What is the recommended treatment for symptomatic low testosterone?

Treatment for Symptomatic Low Testosterone

Testosterone replacement therapy is the recommended treatment for symptomatic low testosterone (total testosterone <300 ng/dL) confirmed by two morning measurements, with the goal of achieving testosterone levels in the mid-normal range (450-600 ng/dL). 1

Diagnosis Confirmation

Before initiating treatment, proper diagnosis is essential:

• Confirm low testosterone with two separate morning measurements below 300 ng/dL 1
• Verify presence of symptoms such as reduced energy, diminished physical performance, depression, reduced motivation, poor concentration, reduced sex drive, or erectile dysfunction 1
• Measure luteinizing hormone (LH) levels to determine the etiology of testosterone deficiency (primary vs. secondary hypogonadism) 1
• Check serum prolactin in patients with low/low-normal LH levels 1
• Consider measuring estradiol in patients with breast symptoms or gynecomastia 1

Treatment Options

Topical Testosterone Preparations

• Testosterone gel (1-2%): Applied daily to shoulders and upper arms
  • Advantages: Convenient daily application, stable testosterone levels, fewer skin reactions than patches 2, 3
  • Disadvantages: Risk of transfer to women and children, higher cost than injections 2, 4
  • Dosing: Start with manufacturer-recommended dose (typically 40.5-50 mg daily) and titrate based on testosterone levels 2

Injectable Testosterone

• Testosterone enanthate/cypionate: Intramuscular injections every 1-2 weeks

  • Advantages: Lower cost, long-established efficacy 4
  • Disadvantages: Fluctuating testosterone levels, more frequent injections 4

• Testosterone undecanoate: Long-acting intramuscular injection every 10-14 weeks

  • Advantages: Fewer injections, more stable testosterone levels 4, 5
  • Disadvantages: May not be available in all regions 5

Other Formulations

• Testosterone patches: Applied daily to non-scrotal skin
  • Advantages: Stable hormone levels 6
  • Disadvantages: High rate of skin irritation 4, 6

Dosing and Monitoring

• Initial dosing should follow product-specific guidelines 2
• Adjust dose to achieve total testosterone levels in the mid-normal range (450-600 ng/dL) 1
• Monitor testosterone levels at 14 and 28 days after starting treatment or dose adjustment 2
• Perform periodic monitoring thereafter to ensure proper dosing 2

Contraindications and Precautions

• Do not prescribe to men currently trying to conceive (causes oligospermia/azoospermia) 1
• Do not use alkylated oral testosterone due to risk of liver toxicity 1
• Wait 3-6 months after cardiovascular events before starting testosterone therapy 1
• Counsel patients about potential transfer risk with topical preparations 2

Lifestyle Modifications

• Recommend weight loss and increased physical activity as adjunctive treatment 1
• These modifications may increase endogenous testosterone levels and reduce symptoms 1

Special Considerations

• Men with diabetes and hypogonadal symptoms should be screened for low testosterone 1
• Testosterone replacement may improve sexual function, well-being, muscle mass, strength, and bone density 1
• Patients should be informed that current evidence does not definitively demonstrate increased cardiovascular risk with testosterone therapy 1

Treatment Monitoring

• Assess symptom improvement and monitor for adverse effects
• Check testosterone levels periodically to maintain target range
• Monitor for development of erythrocytosis, gynecomastia, or other side effects
• Patients should report any cardiovascular symptoms (chest pain, shortness of breath, dizziness) 1