Treating Hypogonadal Men With Prostate Cancer with Testosterone

Morgantaler, in 1996, was first to show hypogonadal men (men with low testosterone levels), with normal exams, and normal prostate cancer screening, had a higher risk of prostate cancer than those with higher testosterone levels. This discovery opened the pathway for a paradigm change in testosterone replacement therapy, TTh, for hypogonadal men. 

Until Morgantaler’s study, the scare of prostate cancer stopped many doctors from treating hypogonadal men.  Hypogonadism was thought to be a “normal aging” process and, therefore, the cause could and should not be treated.  This thinking still persists throughout traditional medicine today.  Hypogonadal men are offered medications such as Viagra and Cialis for erectile dysfunction, but other devastating hypogonadal symptoms of fatigue, poor sleep, poor cognition, irritability, low motivation, weight gain, and foggy brain are not addressed at all.

Subsequent to Morgantaler’s discovery, others also showed the risk of Prostate Cancer, PCa, to be higher in men with testosterone levels less than 385 ng/dl.*  

It was also discovered testosterone levels <300 ng/dl in men with prostate cancer were linked to:

  1. More aggressive PCa
  2. Increased likelihood of positive margins
  3. Gleason scores > 7.9,
  4. Greater incidence of bilateral disease *

Saturation Effect of Testosterone Therapy

To explain his clinical findings Morgantaler proposed and demonstrated, “Prostate growth is exquisitely sensitive to variations in testosterone concentrations at very low concentrations, but prostate growth becomes insensitive to changes in testosterone concentrations at higher levels.”  In conclusion, there is a saturation limit to the ability of testosterone to stimulate PCa growth.

Morgantaler’s  Hypothesis In Treatment of Hypogonadal Men with Prostate Cancer

Hypothetically, since there is a cutoff level at which testosterone does not affect prostate growth, men with prostate cancer can be treated with Testosterone therapy, TTh, without fear of cancer progression.

Research Supporting Morgantaler’s Hypothesis

Three traditional prostate cancer treatment protocols were studied multiple times with the addition of testosterone therapy, TTh, in hypogonadal men.

  1. Not Treated, Active Surveillance, AS
  2. Progression Rates are unchanged with TTh during Active Surveillance when compared to men without TTh
  3. PSA’s may occasionally be increased with TTh but biopsies have been negative
  4. Most studies followed patients up to 27 months
  • Treated with Radiation or Brachytherapy (radioactive seeds implanted in the prostate)
  • Low rate of prostate cancer recurrence, 6% with TTh versus 19-26% without TTh**
  • No significant rise of PSA
  • Treated with Radical Prostatectomy
  • Currently the preferred treatment modality in PCa patients < 70 yr old
  • TTh does not have a significant impact on PCa recurrence or progression
  • In men with high risk PCa, 4 men treated with TTh developed recurrent cancer, however, 8 men not treated with TTh developed recurrent cancer.**

190 Men on TTh with mean 4y follow-up

TreatmentNMean age (y)Mean followup (mo)# recurrences or progressionRate of recurrence or progression with TThPublished 5y rates of recurrence or progression without  TTh
Radical prostatectomy86 66 ±        7.9521011.6%15-30%
XRT or brachytherapy49 73 ±   6.64724.1 %15-25%
Active surveillance47 66.9 ± 8.751510.6%13-37%

AUA 2018 abstract, Neel D et al


To date, with multiple studies showing no increase in incidence or progression of prostate cancer with TTh, research papers continue to state the subject is controversial!? The science is there, the outcomes are there, the desire of the patient to feel better is there.  How many lives are being harmed by not giving such a crucial therapy for men?  What is the reasoning?

Below is typical of what you read in medical journals.  This excellent review article is from 2016.

The use of TTh in the setting of PCa remains controversial due to a lack of definitive, appropriately powered prospective controlled studies.

However, current research supports the overall conclusion Tetsosterone Therapy in patients with a history of  treated or untreated Prostate Cancer is safe and effective, particularly in men with low risk malignancies.

TTh in men with a history of high-risk CaP is supported by small, retrospective studies that overall show no increased risk of CaP recurrence or progression in these men.

In light of the available evidence, we recommend careful consideration of TTh in all men with a history of PCa while weighing the potential risks with the improvement in quality of life so clearly evidenced with TTh.

Treatment of hypogonadism, especially in men with low risk PCa with significant impact on quality of life as a result of hypogonadism, is warranted.

Men with high-risk PCa pose a more difficult scenario, but with appropriate surveillance, the available evidence supports the safe use of TTh in these men as well.”**

Morgantaler continues his crusade using testosterone therapy in hypogonadal men with prostate cancer.  He is a warrior of health and a voice of reason.  All men now on Testosterone replacement therapy have a second chance in life because of Morgantaler’s brilliant medical discoveries and his perseverance for truth. It’s an honor to have him fighting for the betterment of our lives. 

*  review article excellent

**How to handle a relapse after treatment for prostate cancer … › blog › how-to-handle-a-…

*** coverage/testosterone-therapy-safe-despite-prostate-cancer-history/