Is testosterone gel recommended 6 years after a stroke?

Testosterone Gel After Stroke: Safety and Recommendations

Testosterone gel therapy is reasonable and does not increase the risk of stroke in men with confirmed hypogonadism who are 6 years post-stroke. 1

Safety of Testosterone Therapy After Stroke

The safety of testosterone therapy after cerebrovascular events has been a subject of debate for several years. However, recent high-quality evidence provides clear guidance:

• According to the 2024 American Heart Association/American Stroke Association guideline, testosterone replacement therapy is reasonable and does not increase stroke risk in men 45-80 years with confirmed hypogonadism 1
• The 2023 TRAVERSE study (a large multicenter, randomized, double-blind, placebo-controlled trial) found no significant difference in stroke risk between testosterone gel and placebo in men with confirmed hypogonadism, including those with previous cerebrovascular disease 1
• The American Urological Association (AUA) guideline specifically addresses this scenario, stating that testosterone therapy may be considered in patients with a history of cardiovascular events after a 3-6 month waiting period from the most recent cardiac event 1

Treatment Algorithm for Testosterone Gel After Stroke

1. Timing Considerations:

   • Wait at least 3-6 months after a stroke before initiating testosterone therapy 1
   • At 6 years post-stroke, this waiting period has been well exceeded

2. Confirmation of Hypogonadism:

   • Verify hypogonadism with two separate morning testosterone measurements showing levels <300 ng/dL 1
   • Ensure symptoms of testosterone deficiency are present

3. Dosing and Monitoring:

   • Start with transdermal 1.62% testosterone gel with dose adjustments to target levels between 450-600 ng/dL (mid-normal range) 1, 2
   • Monitor testosterone levels 2-3 months after initiation and after any dose changes 1, 2
   • Once stable, monitor every 6-12 months 1, 2

4. Safety Monitoring:

   • Regular cardiovascular assessment
   • Monitor for erythrocytosis through hemoglobin and hematocrit measurements 2
   • Watch for peripheral edema and other potential adverse effects

Important Considerations and Caveats

• Formulation Choice: Transdermal testosterone preparations (gels) are preferred as they produce more stable serum levels compared to injections, which may cause fluctuating levels with peaks and valleys 1
• Risk Minimization: Testosterone gel should be applied to areas that will not come into contact with others, especially women and children, to prevent inadvertent transfer 1
• Contraindications: Avoid testosterone therapy in men currently trying to conceive due to its suppressive effect on spermatogenesis 1
• Off-Label Use: The 2024 AHA/ASA guideline specifically notes that while testosterone gel is safe for men with confirmed hypogonadism, the risks for men using testosterone off-label are not well established 1

Conclusion

Based on the most recent and highest quality evidence from the 2024 AHA/ASA guideline and the TRAVERSE study, testosterone gel therapy is reasonable for a man 6 years post-stroke, provided he has confirmed hypogonadism and follows appropriate monitoring protocols. The 3-6 month waiting period recommended after cardiovascular events has been well exceeded in this case.