How to treat low testosterone?

From the Guidelines

Low testosterone in adult men with age-related low testosterone should be treated with testosterone replacement therapy (TRT) only in cases of sexual dysfunction, as suggested by the American College of Physicians (ACP) 1.

Treatment Approaches

The primary treatment for low testosterone is TRT, which can be administered through various methods, including:

• Injections (testosterone cypionate or enanthate, typically 50-200mg every 1-2 weeks)
• Daily transdermal gels (AndroGel, Testim, 50-100mg applied to shoulders, upper arms, or abdomen)
• Patches (Androderm, 2-6mg daily applied to non-genital skin)
• Pellets implanted under the skin (lasting 3-6 months)

Important Considerations

Before initiating treatment, blood tests should confirm consistently low testosterone levels (below 300 ng/dL) along with symptoms like fatigue, reduced libido, and depression 1.

Lifestyle Modifications

In addition to TRT, lifestyle modifications can also help alleviate symptoms of low testosterone, including:

• Regular exercise (especially strength training)
• Maintaining a healthy weight
• Adequate sleep (7-9 hours nightly)
• Stress management
• A balanced diet rich in zinc, vitamin D, and healthy fats

Monitoring and Safety

Regular monitoring through blood tests is essential during treatment to ensure testosterone levels remain in the normal range and to watch for potential side effects like elevated red blood cell counts, sleep apnea, or prostate issues 1.

Key Recommendations

• The ACP suggests discussing the potential benefits, harms, costs, and patient's preferences before initiating testosterone treatment in men with age-related low testosterone and sexual dysfunction 1.
• The ACP also recommends reevaluating symptoms within 12 months and periodically thereafter, and discontinuing testosterone treatment if there is no improvement in sexual function 1.

From the FDA Drug Label

Testosterone Cypionate Injection, USP is indicated for replacement therapy in the male in conditions associated with symptoms of deficiency or absence of endogenous testosterone.

The treatment for low testosterone is testosterone replacement therapy. This can be achieved through the use of testosterone cypionate injection, which is indicated for replacement therapy in males with conditions associated with symptoms of testosterone deficiency or absence, such as primary hypogonadism or hypogonadotropic hypogonadism 2.

• Key points:
  • Testosterone replacement therapy is used to treat conditions associated with low testosterone.
  • Testosterone cypionate injection is a form of replacement therapy.
  • This treatment is indicated for males with primary hypogonadism or hypogonadotropic hypogonadism.
  • The safety and efficacy of testosterone cypionate in men with age-related hypogonadism have not been established 2.

From the Research

Treatment Options for Low Testosterone

• Testosterone therapy has historically been offered to men with symptomatic testosterone deficiency in the form of injections, gels, or pellets 3
• However, these treatments are invasive or have undesirable effects, including the risk of drug transference, and have been associated with increases in hematocrit and controversy remains regarding the risk of cardiovascular and thromboembolic events while on testosterone therapy 3
• Alternative treatment options for testosterone deficiency include orally-administered medications, lifestyle modifications, varicocelectomy, SERMs, aromatase inhibitors (AIs), and human chorionic gonadotropin (hCG) 3
• The SERM clomiphene citrate (CC) holds the greatest promise as a non-testosterone treatment option for testosterone deficiency 3

Considerations for Testosterone Therapy

• Testosterone therapy should only be started in men with symptomatic androgen deficiency to induce and maintain secondary sex characteristics and to improve their sexual function, sense of well-being, muscle mass and strength, and bone mineral density 4
• Testosterone therapy should not be started in patients with breast or prostate cancer, a palpable prostate nodule or induration or prostate-specific antigen greater than 4 ng/ml or greater than 3 ng/ml in men at high risk for prostate cancer without further urological evaluation, hematocrit greater than 50%, untreated severe obstructive sleep apnea, severe lower urinary tract symptoms with International Prostate Symptom Score above 19, or uncontrolled or poorly controlled heart failure 4
• Men receiving testosterone therapy should be monitored using a standardized plan 4

Effects of Testosterone Deficiency

• Testosterone deficiency can have a negative impact on human health, including reduced lean body mass, increased fat mass, increased insulin resistance, metabolic syndrome, reduced bone mineral density, anemia, sexual dysfunction, and reduced quality of life 5
• 5α-reductase inhibitors, such as finasteride and dutasteride, can also have a negative impact on metabolic function, including fat accumulation in the liver, hyperglycemia, and insulin resistance 5

Diagnosis and Evaluation

• A diagnosis of androgen deficiency should only be made in men with consistent symptoms and signs and unequivocally low serum testosterone levels 4
• The measurement of morning total testosterone level by a reliable assay should be used as the initial diagnostic test, and the diagnosis should be confirmed by repeating the measurement of morning total testosterone and, in some men, by measurement of free or bioavailable testosterone level using validated assays 4
• Physicians should not jump to the diagnosis of hypogonadism based on a single low serum testosterone level, and confirmation and thorough evaluation are warranted before making the diagnosis or starting therapy 6