What is the best course of action for a 45-year-old male with a history of Hypertension (HTN) and low testosterone levels, presenting with decreased libido, who desires to have children in the near future and has been prescribed AndroGel (testosterone)?

From the Guidelines

It is crucial to document a comprehensive discussion about the potential risks and benefits of testosterone therapy, particularly focusing on fertility concerns, given the patient's desire to have children in the near future, as highlighted by the American College of Physicians guideline 1.

Key Considerations

• A baseline PSA test and complete blood count should be ordered before starting testosterone therapy to monitor for potential prostate issues and polycythemia, as suggested by clinical practice guidelines 1.
• Liver function tests should be included to establish baseline values, considering the potential for elevated liver enzymes with testosterone treatment 1.
• The patient should be counseled specifically about fertility concerns, as testosterone supplementation can suppress spermatogenesis, which is particularly relevant given his desire to have children in the near future, and a referral to a fertility specialist for sperm banking should be considered and documented.
• The plan should include regular follow-up appointments to monitor testosterone levels, with the first check recommended at 3 months after starting therapy, then every 6-12 months thereafter, as recommended by the American College of Physicians guideline 1.
• Instructions for AndroGel application should be specified, including proper application technique, avoiding skin-to-skin contact with women and children, and handwashing after application.
• Alternatives to testosterone therapy, such as clomiphene citrate, which may be more appropriate for maintaining fertility while addressing symptoms of hypogonadism, should be discussed and documented, considering the patient's desire for future fertility.

Monitoring and Follow-Up

• Regular monitoring of testosterone levels, liver function, and complete blood count is essential to ensure the safe use of testosterone therapy, as emphasized by the guideline from the American College of Physicians 1.
• The patient should be educated on the potential side effects of testosterone therapy, including polycythemia, prostate issues, and liver enzyme elevations, and instructed to report any concerns promptly.

Patient Education

• The patient should be thoroughly educated on the proper use of AndroGel, including application technique and precautions to avoid exposure to others, as part of the treatment plan.
• The importance of follow-up appointments and monitoring should be emphasized to ensure the patient's safety and the effectiveness of the treatment, in line with the recommendations from the American College of Physicians guideline 1.

From the FDA Drug Label

Children and women should avoid contact with the unwashed or not covered (unclothed areas) where testosterone gel has been applied to your skin. Apply testosterone gel only to the areas of your shoulders and upper arms that will be covered by a short sleeve t-shirt. Wash your hands right away with soap and water after applying testosterone gel. After the gel has dried, cover the application area with clothing Keep the area covered until you have washed the application area well or have showered.

It is important to note the following key points:

• The patient should be educated on the proper use and handling of testosterone gel to minimize the risk of secondary exposure to others, particularly children and women.
• The patient should be instructed to apply the gel only to the recommended areas, wash their hands after application, and cover the application site with clothing.
• The patient should also be advised to wash the application site thoroughly before having skin-to-skin contact with others.
• Monitoring for signs and symptoms of prostate cancer, blood clots, and heart attack or stroke is necessary while using testosterone gel.
• The patient should be informed about the potential side effects of testosterone gel, including skin irritation, increased red blood cell count, and headache.
• The patient's liver enzymes, hematocrit, and lipid concentrations should be monitored periodically while using testosterone gel 2.
• The patient should be educated on the importance of reporting any side effects promptly to their healthcare provider.
• The patient's PSA levels should be checked periodically while using testosterone gel 2.

From the Research

Important Considerations

• The patient's history of hypertension (HTN) and low testosterone levels should be closely monitored, as testosterone replacement therapy (TRT) may exacerbate cardiovascular risks 3, 4.
• The patient's desire to have children in the near future is a crucial factor, as TRT can affect spermatogenesis and may impact fertility 3, 4.
• The patient's sedentary lifestyle and weight gain may be contributing factors to his low testosterone levels, and lifestyle changes such as regular aerobic exercise and weight reduction should be encouraged 3, 4.
• The patient should be educated on the potential risks and benefits of TRT, including the possibility of elevated liver enzymes, thrombosis, and prostate cancer, as well as the importance of regular monitoring and follow-up appointments 3, 4, 5, 6, 7.

Monitoring and Follow-up

• Regular monitoring of the patient's testosterone levels, hematocrit, and liver function should be performed to minimize the risks associated with TRT 3, 4, 7.
• The patient should be screened for prostate cancer, taking into account his age, baseline cancer risk, and patient preference 4, 7.
• The patient should be educated on the importance of reporting any side effects or concerns promptly to his healthcare provider 3, 4.

Treatment and Management

• The patient's treatment plan should be individualized, taking into account his medical history, lifestyle, and personal preferences 3, 4, 7.
• The patient's response to TRT should be closely monitored, and adjustments to his treatment plan should be made as necessary to optimize his benefits and minimize his risks 3, 4, 7.