Why are only a small percentage of men with hypogonadism (low testosterone levels) receiving Testosterone Replacement Therapy (TRT)?

Why Only 5% of Men with Hypogonadism Receive Testosterone Replacement Therapy

Only 5% of men with hypogonadism receive testosterone replacement therapy due to concerns about potential risks, particularly prostate cancer stimulation, despite evidence showing multiple benefits for symptoms like decreased libido, energy, and bone density. 1

Key Factors Contributing to Low Treatment Rates

Concerns About Safety and Risks

• Theoretical concerns about prostate cancer: One of the most significant barriers is the theoretical concern that testosterone might stimulate prostate cancer growth 1
• Cardiovascular risk perceptions: Historical misconceptions linking testosterone to increased cardiovascular disease, despite evidence suggesting neutral or possibly beneficial effects 1
• Lack of long-term safety data: No large-scale, long-term studies have been completed to fully assess benefits and risks of testosterone therapy in men 1

Limited Awareness and Education

• Patient knowledge gap: Only 14% of men with untreated hypogonadism reported being knowledgeable about the condition compared to 48% of those receiving treatment 2
• Healthcare provider hesitation: Physicians may be reluctant to prescribe due to uncertainty about diagnosis criteria and safety concerns 1
• Diagnostic challenges: Symptoms of hypogonadism overlap with normal aging, making diagnosis difficult 1

Treatment Barriers

• Cost considerations: Significant cost differences between formulations (annual cost per Medicare beneficiary: $2,135 for transdermal vs. $156 for intramuscular formulations) 1
• Application challenges: Some formulations have practical limitations:
  • Transdermal patches: High incidence of skin reactions (up to 66%) 1
  • Injections: Pain, frequent medical visits, and "roller coaster" effect of fluctuating testosterone levels 1
• FDA limitations: Safety and efficacy not established for "age-related hypogonadism" 3

Patient-Specific Factors

• Demographic influences: College-educated, heterosexual, married men with comorbid erectile dysfunction living in suburban/urban areas are more likely to initiate treatment 2
• Symptom perception: Men who experience deterioration in work performance (52% vs. 31%) are more likely to seek treatment 2
• Treatment discontinuation: High discontinuation rates (30-62%) suggest patient dissatisfaction with results or side effects 1

Treatment Decision Considerations

When to Consider Treatment

• Persistent low serum testosterone levels with associated symptoms 4
• Primary focus on symptoms affecting quality of life:
  • Sexual dysfunction (erectile dysfunction, decreased libido)
  • Fatigue/lack of energy
  • Decreased muscle mass and strength
  • Reduced bone density
  • Depression and mood changes 1

Contraindications and Cautions

• Known or suspected prostate or breast cancer 3
• Men desiring fertility preservation (consider gonadotropins instead) 5
• Polycythemia, thrombophilia, severe cardiovascular disease 5
• "Age-related hypogonadism" - safety and efficacy not established 3

Improving Treatment Rates

For Healthcare Providers

• Increase education about diagnostic criteria and treatment options
• Discuss both benefits and risks with patients using current evidence
• Consider patient preferences for treatment modality (71% prefer topical gel for convenience, but 53% choose injections due to lower cost) 1
• Monitor appropriately for potential side effects:
  • Erythrocytosis (3-18% with transdermal, up to 44% with injection)
  • Prostate health
  • Cardiovascular parameters 1

For Patients

• Improve education about hypogonadism symptoms and treatment options
• Address misconceptions about testosterone therapy risks
• Consider treatment preferences and lifestyle factors when selecting formulations

Common Pitfalls to Avoid

• Overlooking reversible causes: Address acute and chronic illnesses that can cause low testosterone before initiating TRT 4
• Inadequate monitoring: Failure to measure morning pre-dose testosterone levels approximately 14 days after starting therapy 3
• Secondary exposure risks: Not warning patients about potential virilization in children and women through skin contact 3
• Ignoring fertility concerns: Standard TRT can suppress spermatogenesis; alternative treatments should be considered for men wanting to preserve fertility 5

The low treatment rate of hypogonadism represents a significant gap in men's healthcare that could be addressed through better education, risk assessment, and individualized treatment approaches.