What is the recommended treatment for low testosterone using testosterone cream (testosterone)?

Testosterone Cream for Low Testosterone

Topical testosterone gel/cream is an effective treatment option for men with age-related low testosterone, with most patients preferring topical formulations for convenience and ease of use, though intramuscular formulations may be more cost-effective. 1, 2

Treatment Recommendations

Patient Selection

• Testosterone replacement therapy (TRT) should only be initiated in men with consistent symptoms and unequivocally low morning testosterone levels 3
• Treatment is recommended for symptomatic men to improve sexual function, sense of well-being, muscle mass, strength, and bone mineral density 1, 3

Formulation Selection

• Topical gel/cream advantages:

  • 71% of patients preferred topical gel over injections or patches after trying different formulations 1
  • Benefits include convenience, ease of use, and non-staining of clothes 1
  • Provides stable testosterone levels throughout the day 4

• Intramuscular formulation advantages:

  • Significantly lower cost ($156.24 annually vs. $2,135.32 for transdermal) 1
  • Similar clinical effectiveness and adverse event profile to transdermal formulations 1

Application Instructions for Testosterone Cream/Gel

• Apply to shoulders and upper arms only (areas that will be covered by a short-sleeve t-shirt) 2
• Apply at the same time each morning, after showering or bathing 2
• Wash hands immediately with soap and water after application 2
• Cover application area with clothing until washed or showered 2
• If skin-to-skin contact with another person is expected, wash application area thoroughly first 2

Expected Benefits

• Small improvement in global sexual function (moderate-certainty evidence) 1
• Small improvement in erectile function (low-certainty evidence) 1
• Modest improvements in vitality and fatigue (SMD 0.17 higher) 1
• Slight improvement in depressive symptoms (SMD 0.19 lower) 1
• Little to no difference in physical function or cognitive function 1

Monitoring and Follow-up

• Re-evaluate symptoms within 12 months and periodically thereafter 1
• Discontinue treatment if no improvement in sexual function occurs 1
• Aim for testosterone levels in the mid-normal range during treatment 3
• Monitor patients using a standardized plan 3
• Initial follow-up should occur 3 months after starting therapy, then at least annually 5

Contraindications and Precautions

• Do not use in men with:
  • Breast or prostate cancer 2, 3
  • Palpable prostate nodule or PSA >4 ng/mL (or >3 ng/mL in high-risk men) without urological evaluation 3
  • Hematocrit >50% 3
  • Untreated severe obstructive sleep apnea 3
  • Severe lower urinary tract symptoms (IPSS >19) 3
  • Uncontrolled or poorly controlled heart failure 3
  • Men desiring fertility in the near future 6

Special Considerations

• Transfer risk: Testosterone gel can transfer to women and children through skin contact, potentially causing adverse effects 2
  • Women may develop changes in body hair or acne 2
  • Children may develop signs of early puberty 2
• Showering 2-6 hours after application decreases bioavailability by 12-13% 2
• Application of moisturizing lotion or sunscreen to the application site increases testosterone absorption by 8-14% 2

Common Pitfalls

• Failure to confirm low testosterone with morning measurements on multiple occasions 3
• Not discussing potential benefits, risks, and costs with patients before initiating therapy 1
• Using testosterone in men with contraindications, particularly undiagnosed prostate cancer 3
• Applying to non-approved sites (e.g., abdomen), which increases transfer risk 2
• Discontinuing too early before therapeutic effects are achieved 5