From the Guidelines
Testosterone therapy is not contraindicated in a 77-year-old male with a prolactin level of 26 and no other prior health history, but it should be approached with caution and thorough evaluation. The American College of Physicians suggests that clinicians discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function 1. However, the patient's mildly elevated prolactin level should be investigated to determine its cause, which could include medications, pituitary adenoma, or other conditions.
Key Considerations
- Before initiating testosterone therapy, the patient should undergo a complete hormone panel including total and free testosterone, estradiol, LH, FSH, and thyroid function tests.
- Prostate-specific antigen (PSA) testing and digital rectal examination are essential to rule out prostate cancer, which would be an absolute contraindication.
- A complete blood count is necessary to establish baseline hemoglobin and hematocrit levels, as testosterone therapy can increase these values and potentially lead to polycythemia.
- The patient should also have baseline lipid profiles and liver function tests.
Treatment Approach
- If testosterone therapy is deemed appropriate after these evaluations, starting with a lower dose (such as 50 mg of testosterone cypionate weekly or a 2% gel applied daily) with regular monitoring every 3-6 months is recommended, as suggested by the American College of Physicians for improving sexual function in men with age-related low testosterone 1.
- The elevated prolactin may be contributing to hypogonadism symptoms, so addressing both conditions simultaneously might be necessary for optimal management.
Ongoing Evaluation
- Clinicians should reevaluate symptoms within 12 months and periodically thereafter, and discontinue testosterone treatment if there is no improvement in sexual function, as recommended by the American College of Physicians 1.
From the Research
Testosterone Therapy in Older Men
- The decision to initiate testosterone therapy in a 77-year-old male with a prolactin level of 26 and no other prior health history should be made with caution, as the long-term effects of testosterone on major cardiovascular events and prostate cancer risk remain unclear 2.
- Testosterone treatment in older men has been shown to improve sexual function, physical function, and bone density, but its impact on cardiovascular events and mortality is still a matter of debate 3.
- The Endocrine Society recommends against testosterone therapy for all older men with low testosterone levels, but suggests consideration of treatment on an individualized basis in men who have consistently low testosterone levels and symptoms or conditions suggestive of testosterone deficiency 2.
Considerations for Testosterone Therapy
- Testosterone levels decline progressively with age, and low testosterone levels have been associated with a range of health problems, including decreased muscle mass, strength, and bone density, as well as increased risk of diabetes, coronary artery disease, and mortality 4.
- However, the clinical benefits and long-term risks of testosterone therapy, especially prostate-related and cardiovascular-related adverse events, have not been adequately assessed in large, randomized clinical trials involving older men 4.
- Alternative treatments, such as clomiphene citrate, have been shown to increase endogenous testosterone production and may be considered as a therapeutic option for some patients with symptomatic male testosterone deficiency 5, 6.
Prolactin Levels and Testosterone Therapy
- The study does not provide direct evidence on the relationship between prolactin levels and testosterone therapy in older men.
- However, one study found that prolactin levels were not significantly affected by treatment with clomiphene citrate, a medication used to stimulate endogenous testosterone production 6.