Testosterone Patches for Low Testosterone
Primary Recommendation
Testosterone patches are an effective FDA-approved treatment option for men with confirmed hypogonadism, though topical gels are generally preferred by patients (71% preference) due to superior convenience and lower skin irritation rates (5.5% vs 66% with patches). 1, 2, 3
Diagnosis Requirements Before Initiating Treatment
Before prescribing any testosterone formulation including patches, you must confirm:
- Two separate fasting morning total testosterone measurements below 300 ng/dL 4, 3
- Presence of specific symptoms: reduced energy, diminished work performance, erectile dysfunction, reduced libido, fatigue, depression, or reduced motivation 4
- Exclusion of absolute contraindications: active breast or prostate cancer, men seeking fertility (with standard TRT), recent cardiovascular disease within 6 months, PSA >4 ng/mL, severe heart failure, or untreated obstructive sleep apnea 4, 5
Patch-Specific Application Guidelines
Testosterone patches (Androderm) should be applied to dry, intact skin of the back, abdomen, upper thighs, or upper arms—NOT the scrotum with modern non-scrotal patches. 6, 3
Key application details:
- Apply once daily to achieve stable day-to-day testosterone levels 6
- Rotate application sites to minimize skin irritation 6
- No risk of secondary transfer to partners or children (unlike gels) 6
- Common adverse effect: skin rash or irritation at application site in up to 66% of patients 7
Comparative Formulation Considerations
While patches are effective, consider these evidence-based alternatives:
Topical gels are preferred by most patients:
- 71% of patients chose topical gel over patches after trial due to convenience, ease of use, and non-staining properties 2, 6
- Gel skin irritation rate: 5.5% vs 66% with patches 7
- Annual cost: $2,135 for transdermal formulations (gels/patches) vs $156 for intramuscular injections 4, 6
Intramuscular injections offer cost advantages:
- Significantly lower annual cost ($156 vs $2,135) with similar clinical effectiveness and safety profile 2, 4
- Disadvantage: fluctuating testosterone levels between injections 4
Expected Clinical Benefits
Regardless of formulation (patches, gels, or injections), testosterone replacement provides:
- Small improvement in sexual function and erectile function (moderate to low certainty evidence) 2
- Modest improvements in vitality and fatigue (SMD 0.17) 1, 2
- Slight improvement in depressive symptoms (SMD 0.19 lower) 1, 2
- Increased muscle mass, strength, and bone mineral density 2, 8, 9
- No improvement in cognitive function 1
Monitoring Protocol
Check testosterone levels at 2-3 months after initiation, targeting mid-normal range of 500-600 ng/dL: 6, 8
- Re-evaluate symptoms at 12 months and periodically thereafter 2, 4
- Discontinue treatment if no improvement in sexual function occurs 2
- Monitor hematocrit for erythrocytosis (occurs in 3-18% with transdermal formulations) 4
- Monitor PSA levels annually in men over 40 5
Safety Profile
No increased risk of serious adverse events, cardiovascular events, or mortality with testosterone treatment: 1
- Pooled analysis showed fewer deaths with testosterone vs placebo (0.4% vs 1.5%, Peto OR 0.47), though evidence certainty is low 1
- No increased risk of prostate cancer, pulmonary embolism, or deep venous thrombosis in observational studies 1
- Most common adverse effect with patches: local skin irritation requiring discontinuation in significant proportion of patients 7, 10
Critical Pitfall to Avoid
The FDA explicitly requires testosterone products be used ONLY for hypogonadism due to known causes (primary or secondary), NOT for age-related low testosterone alone. 1, 3 Safety and efficacy in "age-related hypogonadism" have not been established, though the ACP guideline does address this population with cautious recommendations for symptomatic men. 1