Overview

The good news is that therapy is often very effective. The goals are to restore sexual functioning, increase libido and sense of well-being, prevent osteoporosis by optimizing bone density, restore muscle strength and improve mental functions. Our aim is to bring your levels of serum testosterone back to high normal levels. Beyond this, we aim to normalize other hormones that may be abnormal as well. These include, thyroid hormone, DHEA, estradiol (the main female hormone), and prolactin.

There are a number of ways to treat this condition including transdermal (through the skin) patches and gels, injections, and long-acting slow release pellets. Each modality has its own advantages and disadvantages. Factors include: ability to get good levels, transmissibility to others, frequency and ease of use, and personal preference.

It is important to note that testosterone is not available orally. This is because all drugs absorbed in the stomach go to the liver first. The liver thus gets a very high concentration of the medication. In the case of testosterone, this can increase the chance of liver disease and cancer. This is not the case when it is given by other modalities.

Topical Therapy/Applied to Skin or Mucous Membranes

Testosterone can be applied to the skin or to mucous membranes (the inside of the nose or mouth.) Mixed with the testosterone are specific ingredients that help get it into the bloodstream, and then to the rest of your body. Most often, this is the first line therapy. The range of options and number of branded and generic preparations continues to grow.

Locations

The testosterone may be applied to the:

Advantages/Disadvantages

>Daily Use

Most men start with the topical medications, as they are less intimidating. If for some reason, a man doesnt like it, he just doesnt have to do it the next day.

However, to be effective, all of the topicals must be placed every day. For some men, this is a non-issue. For others this is a burden. They may not be able to remember to put it on consistently. They may not like the way it feels, smells, or tastes.

>Variable Absorption

Many men get good absorption and are able to attain good blood testosterone levels. However, a significant number of men are not able to absorb the medication, and never get good levels.

We always check levels, and switch to a different modality of testosterone replacement, if blood levels are not good enough. In general, we find that if a man is not getting good absorption with one gel or solution, he will not get good levels with a different one. Typically, we will switch to a totally different method.

>Activity Limitations

Since the medications take some time to be absorbed, it is important not to remove them until they have had adequate time to be absorbed.

For the gels and solutions, this is a minimum of two hours. Thus, the user should not shower, swim, or work-out until at least two hours after they have been applied.

For the intranasal (up the nose) gel, which is used three times daily, it is important not to sniff or blow your nose for an hour after use.

>Transmissibility

Though the gels and solutions take a minimum of two hours to be absorbed, they are not completely absorbed at this time. Thus, it is important to shower prior to having skin to skin contact (particularly with women and/or children) to the area where the medication was applied. To avoid transmissibility, you can simply put on a T-shirt.

We usually have our patients apply their once daily medications at night, then sleep with a T-shirt, and shower in the morning, so they are finished with the application for the day.

Most men with pregnant wives or children are not particularly comfortable with using the gels or solutions. There should be no transmissibility issue with the patch or the nasal gel.

>Local Irritation

Since the medication is placed on a particular surface (skin or mucosa) it may cause local irritation.

Local irritation seems to be most common with the patch, where our experience shows that almost no men can tolerate it. Men who are very motivated to use the patch can put a thin layer of hydrocortisone cream over the area first. This often cuts down on the irritation, without decreasing absorption.

For the topical gels and solutions, many men develop rashes or burning. This may be true, even if they rotate the site of application. However, many men have no skin issues whatsoever.

Injections

Testosterone may be injected into the layer of fat underneath the skin (subcutaneously) or into the muscle (intramuscularly- IM), usually the thigh, arm, or buttock. This method has been used by physicians for years, and predates the use of topical testosterone by decades. ( It is also the method that has been most abused by bodybuilders and athletes.)

Traditionally, testosterone was injected only intramuscularly. However, experts have recognized that it is also equally well absorbed when injected into the fat underneath the skin. The needle is much shorter this way, and most men report preferring this technique.

Method

There are various formulations of injectable testosterone. The most common are testosterone cypionate and testosterone enanthate. Testosterone cypionate is the one that virtually all physicians, including us, prescribe.

The dosage is dependent on the individual. In general, we are aiming for men to feel better, which usually correlates to being in the high normal range. We have men injecting as low as 100 mg weekly, and as high as 220 mg weekly. We follow both symptoms and blood work.

Some men notice the ups and downs correlated to the variable levels during the week. These men are then counseled to split the dosage into two, and give themselves two injections per week. This often avoids the peaks and valleys experienced if the medication is given only once during the week.

Many physicians require their patients to come into the office weekly for their injections. This is, of course, burden for many patients. In fact, most patients cannot follow through and drop out of treatment. Other physicians, using the same rationale, give their patients a large dosage on a biweekly or monthly basis. However, this makes the patients have huge peaks and valleys based onhow much is in their system. It also results in more side effects.

The rationale for requiring the patient to come into the office is that this is a restricted drug, and could be abused by the patient. This makes no sense to us for several reasons. The prescribing practitioner knows how much s/he is prescribing. If the patient is running through it much faster than he should be, then there is a problem which is immediately apparent. Also, if a patient wants to abuse steroids, he can just obtain them illegally at many gyms, and doesnt need the physician in the first place. By putting a reasonable and doable treatment plan in place, we feel it is more likely that patients will follow a safe medical regimen.

How is Injectable Testosterone Supplied and How Much Does It Cost?

Testosterone cypionate comes in 10cc and 1cc vials. We strongly recommend our patients get the 10cc vials, as the liquid is very thick (viscous) and it is quite hard to empty the 1cc vials. It is usually more expensive, per cc, to purchase 10 vials of 1cc than it is to purchase 1 vial of 10ccs.

It is available at almost all pharmacies, but sometimes needs to be ordered in advance.

Many drug plans will only pay for one month of medication at a time, which means they will not release a 10cc vial. Fortunately, the medication is relatively inexpensive, and sometimes it is even cheaper to purchase the 10cc vial without using your prescription plan than it is to pay a monthly co-pay and get the 1cc vials. Using a website like goodrx.com or rebates.com, you can make the pharmacies compete for a reasonable price, and a 10cc vial should cost between $35 and $55 (without using your prescription plan).

Thus, for patients without insurance, or with poor drug coverage, the injectable testosterone is by far the cheapest option.

Advantages of injectable testosterone

Disadvantages of injectable testosterone

>Not Bio-identical

Testosterone cypionate is the oil-soluble 17 (beta)- cyclopentylpropionate ester of the androgenic hormone testosterone. In other words, it is not bio-identical testosterone. Men have been making their own testosterone since before we evolved into homo sapiens. But, we have not been making testosterone cypionate. Thus ,there may be some long term side effects of testosterone cypionate that we are not aware of. (Testosterone pellets are an excellent alternative that are bio-identical.)

>Side-Effects

There do seem to be more side effects from testosterone cypionate than from bio-identical testosterone. These include more acne and more increases in hematocrit and estrogen. It is unclear whether this is because there are more peaks and valleys in weekly or biweekly doses than with daily application treatments.

>Self-Injections can be Uncomfortable

Testosterone cypionate is a very thick (viscous) liquid. It is slightly difficult to draw up, and somewhat uncomfortable to inject.

>Compliance

Men do have to remember to give themselves an injection every week, or twice weekly. For some men this is simply not feasible, either because they dread it, or they simply cant remember.

Testosterone Pellets

Testosterone pellets can be inserted in the fat underneath the skin (subcutaneously) once every three months. This is done in the office, and takes less than ten minutes. It has become the most popular method in our practice.

The pellets each contain 75 mg of testosterone. Each pellet is approximately the size of a grain of rice.

In terms of dosing, we can always get good levels of testosterone which we can adjust simply by varying the number of pellets placed, all of which go through the same small skin incision.

How is it Done?

Most of the time, the pellets are placed through a small incision in the skin of the buttock. The incision is so small it is closed with a butterfly bandage (steri-strip). The location is chosen so that it is below the belt line, and above where you sit. No matter how many pellets are placed, only one small skin incision is made.

After the procedure, a butterfly dressing is put on the small nick to hold the edges together, and then a clean dressing. The dressing is waterproof so a man can take a shower with it on. The dressing can be removed after 48 hours. The butterfly dressings then fall off on their own.

We ask our patientsto compress the site and apply ice for a total of 15 minutes, directly after the procedure to limit swelling and bleeding.

Advantages

>Compliance

Men love the fact that they only need to think about this once every three months. Once we have determined the correct dosage, they only need to come to the office once every three months.

>Levels

Unlike the topicals, we can always get men good levels with the pellets.

>Bio-identical

The testosterone pellets are bio-identical. This means that they are exactly what your body makes. Thus, any side effects would only be due to the dosing not to the actual medication itself. In our practice we have a strong preference for bio-identical hormones for this exact reason.

>Cost

Most insurance companies pay for this medication and for the procedure. (However, if they do not, it is much more costly than the testosterone injections.)

Disadvantages

>Discomfort

Some men do not like the procedure. Either they are intimidated by the procedure itself, or they have some post-procedure swelling, bruising, and/or discomfort.

>Infection

Slightly less than 1% of the time, the site can have a small infection. Almost invariably the mans body responds by opening up the tract that the pellets went through and spitting them out. We have never had an abscess or needed to drain the area. We have not needed to give systemic antibiotics.

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Testosterone Replacement Therapy Werner, MD