Testosterone Supplementation

1. See Also
   1. Androgen Replacement in Women
2. Indications: Men
   1. Depression, Fatigue, muscle wasting in HIV or AIDS
   2. Symptomatic Testicular Failure with low testosterone
      1. See Male Menopause
      2. See Hypogonadism
      3. Decreased libido
      4. Impotence
3. Contraindications
   1. Prostate Cancer
   2. Sleep Apnea
   3. Normal testosterone
4. Positive effects
   1. Increases bone density or decreases bone loss
   2. Increase Lean Body Mass and Muscle Strength
   3. Decrease body fat
   4. Increase serum Hematocrit
   5. Increases sense of well-being, mood and cognition
   6. Increases libido
5. Disproved Risks for physiologic Androgen replacement
   1. Prostate Cancer risk is not increased
      1. Morales (2005) J Endocrinol Invest 28:122-7
      2. Scultheiss (2004) Andrologia 36:355-65
   2. Cardiovascular disease is not increased
      1. Zmuda (1997) Am J Epidemiol 146:609-14
6. Adverse Effects (decreased if testosterone level stable)
   1. HDL Cholesterol declines
   2. Increased Prostate Cancer growth
   3. Polycythemia and cerebral vascular accident risk
   4. May exacerbates Sleep Apnea
   5. Hepatotoxicity (especially oral preparations)
   6. Behavior and mood changes
      1. Moodiness or irritability
      2. Aggressive behavior
   7. Virilization (Hirsutism, Alopecia, Acne)
   8. Lethargy (low Serum Testosterone fluctuations)
7. Lab Monitoring while on Testosterone
   1. See Androgen Replacement in Women for monitoring women
   2. Baseline Labs
      1. Prostate Specific Antigen (PSA)
      2. Digital Rectal Exam and Prostate examination
      3. Testosterone level
      4. Hematocrit
      5. Liver Function Tests
   3. Monitoring for Establishing Injection Dose
      1. Serum Testosterone at one week post injection
         1. Level above normal: decrease subsequent doses
      2. Serum Testosterone at two weeks post injection
         1. Level below normal: increase injection frequency
   4. Monitoring every 6 months
      1. Prostate (Consider annual screening instead)
         1. Prostate Specific Antigen (PSA)
         2. Digital Rectal Exam
      2. Hematocrit (discontinue testosterone if >50% rise)
      3. Liver Function Tests (indicated in oral testosterone)
      4. Re-evaluate testosterone efficacy
8. Dosing: Testosterone Injection (Intramuscular)
   1. Transdermal delivery is preferred over intramuscular
   2. Preparations
      1. Testosterone cypionate (Depo-Testosterone)
      2. Testosterone enanthate (Delatestryl)
   3. Typical Dose: 200 mg IM every 2 weeks ($4 per month)
   4. Range: 50 to 400 mg IM every 2-4 weeks
9. Dosing: Testosterone Transdermal (preferred, physiologic)
   1. Serum Testosterone peaks 2 hours post-patch application
   2. Testoderm one 4 or 6 mg patch ($72 per month)
      1. Apply to shaved Scrotum every 24 hours
      2. Much less irritating than Androderm
   3. Androderm ($98 per month)
      1. Typical dose: 4 mg patch daily
         1. Manufacturer changed dose in 2011 to 2 mg patch (instead of 2.5 mg) and 4 mg patch (instead of 5 mg)
      2. May cause rash (8% of patients)
      3. Apply to skin every 24 hours
         1. Abdomen
         2. Thigh
         3. Between Shoulder blades
   4. Androgel
      1. Very expensive ($300/month)
      2. Testosterone 1% gel four pumps (5 grams) topically daily
         1. May cause local skin reaction
         2. Apply to upper arms, Shoulders and Abdomen
         3. Avoid bathing for 5 hours after application
      3. Testosterone 1.62% gel two pumps topically daily
         1. Newer preparation released in 2011
         2. Equivalent to 4 pumps of the 1%
         3. Apply to upper arms, Shoulders, but NOT to Abdomen (due to less absorption)
         4. Avoid bathing for 2 hours after application
10. Dosing: Other forms
    1. Testosterone buccal (Striant) 30 mg to gums bid
       1. May cause oral irritation
       2. New option less studied than other forms
    2. Testosterone implanted pellets (Testopel)
       1. 150 to 450 mg implanted SQ q3-6 months
       2. Used for Delayed Puberty in males
    3. Oral testosterone (not recommended)
       1. Listed for completeness
       2. Not recommended due to hepatotoxicity and less effect
       3. Agents
          1. Methyltestosterone (Android)
          2. Fluoxymesterone (Halotestin)
11. References
    1. Dewire (1996) Am Fam Physician 53(6):2101-6
    2. Margo (2006) Am Fam Physician 73(9):1591-603
    3. Schow (1997) Postgrad Med 101(3): 62-79
    4. Tan (1998) Postgrad Med 103(5): 247-56