Management of Elevated Testosterone Levels

Evaluation and Monitoring

Before initiating any treatment, measure baseline hemoglobin/hematocrit and PSA (in men over 40) to establish reference points for monitoring 2
Serial testosterone measurements should be obtained to monitor the decline in testosterone levels, with the goal of reaching a plateau or returning to the pretreatment baseline 1
Stabilization is typically defined as when two consecutive testosterone measurements are within 10% of each other 1
Monitor for potential cardiovascular concerns, as high testosterone levels may be associated with cardiovascular risks 1

For men interested in fertility, exogenous testosterone therapy should be avoided as it suppresses spermatogenesis 2
Recovery of spermatogenesis after testosterone therapy cessation can take months or rarely years 1
For patients requiring continued treatment while maintaining fertility potential, consider human chorionic gonadotropin (hCG) injections, selective estrogen receptor modulators (SERMs), or aromatase inhibitors 1

For men on testosterone therapy who develop concerning PSA changes, perform biopsy or refer to urologist if PSA rises above 4.0 ng/ml 3
Consider biopsy if PSA increases by more than 1.0 ng/ml in the first year 4
For increases of 0.7 to 0.9 ng/ml, repeat PSA test in 3-6 months and perform biopsy if there is any further increase 4
Monitor hematocrit/hemoglobin regularly, as testosterone therapy can cause polycythemia 5
If hematocrit rises above the reference range, consider temporarily withholding therapy, reducing dosage, or performing phlebotomy 5

Therapy should only be resumed once testosterone levels have normalized to the middle tertile of the normal reference range 1
After treatment is initiated, patients should be monitored to determine that normal serum testosterone concentrations are being achieved 6
Testosterone levels should be tested 2 to 3 months after treatment initiation, and/or after any dose change 6
Once stable levels are confirmed on a given dose, monitoring every 6 to 12 months is typically sufficient 6

Exogenous testosterone at high levels may be associated with potential cardiovascular concerns requiring a 3-6 month waiting period after cardiac events 1
Sleep apnea may be exacerbated by testosterone therapy, particularly in men with other risk factors 3