PSA and testosterone: what is checked before starting hormone treatment

Before starting testosterone treatment, the check-up is not just a matter of ordering a PSA test. The guidelines and the summaries of product characteristics in Spain stress something more basic: first confirm that there is genuine hypogonadism, with compatible symptoms or signs and low testosterone shown in appropriate blood tests, ideally repeated. On top of that, the prostate, haematocrit, plans to have children and other possible causes of the symptoms all need to be reviewed.

You do not start with the PSA: the diagnosis has to be confirmed first

The main guidelines agree that testosterone should not be used simply because of tiredness, low sex drive or a single striking blood result. The Endocrine Society recommends using it in men with compatible symptoms or signs and biochemical confirmation of low testosterone in appropriate blood tests, ideally repeated. In Spain, the summary of product characteristics for Testogel takes the same line: hypogonadism must have been demonstrated and other causes of the symptoms must have been ruled out, with confirmation through two separate blood testosterone measurements.

This matters because many symptoms are non-specific. If you want to understand which symptoms are genuinely telling and when they fit with a hormone deficiency, this guide to low testosterone and its real symptoms may help.

What is checked before starting testosterone

According to the EAU, before treatment the following should be assessed: sexual and general symptoms, plans to have children in the near future, prostate history, lower urinary tract symptoms and comorbidities such as sleep apnoea, heart failure or thrombotic or cardiovascular risk.

In practice, a key part of that review concerns the prostate. The EAU states that baseline PSA and a baseline digital rectal examination should be checked before starting, and that if the PSA or the examination suggests risk, a urological assessment is recommended before treatment begins. This avoids reducing prostate screening to a single number and helps interpret the full clinical context.

Red blood cells are also checked. The AUA requires a baseline haemoglobin or haematocrit value before starting, and the EAU considers a haematocrit of 54% or higher an absolute contraindication to testosterone treatment. This is no minor detail: it is why blood monitoring is part of the process from the outset.

High PSA or a suspicious examination: what the guidelines say

The Endocrine Society recommends not starting testosterone in men with prostate or breast cancer, a palpable prostate nodule or induration, a PSA above 4 ng/mL, or above 3 ng/mL in men at high risk of prostate cancer, without further urological evaluation. Put simply, a result or an examination that suggests risk does not automatically mean a definitive conclusion, but it does mean it should be clarified before starting.

During the first year, the same guideline recommends urological referral if there is a confirmed PSA rise of more than 1.4 ng/mL above baseline, a confirmed PSA above 4.0 ng/mL or an abnormality on digital rectal examination. This ties in with another important idea: prostate monitoring does not end on the day treatment is prescribed, but continues afterwards.

Does testosterone make the prostate less safe?

Based on the evidence cited, it cannot be stated that testosterone has been shown to cause prostate cancer. The trial by Bhasin and colleagues, published in 2023 in JAMA Network Open, studied men with hypogonadism and a baseline PSA below 3.0 ng/mL. There were 12 prostate cancers among 2,601 men in the testosterone group, compared with 11 among 2,603 on placebo, with no significant difference.

Small changes in PSA were observed, however. At 12 months, the mean difference between the groups was +0.15 ng/mL, reflecting a greater rise with testosterone. In addition, 37 men had a confirmed PSA rise of more than 1.4 ng/mL in the first year: 25 on testosterone and 12 on placebo. That is precisely one of the reasons why the guidelines insist on measuring the baseline value and monitoring how it changes.

Fertility, secondary causes and other checks that are sometimes forgotten

Another key point is fertility. External testosterone can suppress sperm production, and the EAU considers it an absolute contraindication in men actively wanting to have children. If that is the situation, the initial conversation changes completely. Here it may help to understand the differences between enclomiphene and clomiphene to raise testosterone without affecting fertility and testosterone therapy and what to expect from it.

Moreover, not all hypogonadism is managed in the same way. The EAU recommends a pituitary MRI scan in severe secondary hypogonadism or if there are findings suggesting a pituitary lesion. In other words, the preliminary check-up sometimes looks not only at whether someone can start treatment, but also at why the problem has arisen.

Which preparations are available in Spain and what their summaries of product characteristics remind us

In Spain, CIMA/AEMPS lists authorised presentations such as Testogel 50 mg transdermal gel in sachets, Testavan 20 mg/g transdermal gel and injectable testosterone undecanoate 1000 mg/4 ml. Their summaries of product characteristics share consistent regulatory points: indication in male hypogonadism confirmed clinically and biochemically, contraindication where prostate or breast cancer is suspected or confirmed, the need for regular prostate monitoring with digital rectal examination and PSA, monitoring of haematocrit or haemoglobin, a warning about suppression of sperm production and, for the gels, caution about possible skin transfer to other people.

If you are comparing options, this explanation of testosterone gel versus injection helps clarify what changes depending on the route of administration.

What to take away

The central idea is simple: before starting testosterone, what is checked is not just a PSA but a complete diagnosis and a safe starting point, with particular attention to the prostate, haematocrit and fertility. In Spain today there is medical treatment for men's hormonal health with a prior assessment, a prescription where appropriate from a registered doctor and ongoing follow-up. If you want to take the first step, you can check in a few minutes whether the treatment suits your case.