, it is important for any man with a history of prostate cancer to maintain his perspective on what is important to him. For some, it is enough to be alive and feeling reasonably well despite prostate cancer treatment. Adding a treatment that may stir up anxiety about their cancer may not be worth any benefit they may experience with regard to sex, mood, energy, or vitality. For others, the important thing is to live well. For them, an improved quality of life may be important enough to take on an unknown degree of risk, including a treatment that still lacks approval from the broader medical community.

Dr. Thompson’s perspective on testosterone replacement

What concerns do you have about prescribing testosterone to men who have been successfully treated for prostate cancer?

Obviously, testosterone supplementation has salutary effects for someone who is hypogonadal and suffering from osteoporosis, muscle loss, erectile dysfunction, and other problems. Unquestionably, otherwise healthy men given the choice of being on testosterone or being off testosterone would rather be on it. So, why not prescribe testosterone supplements to men who are hypogonadal and have been treated for prostate cancer?

Well, imagine two men with prostate cancer. The first man had a 12-core biopsy that showed cancer in just a small percentage of one core, cancer that was graded a Gleason 3 + 3. He’s had several prior biopsies, all of which have been negative, and his PSA is 2.5 ng/ml, which is within the normal range. The second man’s biopsy shows cancer in every core on the right side of his prostate, graded a Gleason 5 + 4. The cancer can be felt during a digital rectal exam but is confined to the prostate capsule. Both men have undergone treatment.

The first man’s risk of developing progressive prostate cancer is very, very low; his prostate cancer probably didn’t even need to be treated. In his case, the risk of testosterone supplementation is low. For the second man, who has very high-risk disease, you have to ask yourself, “How would testosterone replacement affect his risk of disease recurrence?” Well, several high-quality studies have shown that men with high-risk disease who have had external beam radiation or surgery and then take androgen deprivation therapy improve their disease-free survival. And that would suggest that testosterone supplementation would increase his risk of disease recurrence.

How does that happen? Testosterone could reactivate existing disease. Or, if the patient had external beam radiation, not all of the tissue becomes fibrotic. Some normal epithelium, the cell layer that lines the prostate, will persist, and that normal epithelium is at risk of becoming cancerous.

So you wouldn’t prescribe testosterone to a patient who’s had prostate cancer unless his case was like that of the first patient you described?

My point is that we can’t make broad, generalized statements. Just because we don’t know if it’s harmful, we can’t presume that it’s safe. For the man with very low risk of disease recurrence who is experiencing serious symptoms of hypogonadism, it’s probably okay. But symptoms like “I’m not as lively and strong as I was at 18” aren’t really sufficient to justify supplemental testosterone. If you apply that standard, every older man would be clinically hypogonadal.

Also, let’s take a look at testosterone levels. Some people say that the threshold for low testosterone is below 250 ng/dl, but other people use different numbers. Where did those numbers come from?

And what else is going on in the body? There are differences from one person to the next in how testosterone is used. And the interactions of other androgens and the androgen receptors are so variable. What other medical tests have a “normal” range as large as 250 ng/dl to 1,250 ng/dl? And then there’s the fact that the variation in test results from one lab to the next is enormous. That’s why I’m unconvinced that there is a blood test you can do to unequivocally label someone as biochemically hypogonadal.

Do you have patients who are on testosterone therapy?

I don’t have very many patients on androgen replacement. If I think someone might need it, I refer him to an endocrinologist who will manage his condition. Managing hypogonadism is a very complicated matter. In fact, an endocrinologist who specializes in hypogonadism often will obtain a blood sample every half hour for two hours, pool them, and then run a testosterone level. A one-time reading isn’t sufficient.

Yes, there will be some clear-cut cases on both sides — the man at very low risk of prostate cancer who won’t die of the disease even if it develops, and the man who has had prostate cancer and has a very high risk of recurrence. But what about the man in the middle? Again, just because we haven’t proven testosterone supplementation harmful doesn’t mean we should prescribe it.

So what’s your biggest concern?

My biggest concern is that, with very little data, we are assuming that androgen replacement is safe. We know that the studies necessary to answer this question will require thousands of patients; they haven’t even begun. We only have to look at history — hormone replacement in women — to see the error of assuming that hormone replacement is safe and effective. We’re living in the era of evidence-based medicine; that we accept current data and then potentially harm our patients just doesn’t seem reasonable today.

Originally published June 2009; last reviewed February 22, 2011.

Bob Thayer`

What PSA level suggest a recurrence of prostate cancer?
Mine has historically been <0.01 until recently. Recently…up to 0.012 – reduced by increasing pH level to 0.8 for 7 weeks.


my prostate was totally removed. my p.s.a has no reading. it has been 14 months since my operation.my energy.muscle mass, has fallin off. am I a candaite for t-supplement treatment. they say I’m cancer free. i’m 63 years old.

Thornton Sanders

I am 75 years old. I had external beam radiation for PC ten years ago. At that time, my PSA and Gleason scores were high enough that “wait and see” was considered too risky. Following the radiation treatment, my PSA scores dropped to the 1.0 range. Now, ten years later, they have jumped to 8-10 in the last two years. A recent bone scan and CAT scan show no PC outside the prostate but I have a large hydrocele (presumably non-malignant) in my scrotum which must be removed. Should I be taking steps to reduce testosterone production in order to stop or slow down this apparent re-occurance of PC? My oncologist (who treats me for MALT lymphoma) and my urologist have both recommended an orchiectomy or estrogen injections rather than waiting to see what develops. The alternative is removing the hydrocele now and waiting to see what the PSA scores are in the near future. If I have the orchiectomy, will the lack of tostesterone have long run side effects which will kill me sooner than the PC?

ken wharam

I Had a 4.8 out of 20 biopsies come back cancerous with PSA of 7.3 Gleason score 7 . I was treated with external beam and pin point high dose to the PSC area 35 treatments.
It has been 1 yr since treatment with 3 mo. followups and PSA is now 1.1 and t level has been coming down to a 187 and Doctor suggest testosterone therapy. After I read these reports I am concerned about the re-occurrence of PSC or should I be? I have most all the symptoms of low T. I am 57 and would like to have a quality of life. Any advice would be appreciated.

Robert Sherman

I was diagnosed with Prostate cancer in 2013.I am told its advanced and I am having surgery in August 2014.I have been on hormone treatment and I have very little energy,sex drive and erectile disfuntion.Will this come back after my surgery.I want a normal healthy life back!

choi chang

why do doctors love to see the PSA go down? Well, it’s because they are confused. They know that higher PSA scores tend to correlate with more cancer and lower PSA scores tend to correlate with less cancer. But they don’t understand the crowding issue or how the PSA compound itself helps fight prostate cancer. So they mistakenly think that lowering the PSA count means they are reducing the cancer. Conventional doctors today use drugs like Lupron or Casodex, which are very effective at lowering the production of PSA in the body and a subsequent lowering of PSA scores. However, by lowering the PSA artificially with hormone-blocking drugs, doctors may actually be promoting the growth of the cancer.

choi chang

Since men are being diagnosed with prostate cancer at younger and younger ages and often face more aggressive forms of it today, they don’t have the luxury of being able to live with it as often as was common in years past. Thus, there are many more men today who MUST receive effective treatment or their prostate cancer will kill them. Unfortunately, the types of treatment offered by conventional medicine are very problematic. The four main conventional options are:
•Hormone-Blocking Drugs

The surgical option involves removal of all or part of the prostate gland. This may sound good at first, but it is often an immasculating procedure with a high likelihood of some degree of impotence and incontinence occurring as a result.

Radiation may sound good, but can actually cause localized prostate cancer cells to mutate into more aggressive forms in some cases and provides no curative benefit once the cancer has metastasized. Chemotherapy has no long-term curative effect on prostate cancer, either, in most cases. That just leaves hormone-blocking drugs, and this is where the MOST ludicrous and dangerous misunderstandings occur in conventional prostate cancer treatment

choi chang


Tobias Bosman

I am 70 years old, had Bracchi-therapy 12 years ago as my PSA reading was quite high. Four months ago I experience a massive urinary blockage and the 25 “inserts” were removed. I now can urinate very easily without any hassle, but the problem now is that I have to wear 24/7 pads for bladder weakness and can hardly control my urine flow during daytime. I am using 3 – 5 level 3 pads per 24hrs constantly for 2months (no problem with dripping while asleep). I have done numerous Keggle exercises to try and overcome the controling of my bladder’s close-release action without success. What is my next step? The prescribed pills for the bladder’s controle-valve has no effect in rectifying the problem.

Janelle Dick

Tobias Bosman my husband had extensive prostate and bladder surgery as a result of metastatic cancer. He uses an external catheter. Go to your local medical supply store and ask them to show you what you need. Takes some getting used to, but definitely superior to the pads. He works full time, plays golf, and we just came back from a camping trip. Hope this helps.

brenda barnard

my husband was a virile and very sexually active person until he developed prostate cancer and with high numbers on all tests had his prostate removed. that was three years ago. he has recovered fully, and with some effort is able to have sex. problem is, he has greatly reduced libido. very little interest, passion, or desire. he does indulge me, but for himself, not a lot of interest. question, is this unusual, is it a reflection of our relationship cooling off and maturing, should i be prepared to move into platonic companionship? we are both 60, in good health. it was difficult to adjust to the new reality as he healed over the two post surgery years, but now i am feeling really worried that our sex life is actually over. i miss sharing real intimacy but it does take two. his testosterone levels are very low.


Reply to Tobias Bosman:
I am 72 yrs. Now five years post radical prostatectomy. Terrible incontinence for first year. Know all to well your distress. Tried male sling, but as Uro Surgeon cautioned, it wasn’t sufficient given the volume of my incontinence. Depression and distaste for the un-empathic surgeon kept me from returning to him. Finally, I want back to NYC urologist (Brady Prostate Cancer Center) and now have AUS (artificial urinary sphincter). It is 99% effective and has restored my confidence when moving around.
Other wise, a terrible out come. Only with testosterone supplement has my sense of mental clarity and a sense of a future. And now urologist legal anxiety and fear of malpractice is reducing level of testiest supplement below where experience dictated my efficacious level needs to be. I am a creative (highly) multi-talented individual. If as I suspect I pitch-pole into the panoply of fatigue depression etc etc I will be on the edge of termination.
Will talk personally if you wish. Reply and I’ll sent contact.
Wishing you best!!!

Nick Parson

Four years ago I had my prostate removed because it was aggressive. My Gleason Scale was 9, and my PSA was at the time 3.4. My cancer was detected by a digital exam. Today my PSA is undetectable. I have sexual desire, but have erectile dysfunction. I haven’t had a sexual relationship since my surgery. My testostrone level is a few points below normal. What does one do when he has desire but no longer has the tools? My doc said I had too much desease so testostrone treatment is not recommended.

Alan Peterson

Had prostrate cancer at age 50 with radical surgery, had PSA of 26 and cancer was aggressive but did come out with clean borders. PSA was undetectable for 10 years then started creeping up and was treated with external radiation, PSA then and now 5 years later undetectable. Always had bad urine leakage, stress incontinence, last year had AUS implanted with near perfect results. Have a small amount of leakage-drops, should have done this years ago. Have to use vacuum system to get erections and have been able to work with that for past 15years. Its been an interesting ride would be glade to to discuss any of my experiences, also avid bike rider so had to adapt bike seat to avoid damage to AUS. There is life after cancer so get out and enjoy it.

Garrett Beverly

my prostate was totally removed. my p.s.a reading is .014. it has been 24 months since my operation. My energy,muscle mass, has fallin off. am I a candaite for t-supplement treatment. they say I’m cancer free. i’m 73 years old.

Randall Jackson Marlowe

Was diagnosed with cancer by biopsy , April of 2013. I am ,today 76, and I was refused treatment because I could not obtain Bone and organ scan because I was over weight. I still don’t know how but after 6 months my wife was able to get these tests for me. In April of 2013 of the 12 bioptic samples only one showed one cancer cell encapsulated, and of the inactive type. At the time PSA was 20 and 3.3 on the Greason Scale. The body scan showed growths in the the prostrate area that were dangerous for any radical treatment.
The only thing I could think to do in April was go on the internet and find the best diet for me. I am sure this had something to do with following. I was given the choice of wait and see or the. I decided on the first but was overuled by the family and started the hormone treatment with all it’s side effects. After the first inyection he PSA came down to 12.5 then went back up to 17. After the 4th inyection the PSA came down to (1) As I find the side effects of the treatment, to much for me, I have decide on two more (monthly inyeccions then another blood and orine test in DEC. and if it still holds at around (1), I will stop the Hormone Treatment and go to a vigilante stage of a test every 45 days. If the PSAstarts moving up, back on the treatment. This is suggested by the American medical Society especially for the bone factor Right? Jack Marlowe

Mike Trochowski

I am 61 years old and was diagnosed November 2013 with PSA 7.3 and Gleason 7. My treatment consisted of radiotherapy with Zoladex hormone injections, last one was end April. I still have hot flushes and libido has still not recovered. Recent blood tests show my LH and testosterone levels are very low. I don’t feel I want to wait until my libido returns to what it was before treatmnet, if it ever will.
I asked my doctor about testosterone replacement therapy but he said that this would ‘defeat the object’ of my treatment.
Thanks to all who shared their experience.

Nicholas Halanych

Diagnosed with prostate cancer by biopsy with a Gleason score of 6, PSA of 3.4. 44 radiation treatments completed August 2011.Did well until June 2014,developed urine residual on voiding. Hospitalized for 3 days for bad bladder infections. Had a cool melt treatment for BPH obstruction. Did self caths, which weren’t successful. Now have a suprapubic catheter. Will try clamping and unclamping SPcather next week. I was 76 years old, when my cancer was discovered. I am 80years old now in good health, except for my bladder condition. Looking for help and suggestions !!!!!

cl dickinson

I had successful FLA procedure 6 months ago. After finding the cancer, my GP took me off testosterone immediately (about a year ago). Life sucks… period. Just like before i was put on the T therapy (for 3 years before). I had the FLA procedure (and paid 100% out of pocket so I could KEEP my sex life, but now…. just no longer interested. Since I cannot seem to get a script here in Reno NV. A trip to Mexico I guess is in order. I appreciate the “first do no harm”… but its my life (and quality of life) my body, and my decision. It really torques me off when Dr.’s play God

cl dickinson

Oh… FLA (Focal Laser Ablation. No life altering side effects (no impotence, no incontinence).. The only “life altering is a hit to the pocket book. Short sighted insurance companies will not cover the procedure as it has not been done in THIS country for the required 20-30 year trials.

John leach

Had cyber knife surgery in Apl 2011, psa levels at that time were 14 came down to less than 1 in about 2.5 years, Gleason score was initially 7. Started using testosterone cream when my psa was down to 0.1 about a year ago, small amounts initially, psa stayed at 0.1. Increased more cream on a daily basis, still psa 0.1 after 10 months of treatment. Using cialis is on a daily routine, everything is back to normal, age 72. Cyber knife seems the way to go, less problems with urination ect.

JW Apple

I was diagnosed with prostate cancer in 07 i had my prostate remove. I still have the will to have sex but I cannot get erect. My question is will hormone booster or anything help me or will they put me at risk?

Kenneth L. Klawuder

I had my prostate removed completely 5 years ago and, like several others reported, my PSA if undetectable. I read several comments from other men who have the same situation but there is no answer to their questions. I’m 72 years old and have noticed a decline in the ability to produce an erection. Now I have been taking Viagra before attempting sex now without a positive result. I exercise regularly, watch my diet but have also notice a decrease in muscle mass. Would it be safe for me to take T therapy if my testosterone level is a bit low?

Alex Cline

I am also a post radical prostatectomy survivor with PSA at the undetectable level every test since my Surgery, 15 months ago and tested a minimum of every 3 months. Am I a candidate for T therapy?

Rick Scott

I was diaganosed with PC in Dec of 13 started EBRT in Jan of 14. Had 43 treatments also had 2 shots of Lupron 6 months apart. It has been a year since finishing the EBRT. My testosterone levels are 158 for total and 31.6 for free. I have every symptom of low T. I want my life back. Am I a candidate for TRT?

gerald fulton, MD

what about men who have low-grade cancer, but have elected not to treat it at ALL? (they are “observing” as their treatment)?

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