How is hypogonadism treated?
The primary treatment for hypogonadism is testosterone replacement therapy (TRT). The aim of TRT is to bring testosterone levels back to normal and to eliminate symptoms that affect patient health and their quality of life. TRT treatment is appropriate if:
- testosterone is low
- there are troubling symptoms are present
- all pituitary causes have been ruled out
- no other complications exist such as sleep apnea, breast cancer or polycythemia (too many red blood cells)
- the patient is willing to be monitored
There are several ways to increase testosterone in the body. Some methods include: injections, patches, gels, buccal tablets (that dissolve in the gum line), pills, and implanted pellets. The best method is determined by the cause of hypogonadism, the patient’s preference and tolerance, and cost.
Injections
For many years the standard treatment was a testosterone injection every two or three weeks, however this can result in highs and lows in drug levels that may lead to symptoms like mood swings, sweating and fatigue. More frequent injections of a lower dose are recommended to reduce these side effects. Testosterone should be injected into the muscle every one to two weeks.
The hormones Delatestryl (testosterone enanthate), and Depo-testosterone (testosterone cyprionate) are both available in Canada. It is important to note that Delatestryl (200mg/ml) is twice the concentration of Depo-testosterone (100 mg/ml).
Other long-lasting forms of injectable testosterone such as testosterone undecanoate (Nebido) require injections only 4 times a year and maintain a steadier blood level. Nebido is now available in the USA and Europe and should soon be available in Canada.
Skin gels and patches (transdermal formulations)
Testosterone gel (Androgel or Testim) should be rubbed into the skin once per day. Since it is used daily, blood levels of testosterone are more stable, which reduces side effects such as mood swings and fatigue. To avoid transferring the gel to a partner or child, a thorough hand washing is recommended after applying the gel, as well as covering the application area with clothing.
The gel is also available in patch form (Androderm) that is applied each day to the skin. The patch is applied to a different area of the body (e.g. abdomen, back, arm, thigh) each day (on a rotating basis) in order to prevent or lessen skin reactions like itching and rashes. Both itching and rashes are a common side effect of this treatment method.
Gels that can be rubbed into the skin have proven less irritating than the patch.
Pills
Only one type of testosterone pill is available, called Andriol (testosterone undecanoate). While some older formulations of testosterone are associated with liver damage, Andriol is absorbed through the lymphatic system, not the blood, and does not cause liver damage. The usual starting dose is 80 mg twice daily. It is widely prescribed in Canada but not available in the USA.
Buccal tablet
A small sticky tablet (Striant) is applied to the buccal cavity (where the gum line meets the upper lip). This is applied twice a day, and it releases testosterone over a 12 hour period. This tablet is not currently available in Canada.
Implanted Pellet
A tiny pellet (Testopel) is implanted just below the fat under the skin. It needs to be replaced every 3 to 6 months. This option is not currently available in Canada.
It is important for men to that testosterone replacement can improve general health and wellness, leading to a better mood and more energy, increased strength, increased sexual libido and function, improved cholesterol profiles, and a lowered risk of osteoporosis. Testosterone replacement therapy may or may not improve the quality of an erection.
Men who take testosterone must be followed by their doctor to document their response to the treatment. They should also be monitored with rectal exams and blood tests, to ensure that no problems are developing in the prostate or elsewhere.
Physicians should monitor patients with a digital rectal exam and check blood levels prior to beginning treatment. A digital rectal exam should be repeated after 6 to 12 months, and blood should be checked after 3 to 6 months of treatment. Testosterone levels for men using testosterone injections will need to be periodically monitored. Men using skin gels, patches or pills should have blood testosterone levels checked if symptoms of hypogonadism are not improving after 3 months.
Remember, for most men, digital rectal exams are an uncomfortable procedure but completely necessary for living a longer, healthier life.
Complementary therapies and supplements
- Herbal preparations have not been scientifically tested to the point that the medical community can endorse them
- There is insufficient evidence to support the use of DHEA (a weak androgen hormone found in the adrenal gland) supplements in testosterone deficient men
