From the Guidelines
Testosterone repletion should be considered in men with age-related low testosterone and sexual dysfunction who want to improve sexual function, with reevaluation of symptoms within 12 months and periodically thereafter. This approach is based on the American College of Physicians' clinical guideline, which suggests discussing the potential benefits, harms, costs, and patient's preferences when considering testosterone treatment 1.
Key Considerations
- The target patient population includes adult men with age-related low testosterone, characterized by a gradual decline in serum total testosterone levels beginning in their mid-30s 1.
- There is no well-defined threshold of testosterone levels below which symptoms of androgen deficiency and adverse health outcomes occur 1.
- Testosterone treatment may improve sexual function, but its effectiveness for other symptoms such as energy, vitality, physical function, or cognition is uncertain 1.
Treatment Approach
- Intramuscular formulations may be preferred over transdermal formulations due to lower costs and similar clinical effectiveness and harms 1.
- Patients should be monitored for improvement in sexual function, and treatment should be discontinued if there is no improvement 1.
- Regular reevaluation of symptoms and potential adverse effects is necessary to ensure the benefits of testosterone treatment outweigh the risks 1.
From the FDA Drug Label
Prior to initiating testosterone gel 1. 62%, confirm the diagnosis of hypogonadism by ensuring that serum testosterone has been measured in the morning on at least two separate days and that these concentrations are below the normal range. The dose should be titrated based on the pre-dose morning serum testosterone concentration at approximately 14 days and 28 days after starting treatment or following dose adjustment.
- Repletion Timing: Testosterone should be repleted when serum testosterone concentrations are below the normal range, as confirmed by morning measurements on at least two separate days.
- Key Considerations:
- Diagnosis of hypogonadism must be confirmed before initiating treatment.
- Serum testosterone concentrations should be measured at approximately 14 days and 28 days after starting treatment or following dose adjustment.
- Dose adjustments should be made based on these measurements to ensure proper testosterone levels 2, 2, 2.
From the Research
Indications for Testosterone Replacement Therapy
- Testosterone replacement therapy (TRT) is indicated for male hypogonadism, which is defined as a low serum testosterone level and signs or symptoms of hypogonadism 3, 4, 5, 6.
- A serum total testosterone level of less than 300 to 350 ng/dL on two separate morning blood samples is considered a low level 3, 5.
- Symptoms of hypogonadism include low energy and fatigue, decreased sex drive and performance, decreased muscle mass and strength, decreased bone mineral density, and increased body fat 5, 6.
Evaluation and Monitoring
- Patients should be evaluated for hypogonadism if they exhibit signs and symptoms, and as part of normal medical screening in men starting at age 40 to 50 years 5.
- Testosterone levels should be assessed in adult men who exhibit signs of hypogonadism, and therapy should be discussed with symptomatic patients who have a serum total testosterone level < 300 ng/dL 3, 5.
- Patients receiving TRT require close monitoring, with assessment of response and adverse events every 3 to 6 months, and therapy adjusted accordingly 3, 5, 6.
Treatment Options
- Numerous testosterone formulations are available, ranging from topical gels to intramuscular injections, and the choice of formulation depends on factors such as cost and patient preference 3, 4, 7.
- Testosterone supplementation therapy should be continued in individuals demonstrating an improvement in signs and symptoms, which may take 3 months to a year for maximum response 6.
- Dose adjustment is possible with most delivery methods, but may not be necessary in all hypogonadal men 7.