Treatment options

Treatment of low testosterone is quite straightforward. Once the decision has been made to increase testosterone levels, low testosterone can be replaced by using one of a number of treatment options. All of these treatment options require a doctor’s prescription. An ideal preparation of testosterone will bring testosterone levels back into the normal range to reverse the symptoms of low testosterone. It will also be safe and offer a convenient dosing schedule and means of administration.

Several months of treatment may be required before changes are apparent. The general recommendations are to raise the blood testosterone level only into the middle of the normal physiological range. As testosterone therapy is long term, it is important that it is convenient, safe and effective.

Testosterone effects tool


Visualisation of the time course for onset of the many beneficial testosterone effects.

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    The different formulations of testosterone currently available as treatments for low testosterone include injections (short- and long-acting), gels, patches and implants. Oral capsules or pills are also available but may not be as reliable as other formulations. 

    The table below provides an overview about available methods, the ways they are used and their advantages and disadvantages.

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      Way used:

      Injected deep intramuscularly (IM) every 1 to 4 weeks (usually in the buttocks)

      • Advantages
        • Testosterone absorbed directly into bloodstream
      • Disadvantages
        • Requires regular IM injections
        • Fluctuating levels of testosterone with high initial levels
        • Mood swings as testosterone levels rise and fall ("roller coaster" effect)
        • Local pain on injection
        • Abscess formation (rare)
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      Way used:

      Injected IM every 3 months following an initial loading dose to stabilise testosterone levels

      • Advantages
        • Testosterone absorbed directly into blood stream
        • Infrequent dosing
        • Provides a steady level of testosterone
        • Avoids peaks and troughs over the day
        • Fewer adverse events such as mood swings or blood changes
      • Disadvantages
        • Local pain on injection
        • Abscess formation (rare)
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      Way used:

      Injected IM every 3 months following an initial loading dose to stabilise testosterone levels

      • Advantages
        • Infrequent dosing - usually required twice a year
        • Testosterone levels remain stable for up to 6 months as the pellets are slowly absorbed
      • Disadvantages
        • May be pain and/or local infection at the site where pellets are inserted
        • Special equipment and minor surgical procedure required
        • Occasionally a pellet is expelled by the body
        • Scars after pellet removal
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      Way used:

      A clear testosterone gel rubbed onto the shoulders, chest or back once a day – dries within a few minutes. Testosterone is released steadily from the skin into the bloodstream over a 24-hour period

      • Advantages
        • Convenient sites of application
        • Quickly normalizes testosterone levels
        • Stable blood levels of testosterone throughout the day
        • Less skin irritation than patches
        • No operation needed
      • Disadvantages
        • Skin irritation may be a rare side effect
        • Potential for transfer to partner or child
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      Way used:

      Applied to various areas of the skin (generally on a non-hairy part of the upper body)

      • Advantages
        • Efficient – steady absorption of testosterone over 24 hour period
      • Disadvantages
        • May not achieve levels of testosterone as effective as other preparations, such as gels
        • High chance of skin irritation
        • May be inconvenient to apply and can be dislodged
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      Way used:

      Forms of testosterone taken orally as pills or capsules – not recommended for long-term replacement of testosterone

      • Advantages
        • Convenient
      • Disadvantages
        • Considerable variation in absorption of dose
        • Should be taken with a fat-containing meal
        • Testosterone has to be in an altered form so that it is not broken down by the liver
        • One such form (testosterone undecenoate) has to be taken 2 or 3 times a day to maintain adequate levels
          Another form (methyl testosterone) produces harmful side effects including liver damage and elevated cholesterol levels

      A blood sample taken a few weeks after the start of treatment is used to measure levels of testosterone in order to check that the right amount of hormone is achieved. Regular blood tests are required to monitor testosterone levels and ensure rare but potentially serious side effects of treatment do not develop.

      The benefits of testosterone replacement on sexual function, fat and lean body mass, blood lipids and bone density in men with low testosterone are clear. The potential benefits of testosterone replacement in reducing the risk of cardiovascular disease, metabolic syndrome and diabetes are still being investigated.

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      Figure 1: Actions of Testosterone in an adult male
      You can discuss with your doctor how testosterone therapy may benefit you.

      Psychological


      • improves mood, energy, wellbeing and quality of life
      • prevents depression

      Cardiometabolic


      • improves blood sugar control (Reduces blood sugar levels)
      • reduces risk of metabolic syndrome and type 2 diabetes
      • reduces risk of heart disease and death

      Sexual


      • controls sexual function (sex drive, erectile function, orgasm)
      • reduces lower urinary tract symptoms (LUTS)
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      Physical


      • increases muscle mass
      • increases strength
      • decreases overall body fat mass
      • decreases belly (visceral) fat mass
      • increases bone mineral density

      Blood


      • prevents anemia

      Health and well-being – quality of life

      Improvements in signs and symptoms of low testosterone, such as libido, sexual, physical and mental functioning and mood, can be expected over time and will show you that the treatment is working.

      Body composition

      Testosterone replacement in men with low testosterone increases lean body mass and strength and decreases fat mass.

      Cardiovascular risk

      Current evidence suggests that testosterone replacement in men is relatively safe in terms of cardiovascular health and does not cause important cardiovascular side effects. Indeed, there is some evidence that testosterone replacement is beneficial for cardiovascular disease and may continue to improve cardiovascular risk factors over time. Evidence is emerging that testosterone may protect against clogging or hardening of the arteries (atherosclerosis).

      Diabetes

      Testosterone therapy may also have metabolic benefits in men with diabetes and/or metabolic syndrome. Men with diabetes have been shown to have substantially lower testosterone levels than men in the general population, yet low testosterone in many remains undiagnosed and untreated. It is not yet fully known whether diabetes is a cause or a consequence of low testosterone. However, some studies have shown testosterone replacement therapy has a beneficial effect on risk factors for diabetes such as central obesity, insulin sensitivity, glucose control and blood lipid profiles in men with low testosterone.

      Bone

      Low testosterone can lead to thinning of the bones (osteoporosis) and men with hip fractures tend to have low testosterone. Testosterone replacement increases bone density.
      If low testosterone occurs during adulthood, you can make some lifestyle and dietary changes to help prevent osteoporosis. Regular exercise and adequate amounts of calcium and vitamin D help to maintain bone strength and are important to reduce the risk of osteoporosis.

      As long as the blood levels of testosterone are kept within the normal range, side effects are uncommon. Occasional side effects may include:

      • Skin reactions, such as spots on the back or chest. These may appear when first starting treatment and usually subside spontaneously
      • Frequent or sustained painful erections may occur in isolated cases. If these occur, your doctor will reduce the dosage or discontinue treatment
      • Changed behaviour possibly leading to aggression may occur in rare cases
      • Blood thickening caused by overproduction of red blood cells (erythrocytosis) may require temporary interruption of treatment
      • Liver disturbances (very uncommon except with oral preparations of testosterone)
      • Worsening of sleep apnoea or new cases of sleep apnoea in men with marked obesity or chronic obstructive lung disease
      • Fluid retention sometimes occurs with high doses or prolonged treatment
      • Gynaecomastia (a condition in which the male's breast tissue enlarges) can sometimes occur at the beginning of treatment, and usually diminishes as treatment continues

      Testosterone has a wide margin of safety and side effects tend to be rare, so you may never experience any of these effects. If any do cause you concern, discuss them with your doctor.

      The benefits of testosterone replacement

      The benefits of testosterone replacement on sexual function, fat and lean body mass and bone density in men with low testosterone are clear. The potential benefits of testosterone replacement in reducing the risk of cardiovascular disease, metabolic syndrome and diabetes are still being investigated.

      Blood


      • Prevents anaemia

      Sexual


      • Controls sexual function (sex drive, erectile function, orgasm)
      • Reduces lower urinary tract symptoms (LUTS)
      What are the benefits of treating low testosterone?

      Psychological


      • Improves mood, energy, wellbeing and quality of life
      • Prevents depression

      Physical symptoms


      • Increases muscle mass
      • Increases strength
      • Decreases overall body fat mass
      • Decreases belly (visceral) fat mass
      • Increases bone mineral density

      Health and well-being – quality of life

      Improvements in signs and symptoms of low testosterone, such as libido, sexual, physical and mental functioning and mood, can be expected over time and will show you that the treatment is working.

      Body composition

      Testosterone replacement in men with low testosterone increases lean body mass and strength and decreases fat mass.

      Diabetes

      Testosterone therapy may also have metabolic benefits in men with diabetes and/or metabolic syndrome. Men with diabetes have been shown to have substantially lower testosterone levels than men in the general population, yet low testosterone in many remains undiagnosed and untreated. It is not yet fully known whether diabetes is a cause or a consequence of low testosterone.

      Bone

      Low testosterone can lead to thinning of the bones (osteoporosis) and men with hip fractures tend to have low testosterone. Testosterone replacement increases bone density.

      If low testosterone occurs during adulthood, you can make some lifestyle and dietary changes to help prevent osteoporosis. Regular exercise and adequate amounts of calcium and vitamin D help to maintain bone strength and are important to reduce the risk of osteoporosis.

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      References

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      • Dohle GR, Arver S, Bettocchi C, Jones TH, Kliesch S, Punab M. 2017 EAU Guidelines on Male Hypogonadism. Return to content
      • Dean JD, McMahon CG, Guay AT, et al. The International Society for Sexual Medicine's Process of Care for the Assessment and Management of Testosterone Deficiency in Adult Men. The journal of sexual medicine. 2015;12(8):1660-1686. Return to content
      • Morales A, Bebb RA, Manjoo P, et al. Diagnosis and management of testosterone deficiency syndrome in men: clinical practice guideline. Appendix available at: http://www.cmaj.ca/content/suppl/2015/10/26/cmaj.150033.DC1/15-0033-1-at.pdf (accessed Jan 10, 2016). CMAJ. 2015;187(18):1369-1377. Return to content
      • Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010;95(6):2536-2559 Return to content
      • Morgentaler A, Zitzmann M, Traish AM, et al. Fundamental Concepts Regarding Testosterone Deficiency and Treatment: International Expert Consensus Resolutions. Mayo Clin Proc. 2016;91(7):881-896 Return to content
      • Saad F, Aversa A, Isidori AM, Zafalon L, Zitzmann M, Gooren L. Onset of effects of testosterone treatment and time span until maximum effects are achieved. Eur J Endocrinol. 2011;165(5):675-685