What is the optimal dosage of testosterone (TRT) for an elderly man with hypogonadism despite receiving injections of 200mg/ml every 3 weeks?

Optimal Testosterone Dosage for Elderly Men with Persistent Low Levels

For elderly men with persistently low testosterone levels despite receiving injections every 3 weeks, the recommended dosage should be adjusted to 50-100mg weekly or 100-200mg every 2 weeks of testosterone cypionate or enanthate.1, 2

Understanding the Current Issue

The current regimen of testosterone 200mg/ml every 3 weeks is likely causing significant fluctuations in testosterone levels, leading to:

• Periods of supratherapeutic levels immediately after injection followed by subtherapeutic levels before the next dose 2, 3
• Inadequate symptom control due to these fluctuations 4
• Potentially increased cardiovascular risk compared to more frequent dosing regimens 2

Recommended Dosing Adjustments

Option 1: More Frequent Dosing (Preferred)

• Weekly injections: 50-100mg per week intramuscularly 1, 3
  • Provides more stable serum testosterone levels
  • Reduces peaks and troughs in testosterone concentration
  • May improve symptom control and reduce side effects

Option 2: Shorter Interval

• Every 2 weeks: 100-200mg every 2 weeks intramuscularly 1, 3
  • Still better than every 3 weeks
  • Represents a good balance between injection frequency and stable levels
  • Supported by FDA labeling for testosterone replacement 1

Evidence Supporting This Recommendation

• The FDA-approved dosing for testosterone replacement in hypogonadal males is 50-400mg every 2-4 weeks, with more frequent administration providing more stable levels 1
• Studies show that 200mg every 2 weeks and 100mg weekly regimens provide more stable testosterone levels than longer interval dosing 3
• The American College of Physicians specifically suggests intramuscular rather than transdermal formulations when initiating testosterone treatment due to similar effectiveness but considerably lower cost 2
• Research demonstrates that the 200mg every 2 weeks regimen effectively suppresses elevated LH and FSH to normal levels, indicating adequate testosterone replacement 3

Monitoring Recommendations

• Re-evaluate at 3 months after changing the dosing regimen 4
• Check:
  • Total and free testosterone levels (aim for mid-normal range) 4
  • Symptom improvement (sexual function, energy, mood) 2
  • Hematocrit (to monitor for polycythemia) 4
  • PSA levels (to monitor prostate health) 4

Important Considerations and Cautions

• Age-related decline: Testosterone naturally declines at approximately 1.6% per year starting in mid-30s 2, 5
• Cardiovascular safety: Evidence suggests injectable testosterone may have different cardiovascular risk profiles based on dosing frequency, with more frequent administration potentially being safer 2
• Cost considerations: Intramuscular testosterone is significantly less expensive ($156.24 annually) compared to transdermal formulations ($2135.32 annually) 2
• Discontinuation criteria: If no improvement in symptoms is observed after 12 months of optimized therapy, consider discontinuing treatment 2

Pitfalls to Avoid

• Avoid long intervals between doses (>2 weeks) as this creates significant fluctuations in testosterone levels 2, 3
• Don't rely solely on total testosterone levels - assess symptom improvement as the primary indicator of successful treatment 2
• Don't continue therapy indefinitely without periodic reassessment of benefits and risks 2
• Don't use testosterone for improving energy, vitality, physical function or cognition without sexual dysfunction, as evidence doesn't support these indications 2