Prostate health and PSA monitoring on TRT

For decades, the medical position was that testosterone supplementation risked fuelling prostate cancer. The science has moved on substantially. Current evidence, including the large TRAVERSE trial published in 2023, shows that TRT does not increase the incidence of prostate cancer in men who do not already have it. The picture is more nuanced for men with existing risk factors or known disease. This article describes the evidence, the monitoring we do, and what each result means.

What the evidence actually shows

TRT does not cause prostate cancer. Repeated large-cohort studies and meta-analyses have not found an elevated incidence of prostate cancer in men on TRT versus controls. The TRAVERSE trial, 5,200 men with hypogonadism followed for five years, found no difference in prostate cancer diagnosis rates between TRT and placebo groups.

TRT does not accelerate growth of existing prostate cancer in a clinically meaningful way in most men. The older "saturation model" of androgen binding suggests that prostate tissue responds to testosterone below a threshold but plateaus above it, which is consistent with clinical observation. Men with treated localised prostate cancer (post-radical prostatectomy, post-radiotherapy with stable PSA) can often be offered TRT safely with urology agreement.

Men with active untreated prostate cancer should not be on TRT. Full stop. Men with significantly raised PSA should not start TRT without investigation.

PSA does tend to rise modestly after starting TRT, particularly in the first 6 to 12 months. This is a physiological response of prostate tissue to the restoration of androgen levels, not a sign of cancer. Typical rise is 0.2 to 0.5 ng/mL in the first year and then plateau.

What we do at baseline

Every man starting TRT gets:

- Baseline PSA (total, not free/total ratio unless specifically indicated) - Digital rectal examination if aged 45 or over and consenting - Personal history of prostate disease, family history, urinary symptoms screen (IPSS)

If baseline PSA is above 3.0 ng/mL (for any age under 70), we typically arrange urology consultation before starting TRT. If DRE is abnormal (firm, nodular, asymmetric), same.

If baseline PSA is age-adjusted normal and symptoms are mild, we proceed with TRT and schedule repeat PSA at 3 months, 6 months, 12 months, then annually.

What we do during monitoring

3-month PSA check. Expected: modest rise of up to 0.2 to 0.3 ng/mL. Rise above this rate triggers a re-check.

6-month PSA. Expected: stable or small further rise. Rapid rise (over 0.4 ng/mL per year) triggers urology referral regardless of absolute value.

12-month PSA. Expected: plateau within 1 ng/mL of baseline. Continuing rise beyond the first year needs investigation.

Annual PSA from year 2. Plus DRE at annual comprehensive review from age 50.

When we refer to urology

- Baseline PSA above 3 ng/mL in men under 70 - Baseline DRE abnormal - PSA rising more than 0.4 ng/mL per year on TRT (sustained) - Any new LUTS (lower urinary tract symptoms) of significant severity - Any patient-reported change in prostate or urinary function

Urology referral does not mean stopping TRT automatically. We usually continue treatment during investigation unless the urologist advises otherwise. Specific investigations they may request include multiparametric MRI (much improved diagnostic yield), targeted biopsy if the MRI flags a lesion, and sometimes repeat measurements after a short pause in treatment.

What the multiparametric MRI can and cannot do

Multiparametric MRI (mpMRI) of the prostate has transformed prostate investigation. For men with rising PSA and no abnormal DRE, mpMRI can confidently rule out significant cancer in most cases (negative predictive value around 95 percent for clinically significant disease). Low-risk men with a negative mpMRI avoid biopsy entirely.

mpMRI detects clinically significant lesions with high sensitivity. It does not detect low-grade microfoci, which are often clinically irrelevant anyway. Guided biopsy targets MRI-flagged lesions rather than random sampling.

For men on TRT with rising PSA, we usually arrange mpMRI as first-line investigation and biopsy only if MRI flags a concern.

Men with a prostate cancer history

Active, untreated, or metastatic prostate cancer: TRT is contraindicated.

Treated localised prostate cancer with durable remission: TRT can often be offered with urology agreement, typically 2 or more years after treatment with stable PSA. The urology team at your treating centre usually drives this decision.

Raised PSA being monitored without biopsy: TRT is not started during active investigation. Once the picture is clear, the decision is made.

Family history

Men with a first-degree relative with prostate cancer, particularly early-onset disease or multiple affected relatives, are higher baseline risk. We lower our referral threshold for these men and do mpMRI earlier if PSA changes.

Men of African or African-Caribbean ancestry have a higher baseline prostate cancer risk than white UK men. We also lower referral threshold and often start baseline mpMRI particularly if over 50.

Self-monitoring

We ask you to report:

- Any change in urinary stream, frequency, urgency, or nocturia - Any blood in urine or semen - Any bone pain (particularly lower back, hips, pelvis) that is new - Any pelvic discomfort or change in sexual function beyond what TRT is doing

None of these are common on TRT but all warrant prompt review if they occur.

What we do not do

We do not ignore rising PSA. We do not stop TRT reflexively at the first rise without investigation. We do not charge extra for urology referral coordination. We do not attempt to manage suspected prostate cancer ourselves; urology is the right specialty.

The honest bottom line

TRT is safe for most men from a prostate perspective when baseline assessment is done and monitoring is in place. The evidence does not support the old fear that TRT causes prostate cancer. The monitoring is straightforward and catches the small number of men who need investigation. Starting TRT does not commit you to prostate problems; it commits you to sensible screening that you should be doing anyway.

Ready to start?

If this article has made you think an assessment might help, the next step is a short consultation with one of our men's health doctors.

Begin your consultation at this link. Online or in person at Westfield London.