What is the recommended approach to initiate testosterone replacement therapy (TRT) in a 65-year-old male?

Initiating Injectable Testosterone in a 65-Year-Old Male

For a 65-year-old male with age-related low testosterone, intramuscular testosterone injections should be initiated if total morning testosterone is <300 ng/dL and the patient has sexual symptoms that he wishes to improve. 1

Diagnostic Confirmation

Before starting treatment:

• Confirm hypogonadism with at least two morning testosterone measurements showing levels <300 ng/dL 1
• Verify presence of symptoms attributable to low testosterone (particularly sexual dysfunction)
• Rule out other causes of symptoms and contraindications to therapy

Initial Workup

Baseline tests required:

• Complete blood count with hematocrit/hemoglobin
• Prostate-specific antigen (PSA)
• Digital rectal examination
• Consider lipid panel 2

Treatment Protocol

Formulation Selection

• Intramuscular testosterone is strongly preferred over transdermal formulations due to:
  • Significantly lower cost ($156.24 vs $2135.32 annually) 1
  • Similar clinical effectiveness and adverse event profile 1

Dosing Approach

• Start with a conservative dose of injectable testosterone
• Titrate to achieve mid-normal range testosterone levels (350-600 ng/dL) 2
• Common regimens include:
  • Testosterone cypionate or enanthate 100-200 mg IM every 1-2 weeks
  • Consider adjusting dose based on symptom response and testosterone levels

Monitoring Protocol

1. Initial follow-up: 1-2 months after starting therapy 2

   • Check testosterone levels (mid-cycle between injections)
   • Assess hematocrit/hemoglobin
   • Evaluate symptom improvement

2. Subsequent monitoring: Every 3-6 months for the first year, then annually 2

   • Testosterone levels
   • Hematocrit/hemoglobin
   • PSA and digital rectal exam
   • Symptom assessment

Managing Potential Complications

Erythrocytosis

• Risk is higher with injectable formulations (43.8%) compared to transdermal options (2.8-17.9%) 2
• If hematocrit exceeds 54%:
  • Temporarily withhold testosterone
  • Reduce dosage
  • Consider therapeutic phlebotomy
  • Possibly switch to transdermal preparation 2

Prostate Health

• Monitor PSA regularly
• Discontinue therapy if rapid PSA rise or abnormal prostate examination

Efficacy Assessment

• Evaluate sexual function improvement within 12 months 1
• Discontinue treatment if no improvement in sexual function occurs 1
• Document specific improvements in:
  • Erectile function
  • Sexual desire
  • Overall sexual satisfaction

Special Considerations for Elderly Patients

• Elderly patients may be more vulnerable to adverse effects but may also experience more dramatic functional improvements 3
• Carefully weigh potential benefits against risks, particularly cardiovascular and prostate concerns
• Be vigilant for fluid retention, gynecomastia, and worsening of sleep apnea 4

Treatment Expectations

• Modest improvements in sexual function can be expected 1
• Less significant improvements in energy, vitality, and physical function 1
• No significant improvement in cognitive function 1
• Benefits on bone mineral density may occur with longer treatment 1

Remember that testosterone therapy should be viewed as a trial, with continuation dependent on documented symptom improvement and absence of adverse effects.