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On testosterone replacement for 4 years PSA suddenly rises

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Posted 9/29/2014 4:41 PM (GMT 0)
I was diagnosed with hypogonadism at the age of 40 (in 2010, now I am 44) when presented with fatigue, dysthymic mood, and periodic anxiety. Started on Androgen replacement by a urologist who is subspecialized in endocrine field of TRT. My first PSA was checked at the age of 40 came back high for a 40 year old at 1.5! Urologist was not overtly concerned. Started Testopel (12-16 pellets) every 3-4 months. What a difference! Working out great, metabolic indices improved, slimmed from the belly, (not to mention better sexual function),etc. Not unexpectedly, PSA went up modestly and continued to fluctuate between 1.7 - 2.3 over a period of 4 years. Back in April 2014 T measured 455 and PSA was 2.2 --> received 12 pellets. Then, all of a sudden, PSA is up to 5.6, DRE normal (T level 401, coming down on androgens feeling like crap). However, urinary stream is a little weaker.
Urologist commented that even DRE is normal, sometimes "concentric" prostate hyperplasia could result in lower urinary stream. He opted to hold off on testosterone. He wants to give it 6-8 weeks to see whether with the falling T level, PSA will go down.
1. I am feeling like crap coming down on T
2. Urologist is not a believer in empiric antibiotics
3. He argues against biopsy if PSA falls down
4. I did have intercourse and was riding bike prior to recent PSA test, but according to medical literature, those bump PSA only minimally
5. Not a "high risk" - no family history of PCa and not African American.

Suggestions? Biopsy - PCA3 - mpMRI, etc.

Thanks
Posted 9/29/2014 7:47 PM (GMT 0)
It sounds like your urologist suspects BPH that is being exacerbated by tour TRT. You didn't mention the size of your prostate, however. PSA density (=PSA/prostate size) is a pretty good indicator - if it is much higher than .15, then there may be something beyond BPH going on. You can also talk to him about taking Proscar or Avodart for BPH. In addition to shrinking the prostate, it is known to prevent PC. In fact, it improves the diagnostic accuracy of PSA for prostate cancer -- if PSA does not drop, or if it drops and rises, a biopsy may be warranted.

If your PSA doesn't go down when you're off TRT, prostatitis may be suspected. One thing you can do now is look at your neutrophil-to-lymphocyte ratio. I salute him for not wanting to use empiric antibiotics, but is he willing to do a 4-cup test to find pathogens? It has a low probability of success, however. That's why many Uros just give a 10-day course of Cipro, understanding that most prostatitis is not relieved by antibiotics.

There is a new test called PHI that includes PSA, % free PSA and -2ProPSA - together they are more prognostic than any alone. You can find out how to get it at this website. You probably can't get your insurance to pay for PCA3 until after you've had a negative biopsy. There are several other biochemical tests, but they are expensive and not covered by insurance. mpMRI would be premature.

PSA variances from sex and bike riding will vary from person to person.

- Allen
Posted 9/29/2014 10:46 PM (GMT 0)
If you feel like crap with a testosterone level of 401, imagine what it feels like when its between 5 and 20....

I would back off on the TRT for a while, let your numbers stabilize (both "T" and PSA) and take it from there....
Posted 9/29/2014 11:26 PM (GMT 0)
Lol! how about when T is 3? But I don't feel like crap even at this low level and I believe it's because I'm on cymbalta and deplin which together reduce depression, anxiety, and muscle pain. I was on the same road you appear to be on albeit at age 56. You can see from my signature that I was on avodart, tamsulosin and androgel for many years before being DXed with stage 3 PCa. Now another battle which so far I am winning it appears. Life is not a bowl of cherries!
Bob
Posted 9/30/2014 1:51 AM (GMT 0)
cbroaster,

I was on quarterly T injections for years. I had a steady PSA increase, but nothing to be too concerned about. However, after a period of steady increases the PSA JUMPED (see my profile) but still less than 4.

I had read somewhere that 1) a jump is cause for concern; and 2) having been on T for a while, the grade of cancer is generally more virulent so I opted for a DRE at a 3.7PSA and later a Biopsy, which confirmed that I indeed had PCA and a Gleason 9. Now here is the Good news. I only had a smidgen in one core out of 16 and it hadn't spread.

Your doctor like mine put my T injections on hold after my PSA registered 3.7 and before the Biopsy. However after my RRP and with a PSA < .01, I resumed T replacement and have been on it for 9 months. My PSA remains at < .01

I wished that I had researched all the diagnostic options FIRST, because the outcome would have helped with my decision for my choice of intervention.

All the best with your decision making.
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Posted 9/30/2014 12:20 PM (GMT 0)
Thanks for all three replies - very informative. I should clarify one point though. My most recent T was 401 and that was 5 weeks ago when I was due for testopel. I did not start feeling rough until last 2 weeks which I assume is because I am coming down on androgens. My PCP (not urologist) suggested Wellbutrin or Duloxetine but I am scared of psychoactive pills when you read how it acts on brain receptors, etc. Proscar is a brilliant idea if you believe what you read on the internet. I used my-chart-messaged the urologist about it and he replied "will discuss when you see me next" - I guess that was a NO for calling in the pill.
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