Contraindications to Testosterone Propionate
Testosterone propionate is absolutely contraindicated in men with active or treated male breast cancer, men seeking fertility, and men with known or suspected prostate carcinoma. 1, 2, 3
Absolute Contraindications
Male breast cancer (active or previously treated): Breast cancer growth is influenced by testosterone and its conversion to estradiol, making this an absolute contraindication due to limited safety data 1, 2
Men seeking fertility: Testosterone therapy suppresses spermatogenesis through down-regulation of gonadotropins, making it contraindicated in any man desiring fertility 1, 2, 3
Known or suspected prostate carcinoma: The FDA mandates that testosterone is contraindicated in men with a history of or suspected prostate cancer 3
- Important caveat: Recent evidence challenges this traditional contraindication. The TRAVERSE trial showed no difference in prostate cancer incidence between testosterone and placebo groups at 33-month follow-up 1, 2
- For prostate cancer survivors who appear cured after definitive treatment (radical prostatectomy with undetectable PSA), some guidelines now suggest testosterone may be considered with careful monitoring 2, 4, 5
Prostate cancer on active surveillance: Testosterone should not be used in men with prostate cancer on active surveillance 1, 2
Prostate cancer on androgen deprivation therapy: This remains an absolute contraindication 1, 2
Relative Contraindications and High-Risk Situations
Severe untreated obstructive sleep apnea: Testosterone can exacerbate or cause development of sleep apnea, particularly in men with other risk factors receiving higher doses 1, 2
- However, recent evidence suggests untreated sleep apnea may not be an absolute contraindication, and combined CPAP with testosterone gel showed better outcomes than CPAP alone 1
Severe lower urinary tract symptoms (LUTS): Use with extreme caution in men with severe LUTS, though studies show testosterone generally doesn't worsen symptoms in mild-moderate cases 1, 2
- Patients with benign prostatic hypertrophy may develop acute urethral obstruction 3
Renal insufficiency: Use cautiously due to fluid retention risk 2
Hepatic dysfunction: While intramuscular and transdermal preparations don't cause hepatic dysfunction, oral testosterone formulations are strongly discouraged due to hepatotoxicity and risk of hepatocellular carcinoma 1, 2, 3
Recent cardiovascular events: Limited safety data exists for men with recent cardiovascular events 2
Acute illness: Testosterone testing and therapy should be avoided during acute illness 2
Monitoring Requirements Before Initiation
Before starting testosterone propionate, you must:
- Perform digital rectal examination 2
- Measure PSA levels 2, 3
- Check hemoglobin and hematocrit to establish baseline 3
- Measure serum cholesterol (may increase during therapy) 3
- Assess for sleep apnea risk factors 1
Critical Drug Interactions
Oral nitrates: Absolutely contraindicated if patient is taking nitrates, as combination causes dangerous blood pressure decreases (this applies when testosterone is used with PDE5 inhibitors for erectile dysfunction) 1, 2
Oral anticoagulants: Testosterone increases sensitivity to anticoagulants; dosage reduction may be required 3
Insulin: In diabetic patients, testosterone may decrease blood glucose and reduce insulin requirements 3
Oxyphenbutazone: Concurrent administration may result in elevated serum levels 3
Special Warnings
- Priapism or excessive sexual stimulation may develop and requires stopping the medication 3
- Oligospermia occurs after prolonged administration 3
- Polycythemia risk requires periodic hemoglobin/hematocrit monitoring 3
- Not for intravenous use and should not be used interchangeably with other testosterone esters due to differences in duration of action 3
- Pregnancy Category X: Absolutely contraindicated in pregnancy 3
- Not recommended for nursing mothers 3