Can a male with Chronic Lymphocytic Leukemia (CLL) take testosterone supplements?

Testosterone Supplementation in Males with CLL

Yes, a male with CLL can take testosterone supplements if he has documented testosterone deficiency (hypogonadism), as there is no evidence that testosterone therapy increases cancer risk or worsens CLL outcomes. 1

Key Diagnostic Requirements Before Starting Therapy

Before prescribing testosterone, you must establish true hypogonadism through:

• Two early morning total testosterone measurements below 300 ng/dL (10.41 nmol/L) 1, 2
• Presence of hypogonadal symptoms (decreased libido, erectile dysfunction, fatigue, decreased muscle mass) 1
• Measurement of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to determine if hypogonadism is primary or secondary 1, 2

Note that CLL patients may have hormonal dysregulation with elevated FSH, LH, and altered testosterone/estradiol ratios, making proper diagnostic workup essential 3.

Safety Considerations Specific to CLL

Testosterone therapy does not increase cancer risk or worsen outcomes in men with malignancies, including those with CLL. The 2024 European Urology guidelines explicitly state that hypogonadal men receiving testosterone supplements do not have increased risk of developing cancer, and men managed expectantly for malignancies or who received curative therapy do not have worse outcomes when receiving testosterone supplementation 1.

Treatment Approach

Target Testosterone Levels

• Aim for mid-normal range: 450-600 ng/dL (15.6-20.8 nmol/L) 2
• For men over 70 years or with chronic illness (which may include CLL), use easily titratable formulations (gel, spray, or patch) rather than long-acting injectables 1

Formulation Selection

• Use commercially manufactured testosterone products only 2
• Avoid alkylated oral testosterone due to hepatotoxicity risk 2
• Transdermal preparations (gels, patches) or intramuscular injections are acceptable 1

Mandatory Pre-Treatment Evaluation

Before initiating testosterone therapy, obtain:

• Baseline hemoglobin/hematocrit - withhold if Hct >50% until investigated 1
• PSA testing in men over 40 years to exclude occult prostate cancer 1
• Assessment of cardiovascular risk factors (hypertension, diabetes, dyslipidemia, smoking) 1
• Fertility assessment if future conception desired - testosterone suppresses spermatogenesis 1, 4

Monitoring Requirements During Treatment

• Hematocrit monitoring - intervention required if Hct >54% (dose reduction or temporary discontinuation) 1
• Testosterone levels to ensure therapeutic range 2
• PSA monitoring using shared decision-making approach 1
• Cardiovascular status - particularly important given CLL patients may have other comorbidities 1

Expected Benefits

Men with documented hypogonadism can expect improvements in:

• Sexual function and libido (effect size 0.35-0.45) 1
• Muscle mass and strength 1
• Bone mineral density 1
• Mood and depressive symptoms 1

Critical Contraindications

Defer testosterone therapy for 3-6 months in patients with recent cardiovascular events 2

Do not prescribe to men actively trying to conceive - testosterone inhibits spermatogenesis 1, 2

Clinical Pitfalls to Avoid

• Do not assume all CLL patients need testosterone - only treat documented deficiency with symptoms 1, 2
• Do not use compounded testosterone preparations 2
• Do not ignore the hormonal dysregulation that may occur in CLL itself (elevated FSH/LH) when interpreting labs 3
• Do not prescribe without proper baseline PSA and hematocrit assessment 1
• Injectable testosterone carries highest risk of polycythemia - monitor closely 1