Testosterone therapy raises PSA a little, usually in the first year, but it did not raise prostate cancer rates in the largest placebo-controlled trial to date. In TRAVERSE, 5,204 men with low testosterone were followed for about 33 months, and high-grade prostate cancer turned up in 0.19 percent of the testosterone group and 0.12 percent of the placebo group, a difference small enough to be chance. That is reassuring for men with a normal PSA. It says little about men who already have prostate cancer.
Quick answer: PSA is a protein made by the prostate that rises with cancer, but also with enlargement, infection, recent ejaculation and long bike rides. Testosterone therapy nudges PSA up early on. In the TRAVERSE trial it did not increase prostate cancer in men who started with a PSA under 3 ng/mL. Men on testosterone should have PSA checked before starting and during treatment, and a rise of more than 1.4 ng/mL in a year warrants a urology visit.
What PSA is and what raises it
PSA, prostate-specific antigen, is a protein made by prostate cells. Cancer can push it up. So can a lot of other things. UCLA Health lists a urinary tract infection or prostatitis as causes that can raise PSA a lot. Ejaculation and long-distance cycling raise it slightly, by under 1 ng/mL, for up to about 24 hours. Most men with a PSA between 4 and 10 ng/mL do not have prostate cancer.
Some drugs push it the other way. Finasteride lowers PSA, and doctors typically double the reading to get a comparable number. That matters if you take finasteride for hair loss and nobody has told the person reading your labs.
Practical point: skip sex and cycling for a day or two before a PSA draw.
Should you get PSA screening?
The U.S. Preventive Services Task Force’s 2018 recommendation says the decision to screen men aged 55 to 69 should be an individual one, made after talking through benefits and harms, and recommends against routine screening at 70 and older. The Task Force has an update in progress. The harms it weighs are false alarms, biopsies and treatment of slow cancers that would never have caused trouble.
Men on testosterone are a different case. For them, PSA is not a population screening question. It is part of safety monitoring for a drug they are taking.
Does testosterone cause prostate cancer?
The fear goes back to 1941, when Charles Huggins showed that castration made advanced prostate cancer shrink. If removing testosterone slowed cancer, the reasoning went, adding it must speed cancer up. For decades that kept doctors away from testosterone in older men.
The picture changed as data came in. One explanation, the saturation model described by Abraham Morgentaler and Abdulmaged Traish in 2009, holds that prostate tissue responds to testosterone only up to a fairly low level, after which the receptors are full and more testosterone adds little. It is a model, not settled fact, but it fits what the trials have since found.
What the TRAVERSE prostate data showed
The TRAVERSE prostate safety analysis in JAMA Network Open in January 2024 followed 5,204 men with low testosterone and a baseline PSA under 3 ng/mL for a mean of 33 months.
- High-grade prostate cancer: 5 of 2,596 men on testosterone (0.19 percent) vs 3 of 2,602 on placebo (0.12 percent). Not a significant difference.
- Any prostate cancer: no difference between the groups.
- PSA: rose more on testosterone at 3 and 12 months. After month 12 the two groups were no longer different.
- Urinary retention, prostate surgery and new drugs for urinary symptoms: no difference.
The limits matter as much as the results. Men with a high PSA or a history of prostate cancer were not in the trial. Follow-up was under three years, and prostate cancer can take much longer than that to show itself.
PSA before and during testosterone therapy
Guidelines agree on checking PSA before testosterone is started in men over 40 and again during the first year. The Endocrine Society’s 2018 guideline advises a urology evaluation before starting testosterone in men with a palpable prostate nodule or an elevated PSA, and does not recommend testosterone for men with prostate cancer outside of specialist care.
Once treatment starts, the thresholds used in the British Society for Sexual Medicine guidance are a PSA increase of more than 1.4 ng/mL over one year, or a rise of more than 0.4 ng/mL per year across two or more years. Either one means a urologist should take a look. A small bump in the first few months, without either of those, is what TRAVERSE would lead you to expect.
Our position is simple. A normal PSA is not a reason to avoid testosterone therapy, and a rising PSA on testosterone is not something to explain away. It gets checked.
If you are weighing treatment, our guide to TRT benefits, risks and delivery methods covers the other monitoring, including hematocrit and blood pressure.
What about men who have had prostate cancer?
This is the open question. Some urologists now offer testosterone to carefully selected men after successful treatment for low-risk cancer, with close PSA follow-up. The trials that would settle it have not been done at scale. Any decision here belongs with a urologist who knows your pathology report, not with a general clinic.
Other prostate symptoms worth checking
A weak stream, getting up at night to urinate, or pain in the pelvis or perineum can come from an enlarged prostate or prostatitis. Our post on prostate and perineal pain covers those, and the top health issues facing men over 50 puts prostate health alongside heart, metabolic and hormone risks.
Frequently asked questions
Does testosterone therapy raise PSA?
Usually a little. In the TRAVERSE trial, PSA rose more in men on testosterone than on placebo at 3 and 12 months, and after 12 months the groups were no longer different. A rise of more than 1.4 ng/mL within a year on testosterone is a common threshold for a urology referral.
Does testosterone cause prostate cancer?
The best current evidence says no for men starting with a normal PSA. In the TRAVERSE trial of 5,204 men with a baseline PSA under 3 ng/mL, rates of any prostate cancer and high-grade prostate cancer did not differ significantly between testosterone and placebo over about 33 months. Men with existing prostate cancer were not studied.
What can falsely raise a PSA test?
A urinary tract infection or prostatitis can raise PSA a lot. Ejaculation and long-distance cycling raise it slightly, by less than 1 ng/mL, for up to about 24 hours. An enlarged prostate also raises PSA. Finasteride lowers it, so results for men taking it are usually doubled for comparison.
At what age should men get a PSA test?
The U.S. Preventive Services Task Force’s 2018 recommendation says men aged 55 to 69 should make an individual decision with their clinician, and recommends against routine screening at 70 and older. Men starting testosterone therapy are different: PSA is checked before treatment, usually from age 40, and during the first year as a safety check.
Can men with prostate cancer take testosterone?
Guidelines, including the Endocrine Society’s 2018 guideline, do not recommend testosterone for men with active prostate cancer. Some urologists use it in selected men after successful treatment, with close PSA monitoring, but large trials are lacking. That decision should be made with a urologist who knows the details of the cancer.
If you have low testosterone symptoms and want your PSA and hormone labs reviewed together, Dr. Drew Collins, ND, checks PSA before any treatment decision and refers to urology when the numbers call for it. You can read how testosterone therapy in Bend is monitored at Proactive Choice.
Sources
- Bhasin S, et al. Prostate safety events during testosterone replacement therapy in men with hypogonadism (TRAVERSE). JAMA Network Open, 2024 (2 Minute Medicine summary).
- U.S. Preventive Services Task Force. Prostate Cancer: Screening, final recommendation statement, 2018.
- UCLA Health. PSA test results can be affected by different factors.
- Bhasin S, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline, 2018.
- GPnotebook. Monitoring testosterone therapy (British Society for Sexual Medicine thresholds).
- Morgentaler A, Traish AM. Shifting the paradigm of testosterone and prostate cancer: the saturation model and the limits of androgen-dependent growth. European Urology, 2009.
This article is for education and is not a diagnosis. Talk with a licensed clinician about your own labs and symptoms.
Want to talk this through for your own health? Book a visit with Dr. Drew Collins, ND at 601 NW Harmon Blvd in Bend, or call (858) 333-5196.
