What is the approach to managing hypogonism (low testosterone) with decreased libido?

From the Guidelines

For men with confirmed low testosterone (typically below 300 ng/dL) and decreased libido, I recommend a comprehensive approach including both medical treatment and lifestyle modifications, with testosterone replacement therapy (TRT) being a viable option, as supported by the most recent evidence from 1. When considering TRT, common options include testosterone cypionate injections (50-100mg weekly or 100-200mg every two weeks), transdermal gels like AndroGel or Testim (50-100mg applied daily), or testosterone patches (2-6mg applied nightly). Before starting TRT, a complete hormone panel, prostate-specific antigen test, and hematocrit measurement are necessary, as indicated by 1. Lifestyle changes should be implemented alongside medical treatment, including:

• Regular exercise (especially resistance training)
• Adequate sleep (7-9 hours nightly)
• Stress reduction
• Maintaining healthy weight
• A balanced diet rich in zinc, vitamin D, and healthy fats
• Limiting alcohol consumption and avoiding smoking Some supplements that may help include zinc (25-30mg daily), vitamin D (1000-2000 IU daily), and ashwagandha (300-600mg daily), as suggested by general medical knowledge. TRT works by directly increasing testosterone levels, while lifestyle changes support natural hormone production. Regular follow-up appointments are essential to monitor hormone levels, adjust dosing, and watch for side effects like elevated red blood cell count or prostate changes, as recommended by 1.

From the FDA Drug Label

Testosterone gel 1.62% is indicated for replacement therapy in males for conditions associated with a deficiency or absence of endogenous testosterone: Primary hypogonadism (congenital or acquired). Hypogonadotropic hypogonadism (congenital or acquired).

The approach to managing hypogonism (low testosterone) with decreased libido is to use testosterone replacement therapy, such as testosterone gel 1.62%. The starting dose is 40.5 mg of testosterone, applied topically once daily in the morning, and can be dose adjusted between 20.25 mg and 81 mg based on serum testosterone concentration.

• Key considerations:
  • Confirm the diagnosis of hypogonadism by ensuring that serum testosterone has been measured in the morning on at least two separate days and that these concentrations are below the normal range.
  • Monitor patients for signs and symptoms of benign prostatic hyperplasia (BPH), venous thromboembolism (VTE), and other potential adverse reactions.
  • Dose adjustment should be based on pre-dose morning serum testosterone concentration at approximately 14 days and 28 days after starting treatment or following dose adjustment. 2

From the Research

Approach to Managing Hypogonism with Decreased Libido

• The approach to managing hypogonism (low testosterone) with decreased libido involves a systematic diagnosis and evaluation of hypogonadism, as outlined in the study 3.
• This includes establishing the presence of symptoms/signs of testosterone deficiency, considering other potential causes of manifestations, and excluding conditions that transiently suppress testosterone.
• The diagnosis of hypogonadism is confirmed by measuring fasting serum total testosterone in the morning on at least 2 separate days, or free testosterone by equilibrium dialysis or calculated free testosterone in men with conditions that alter sex hormone-binding globulin or serum total testosterone near lower limit of normal.

Treatment Options

• Testosterone replacement therapy (TRT) is the standard treatment for hypogonadism, but it has some disadvantages, as discussed in the study 4.
• Alternative treatments for central hypogonadism include gonadotposins, clomiphene citrate, and tamoxifen, which can increase testosterone levels, as reported in the studies 4 and 5.
• However, the use of clomiphene citrate and tamoxifen is off-label and data supporting their efficacy on hypogonadal symptoms are insufficient, as noted in the study 4.
• A comparison of testosterone versus clomiphene citrate in managing symptoms of hypogonadism in men found that both treatments are effective, but testosterone supplementation therapy (TST) is more effective in raising serum testosterone levels and improving hypogonadal symptoms, including libido, as reported in the study 6.

Considerations for Treatment

• The choice of treatment for hypogonism with decreased libido should take into account the individual's specific needs and circumstances, such as fertility preservation or the presence of certain medical conditions, as discussed in the studies 4 and 7.
• Non-pharmacological interventions can be therapeutic if reversible causes are present, as noted in the study 4.
• Novel therapies, such as nasal testosterone, new oral testosterone formulations, anabolic-androgenic steroids, and selective androgen receptor modulators, are being developed and may offer more convenient and effective treatment options, as reported in the study 7.