What is the typical starting dose of intramuscular (IM) testosterone for a male patient with diagnosed hypogonadism?

Intramuscular Testosterone Dosing for Hypogonadism

For adult males with confirmed hypogonadism, start with testosterone cypionate or enanthate 100-200 mg every 2 weeks, or preferably 50-100 mg weekly for more stable serum levels, targeting mid-normal testosterone values of 500-600 ng/dL. 1, 2

Standard Starting Doses

• Testosterone enanthate or cypionate 100-200 mg every 2 weeks is the FDA-approved and guideline-recommended starting regimen for most hypogonadal men. 1, 2
• Weekly dosing of 50-100 mg provides more stable serum testosterone levels compared to biweekly administration and is the preferred approach when feasible. 3, 4
• The 200 mg every 2 weeks regimen effectively suppresses elevated LH and FSH to normal range while maintaining serum testosterone within physiologic levels. 3, 5

Dose Selection Algorithm

• Begin with 50-100 mg weekly for patients who can tolerate more frequent injections, as this minimizes the supraphysiological peaks and subtherapeutic troughs seen with biweekly dosing. 4
• Use 100-200 mg every 2 weeks for patients who prefer less frequent administration, recognizing that peak serum levels occur 2-5 days after injection with return to baseline by days 10-14. 1, 2
• An alternative regimen of 300 mg every 3 weeks may be considered, though it produces greater fluctuation in testosterone levels. 1, 5, 6

Critical Monitoring Requirements

• Measure testosterone levels 2-3 months after treatment initiation or any dose change, drawing blood midway between injections (days 5-7 for biweekly dosing). 1, 2, 4
• Target mid-normal testosterone values of 500-600 ng/dL when measuring at the midpoint between injections. 1, 2
• Once stable levels are confirmed, monitor testosterone every 6-12 months along with hematocrit and PSA (in men over 40 years). 1, 2

Dose Titration Strategy

• If testosterone levels remain in the low-normal range and clinical response is suboptimal at 2-3 months, increase the dose in 25-50 mg increments. 1, 4
• If adequate clinical response is achieved even with low-normal testosterone levels, no dose adjustment is necessary. 1
• Maximum recommended dosing is 200 mg weekly, though doses exceeding this significantly increase erythrocytosis risk and are considered supraphysiologic. 3

Safety Thresholds and Contraindications

• Withhold testosterone therapy if hematocrit exceeds 54% and consider phlebotomy in high-risk cases. 2, 3, 4
• Injectable testosterone carries higher erythrocytosis risk (up to 44%) compared to transdermal preparations due to fluctuating levels. 1, 7
• Testosterone therapy is absolutely contraindicated in men actively seeking fertility—these patients require gonadotropin therapy (hCG plus FSH) instead. 2

Common Pitfalls to Avoid

• Do not use biweekly dosing if the patient experiences mood fluctuations or symptom recurrence before the next injection—this indicates the need for weekly administration. 4
• Do not measure testosterone levels at random times; timing must be midway between injections for accurate assessment of steady-state levels. 1, 2, 4
• Do not continue therapy beyond 12 months if no improvement in sexual function is observed, as this exposes patients to risks without benefit. 2
• Injectable testosterone may carry greater cardiovascular risk than transdermal preparations, possibly related to time spent in both supratherapeutic and subtherapeutic ranges. 1, 4

Expected Treatment Outcomes

• Small but significant improvements in sexual function and libido (standardized mean difference 0.35) are the primary benefits. 2
• Little to no effect on physical functioning, energy, vitality, depressive symptoms, or cognition should be expected, even with confirmed hypogonadism. 2
• Improvements in fasting glucose, insulin resistance, triglycerides, and HDL cholesterol may occur. 2