My testosterone level is low. Should I receive supplemental testosterone?
At this point in time, the prime indication (rationale) for testosterone supplementation is a low testosterone level associated with decreased libido. In this context, improving the testosterone level will improve libido. If the testosterone level is normal, there is no advantage to additional testosterone. “Supercharging” you won’t necessarily improve your libido.
What are the benefits and risks of testosterone therapy?
The main benefit of testosterone therapy is the improvement in serum testosterone level and consequently increased libido. Other theoretical benefits are preservation or improvement in bone mass, thus preventing osteoporosis and bone fractures; increased muscle mass and strength, improving stamina and physical function; decreased cardiovascular disease risk, improving mood and general sense of well-being; and improvement in some aspects of cognition. Probably the most significant risk of testosterone therapy is that it may cause the growth of a clinically occult prostate cancer. Testosterone therapy does not cause prostate cancer to develop; however, if prostate cancer that has not been previously detected is present, it may cause the cancer to grow. Prostate cancer is a hormone-sensitive cancer. Removal of the male hormone testosterone has been shown to shrink prostate cancer and slow down its rate of growth. Thus, the concern with giving testosterone, even if it is only to restore the testosterone level to a normal range, is the risk of stimulation of the growth of a clinically occult prostate cancer. Testosterone therapy may also stimulate the growth of benign prostate tissue, and if the growth is significant it could lead to changes in voiding function, such as needing to urinate more often, getting up at night more often to urinate, a decline in the force of the urine stream and/or hesitancy with starting the urine stream, to mention a few of the possible symptoms of an enlarged prostate. Other risks of testosterone therapy include an increase in red blood cell count, polycythemia (an increase in the total red blood cell mass in the blood), elevation in liver function enzymes if testosterone is given orally, breast enlargement, and fluid retention, causing or worsening sleep apnea and possibly increasing cardiovascular disease risk. If testosterone is administered in large quantities, it may lead to decreased sperm production, causing problems with fertility.
What are the types of testosterone that I can use?
Oral Testosterone Therapy
Currently, oral therapy is not being used in the United States. The oral forms of testosterone that are available in the United States provide erratic levels of androgens (male hormones) and carry a risk of liver toxicity; thus, they are not recommended. In other countries, there is an oral form of testosterone (testosterone undecenoate) that is well tolerated and provides more consistent testosterone levels.
Parenteral (Intramuscular) Testosterone Therapy
Parenteral testosterone has been around longer than oral testosterone. It is inexpensive and safe, but it has several disadvantages. Use of parenteral (taken by a route other than the mouth) testosterone requires periodic deep intramuscular (into the muscle) injections, usually every 2 to 3 weeks. Use of testosterone injection therapy results in supraphysiologic (higher than normal) levels of testosterone, usually within 3 days of the shot, which then steadily decline over the following 10 to 14 days, with a low level around the time of the next injection. This peak-and-trough effect can affect one’s mood, well-being, and sexual interest, and in some men these fluctuations can be disturbing. The recommended dose of intramuscular testosterone is 200 to 400 mg every 10 to 21 days to maintain normal average testosterone levels.
Transdermal Testosterone Therapy
Transdermal testosterone therapy (Testoderm and Androderm) provides the most physiologic restoration of testosterone level-meaning that the therapy brings your testosterone level back to levels resembling the natural amount of testosterone that should be in your body throughout the day. Transdermal testosterone therapy (therapy that enters through the skin) can be given as a scrotal or a nonscrotal patch. The limitations of the scrotal patch make it less appealing, as its use requires shaving the scrotum – and in some rnen, the scrotum may be too small to apply the patch. The nonscrotal patch must be applied to a non-hairbearing skin surface and one that pressure is not applied to (i.e., you cannot put the patch on your buttocks because pressure would be applied when you sit down). Also, the site of patch placement must be rotated each day. The testosterone patch is usually applied at bedtime and produces the highest testosterone level in the morning and the lowest level at the time of next patch application; this reflects the normal variation in testosterone levels during the day. Unlike the parenteral form of testosterone, there is little effect on the blood cell count with the transdermal form. The most common side effects of the patch are skin related and may vary from skin irritation to a chemical burn. Application of triamcinolone cream to the skin underneath the patch reservoir decreases the incidence of skin irritation.
Another form of transdermal testosterone therapy is a topical gel, Androgel. The gel is also applied once daily. Once the gel is applied, it is important to make sure that the gel has completely dried prior to wiping the affected area. One should not shower or swim shortly after the gel is applied. One must also be careful about physical contact when the gel is first applied, because it may be absorbed by your partner if it gets onto your partner’s skin. The gel has not been associated with significant skin irritation.
Limitations of Androgel are primarily its cost. Androgel is available in packets of two different strengths: 25 mg (2.5 g) and 50 mg (5g). Checking a serum testosterone level after 2 weeks of therapy will help determine whether the dose is adequate. It is not uncommon to require two packets for adequate dosing.
How should I be monitored while I’m receiving testosterone therapy?
Before starting testosterone therapy, you should undergo a digital rectal examination (examination of the prostate by placing a gloved finger into the rectum) and have a prostate-specific antigen (PSA) level taken if you have not had these performed recently. If either of these is abnormal, a transrectal ultrasound-guided biopsy – in which small samples of tissue are removed from the prostate for examination under the microscope – should be performed to rule out prostate cancer before you start testosterone therapy because the presence or suspicion of prostate cancer is a contraindication to testosterone therapy. A follow-up serum testosterone level should be checked to ensure that normal levels of testosterone are being produced. In addition, the red blood count should be checked after 1 month of therapy and periodically thereafter to make sure that the count is not rising. Liver function tests should be performed on a yearly basis. A digital rectal examination should be performed and a PSA should be obtained every 6-12 months to make sure that there are no changes in either. If the PSA increases significantly or if there is a change in the results of the rectal examination, the testosterone replacement therapy should be withheld and a transrectal ultrasound-guided prostate biopsy should be performed.