A recent case of a 51 year old male with an interest in testosterone replacement illustrates the benefits of the multi-parametric prostate MRI scan. Noting a PSA value of only ng/ml; the digital rectal exam (DRE) identified an area of interest on the left side, albeit, it was not definitive for prostate cancer. Neither the gray scale ultrasound nor Color Flow Doppler ultrasound evaluation suggested any specific abnormality consistent with the area of interest previously identified on DRE. An MRI scan was suggested as the next best step in the evaluation. The scan isolated a region of interest on the left side at the Apex to Middle portion of the prostate gland concordant with the findings on the DRE. Based upon the findings of the MRI scan, a targeted biopsy with 6 needle cores was recommended and implemented. An Antiandrogen was initiated pre-biopsy to mitigate against “needle tracking”. Specifically, an Antiandrogen selectively blocks the receptor on the prostate cell from attracting testosterone as it exits the capsule, thereby, disabling the cells in preparation for cell death or apoptosis. The Pathology evaluation revealed a grade of cancer that was amenable to being treated conservatively or focally. In this case, the failure to use a MRI scan would have exposed this patient to the possibility of missing the cancer altogether; associated with sampling bias, a very real possibility for needle tracking (assuming cancer was found), or worse yet, the go ahead to supplement with testosterone, when in fact, the cancer was missed. Using testosterone in this scenario would have stimulated cancer cells to grow wildly, while causing the PSA to spike abnormally, thereby, making the diagnosis of prostate cancer – a potentially uncontrollable clinical event, albeit, avoidable. Given the expertise of a Urolologic consultation, this case turned out well. The patient is now contemplating a focal treatment with high intensity focused ultrasound with a plan to supplement with testosterone once his cancer has been cured. An inability to document the resolution of prostate cancer by a repeat MRI scan and/or a stable PSA post-operatively will preclude this patient from using testosterone replacement therapy.
Estradiol's efficacy seems to vary widely with the person and the particular vehicle: I was on transdermal patches for two years ( , 2 patches changed twice weekly – considered a "high" dose of 17-beta estradiol), and my levels mostly stayed around 100 pg/mL, and I needed 100mg spironolactone daily to keep my testosterone down. When I switched to injections of Estradiol Valerate, as I was "titrating up" my testosterone was unmeasurably low at the same E2 level my patches were delivering. (I had decided to drop spiro at the same time due to it's side effects: for me it seemed to be fogging my brain and inducing suicidal ideation.) Increasing the dosage had the effect of adding a cup-size to my breasts after about two months of injections, after two years of HRT, at age 53 and with b-cup breasts already. This story is not unusual in the community, and it led me to try this form of HRT.