From the Guidelines
If your testosterone level remains low despite 100 mg weekly testosterone supplementation, the dose can typically be titrated up before considering alternative medications. Most clinicians would increase the dose in increments of 25-50 mg per week, potentially up to 200 mg weekly, while monitoring blood levels to achieve normal testosterone ranges (typically 350-1000 ng/dL) 1. The timing of blood tests is crucial - they should be performed midway between injections for accurate assessment. Before increasing the dose, ensure you're using proper injection technique and consistent timing. Some patients metabolize testosterone more quickly than others, so splitting the dose to twice weekly injections (e.g., 50 mg twice weekly instead of 100 mg once weekly) can provide more stable levels and reduce side effects. Key considerations when titrating the dose include:
- Monitoring for potential benefits on sexual function, as suggested by the American College of Physicians (ACP) 1
- Regular reevaluation of symptoms, as recommended by the ACP, to discontinue treatment if no improvement is seen 1
- Weighing the potential benefits and harms of treatment, including the risk of serious adverse events and major adverse cardiovascular events 1 If dose increases don't help or cause unacceptable side effects like elevated red blood cell counts, estrogen conversion, or acne, alternative options include testosterone gels, patches, or pellets. These alternatives provide more consistent hormone levels but may be more expensive or less convenient. Always make dosage changes under medical supervision with regular monitoring of testosterone levels, complete blood count, estradiol, and PSA (in men over 40).
From the Research
Testosterone Supplementation
- The current dosage of 100 mg weekly may not be sufficient to achieve optimal testosterone levels, as evidenced by the ongoing low testosterone levels 2.
- Titration of the dose may be considered, but it is essential to weigh the potential benefits against the risks of adverse effects, such as erythrocytosis, which may be more likely with higher doses 2.
Alternative Therapies
- Human chorionic gonadotropin (HCG) has been shown to be effective in treating secondary hypogonadism and preserving fertility in men undergoing testosterone replacement therapy 3, 4.
- The combination of HCG and clomiphene citrate may be a viable option for men with hypogonadotropic hypogonadism who desire to preserve fertility 5.
Considerations for Dose Titration
- A study comparing two different intramuscular testosterone therapy regimens (100 mg weekly and 200 mg biweekly) found no significant differences in the increase in total testosterone, free testosterone, prostate-specific antigen, and estradiol levels between both groups 2.
- However, the 200 mg regimen was associated with a higher risk of erythrocytosis, highlighting the need for careful consideration of the potential risks and benefits of dose titration 2.