Joey Wahler (Host): There's a link between them. So, we're discussing testosterone replacement therapy or TRT and PSA. Our guest is Dr. Matthew Karlovsky. He's a urologist and urogynecologist and Chair of the Surgery Department at Wickenburg Community Hospital. This is WickCare Talks, the podcast from Wickenburg Community Hospital and Clinics, dedicated to helping our community lead healthier, more active lives. In each episode, we connect you with trusted health experts to share valuable insights on a wide range of topics. From managing chronic conditions to simple tips for everyday wellness, we're here to provide practical information to support you on your health journey. Be sure to follow us so you never miss an episode. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Matthew E. Karlovsky, MD, FACS: Hi, good morning. Welcome.

Host: Appreciate the time. So first, remind us please, if you would, what exactly is testosterone And what does it do for us?

Matthew E. Karlovsky, MD, FACS: Testosterone is the male hormone, which everybody knows about. Even women do produce a small amount of testosterone. But essentially, testosterone is the wellness hormone that increases during puberty, and it helps build muscle mass, gives men their masculine features, helps with what we call the growth spurt.

Over time, as you get older, testosterone levels do wane a little bit and people notice that or men notice that as they get older they have a little bit less energy. They may notice some less muscle mass over time. They may notice less libido. So, these are the common and typical signs of waning testosterone that men may notice as they get older.

Host: Before we get to the specifics of this link between that and PSA, remind us please, Doctor, what does PSA stand for?

Matthew E. Karlovsky, MD, FACS: Well, PSA is a very common blood test that's used in men to screen for prostate cancer. It stands for prostate specific antigen. And it's been around for about 30 years or more. It's a very prevalent blood test, and it's used usually to start screening men for prostate cancer at age 50. And for men who have risk factors regarding either race or family history of prostate cancer, we start screening using the blood test at age 40.

Now, the PSA test can vary based on your age, based on family history. And it's also affected by a number of different things such as straining, urinary tract infections. Even if you check your PSA after having sex, the PSA can vary. So, just because the PSA may be slightly elevated does not 100% indicate prostate cancer. Following the trend of the PSA is one of the most common useful tools to figure out if the PSA number is meaningful or if it's something that can be continued to be observed and you track over time.

Host: Gotcha. So having said that, what is testosterone replacement therapy and how does it relate to the PSA test?

Matthew E. Karlovsky, MD, FACS: Well, both are linked in one way. The fact is that the prostate gland is what makes the PSA molecule. And as the prostate grows, we do expect the PSA to go up gradually over time. In fact, with most prostate cancers, PSA does go up as well. Testosterone is the driver hormone that makes the prostate grow.

So necessarily, if someone were to be giving themselves testosterone replacement, which is highly prevalent and many people use for betterment of health and other things, they have to be cognizant of the PSA because the PSA may go up while they're taking testosterone. And so, the variation of the PSA may be interpreted as potentially normal, as long as you can track that with giving testosterone and when the testosterone is given. If the PSA goes up too much, and the urologist has many ways to figure that out, then it may be wise to take testosterone supplementation away and see if the PSA responds by going down. So, they are linked And the men who take testosterone should not ignore the PSA test, and it's just another test to do when doing testosterone replacement therapy.

Host: To back up for a moment, in terms of TRT, what does that consist of actually? If you're low on testosterone, how does someone like yourself address that?

Matthew E. Karlovsky, MD, FACS: Great question. So, testosterone replacement therapy, at least in men, is usually considered if men demonstrate or complain of, or they feel like they're having either a low mood or low libido if they feel they can't work out at the gym as long, or they're not getting the muscle mass they want at the gym, or they feel that all of these changes are slowly kind of what we call creeping up on them.

And then, we check a testosterone level. It's a blood test. You also want to check a number of other things, which could be affecting energy, mood, and libido. At the same time, you want to check your thyroid, you want to check your cholesterol, you want to check your blood pressure, you want to do a basic thorough health check. Just because you have low energy and you don't have the libido you had when maybe you're 20 years old, it doesn't necessarily mean that testosterone is low. You also want to make sure it's not early diabetes or other general medical conditions, which can also cause less muscle mass, fatigue, poor sleep. So to evaluate low testosterone, you need to do a very good general health workup.

Now, let's say all the general health workup works out fine. Your thyroid's normal, your blood pressure's normal and so on, but your testosterone is low, then by process of elimination, we can say that, "Okay, maybe we can now link low energy, poor sleep habits, low libido to low testosterone." Replacing testosterone can be done in many forms. There are gels, there are creams, there are patches, and there are shots. And there's even a gel that you may put in your nostril. Now, which to give depends on what the patient's preference is. Do they like to put a gel or a cream on every morning after a shower? Maybe, maybe not. Maybe insurance doesn't cover that right away, and you have to try shots. So, many men are used to hearing that other men are doing TRT with shots. And it is one of the simplest forms. It's also one of the least expensive forms. But you want to also do your testosterone replacement with the eye towards perhaps you may not respond well to it. And so, if you're doing creams or shots, you know, you can wash it off or the shot will wear off after about a week. No harm, no foul. So when starting testosterone therapy, you want to be sure that you're not just thinking about the positives of it, but will you react well; and if not, easy to withdraw.

Host: Speaking of which, how about the potential risks of starting the TRT and then affecting prostate health?

Matthew E. Karlovsky, MD, FACS: Okay. Great two-part question. So, testosterone replacement therapy is generally safe. The main things you want to screen or be concerned about is basically cardiovascular health. There is a lot of ink on estrogen replacement therapy and risk factors for women regarding deep vein thrombosis, DVT. And that was always an outside concern for men doing testosterone replacement therapy. Would it affect men the same way? And generally speaking, that is very, very rare. But if somebody does have cardiovascular disease, whether they've had prior heart attack or stroke, it's not a bad idea to ask the cardiologist if it's okay to take testosterone therapy.

Now, if the rest of you is normal, your normal liver, normal kidneys, no diabetes, in fact, even if you have mild diabetes, testosterone may help with that because it'll improve your energy and may contribute to weight loss. So, it's a very measured, balanced approach. It's not just set it and forget it, start taking TRT and then you're good to go. You want to make sure that the patient is observed, come back in in a month, three months. Make sure they're responding well to the hormone and that their blood work is normal and that they feel like they're getting the desired effect out of it, that they're meeting their desired goals, whether it's libido, muscle mass, sleep, and so on.

The prostate, as we said, uses testosterone for growth. It's its food basically. If you withdraw testosterone such as we do sometimes for prostate cancer treatments, the PSA And the prostate will go down or shrink. And if you add testosterone, there's always the risk, although small, that the prostate will grow. So in older men who want to regain that gym life and they want to do testosterone replacement therapy, they do have to watch out for not only if the PSA is going to go up, but if the prostate grows, but attention to urinary stream. Are you urinating more frequently? Do you feel like the stream is weaker? Are you not able to empty the bladder as well? Because the prostate has grown and blocking the flow. Now, that is theoretically reversible if you take testosterone away. So, it's a matter of balance of how much you want to invest in testosterone and if you're having prostate symptoms, what you're willing to put up with for the trade off, right? Nothing in life is free and there are ways to treat an enlarged prostate. But then, it means now you're on testosterone therapy and now maybe you may have to take something for enlarged prostate and urinary symptoms, whether that's herbals or medications or just even dietary changes. But it's something else to pay attention to. So, testosterone therapy is very useful for people, but you do have to monitor it on a daily, monthly, weekly, yearly basis. It's not an open-ended treatment forever.

Host: Along those lines, what are the typical steps or testing involved in monitoring prostate health during TRT?

Matthew E. Karlovsky, MD, FACS: Well, in the very beginning, you want to do all the blood work that screens for other health conditions like we were mentioning: thyroid, cholesterol, kidneys, liver, blood pressure. Make sure you're in good cardiovascular shape. Maybe you pick up something that you didn't know you had, such as high cholesterol. And then, you can take care of that through diet, exercise, or other means.

Screening in for testosterone placement therapy is a good way to achieve a general checkup. But from a testosterone treatment point of view, it's basically monitoring your PSA and doing a prostate exam if you're at the onset of testosterone therapy, if you're about somewhere between 40 to 50 years old or older. And those are the prostate-specific screening tests, you can say, before doing TRT in addition to the other general health tests that we spoke about.

Host: Any newer treatment methods or protocols these days for this managing of TRT patient's with high PSA levels?

Matthew E. Karlovsky, MD, FACS: Well, great question. So, anybody who has a high PSA should go see the urologist, even if it's slightly elevated. The primary care doctor will usually be diligent enough, to send the patient over, the male patient over to the urologist to figure out what is the meaning of the PSA going up? Is it benign? Is it infection, inflammation, enlargement of the prostate, prostate cancer? Is it related to exercise straining? Is it related to testosterone replacement? So, that's the job of the urologist. It's not very difficult to figure out. You just have to be methodical.

Once the PSA is elevated though in someone who is on testosterone therapy, a very simple way to see if that's a benign rise of the PSA-- in other words, not something worrisome, not related to prostate cancer-- is to just stop the testosterone. Wait a few weeks and see if the PSA comes down. Now, if somebody's PSA remains elevated, and they don't want to stop testosterone because they feel great, their mood is good, they're working out, they have more energy, they're running a marathon now, then you have to make sure that the PSA elevation is not sinister, it's not prostate cancer. And in that way, you can do an MRI. There's other blood tests that you can do. You can even do a prostate biopsy because you want to gain the certainty that the rising PSA after you've started testosterone is not from prostate cancer. And there's a lot of ways to figure out, which we mentioned, and that's done methodically also by the urologist.

Recently, I had a patient who was in his mid-70s. He wanted to continue testosterone. His PSA continued to go up. And I said, "Well, we can do a couple things. We can stop the testosterone and observe, or we can do some imaging, other tests, or do a prostate biopsy." He was very adamant about maintaining body health and energy and working out at the gym. So, we ended up doing other blood tests, MRI, prostate biopsy. Thankfully for him, no prostate cancer. He has a clean slate. He can continue testosterone therapy. So, that's a very common clinical picture of how we manage PSA if it happens to go up with testosterone supplementation.

Host: Gotcha. A couple of other things. How about lifestyle changes, Doctor, that can naturally boost testosterone levels or just improve overall prostate health?

Matthew E. Karlovsky, MD, FACS: So, we like to say as urologists that the heart is urologic organ because it pumps blood to the prostate and penis. The fun part about that is that it's a little bit of a joke. But in actuality, anything that's heart healthy is going to be healthy also for the prostate and the male organs. If you are thinner, if you have good diet, if you exercise; if you have diabetes, you want to reverse that. If you don't have diabetes, you want to maintain a healthy lifestyle, no smoking, minimize alcohol, following good food habits, good sleep habits. Whatever's healthy for the heart will be healthy for the prostate, it will be healthy for every organ. It'll be healthy for your brain, your healthy for your lungs, and so on and so forth. And so, anybody who finds himself, as we say in the United States, obese over BMI of 30, it's time to do a little bit of a recheck of your body, institute some health changes. Whatever's heart healthy will be prostate healthy.

As far as urinary issues are concerned, a man may still be very heart healthy, and yet as you get older, the prostate will inevitably grow. And then, you have urinary concerns. And there are lots of herbals available on the market for enlarged prostate and urinary symptoms. Some of them do have studies and research. Some of them are just generally thought of without a lot of research to help with the prostate. There's many of them. I don't promote any which one. Many patient's do take them. They can be taken in addition to regular diet and exercise and all types of other general health things that people do. But it's not a substitute for healthy lifestyle living. So, it can certainly help if somebody has urinary trouble, even if they're otherwise healthy.

Host: So in summary, Doctor, what's the most important takeaway for our audience about the link between TRT and PSA levels? What's job one here for the patient?

Matthew E. Karlovsky, MD, FACS: Job one is that there's no harm in investigating whether you're a good candidate for TRT, testosterone replacement therapy. Go to the urologist specifically because they'll have a mind's eye specifically on the prostate and the PSA. You can do a general health screening with your primary care doctor, or you can come to the urologist And we do those health screenings anyway. We're checking blood pressure, we're checking weight, we're checking all the blood work. That's the lead in to TRT. And we just want to monitor PSA, like we're monitoring cholesterol and other blood work in the process of taking testosterone replacement therapy, which is checking your blood work somewhere between every three to six months, depending on your general health. So, it just means keeping ahead of it. That's all.

Host: Folks, we trust you're now more familiar with TRT and PSA. Dr. Karlovsky, valuable information indeed. Thanks so much again.

Matthew E. Karlovsky, MD, FACS: Thank you so much.

Host: And for more information, please visit wickhosp, W-I-C-K-H-O-S-P.com/wickcaretalks. We hope today's discussion has provided you with valuable insights to support your wellbeing. Remember. Every step you take is a step toward a healthier life. To ensure you don't miss future episodes, please follow us on your favorite podcast platform and connect with us on social media as well. We appreciate you being a part of our community. Until next time, stay well.