What blood tests should a 69-year-old man on Testosterone Replacement Therapy (TRT) have?

Blood Tests for a 69-Year-Old Man on Testosterone Replacement Therapy

A 69-year-old man on testosterone replacement therapy requires regular monitoring of hematocrit/hemoglobin, PSA, and serum testosterone levels at baseline, 1-2 months after initiation, every 3-6 months during the first year, and annually thereafter. 1, 2

Baseline Testing (Before Starting TRT)

Before initiating testosterone therapy, the following tests are mandatory:

• PSA measurement is required for all men over 40 years to exclude prostate cancer before starting therapy 1
• Hematocrit or hemoglobin must be measured, and therapy should be withheld if hematocrit exceeds 50% until the underlying cause is investigated 3, 1, 2
• Digital rectal examination should be performed alongside PSA testing 4, 1
• Lipid profile assessment is optional but recommended 4, 1
• Voiding symptoms should be assessed using the International Prostatic Symptoms Score 4, 1
• Sleep apnea history should be determined before initiating therapy 1

Follow-Up Monitoring Schedule

The monitoring schedule follows a specific timeline to catch complications early:

• First follow-up at 1-2 months after starting TRT to assess efficacy and adjust dosage if needed 4, 1
• Every 3-6 months during the first year for ongoing monitoring 4, 3, 1, 2
• Annually thereafter if levels remain stable 4, 3, 1, 2

Key Parameters to Monitor at Each Visit

Hematocrit/Hemoglobin Monitoring

• Hematocrit >54% warrants immediate intervention including therapeutic phlebotomy, dose reduction, or temporary discontinuation to reduce cardiovascular and thromboembolic risk 3
• Injectable testosterone formulations carry a significantly higher risk of erythrocytosis (43.8%) compared to transdermal preparations (15.4%), requiring closer monitoring 3
• If hematocrit becomes elevated, stop therapy until it decreases to an acceptable concentration 2

PSA Monitoring

• PSA must be monitored at every visit due to potential prostate cancer risk 4, 1, 2
• A rise of >0.5 ng/mL within the first 3-6 months after starting treatment requires further investigation 5
• PSA velocity should be monitored, and substantial increases warrant investigation for possible prostate cancer 1

Testosterone Level Monitoring

• Target testosterone levels to the mid-to-upper normal range (approximately 300-1,000 ng/dL) for optimal response 4, 1
• If clinical response is suboptimal and testosterone levels remain in the low-normal range, increase the dosage 4
• If adequate clinical response occurs, no dosage adjustment is needed even if levels are in the low-normal range 4

Clinical Assessment

• Symptomatic response to treatment should be assessed at each visit 4, 1
• Voiding symptoms require ongoing evaluation 4, 1
• Sleep apnea symptoms should be monitored, as testosterone can worsen sleep-disordered breathing 4, 1
• Digital rectal examination should be performed at each visit 4

Special Considerations for a 69-Year-Old Patient

At age 69, this patient falls into a higher-risk category requiring more aggressive surveillance:

• Elderly patients with pre-existing cardiovascular disease require more aggressive monitoring due to increased risk of complications 3
• For patients older than 70 years, easily titratable formulations (gel, spray, or patch) are preferred over long-acting injectables to reduce erythrocytosis risk 3
• Elevated hematocrit increases blood viscosity, which is particularly dangerous in elderly patients with pre-existing vascular disease 3

Critical Thresholds Requiring Action

• Hematocrit >54%: Initiate therapeutic phlebotomy, reduce testosterone dose, or temporarily withhold therapy 3
• PSA increase >0.5 ng/mL within 3-6 months: Investigate for prostate cancer 5
• Abnormal digital rectal examination: Perform prostate biopsy regardless of PSA level 4, 2

Common Pitfalls to Avoid

• Do not ignore modest PSA increases in the first 3-6 months, as an initial rise is common but increases >0.5 ng/mL require investigation 5
• Do not rely solely on annual monitoring during the first year—the 3-6 month intervals are critical for detecting early complications 4, 1, 2
• Do not continue therapy if hematocrit exceeds 54% without intervention, as this significantly increases thromboembolic risk 3, 2