Low Testosterone (Male Hypogonadism)

Management and Treatment

How is low testosterone treated?

Low testosterone is treated with testosterone replacement therapy, which can be given in several different ways:

• Intramuscular injections (into a muscle), usually every 10 to 14 days;
• Testosterone patches, which are used every day and are applied to different parts of the body, including the buttocks, arms, back, and abdomen
• Testosterone gels that are applied every day to the clean dry skin of the upper back and arms (the gels require care in making sure that the hormone is not accidentally transferred to another person or partner)
• Pellets that are implanted under the skin every two months

(Oral testosterone is not approved for use in the United States.)

What are the benefits of testosterone replacement therapy?

Potential benefits of testosterone replacement therapy may include:

• In boys, avoiding problems related to delayed puberty
• Loss of fat
• Increased bone density and protection against osteoporosis
• Improved mood and sense of well-being
• Improved sexual function
• Improved mental sharpness
• Greater muscle strength and physical performance

What are the side effects of testosterone replacement therapy?

The side effects of testosterone replacement therapy include:

• Acne or oily skin
• Swelling in the ankles caused by mild fluid retention
• Stimulation of the prostate, which can cause urination symptoms such as difficulty urinating
• Breast enlargement or tenderness
• Worsening of sleep apnea (a sleep disorder that results in frequent nighttime awakenings and daytime sleepiness)
• Smaller testicles
• Skin irritation (in patients receiving topical testosterone replacement)

Laboratory abnormalities that can occur with testosterone replacement include:

• Increase in prostate-specific antigen (PSA)
• Increase in red blood cell count
• Decrease in sperm count, producing infertility (inability to have children), which is especially important in younger men who desire fertility

If you are taking hormone replacement therapy, regular follow-up appointments with your physician are important.

Guidelines suggest discussing the potential risk vs. benefit of evaluating prostate cancer risk and prostate monitoring. The doctor and patient will decide together regarding prostate cancer monitoring. For patients who choose monitoring, clinicians should assess prostate cancer risk before starting testosterone treatment, and 3 to 12 months after starting testosterone:

• PSA levels should be checked at 3, 6, and 12 months within the first year, and then every year after that.
• A digital rectal examination of the prostate should be done at 3-6 months and 1 year after beginning therapy, and then every year after that. This is recommended even for men who are not on testosterone replacement therapy, as an age-related prostate cancer screening. This usually begins at age 50.
• Hematocrit levels will be checked before testosterone therapy starts, and then on a regular basis to make sure red blood cell levels remain normal.

Who shouldn't take testosterone replacement therapy?

Testosterone replacement therapy may cause the prostate to grow. If a man has early prostate cancer, there is concern that testosterone may stimulate the cancer's growth. Therefore, men who have prostate cancer should not take testosterone replacement therapy. It is important for all men considering testosterone replacement therapy to undergo prostate screening before starting this therapy.

Other men who should not take testosterone replacement therapy include those who have:

• An enlarged prostate resulting in urinary symptoms (difficulty starting a urinary stream)
• A lump on their prostate that has not been evaluated
• A PSA measurement above 4
• Breast cancer
• An elevated hematocrit level (higher-than-normal number of red blood cells)
• Severe congestive heart failure
• Obstructive sleep apnea that has not been treated