Testosterone naturally decreases with age. This can mean loss of libido, fatigue, and decrease in muscle. So why are you waiting for your doctor to talk to you about your low testosterone? What solutions are you missing out on?
Testosterone replacement therapy can help reverse side effects of low testosterone and improve quality of life. This episode of PROSTATE PROS covers how testosterone replacement therapy can be used for aging men, men with chronically suppressed testosterone after TIP, men with advanced prostate cancer, and even spouses.
Dr. Scholz: [00:03] We’re guiding you to treatment success and avoiding prostate cancer pitfalls. I’m your host, Dr. Mark Scholz.
Liz: [00:09] And I’m your cohost, Liz Graves.
Dr. Scholz: [00:13] Welcome to the PROSTATE PROS podcast.
Liz: [00:20] Testosterone is the primary male hormone. As men age testosterone naturally decreases. Low testosterone can mean loss of libido, fatigue, or muscle loss. This episode we’re going to talk about testosterone replacement for aging men and men with prostate cancer.
Dr. Scholz: [00:39] So this is a controversial thought. Men with prostate cancer often are treated with testosterone blockade. There are situations though to consider giving testosterone. We’re going to briefly cover three broad categories: aging men, as Liz mentioned, category number two will be men that have had previous TIP or testosterone inactivating pharmaceuticals and their testosterone just isn’t recovering normally, and then the third situation is in very advanced prostate cancer. There are controversial new treatments to administer high-dose testosterone as a form of therapy to control prostate cancer.
Liz: [01:22] There are a lot of appeals of testosterone replacement. One being that it can help return your libido, two, it provides energy, three, it assists in muscle gain, and four, it can improve your mood.
Dr. Scholz: [01:35] One of the things to realize about testosterone is that the blood tests give you an accurate number, but they don’t necessarily tell you how you’re going to feel. Throughout the years I’ve seen how some men have rather low testosterone, but feel perfectly fine. Other men may have somewhat or mildly diminished testosterone, but really feel poorly. So, one of the things to know in this whole realm of giving testosterone is that the lab numbers, the amount of testosterone in the blood, is not the most important thing—it’s how men feel—because giving testosterone is designed to restore a better quality of life, provide energy, improve libido. If men are already feeling well, you really can’t improve on that.
Liz: [02:22] Is testosterone something that’s tested annually or do men have to ask what their testosterone levels are?
Dr. Scholz: [02:29] Oftentimes this is something that gets overlooked. Of course, physicians tend to think that as men get older, their testosterone levels are going to drop and that even if they are somewhat low, that’s just part of life. So I think it’s a good question to put to your physician is “is my testosterone normal?” This is particularly relevant for men that are over age 60. If testosterone levels are running low, there are situations where men are going to feel better if they take some supplemental testosterone.
Liz: [03:00] So Dr. Scholz, if you have an older man who has no known prostate cancer, and he goes to the doctor and asks about testosterone replacement, will the doctor say, “there’s no way, that’s going to cause prostate cancer?”
Dr. Scholz: [03:15] You may get that kind of an answer. This thinking is rooted in the fact that many people are aware of the fact that when you block testosterone, prostate cancer shrinks. So they falsely assume that if you give testosterone, you’ll make it grow. But this concept has been tested very thoroughly. Testosterone does not cause prostate cancer. You certainly can treat prostate cancer by removing it. That may sound controversial, but this has been studied very thoroughly.
Liz: [03:50] So older men can safely get testosterone replacement.
Dr. Scholz: [03:54] So yes, older men can get testosterone, but there are other concerns. Some men will make excessive red cells. That’s the opposite of anemia. If the red count goes too high, it could place these men at risk for heart attacks or strokes. So it’s certainly something that has to be monitored appropriately and carefully.
Liz: [04:18] How do you test for red blood cell counts that are too high?
Dr. Scholz: [04:22] Really anyone that’s taking testosterone, I recommend that they look at their own test results, things get lost in doctor’s offices and this is so important that if people are going to do testosterone, we want it to be safe. So the test is called a CBC or a complete blood count. It’s a very inexpensive and commonly used test. The section of the testing that you look at is called the hematocrit. The hematocrit should be less than 50%. If it starts going above 50%, that’s too many red cells and men should consider either reducing the dose of testosterone or possibly going down to the Red Cross and donating a little blood—that will bring the red count down as well.
Liz: [05:04] So we’re talking about giving testosterone. What does that mean? Is it a shot? Is it a pill?
Dr. Scholz: [05:10] It turns out that there are a lot of different ways to give testosterone. I think the big resurgence has been because you can purchase a cream with a prescription that you can rub on your skin every morning. It’ll go through the skin and restore testosterone levels. There’s other ways: There are long acting shots, there are short acting shots and there are patches, I think they have lozenges that you can actually put on your tongue. All of these things have their pros and cons. I’d say the two most common approaches that we use are either the injections, which are given under the skin like an insulin shot, every week or two, or the creams, where someone is just rubbing a gel on their upper arms and chest every morning.
Liz: [06:00] Giving testosterone really depends on the patient. Are dosages matched to that?
Dr. Scholz: [06:05] What we typically do is we start someone off on a standard dose. Say, if you’re getting an injection every two weeks, we’d give 200 milligrams of testosterone under the skin every two weeks, and this can be done by the patient himself. We let that run for a couple months, bring the patient back, check the CBC, make sure the red count isn’t going up, recheck the testosterone levels. Then, most importantly, ask how the patient is feeling. Is he actually getting a benefit? Then the dosage can be adjusted up or down. You can say, well, what does excess testosterone feel like? And some men, you know, they’re a little jittery and they don’t have a sense of calm and it could be a sign of too much testosterone.
Liz: [06:55] Dr. Scholz, does everybody with low testosterone feel better after they start testosterone replacement?
Dr. Scholz: [07:02] Interestingly, the answer to that’s no. So you can see people who are running low testosterone and then you give it to them and you can bring them back. Their blood levels are now normal because they’re taking enough testosterone to make the blood levels normal, but they don’t feel any different. This is one of the confusing things. Some men we’ve put on hormone treatments to block testosterone and they don’t feel any different. That’s not common, but it turns out we all have a little bit different wiring. And this is why it’s so important to have good communication between the physician and the patient about what you’re accomplishing. Just creating a normal number on a blood test isn’t really accomplishing much. The whole point is to restore quality of life. I’ve had men we give three or four months of testosterone replacement and they say, honestly, Dr. Scholz, I just don’t feel any different, I don’t see the point. We’ll stop it at that point. So it’s a quality of life decision just as much or more than it is a laboratory finding.
Liz: [08:06] A lot of men are really afraid about losing their testosterone when they go on hormone therapy. Let’s talk a little bit about testosterone replacement for men with prostate cancer.
Dr. Scholz: [08:17] One of the most popular ways to administer TIP is with an injection called Lupron and treatment is administered for variable periods from four to 18 to 24 months. After that, we know that there’s no additional value for continuing the treatment any longer, but especially as men get older above age 70, the recovery of natural testosterone production is greatly delayed or sometimes permanently suppressed. The question arises if other men are allowed to get their normal testosterone back and it’s known to be safe, why can’t we administer testosterone in the men whose testicles have just given up the ghost and stopped working? The answer is you can give testosterone to these people and it doesn’t increase the risk. It allows men that have been on a course of hormone treatment who failed to recover normally to get back their good feelings associated with having a normal testosterone level.
Liz: [09:22] How long do you wait to make the judgment if someone’s testosterone is going to come back or if it isn’t?
Dr. Scholz: [09:29] Typically we’ll allow men about six months after the TIP has been stopped to start to generate their own testosterone. Then if the testosterone levels are still greatly lagging, or perhaps haven’t even started to rise, we’ll start a discussion about this with the patient about the possibility of taking testosterone so that they don’t have to live in this deprived state for, you know, several years, perhaps.
Liz: [09:57] Do you find that a lot of your patients are nervous about starting testosterone? I mean, they just went through this whole process to get all their testosterone out of their system and now you’re putting it back in.
Dr. Scholz: [10:09] They are, initially. After we explained that the whole point of stopping the Lupron is to recover testosterone, it seems to make sense to people. But oftentimes people haven’t thought it through. And many people feel like they’ve dodged a bullet, they’re grateful that their PSA is undetectable. I do have some patients that decide that they feel better with a zero testosterone and a zero PSA. Of course we have to take precautions for those people because they’re at increased risk for osteoporosis and other side effects, but people can manage a chronically low testosterone. If they’re comfortable with that, it, as I said before, is a quality of life decision.
Liz: [10:52] So it is generally safe to give testosterone to men with prostate cancer. My question is: does it matter if someone’s hormone resistant or hormone sensitive?
Dr. Scholz: [11:04] Yeah, of course we’re talking about giving testosterone in very structured situations. There are definitely situations where men shouldn’t be taking testosterone. If they’re on Lupron to keep their testosterone low, we want to maintain that low testosterone until we’ve gotten the maximum anticancer value out of it. But, for men that have hormone sensitive disease or possibly have been cured, they took radiation and we think they’re probably cured and there’s no guarantee yet, but it is safe to give them some testosterone, under careful supervision. But the other question you asked is what about men that have advanced prostate cancer? We know that they’re not cured but they’ve been on Lupron and their PSA has become undetectable. In the old days the thinking was, wow, aren’t we fortunate to get people into a complete remission, let’s not mess with success. But, clinical trials have been done showing that it is possible to be exposed to testosterone, intermittently and variably in these men with more advanced disease, the PSA will start rising. The studies show that it’s safe to let the PSA rise up to maybe 5 or 10 and then Lupron should be restarted. So there are situations even with known, persistent cancer where men can take testosterone and their quality of life is improved by doing that.
Liz: [12:37] Are these men getting their PSAs tested monthly, weekly?
Dr. Scholz: [12:41] Well it’s in someone that’s achieved a complete remission, we call that a PSA less than 0.1, things move pretty slowly. So we’ll probably check their blood tests every three months or so.
Liz: [12:52] Testosterone can also be used to treat prostate cancer. Can we talk a little bit about that?
Dr. Scholz: [12:59] So this is new and controversial, but the research that’s been done comes out of some reputable university settings, that makes their findings believable. These relatively small trials, you know, in 30 or 40 patients, what’s been done is for men with very advanced prostate cancer who have become resistant to practically every known treatment. There have been men, who’ve had PSA responses and cancer regression through the administration of an injection of testosterone which is very counterintuitive because these men, no doubt have had their testosterone very low for years in their battle against advancing cancer. So this cyclical injection of testosterone given on a monthly basis is causing PSA declines in some men with very advanced disease. The idea of giving testosterone as a therapeutic maneuver to earlier stage prostate cancer hasn’t been tested and may not be a very practical idea, but as a last ditch effort in certain individuals, it may be helpful.
Liz: [14:11] Are there any other unrelated concerns about testosterone?
Dr. Scholz: [14:15] Not really. It’s more doctor visits, some careful monitoring, occasional blood tests, but one interesting thing is that men with diabetes or borderline blood sugar problems get better control of their blood sugar levels when they take testosterone. So for the most part, we think of it as kind of a tradeoff of convenience, quality of life without a whole lot of medical ramifications, but for men with diabetes, it may be better if they take testosterone and try and restore their normal levels.
Liz: [14:49] As I was researching for this, I came across giving testosterone to women. This is called bioidentical hormones. Why would we do that, Dr. Scholz?
Dr. Scholz: [15:00] Many people are unaware of the fact that women have testosterone too. They obviously have estrogen, but the testosterone, the small amounts of testosterone that are secreted by the ovaries create libido in women. A lot of the spouses of the patients in my age group are postmenopausal and they’ve lost their estrogen and they’ve lost their testosterone. As a result have a low libido. Some of the other advantages of testosterone, two of course, are better energy, more strength and more stable mood, a sense of wellbeing. So it’s become popular to give small doses of testosterone, to postmenopausal women, to restore the normal range, so they feel better and that they have a return of their natural libido. This comes up in my practice a lot because when men are on TIP with chronically low testosterone levels, and now are starting to recover after stopping TIP and getting their libido back, it will come up in conversation. They’ll point out that their spouse doesn’t really have much interest in the resumption of sexual activity. So I typically at that point will refer them to a physician who specializes in giving bioidentical hormones. And there’s an educational process because it sounds, you know, taking chemicals and all this sort of thing. But the treatment is usually administered with a cream that’s rubbed on every day. A lot of women enjoy it also because it can help with weight loss. So the idea of restoring libido in one spouse without doing it in the other seems a little bit problematic and sometimes both members need some supplementation.
Liz: [16:51] So there’s a lot to talk about when it comes to testosterone replacement. And this comes up in our office a lot because we are so conscious of quality of life. Is this something that your patients bring up with you, Dr. Scholz? Or do you talk to your patients about it first?
Dr. Scholz: [17:09] Well, a lot of our patients, we attract a clientele that’s pretty much into doing online research and so patients will bring it up, but half the time, I think you’re right, if we didn’t broach the subject, I think it would just sort of lay there unmentioned. People tend to be a little nervous talking about sexuality and these sorts of things, and they may figure that just, well, I had prostate cancer and I’m stuck with whatever situation I’m in. So I’m glad you raised that point that we sometimes, well in certain practices that may be necessary for patients to broach the subject. So in summary, the administration of testosterone to prostate cancer patients is feasible, practical, and helpful. It does need to be carefully supervised. The beauty of prostate cancer is that PSA gives you very quick and accurate feedback as to what is actually going on. There’s a lot of education involved because it’s not just following the numbers. There has to be a dialogue between the physician and the patient about quality of life, energy levels, libido levels, and what the goal is. Some of my men are such diligent exercisers, even with a low testosterone, they feel pretty good. Some of my patients really enjoy having a low PSA and they don’t want to rock the boat. That’s a perfectly fine attitude if all the other compensatory things are done to keep muscles strong, keep bones strong, and to keep your energy up through exercise.
Liz: [18:49] I know a lot of men have questions about this, so thank you for approaching this topic today. If you have any questions about testosterone replacement, email them to podcast@prostateoncology.com and we’ll bring them up in another episode. This is another important topic to share, and you can share it with your friends that don’t have prostate cancer, and even your wives.