Treatment options

Treatment options for low testosterone

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, at a reasonable cost. 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 replacement therapy is long term, it is important that it is convenient, safe and effective. 

Adherence to testosterone therapy thumb

1 Februrary 2015

Adherence to testosterone therapy – Short term treatment is not sufficient for achievement of maximal benefits

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    What treatments are available?

    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.

      Depot injection therapy

      Depot Injection Therapy

      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)

      Long-acting injection therapy

      Long-acting Injection Therapy

      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)

      Implant therapy

      Implant Therapy

      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

      Gels

      Gels

      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

      Patches

      Patches

      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

      Oral therapy

      Oral Therapy

      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

      How is testosterone treatment monitored?

      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.

      What are the benefits of treating low testosterone?

      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.

      Figure 1: Actions of Testosterone in an adult male

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

      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.

      What are possible side effects of testosterone therapy?

      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.

      Recommendations

      Do you have symptoms of low testosterone?

      Precautions

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