From the Guidelines
Testosterone levels should ideally be maintained around 650 ng/dL rather than higher levels because this represents the mid-normal physiological range that balances benefits while minimizing risks. When considering the optimal level of testosterone, it's crucial to focus on the normalization of total testosterone levels combined with improvement in symptoms or signs, as recommended by the American Urological Association (AUA) guideline 1. The AUA suggests that clinicians should adjust testosterone therapy dosing to achieve a total testosterone level in the middle tertile of the normal reference range, which is generally considered to be between 450-600 ng/dL 1.
Key Considerations
- The goal of testosterone therapy is not to maximize testosterone levels but to restore normal physiological function, which typically occurs within the mid-normal range.
- Levels above this range, particularly exceeding 900-1000 ng/dL, are associated with increased risks of adverse effects such as polycythemia, sleep apnea, acne, testicular atrophy, reduced sperm production, and potential cardiovascular complications.
- Most men experience symptom improvement, including increased energy, libido, muscle mass, and improved mood, when testosterone reaches the mid-normal range without needing supraphysiological levels.
Treatment Approach
- For those beginning testosterone replacement therapy (TRT), typical starting doses may include 50-100mg testosterone cypionate or enanthate weekly via injection, 5-10g of 1% testosterone gel daily, or 75-150mg testosterone pellets implanted every 3-6 months.
- Dosage adjustments should be based on regular blood work monitoring testosterone, estradiol, hematocrit, and PSA levels every 3-6 months to ensure that testosterone levels remain within the target range and to minimize potential side effects.
From the Research
Testosterone Levels and Replacement Therapy
- The ideal testosterone (TST) level is a topic of discussion, but there is no direct evidence to suggest that 650 is the optimal level [(2,3,4,5,6)].
- Testosterone replacement therapy (TRT) is recommended for hypogonadal men, with the goal of maintaining serum T levels in the normal physiologic range [(2,3,4,5,6)].
- The normal physiologic range for testosterone levels is generally considered to be between 300-1050 ng/dL [(3,6)].
Risks of High Testosterone Levels
- High testosterone levels (>1500 ng/dL) do not appear to have a distinct impact on safety parameters, but further optimization of titration schema to reduce peak levels is warranted 6.
- Supra-physiological levels of testosterone can be prevented by assessing TRT with transdermal gels at its peak and at its minimum 2.
Monitoring and Adjusting Testosterone Replacement Therapy
- Monitoring of TRT should include assessments of serum total testosterone, bioavailable testosterone, and free testosterone levels [(2,5,6)].
- Adjustments to TRT should be made based on individual patient response and adverse events [(3,4,5,6)].
- The choice of testosterone formulation and dosage should be individualized to address patient needs and goals [(4,6)].