What is the recommended testosterone dosing for central hypogonadism?

Testosterone Dosing for Central Hypogonadism

For central hypogonadism, the recommended testosterone replacement therapy is 50-400 mg of intramuscular testosterone cypionate every 2-4 weeks, with 200 mg every 2 weeks or 300 mg every 3 weeks being the most effective regimens. 1

Dosing Options and Administration

Intramuscular Testosterone

• First-line option: Intramuscular testosterone cypionate
  • Dosage: 50-400 mg every 2-4 weeks 1
  • Optimal regimens:
    • 200 mg every 2 weeks 2
    • 300 mg every 3 weeks 2
  • Administration: Deep gluteal muscle injection 1
  • These regimens provide the best balance between effective suppression of elevated LH/FSH and less frequent administration 2

Transdermal Testosterone

• Alternative to intramuscular injections
• Preferred by some clinicians due to more stable day-to-day testosterone levels 3
• Target testosterone levels: 450-600 ng/dL (mid-normal range) 3
• Dose adjustment based on serum levels:

  Pre-Dose Morning Testosterone	Dose Adjustment
  >750 ng/dL	Decrease daily dose by 20.25 mg
  350-750 ng/dL	No change
  <350 ng/dL	Increase daily dose by 20.25 mg

Subcutaneous Testosterone

• Newer option with promising results
• Weekly administration via auto-injector
• Starting dose: 75 mg weekly, with adjustments to 50-100 mg based on trough levels 4
• Provides steady serum testosterone levels with small fluctuations 4

Monitoring and Dose Adjustment

Initial Monitoring

• Check testosterone levels 2-3 months after initiation and after any dose changes 3
• For intramuscular injections:
  • Peak levels occur 2-5 days post-injection
  • Levels return to baseline by 10-14 days post-injection 5
  • Interpret blood tests based on time since last injection 5

Ongoing Monitoring

• Once stable, monitor testosterone levels every 6-12 months 3
• Monitor hematocrit/hemoglobin regularly
  • If hematocrit rises above reference range: temporarily withhold therapy, reduce dosage, or perform phlebotomy 5
• Monitor PSA in men over 40 3
  • Consider urologic evaluation for biopsy if PSA increases by >1.0 ng/mL during first 6 months or >0.4 ng/mL per year thereafter 5

Clinical Considerations

Benefits of Therapy

• Increased lean muscle mass
• Reduced body fat
• Improved sense of well-being and energy levels
• Improved bone density and reduced fracture risk
• Increased hemoglobin levels 3
• Small but significant improvements in sexual function and quality of life 3

Potential Adverse Effects

• Erythrocytosis (dose-dependent: 2.8-17.9%)
• Suppression of spermatogenesis
• Peripheral edema
• Emotional lability
• Potential cardiovascular effects (long-term safety uncertain) 3
• Skin reactions with transdermal preparations (up to 66% with patches, 5% with gels) 3

Contraindications

• Prostate cancer
• Male breast cancer
• Desire for near-term fertility
• Severe sleep apnea
• Uncontrolled heart failure
• Hematocrit >54% 3
• Use caution in men with congestive heart failure or renal insufficiency due to potential fluid retention 3

Special Considerations

• For men desiring fertility, gonadotropin therapy is preferred over testosterone replacement 6
• Clomiphene citrate and tamoxifen may increase testosterone levels in functional central hypogonadism but are off-label and have insufficient data supporting efficacy for hypogonadal symptoms 6
• The American College of Physicians recommends testosterone therapy for men with confirmed hypogonadism 5, 3