Testosterone Treatment Options

Androgen Replacement

Currently the only form of androgen replacement in common clinical use is as testosterone, which is available in various forms.

Options for treatment include topical testosterone gels and creams, short and long acting injections of testosterone esters, application of testosterone via transdermal skin patches, subcutaneous testosterone implants and oral testosterone as the undecanoate ester.

Testosterone esters must be injected every 2-4 weeks, customarily in doses of 250mg. The injection must be deep intramuscular and is quite often painful. The injection results in markedly supra-physiological circulating concentrations of testosterone for several days after administration, with a progressive fall to normal or sub-normal concentrations over the succeeding 2-3 weeks.

The rise and fall in concentration may be accompanied by fluctuations in the symptoms of androgen excess and deficiency.

Testosterone skin patches provide physiological testosterone replacement, with nocturnal applications leading to a pattern of circulating concentrations similar to the normally observed diurnal variation. Patches must be applied daily, and there is a relatively high incidence of adverse skin reactions, which may be sufficiently severe to lead to discontinuation of use. The patches are readily visible and may discourage users from participation in sporting activities, including swimming and other sports requiring the use of change rooms.

Testosterone pellets in doses of 600-1200 mg, are inserted subcutaneously under LA using a trocar and cannula and lead to psychological testosterone concentrations which may be sustained for 4-6 months. Problems include the need for repeated local surgical procedures, and extrusion which may occur after 5-10% of procedures, often several weeks later.

Extrusion rates appear to be related to operator skills; hence pellets are best administered in specialised centres by experienced staff.

Oral testosterone provides only moderately effective testosterone replacement, with wide fluctuations in circulating concentrations, due to erratic bio-availability and sometimes gastro-intestinal intolerance. Up to 4 to 8 40mg oily capsules daily are required and the use of oral testosterone is generally confined to patients who are intolerant of other preparations.

Topical transdermal testosterone gels (AndroGel®/Testogel®, Testim® 1% testosterone gels) and creams (Andromen®/Andromen® Forte 2% & 5% testosterone cream) require daily application, but provide physiological replacement with few problems and satisfactory efficacy. Well designed studies show the efficacy and safety of this mode of administration to be high when given for an average of 36 months follow-up.

In practical terms the gels need to be applied over a very large skin surface area (back, chest, shoulders and arms) compared to the higher concentration creams which require smaller surface areas for application (forearms, torso and thigh).

Scrotal application of the cream does not meet with discomfort in patients, whereas the alcohol-based gel creates a burning sensation when applied to the genitalia.

A recent medical paper established which compared the cost effectiveness versus efficacy of currently available testosterone treatments determined that the testosterone cream, Andromen® Forte 5% (Lawley Pharmaceuticals, Australia) was the most affordable and effective testosterone therapy. To view this paper click here.