Testosterone Replacement Therapy (TRT)

BY JEFFREY TURNER, MD


Testosterone (T) preparations have been available for more than 70 years.  In 2013, over 2.2 million Americans were prescribed testosterone.  Interestingly enough, about 1 in 4 men prescribed testosterone do not have a baseline testosterone level drawn as primary care physicians may write the prescription without ordering a blood test first.  In a study of 63,000 men from the Truven Health Marketscan Commercial and Medicare Supplemental Insurance database between 2010 and 2012, 71% of men had their testosterone level checked once, 40% twice, and 29% had no measurement at baseline.  Physicians need to do a better job following men on testosterone replacement. Is testosterone replacement therapy really all that good for anything aside from rejuvenation and virility? 

Let’s break this down to risks and benefits below:

Risks of Prostate Cancer

The most universal risk which has been the controversy of much discussion is the association with prostate cancer.  Clinicians remain concerned that Testosterone Replacement Therapy (TRT) can cause or stimulate prostate carcinogenesis and therefore they are reluctant to prescribe it for the aging male who has a higher risk of prostate cancer.  In the 1940s, Huggins and Hodges discovered the association of testosterone with prostate cancer by demonstrating that castration causes the disease to regress. The reality is that TRT may stimulate the growth of existing prostate cancer cells, but it will not cause cancer to form.  As the general male population grows, so does the risk for prostate cancer--patients should be closely evaluated with digital rectal examinations, PSA checks and prostate imaging such as color Doppler ultrasound.

Risk of Prostate Enlargement

Another controversial topic is the assumption that supplemental testosterone leads to a prostate growth, benign prostate hypertrophy, which leads to worse quality of life due to worsening urinary symptoms.  It has long been assumed that high T levels induce prostate overgrowth, but most studies failed to find the correlation between circulating T levels and BPH.  It has been hypothesized that dihydrotestosterone (DHT) could be more responsible for prostate growth than T.  There have been a number of studies evaluating TRT in hypo-gonadal men with BPH.  The results have suggested that there is actually a trend toward an improvement in urinary symptoms.

Risk of High Red Counts—Polycythemia or Erythrocytosis

Erythrocytosis is the increase in red blood cell mass production which can be the result of testosterone replacement therapy.  This is the most frequent adverse effect associated with TRT.  Recent trials have demonstrated that men on TRT have a 4 times higher chance of having high red blood cell counts.  Some reports have implicated excessively high red blood cell levels with an increased risk for heart attack or stroke. We commonly recommend patients remain on a baby aspirin daily and monitor their blood counts. Some patients may benefit by donating a unit of blood if the levels are too high.

Risk of Obstructive Sleep Apnea

Frequently reported in various literature is the association of worsening sleep apnea symptoms for men on testosterone replacement.  There has been only one randomized control trial to date that addresses this association and it showed that obese men with severe sleep apnea may worsen their oxygenation with TRT at relatively high doses.  This study evaluated injection formulations of testosterone. So far transdermal formulations have not been similarly implicated.

Risk of Infertility

Testosterone replacement leads to inhibition of the pituitary gland located at the base of the brain which can potentially suppress the production of sperm.  Hence, cases of TRT-induced male infertility have been reported. This impact appears to be transient and disappears once TRT is stopped.

Improved Sexual Function

A decreased libido and/or potency remains one of the most common reasons that men desire testosterone replacement.  TRT can certainly improve sexual function in those who have erectile dysfunction primarily due to a low level of testosterone.  Patients need to recognize that there are a series of other reasons for being impotent that are unrelated to low levels of testosterone which must also be investigated as well before concluding that TRT will be the optimal corrective measure.

Improved Cardiovascular Effects

The association of TRT with heart attacks has been very controversial. We must not forget that men with low T levels are at higher risk for poor health due to being more frail and susceptible to other medical issues including obesity and diabetes. As a result, they become more prone to adverse cardiovascular outcomes.  Four out of five of the most recent meta-analyses demonstrated neither a protective or harmful effect of TRT on cardiovascular events. In men with heart failure, it has been demonstrated that low T levels are an independent risk factor for worse outcomes.  Studies also demonstrated that men with heart failure who supplemented with testosterone had a better exercise capacity, oxygen levels, and less fatigue.

Improved Metabolic Effects

Large scale data exists to document the association of low T and worsening blood sugar levels along with a higher chance of developing diabetes. TRT can improve body composition and help to reduce fat which can lead to better control of diabetes.

Reversal of Osteoporosis

Lower testosterone levels are associated with a higher risk of bone fractures and worsening bone health.  TRT has been demonstrated to have a positive effect on bone mineral density.

Improvement in Chronic Kidney Disease

Low T is very common (approximately 50%) in men undergoing dialysis for end stage renal disease. Reduced T levels have in men on hemodialysis have been tied to higher rates of all-cause cardiovascular mortality.   Studies suggest that TRT may improve the levels of a hormone called erythropoeitin (EPO). This hormone stimulates improved production of red blood cells which in turn increases levels of red blood cell mass, energy, stamina, and overall well-being.

Conclusion

It is clear to see that testosterone replacement offers a multitude of benefits which span past merely increasing one’s libido or potency.  The bottom line remains that patients on testosterone supplementation must have close follow-up including both clinical and laboratory evaluation to ensure they are gaining benefit and not placing themselves at increased risk from potential adverse effects.  Physicians must clearly discuss the risks and benefits of supplementation along with employing routine monitoring of PSA, testosterone levels, blood counts, digital rectal examination, and color Doppler ultrasound. 

Metformin and Statins for Prostate Cancer

BY MARK SCHOLZ, MD

As an internist and an oncologist, throughout my long career treating prostate cancer patients, I have periodically been asked by patients, “What do you do?  Surgeons (urologists) operate, and radiation doctors give radiation, but what do prostate oncologists do?”  My day-to-day, bread and butter is giving medical advice and prescribing oral medications. Unfortunately, I think this leads to some patients seeing me as a “pill pusher.” As such, I think I need to explain my motives for recommending the use of metformin and statins to my patients with prostate cancer.

One of the things that the last 20 years of my career treating prostate cancer has taught me is that a good diet has a favorable effect on inhibiting prostate cancer progression.  What converted me from a nonbeliever to a believer?  My patients.  A number of men have come to me through the years whose PSA was rising after surgery and who subsequently embarked on stringent vegan or macrobiotic diets. Lo and behold, as long as they stayed on their diets their PSA levels would stabilize. Subsequently, T. Colin Campbell published a very convincing book called The China Study that evaluated the connection between increased animal protein intake and cancer rates.  His findings conclusively demonstrated that high animal protein intake increases cancer risk.

How can diet make such an impact?  We don’t have all the answers but there are some very logical suppositions.  First, cancer cells “hurt” people by the process of cellular multiplication, ultimately spreading throughout the body and causing organ malfunction. It’s logical to assume that “better fed” cancers, the ones that get plenty of protein and energy, will grow faster and better than cancers that are relatively deprived.  Animal protein not only provides all the necessary amino acids for the construction of new cells, animal protein is invariably accompanied by substantial amounts of a potent energy source—fat (People forget that the average hamburger is over 50% fats). High protein diets also increase the level of insulin in the blood. And high insulin levels drive sugar and protein uptake into the cancer cells, further promoting growth. And lastly, dietary cholesterol is not only a type of “fat,” but it is also a hormonal precursor, a building block for DHEA and testosterone.

Unfortunately, few of us have the ability to follow strict vegan diets. It’s a lot of work and requires constant self-denial.  Certain medications, however, can achieve some of the same effects. Metformin, a generic medication approved for the treatment of diabetes, suppresses insulin levels in the blood. Studies in diabetic men with prostate cancer who are treated with metformin have shown lower prostate cancer mortality rates compared to diabetic men who are treated with other types of diabetic medications besides metformin.  Statins pills, medications such as Lipitor and Crestor, dramatically lower cholesterol levels.  Numerous studies have reported higher cure rates in prostate cancer patients receiving radiation who are treated with statins compared to radiation-treated patients who don’t receive a statin.

Regular exercise prolongs life in cancer patients.  If we had a pill that could accomplish what exercise can do—improved energy levels, sleep, digestion, memory, longevity and less depression—everyone would take it.  Many patients are lukewarm about prescription pills like metformin and statins, probably mainly due to concerns about side effects.  But side effects can be anticipated with careful monitoring.  When a medication side effect occurs it can be detected early and when the medication is stopped the problem is almost always resolved.  Following a rigorous macrobiotic diet for the rest of your life is beyond the reach of most of us. Taking an FDA-approved pill, while using careful precautions against potential side effects, is achievable for almost all of us. 

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Testosterone for Men and Women

BY MARK SCHOLZ, MD

Testosterone is really cool. It improves concentration, energy, strength, and libido. Both men and women experience enhanced performance with higher testosterone levels.  The problem is that testosterone tends to decline with age.  Also, testosterone-blocking therapy to treat prostate cancer can have lingering effects, even after the treatment is stopped.  For women, testosterone levels often decline sharply after menopause.

Low testosterone causes many undesirable effects including muscle atrophy, weight gain, tiredness, osteoporosis, low libido and impotence.  Absent testosterone in women* is usually a secondary effect of menopause, so it usually occurs in conjunction with low estrogen. In women the loss of estrogen and testosterone causes weight gain, tiredness, osteoporosis vaginal atrophy and low libido.

Judicious administration of testosterone in men and a combination of estrogen and testosterone in women, can dramatically improve quality of life. Bioidentical hormone therapy is the term often used by the doctors who specialize in this area.  The idea is to restore hormone levels back to normal.

Risks of Testosterone Therapy
As might be expected, like any powerful tool, misuse of testosterone can be dangerous. Administering testosterone in men with prostate cancer is controversial (see below).  However, there are also risks even in men without prostate cancer.  One reason is that when testosterone is administered to men estrogen levels also rise.  Higher estrogen in men may increase the risk of heart attacks and strokes. Therefore, estrogen levels should be monitored and compensatory treatment with Femara®, an estrogen blocking pill, may be necessary in some cases.

In men, testosterone may also cause an excessive increase in the red blood cell count (RBC). Overly high RBC levels have also been linked to higher risks of heart attack or stroke. The RBC count, therefore, needs to be monitored by measuring the hematocrit, a component of the complete blood count (CBC). If the hematocrit rises above 50% men should consider lowering their testosterone dosage or undergoing a phlebotomy (donating a unit of blood).  In women, excessive amounts of testosterone can cause masculinization.  Estrogen replacement also slightly increases the risk of breast and uterine cancer.  Obviously a full discussion of all the risks and benefits is essential before starting treatment.

Administering bioidentical hormones is as much an art as a science. The hormones themselves are delivered in the form of creams, pills or shots. Studies show that the measurement of hormone levels in the blood stream or in saliva is moderately helpful for guiding the selection of an appropriate dosage. A better indication of proper dosage, however, is the subjective sense of well-being reported by the person receiving the treatment. Therefore, starting hormone therapy should proceed slowly with an incremental escalation of dose while closely observing for the appearance of side effects.

Giving Testosterone to Men with Prostate Cancer
Denying every man with a history of prostate cancer from receiving testosterone is ridiculous. Studies clearly show that about half the men in their 50s and almost all men in their 80s harbor minor forms of prostate cancer; most is low-grade and harmless.  Almost all of these men have substantial testosterone coursing through their blood (from their testicles).  They seem to do just fine. As long as men are regularly screened to ensure the absence of clinically significant prostate cancer, the risks of restoring low levels of testosterone back to normal should be quite low.

Living Longer and Living Better
Just in our lifetimes we are observing a dramatic enhancement of human longevity.  When I was in oncology training at USC just twenty-five years ago, the attitude toward a patient’s death while in his in early 70s would have been, “He lived a full life.”  That attitude is no longer accepted.  Now men and women are not only living longer, they are retaining substantial youthfulness into their 80s. As part of an overall health program that includes diet, exercise and appropriate healthcare, restoring sex hormone levels back to normal can be transformational.  Since giving small amounts of testosterone to females is a foreign idea to many people, in my next blog I will elaborate on this concept further.

* Premenopausal women normally have testosterone in their blood, albeit at much lower levels than men.

The Lowdown On Testosterone Supplement and Low T

BY RALPH BLUM

Low testosterone or “low T,” also called hypogonadism, affects millions of aging men. Testosterone levels normally peak in a man’s 20s, then fall by 1% to 2% per year. Indisputably, low T is responsible for reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, and diminished muscle mass and bone density.  As the poet T.S. Eliot reminded us, time the healer is also time the destroyer.

Men through the ages have tried outlandish cures for impotence, including chewing the roasted penis of a wolf! More recently they have plunged the family jewels into cold baths, choked down heaping spoonfuls of wheat germ, swallowed vitamins and most recently stockpiled Viagra.

When, in 1939, two scientists shared the Nobel Prize for Chemistry for their work in isolating and identifying testosterone, the mad rush for injected, implanted, inhaled or absorbed versions of the hormone began, promising, in the words of one product’s pitch, “power, performance, passion.”

In 2013, U.S. sales of testosterone reached $2.4 billion. According to Global Industry Analysts, the market is projected to swell to $3.8 billion by 2018. Moreover, in 2013, 7.5 million prescriptions for testosterone were written. And all this is happening without explicit FDA approval. There have been few, if any, large, randomized studies on the long-term risks or benefits of testosterone supplementation. Some maintain that we are undergoing a massive science experiment with unknown risks. But foggy science has not deterred Big Pharma from spending untold millions to encourage those of us who are wan, limp and flabby to climb onto the low T bandwagon.

Meanwhile, the most heated debate is centered on whether testosterone fuels prostate cancer. Not long ago, the consensus was that, as far as prostate cancer cells were concerned, testosterone was nature’s perfect food. It was like spinach to Popeye. Suppressing the hormone is still a standard part of treating the disease. But attitudes are changing.

The debate goes something like this:  If it’s true that testosterone fuels prostate cancer, why do most men develop the disease when they are older and their testosterone levels are dropping?  Others, however, point out that when men take hormone therapy that virtually stops the production of testosterone, tumors regress. So wouldn’t the opposite be true--adding testosterone should be expected to accelerate tumor growth? I personally believe that my episode of hormone treatment—monthly Lupron injections over a 15 months’ period—helped to delay the growth of my non-aggressive cancer for many years.

So far a few small studies of using testosterone in men with prostate cancer have shown fairly positive results. For example, men who had been treated for prostate cancer and who then received testosterone therapy did not appear to have an increased risk of recurrent disease. But it’s impossible to make broad, generalized statements based on these studies. Chances are the result will depend on a number of variables, not the least of which is the seriousness of the cancer. It seems likely that a man with low-risk of disease recurrence would also have low-risk of testosterone creating a problem. Therefore, it would seem ridiculous to deny that man testosterone when it would improve his quality of life.

There has been a major push for reconsidering testosterone therapy from the large population of men who have been treated for prostate cancer over the last 10-25 years. No surprise there. Which of us wouldn’t prefer to be firm and sharp rather than soft and dull? But remember, marketers are spending millions to raise our expectations, and testosterone is not a silver bullet.

In September, the FDA is gathering a group of experts for a T summit. But it’s doubtful if they will clarify a topic that has more guesses and theories than real answers based on reliable information. Bottom line it is our decision when the conditions are right to use testosterone, and when to refrain. As the old saying goes, “You pays your money and you takes your choice.”

Introduction to Hormone Therapy for Prostate Cancer

BY MARK SCHOLZ, MD

Testosterone is the primary male hormone. It comes mostly from the testicles and to a lesser degree, from the adrenal glands. Testosterone causes the common male characteristics such as bigger muscles, facial hair growth and increased sex drive. Testosterone is also essential for prostate cancer to grow.

 

Why Blocking Testosterone Kills Prostate Cancer

The prostate gland, located near the bladder, makes semen. Prior to puberty the gland is only the size of a peanut. However, when the testicles begin making testosterone, the prostate comes to life and grows to the size of a walnut. The cells of the prostate, therefore, require testosterone to proliferate. Since prostate cancer originates from the prostate gland, the cancer also depends on testosterone.

 

Hormonal therapy works by blocking testosterone. When prostate cancer cells are deprived of testosterone they commit suicide in a cell death process called apoptosis.  The amount of cell death in early-stage prostate cancer is usually dramatic.  Not uncommonly, when men are pretreated with potent forms of hormonal therapy, there is no residual cancer after surgery. More typically, there is a dramatic reduction in the number of cancer cells, but not total elimination of the cancer.

 

The mechanism for testosterone to stimulate cancer growth occurs through the activation of a multifaceted protein called the androgen receptor.  Before binding with testosterone the androgen receptor is inactive. Once the receptor comes into contact with testosterone, the activated androgen receptor is transported into the nucleus of the cell where it stimulates DNA.  As a result, a plethora of cell-growth-enhancing proteins are synthesized that stimulate cancer growth and progression.

Hormone Therapy Comes in Many Form
Prior to the advent of modern medications, hormone blockade was accomplished by surgical castration. These days, testosterone is blocked with shots or pills. Agents that block testosterone by inhibiting the pituitary gland are Lupron, Zoladex, Firmagon, Eligard and Trelstar.  Medications that work by interposing themselves between testosterone and the androgen receptor to block its activation are Casodex, Nilutamide or Flutamide.  A third milder type of hormonal agent, the 5-alpha-reductase inhibitors, such as Avodart and Proscar, work by inhibiting the chemical conversion of testosterone into its more potent form, dihydrotestosterone (DHT).

Recently the FDA approved two new, and more potent, hormonal agents, Zytiga and Xtandi. Their increased anticancer efficacy was demonstrated through prolonged survival in men whose cancer became resistant to Lupron. Zytiga and Xtandi work by different mechanisms. Zytiga inhibits cancer cells from making their own testosterone. Xtandi works by blocking the activity of the androgen receptor.

The Nitty Gritty of Treatment Selection
The most potent anticancer action is achieved through complete blockade with agents from different functional classes administered together for a prolonged period of time. Therefore, the variables that affect the intensity of hormone blockade treatment are:  1. the type of medicine; 2. how many medicines are used; and 3. how long the medications are continued.  Of course, medical skill and experience is required to fine-tune the selection and duration of therapy.  Nevertheless, here is a brief presentation of some rough guidelines.
 

1.    A short course, say three to four months, to shrink the prostate or to improve cure rates in men with intermediate-risk disease (Teal Shade of Blue) undergoing radiation

2.    A short course of four months to improve cure rates with radiation in men with intermediate-risk disease (Teal Shade of Blue)

3.    An intermediate course (6-12 months) for treatment for intermediate-risk disease (Teal Shade of Blue) as a sole form of therapy

4.    A long course (18-24 months) to improve cure rates in men with high-risk (Azure Shade of Blue) prostate cancer undergoing radiation

5.    An intermediate to long course in conjunction with radiation to improve cure rates in men with a rising PSA after surgery (Indigo Shade of Blue) who are undergoing salvage radiation

6.    Intermittent use to suppress a rising PSA after surgery or radiation (Indigo Shade of Blue)

7.    Intermittent or continuous use to treat men with metastatic disease (Royal Shade of Blue)

8.    Salvage treatment with Xtandi or Zytiga to control disease in men on Lupron who have progressive disease (Royal Shade of Blue) 

Over the last ten years the medical community has been roiled by the discovery that some forms of prostate cancer are truly harmless, raising a serious concern about men receiving surgery and radiation they don’t need. However, overtreatment with hormone therapy also occurs. The overriding goal is to use a hormone therapy approach that achieves a maximum anticancer benefit while minimizing side effects as much as possible. Treatment always has to be personalized so the intensity and duration of treatment is appropriate for each individual’s specific situation.

Two “Positive Side Effects” of Prostate Cancer

BY RALPH BLUM

There is an aspect of being diagnosed with prostate cancer that has proved to be, for many men, quite literally, a life-saver, and that is being compelled to undergo a physical. For example, men who had always avoided getting regular physical exams learned that they had dangerously clogged arteries, making that checkup, literally, a life saving event. So that although prostate cancer is no day at the beach, and every treatment comes with a stiff price, there can be unexpected benefits. What I think of as “positive side effects.” Getting a check-up is one such.

The second positive side effect concerns the loss of sexual drive. Aka the loss of libdo. So is there life without libido? Wrong question. Better ask, “After a life lived entirely with sex as your objective, what happens when your libido is gone?”

I spent 24 months with no libido. When I was diagnosed with prostate cancer, given my aversion to being sliced open, fried by radiation, or poisoned by chemotherapy, my choice of treatment was hormone blockade. At the same time, I was far from enthusiastic about becoming a chemical eunuch. So instead of the suggested three drug protocol—Proscar, Casodex, and Lupron—with the approval of my oncologist, Mark Scholz, I decided on “monotherapy,” a single drug treatment with Lupron. In less than four weeks my PSA had dropped from 18 o 5.3, so I knew that the Lupron was working. With no testosterone, however, my libido was zip. Nada.

A fate worse than death, right? Wrong. To my surprise, I didn’t feel defeated or “less of a man.” I realized it was not the end of the world. In fact, if not getting my libido back is my fate, well and good. Been there, done that. And then I got another big surprise: Being in this unfamiliar, hormonally uncharged space, permits a freedom I had not experienced during over half a century of full-blown libido. And a much richer emotional life with my partner. A new kind of intimacy.

In his play, Testosterone: How Prostate Cancer Made a Man out of Me, Hal Ackerman confessed that when he was on hormone blockade he found women’s bodies about as exciting as covered furniture. But through the wonders of Big Pharma, Ackerman discovered that having sex, love-making without libido, was a completely different and very rewarding experience: During their love-making, he focused totally on his partner’s pleasure instead of on his own.

When I was doing research for Invasion of the Prostate Snatchers, I interviewed a number of men who expressed their own surprise as the result of having no libido. As one man put it, “Remove the ‘slam-bam-thank-you, Ma’am’ routine and what’s left? I guess you could call it taking pleasure in giving pleasure.”

Now there’s a positive side effect if there ever was one.

Avodart & Proscar for Men on Active Surveillance

BY MARK SCHOLZ

More and more men are embarking on active surveillance—close monitoring of their prostate cancer—rather than implementing immediate radical therapy. Of course, only individuals with carefully selected low-grade prostate cancer are eligible for this approach. During the extended observation period many men enquire if there are nontoxic interventions to improve their odds that the cancer will stay dormant. The important issue of diet often arises though that is not the subject of today’s topic. Hormonal treatment, on the other hand, is a treatment that calls for further discussion.

Targeted Hormone Blockade

Blocking testosterone production with testosterone inactivating pharmaceuticals (TIP) is an amazingly effective anticancer maneuver unique to prostate cancer. However, TIP is generally reserved for treating the more aggressive types of prostate cancer since it has potentially unpleasant side effects like impotence, weight gain and reduced muscle strength.  However, there is a way that hormonal therapy can be targeted to specifically block testosterone activity inside the prostate while sparing the rest of the body from negative side effects. Proscar and Avodart—both FDA-approved medications to shrink the prostate gland function by this very mechanism. They block a special form of testosterone called dihydrotestosterone (DHT) that only occurs inside the gland.  The general public is familiar with these medications due to their ability to reduce the size of the prostate gland and ameliorate a common problem familiar to aging men:  the need to get up frequently at night to urinate.  Yet thanks to their lowering effect on DHT, these drugs also have anti-cancer effects.   

The Benefits of Proscar and Avodart for Fighting Prostate Cancer

The effect of Proscar and Avodart against cancer have been evaluated in several double blind placebo controlled trials.  In one trial 18,000 men¹ were treated with Proscar or placebo for seven years. Ten thousand of these men then underwent a prostate biopsy. The Proscar treated men were 25% less likely to be diagnosed with prostate cancer, compared to the men treated with placebo. In two other double blind placebo controlled trials, Avodart was also shown to reduce the risk of a prostate cancer diagnosis by about 22%.^2,3

More recently, in a study reported in abstract form at the American Society of Clinical Oncology in March this year, 302 men on active surveillance were given either Avodart or placebo for 3 years. As is typically the case with men on active surveillance, repeat prostate biopsies were performed 18 and 36 months after the initial diagnosis to determine if the cancer was progressing.  Men who received Avodart had a progression rate that was 38% less than the men on placebo.

Another study published in European Urology retrospectively evaluated 288 men on active surveillance who received Avodart or Proscar that were compared to men who received neither.  After three years of observation, the biopsy progression rate was 50% lower—18% for the men on treatment vs. 36% for the men on no treatment.⁴

Is There a Downside Risk?

Given that Avodart and Proscar lower PSA by about 50%, the question becomes: “Are they masking the capacity of PSA to detect cancer progression?”  The answer is no.  PSA still rises in men with progressive disease.  In fact, studies show that Avodart and Proscar improve the accuracy of the PSA monitoring process, enhancing the likelihood of detecting High-Risk cancer.⁵  The standard approach in our practice is to offer Avodart or Proscar to all our patients on active surveillance. 

When taking these pills, about one out of five men will notice a modest reduction in their sex drive.  This reduction in libido may fade away after a few months with continued treatment.  Even so, if a reduction in libido occurs, we often simply advise stopping the medication since these medications are not essential to the active surveillance approach but rather an optional enhancement.

References

1. Ian Thompson, The influence of finasteride on the development of prostate cancer. The New England Journal of Medicine, July 2003.
2. Gerald Andriole, Effect of dutasteride on the detection of prostate cancer in men with benign prostatic hyperplasia. UROLOGY, 2004.
3. Gerald Andriole, Further analysis from the REDUCE prostate cancer risk reduction trial. The Journal of Urology, April 2009.
4. Antonio Finelli, Impact of 5-Alpha-Reductace inhibitors on men followed by active surveillance for prostate cancer.  European Urology, Vol. 59; 509.
5. Ian Thompson, Effect of finasteride on the sensitivity of PSA for detecting prostate cancer. Journal of the National Cancer Institute, August 2006.