What are the treatment options for elevated testosterone levels?

Treatment Options for Elevated Testosterone Levels

For patients with elevated testosterone levels, the most effective approach is to temporarily pause testosterone therapy for at least one year to allow normalization of levels before considering resumption of treatment. 1

Evaluation and Monitoring

• Before initiating any treatment, measure baseline hemoglobin/hematocrit and PSA (in men over 40) to establish reference points for monitoring 2
• Serial testosterone measurements should be obtained to monitor the decline in testosterone levels, with the goal of reaching a plateau or returning to the pretreatment baseline 1
• Stabilization is typically defined as when two consecutive testosterone measurements are within 10% of each other 1
• Monitor for potential cardiovascular concerns, as high testosterone levels may be associated with cardiovascular risks 1

Pharmacological Treatment Options

Antiandrogens

• Flutamide, an antiandrogen, works by inhibiting androgen uptake and/or inhibiting nuclear binding of androgen in target tissues 3
• Dosing is typically 250mg three times daily, with monitoring for potential side effects 3
• Key side effects include:
  • Gynecomastia (occurs in 9% of patients) 3
  • Potential hepatotoxicity requiring liver function monitoring 3
  • Possible interactions with warfarin requiring close monitoring of prothrombin time 3

Considerations for Specific Populations

• For men interested in fertility, exogenous testosterone therapy should be avoided as it suppresses spermatogenesis 2
• Recovery of spermatogenesis after testosterone therapy cessation can take months or rarely years 1
• For patients requiring continued treatment while maintaining fertility potential, consider human chorionic gonadotropin (hCG) injections, selective estrogen receptor modulators (SERMs), or aromatase inhibitors 1

Monitoring Protocol During Treatment

• Regular assessment of serum Prostate Specific Antigen (PSA) may be helpful in monitoring response to treatment 3
• For men on testosterone therapy who develop concerning PSA changes:
  • Perform biopsy or refer to urologist if PSA rises above 4.0 ng/ml 2
  • Consider biopsy if PSA increases by more than 1.0 ng/ml in the first year 2
  • For increases of 0.7 to 0.9 ng/ml, repeat PSA test in 3-6 months and perform biopsy if there is any further increase 2
• Monitor hematocrit/hemoglobin regularly, as testosterone therapy can cause polycythemia 2
• If hematocrit rises above the reference range, consider temporarily withholding therapy, reducing dosage, or performing phlebotomy 2

Resumption of Therapy Considerations

• Therapy should only be resumed once testosterone levels have normalized to the middle tertile of the normal reference range 1
• After treatment is initiated, patients should be monitored to determine that normal serum testosterone concentrations are being achieved 2
• Testosterone levels should be tested 2 to 3 months after treatment initiation, and/or after any dose change 2
• Once stable levels are confirmed on a given dose, monitoring every 6 to 12 months is typically sufficient 2

Potential Risks and Complications

• Exogenous testosterone at high levels may be associated with potential cardiovascular concerns requiring a 3-6 month waiting period after cardiac events 1
• Long-term studies of the effects of testosterone on prostate cancer, breast cancer, and heart disease are not complete, requiring careful monitoring 4
• Sleep apnea may be exacerbated by testosterone therapy, particularly in men with other risk factors 2