From the Guidelines
When a patient has elevated serum testosterone, the most appropriate initial step is to confirm the elevation with repeat testing and identify the underlying cause, as management approaches vary significantly depending on the etiology. The management of elevated serum testosterone involves a multifaceted approach, considering the patient's symptoms, gender, and potential underlying conditions. For instance, in the context of hidradenitis suppurativa (HS), particularly in adolescent female patients, using spironolactone or combined oral contraceptives is suggested as part of the management strategy, as indicated by recent clinical guidelines 1. Key considerations include:
- Identifying and addressing the underlying cause of the elevated testosterone levels
- Confirming the elevation with repeat testing, preferably in the morning
- Considering the use of anti-androgens such as spironolactone or finasteride in select cases, particularly in pediatric patients with HS 1
- Monitoring for potential side effects and adjusting treatment as necessary In clinical practice, the goal is to normalize hormone levels, alleviate symptoms, and address any underlying pathology, prioritizing the patient's morbidity, mortality, and quality of life. Given the complexity of managing elevated serum testosterone, a personalized approach based on the most recent and highest quality evidence, such as the North American clinical practice guidelines for the medical management of hidradenitis suppurativa 1, is essential for optimal patient outcomes.
From the FDA Drug Label
The median circulating level of testosterone increased by approximately 10 to 20% but remained within the physiologic range In a separate study in healthy men treated with finasteride 1 mg per day (n=82) or placebo (n=69), mean circulating levels of testosterone and estradiol were increased by approximately 15% as compared to baseline, but these remained within the physiologic range
When a patient has elevated serum testosterone, finasteride does not directly lower testosterone levels. Finasteride works by inhibiting the conversion of testosterone to dihydrotestosterone (DHT), and as a result, testosterone levels may increase by approximately 10 to 20%. However, in the studies, these increased levels remained within the physiologic range 2.
- Key points:
- Finasteride inhibits the conversion of testosterone to DHT
- Testosterone levels may increase by approximately 10 to 20%
- Increased testosterone levels remain within the physiologic range
- Clinical decision: The use of finasteride in patients with elevated serum testosterone levels may not be the primary treatment for reducing testosterone levels.
From the Research
Elevated Serum Testosterone
When a patient has elevated serum testosterone, several factors need to be considered:
- The patient's medical history and current symptoms
- The potential causes of elevated testosterone levels, such as testosterone replacement therapy (TRT) or other medical conditions
- The potential risks and side effects associated with elevated testosterone levels, such as gynecomastia or other hormonal imbalances
Treatment Options
Treatment options for elevated serum testosterone may include:
- Adjusting or discontinuing TRT, if applicable
- Using aromatase inhibitors, such as anastrozole, to reduce estrogen levels and alleviate symptoms like gynecomastia 3
- Monitoring hormone levels and adjusting treatment as needed to maintain therapeutic testosterone levels and prevent complications 4, 5
Hormone Regulation
Hormone regulation is crucial in managing elevated serum testosterone:
- Testosterone replacement therapy can increase testosterone levels, but may also lead to elevated estradiol levels and associated side effects 4, 5
- Aromatase inhibitors, like anastrozole, can help maintain low estradiol levels and prevent side effects like gynecomastia 4, 5, 3
- Regular monitoring of hormone levels, including testosterone and estradiol, is essential to ensure therapeutic levels and prevent complications 4, 5
Potential Risks and Side Effects
Potential risks and side effects associated with elevated serum testosterone and TRT include:
- Gynecomastia, which can be treated with aromatase inhibitors like anastrozole 3
- Hormonal imbalances, which can be managed with regular monitoring and adjustments to treatment 4, 5
- Other metabolic dysfunctions, such as non-alcoholic fatty liver disease, insulin resistance, and type 2 diabetes, which may be associated with long-term use of certain medications like finasteride and dutasteride 6