What are the recommended testosterone treatment increments for a male patient with confirmed hypogonadism?

Testosterone Treatment Increments for Male Hypogonadism

Injectable Testosterone Dosing

For intramuscular testosterone cypionate or enanthate, start at 100-200 mg every 2 weeks or 50-100 mg weekly, with weekly dosing providing more stable testosterone levels and reducing the risk of erythrocytosis. 1, 2

Initial Dosing Strategy

• Testosterone cypionate or enanthate: Begin with 100 mg every 2 weeks or 50 mg weekly for most patients 1, 2
• Higher initial doses (150-200 mg every 2 weeks) may be appropriate for men with very low baseline testosterone (<150 ng/dL) 2
• Weekly dosing (50-100 mg) is preferred over biweekly administration because it produces more consistent day-to-day testosterone levels and lower rates of erythrocytosis 1, 2

Dose Titration Protocol

• Measure testosterone levels at 2-3 months after treatment initiation or any dose change 1, 2
• For injectable formulations, draw blood midway between injections (days 5-7 after injection) to capture representative levels 1, 2
• Target mid-normal testosterone levels of 450-600 ng/dL at this midpoint measurement 1, 2

Dose Adjustment Algorithm

If testosterone level is <450 ng/dL at follow-up:

• Increase dose by 25-50 mg per injection 2
• Example: If on 100 mg every 2 weeks, increase to 150 mg every 2 weeks 2
• Alternatively, switch from biweekly to weekly dosing (e.g., 100 mg every 2 weeks → 50 mg weekly) 2

If testosterone level is 450-600 ng/dL:

• Continue current dose 2
• Monitor every 6-12 months once stable 1, 2

If testosterone level is >750 ng/dL:

• Reduce dose by approximately 25-50% 2
• Example: If on 200 mg every 2 weeks, reduce to 100-150 mg every 2 weeks 2

If testosterone level is >1000 ng/dL (supraphysiologic):

• Reduce dose by 50% immediately 2
• Supraphysiologic levels significantly increase risk of erythrocytosis (43.8% with IM injections vs 15.4% with transdermal) 2

Transdermal Testosterone Dosing

Transdermal testosterone gel is the preferred first-line formulation, starting at 40.5-50 mg daily, as it provides more stable day-to-day levels and lower risk of erythrocytosis compared to injections. 1, 2

Initial Dosing by Formulation

• AndroGel 1.62%: Start at 40.5 mg daily (2 pump actuations) 1, 2
• AndroGel 1%: Start at 50 mg daily (two 2.5g packets or equivalent gel) 2
• Testim 1%: Start at 50 mg daily (one 5g tube) 2
• Fortesta 2%: Start at 40 mg daily (4 pump actuations) 2

Dose Titration for Transdermal Preparations

• Measure testosterone levels at 2-3 months after initiation or dose change 1, 2
• For transdermal formulations, levels can be measured at any time after 2-3 months of stable therapy 1
• Target mid-normal levels of 450-600 ng/dL 2

Dose Adjustment for Gels

If testosterone level is <450 ng/dL:

• Increase dose by 20.25-25 mg daily 2
• Example: AndroGel 1.62% from 40.5 mg → 60.75 mg daily 2
• Maximum recommended dose: AndroGel 1.62% 81 mg daily, AndroGel 1% 100 mg daily 2

If testosterone level is 450-600 ng/dL:

• Continue current dose 2
• Monitor every 6-12 months 1, 2

If testosterone level is >750 ng/dL:

• Reduce dose by 20.25-25 mg daily 2

If maximal transdermal dose fails to achieve adequate levels:

• Consider switching to intramuscular injection therapy 2

Long-Acting Injectable Testosterone

Testosterone undecanoate provides an alternative with fewer yearly injections and more stable levels, dosed at 750 mg initially, repeated at 4 weeks, then every 10 weeks thereafter. 1, 2

• Initial dose: 750 mg intramuscular gluteal injection 2
• Second dose: 750 mg at 4 weeks 2
• Maintenance: 750 mg every 10 weeks 2
• Must be administered as gluteal IM injection only (not suitable for self-administration in thigh) 2

Critical Monitoring Parameters

Testosterone Level Monitoring

• Initial assessment: 2-3 months after starting or changing dose 1, 2
• Ongoing monitoring: Every 6-12 months once stable 1, 2
• Target range: 450-600 ng/dL (mid-normal) 1, 2

Safety Monitoring

Hematocrit monitoring is mandatory:

• Check at baseline before initiating therapy 1
• Monitor at each follow-up visit 1, 2
• Withhold treatment if hematocrit >54% and consider phlebotomy in high-risk cases 1, 2
• Injectable testosterone carries higher erythrocytosis risk (43.8%) compared to transdermal (15.4%) 2

PSA monitoring in men over 40 years:

• Baseline PSA before initiating therapy 1
• Monitor periodically during treatment 1, 2
• Refer for urologic evaluation if PSA increases >1.0 ng/mL in first 6 months or >0.4 ng/mL per year thereafter 1

Common Pitfalls to Avoid

• Do not draw testosterone levels at peak (days 2-5 after injection), as this shows supraphysiologic levels and may lead to inappropriate dose reduction 1
• Do not draw levels at trough (days 13-14 after injection), as this may lead to unnecessary dose escalation 1
• Do not continue supraphysiologic dosing (testosterone >1000 ng/dL) even if patient feels well, as this significantly increases adverse event risk 2
• Do not assume all gel formulations are interchangeable, as 1.62% delivers more testosterone per gram than 1% formulation 2
• Do not ignore mild erythrocytosis (hematocrit 50-52%) in elderly or cardiovascular disease patients, as even modest elevations increase thrombotic risk 1

Formulation Selection Considerations

Advantages of weekly injections over biweekly:

• More stable testosterone levels 2
• Lower risk of erythrocytosis 2
• Reduced fluctuation in symptoms 2

Advantages of transdermal over injectable:

• More consistent day-to-day levels 1, 2
• Lower erythrocytosis risk (15.4% vs 43.8%) 2
• No injection discomfort 2
• Easier dose titration 2

Disadvantages of transdermal:

• Higher cost ($2,135 annually vs $156 for IM) 1, 2
• Potential for transfer to partners/children 2
• May not achieve adequate levels in all patients 2