Testosterone supplements and new AUA guidelines on management of testosterone deficiency

The increasingly widespread use of testosterone supplements has been of concern for many years. In particular, for men with a history of prostate cancer diagnosis, the appropriate use of testosterone supplementation has been a matter of special focus.

The American Urological Association (AUA) has just issued a complete set of new guidelines by Mulhall et al. entitled “Evaluation and management of testosterone deficiency: AUA guideline” which includes specific guidance about the appropriateness of testosterone supplements in men diagnosed with prostate cancer.

An overview of the new guideline can be found here on the AUA web site. The complete text of the guideline can be downloaded if you click here.

There are a total of 31 itemized recommendations listed in this new set of guidelines, and all the 31 recommendations apply to all men considering this type of therapy. However, …

With regard to testosterone deficiency and the use of testosterone supplements in men who have already been given a diagnosis of prostate cancer, whether they have received treatment for prostate cancer or not, we would draw our readers’ particular attention to the following, specific, itemized recommendations:

1. Clinicians should use a total testosterone level below 300 ng/dL as a reasonable cut-off in support of the diagnosis of low testosterone.

2. The diagnosis of low testosterone should be made only after two total testosterone measurements are taken on separate occasions with both conducted in an early morning fashion.

3. The clinical diagnosis of testosterone deficiency is only made when patients have low total testosterone levels combined with symptoms and/or signs.

9. Serum estradiol should be measured in testosterone deficient patients who present with breast symptoms or gynecomastia prior to the commencement of testosterone therapy.

18. Patients with testosterone deficiency and a history of prostate cancer should be informed that there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy.

The bottom line is as follows:

  • The new guideline suggests that testosterone supplementation in men with low levels of serum testosterone is perfectly reasonable for all men — inclusive of men with a prior history of prostate cancer. However, …
  • Men with a prior history of prostate cancer need to appreciate that we still haven’t been able to quantify the risk-benefit ratio and there is real risk that testosterone supplementation can stimulate prostate cancer recurrence in some men.

9 Responses

  1. 300 is awfully low. That’s not even median! When mine is in the 300s I feel like crap and have little drive.

    (TrT since 2009, active surveillance since 2012.)

    I mean this is better than the Stone Age “T is gas on a fire” nonsense, but …

  2. PS: Number 2 and number 9 are excellent by the way; fully support!

  3. Dear Sitemaster,

    Thank you for posting this. The urologist and I did not want to risk TRT. We decided this more than a year ago, as my T level had not risen to baseline or a bit under that, following 3 years of ADT. I knew from reading that this sometimes happens and that the jury is out about the risk of recurrence. This supports our decision.

  4. Very interesting. I have had two medical oncologists, and one radiation doctor tell me that they do not recommend TrT. I am 10 years out from RP for a T2c, Gleason 8 situation. Biochemical recurrence did occur, beginning approx. 36 months post-op, but it went very slowly, reaching 0.4, before a decision was made to go ahead with salvage radiation, with concurrent Lupron. Thankfully, my PSA is now undetectable. T is in the lower 200s and seems stable. This seemed low to me, this article confirms that. Radiation was completed 1 year ago, and Lupron timed out approx 8 months ago. What to do?

  5. Dear Michael:

    I think we need to be very clear that this set of guidelines absolutely does not state, anywhere, that a man who has a low serum testosterone after a diagnosis of and treatment for prostate cancer can or should be advised to have TRT. Indeed, I would draw your attention very specifically to recommendation 18 of the guideline, very deliberately called out above.

    I would suspect that your physicians believe that — for a man like you (who had high-risk prostate cancer at diagnosis and a recurrence after first-line treatment) — the risks associated with TRT far outweigh the potential benefits.

    You are, of course, at liberty to take a different point of view, and I am sure that if you hunted around, you would be able to find a physician who would write the relevant prescription for you. However, the fact that someone might be willing to write such a prescription does not necessarily mean that it is a good idea.

  6. I feel the terms used in the posting may be very misleading. There is a difference between testosterone supplementation from replacement. This discussion is about testosterone replacement. Thanks for the posting and please do continue the good job

    Rajeentheran Suntheralingam

  7. I boosted my total testosterone from 277 to 437 by losing weight, taking 5000 IU of D3, 15 mg zinc, avoiding soy and plastic BPA. Lots of good info on the web. Also have your estrogen levels tested.

  8. Dear JJ:

    That’s all very well. Unfortunately, just because this worked for you, we have minimal actual data from meaningful clinical trials to suggest that it would work for others at all.

  9. JJ, You make good points. I have benefited greatly from D3 as well. The science already shows that it is key to many human systems, especially how testosterone acts effectively within the male body.

    Keep up the good work!

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