Testosterone Therapy (TT)

In recent years, the media has reported more about Testosterone Therpy (TT), and more men between the ages of 40 and 64 have been tested and given TT. Some men with certain symptoms may even want TT without being tested. This action may not be safe or helpful for them. Total testosterone level should always be tested before any TT.

The AUA recommends that TT be prescribed only to men who meet the clinical and laboratory definition of testosterone deficiency (Testosterone level of less than 300 ng/dL). Here are some of the things you will need to know about TT:

  • Your doctor will likely measure your testosterone level if you have these conditions:
    • Unexplained anemia 
    • Diabetes 
    • Bone density loss 
    • Low-trauma bone fracture
    • Radiation to your testicles 
    • HIV/AIDS positive test results
    • Chronic narcotic use
    • History of infertility 
    • Pituitary gland disorders
  • Even if you do not have specific signs and symptoms, your doctor may test your total testosterone level for these conditions:
    • Insulin resistance
    • History of chemotherapy
    • History of using corticosteroid medicines
  • Health changes such as losing weight and getting more physical activity will likely raise your testosterone levels. 
  • Your doctor will want to check your hemoglobin/hematocrit (Hgb/Hct) levels while you are on TT. This blood test will help check for thickening of the blood. 
  • Blood thickening may cause blood clots. Your doctor may do Hgb/Hct levels two to six weeks after you start TT and every six to twelve months after that test. 
  • If you are at risk for heart disease, your doctor will follow you more closely when you are on TT. It also is important to make health changes to decrease the chances for heart and blood vessel disease. 
  • Your doctor will treat your Low-T level to raise it above 300ng/dl but the exact level may vary.
  • Your doctor will watch you for signs and symptoms of improvement. Any changes will likely appear within three to six months of treatment.
  • If your total testosterone blood level returns to normal and you still have symptoms, it is likely that there are other reasons for your symptoms. Your doctor may stop TT and try to find out what else might be the problem.

How Do I Take Testosterone?

There are generally five different ways to take testosterone. They are: transdermal (through the skin), injection, oral/buccal (by mouth), intranasal (through the nose), and by pellets under the skin. No method is better than another. While you are taking TT, your doctor will test your blood to determine testosterone levels.

Here are some details about the five different methods:

  • Transdermal (Topical). There are topical gels, creams, liquids and patches. Topical medicines most often last for about four days. They absorb better if covered with an air- or water- tight dressing. 
    • Apply liquids and gels, creams or patches to skin that is dry and without cuts or scratches. 
    • Do not wash the area until it is time for the next dose. 
    • Wash your hands after you apply liquids, gels or creams. 
    • Make sure that other people, especially women and children, do not touch the medicines. 

A topical patch is like a band-aid with medicine on it. You put it on and leave it until the next dose is due. The medicine on the patch is less likely than liquids, gels and creams to transfer to others.

  • Injection. There are short-acting and long-acting forms of testosterone injection. The short-acting medicine may be given under the skin or in the muscle. The long-acting one is usually given in the muscle. Injections are usually given either weekly, every two weeks, or monthly.
  • Oral/buccal (by mouth). The buccal dose comes in a patch that you place above your incisor (canine or "eyetooth"). The medication looks like a tablet but you should not chew or swallow it. The drug is released over 12 hours. This method has fewer harmful side effects on the liver than if the drug is swallowed, but it may cause headaches or cause irritation where you place it.
  • Intranasal. This form of testosterone comes in a gel. You pump the dose into each nostril, as directed. It is usually taken three times daily.
  • Pellets. Your doctor will place the testosterone pellets under the skin of your upper hip or buttocks. Your doctor will give a shot of local anesthesia to numb your skin, then make a small cut and place the pellets inside the fatty tissues underneath your skin. This medication dissolves slowly and is released over about 3-6 months, depending on the number of pellets. 

You may want to choose how you take your testosterone based on what is best or most useful for you. In some cases, your insurance provider may decide the order in which testosterone therapies are provided. Talk about the choices with your doctor.

Are There Side Effects of TT?

There are some side effects of TT. Some side effects are mild while others are more serious. You should ask your doctor or pharmacist about these side effects and watch for them while you are taking TT. Some of the side effects are as follows:

  • For gels and liquids, there may be some redness at the skin site. With patches, you may have itching and a rash around the area. A very small number of patients report back pain.
  • For short-acting injections, you may have some reaction at the injection site. Some persons have had serious allergic reactions to the long-acting injection. Because of this, when you get the long-acting injection they will watch you closely for a while afterwards in the medical office.
  • For testosterone pellets, possible adverse effects include swelling, pain, bruising and, rarely, hematoma (clotted blood under the skin).
  • During TT, there is increased risk of erythrocytosis (abnormal raising of blood hemoglobin and hematocrit).
  • TT may interrupt normal sperm production. You should not have TT if you plan on having children soon. If you are being treated for Low-T your doctor may suggest added treatment for sperm production.
  • Topical testosterone, specifically gels, creams and liquids, may transfer to others. Women and children are most at risk of harmful effects from contact with them. You should take care to cover the area and wash your hands well after putting on the medication. Be careful not to let the site with the topical TT touch others because that could transfer the drug.
  • The FDA suggests watching for signs and symptoms of early puberty in a child you live with or have contact with if you use topical testosterone. Do not let children touch the unwashed or unclothed area where you put the drug.

Here are some things you should know:

  • There is no evidence linking TT to prostate cancer.
  • There is no strong evidence linking TT to increase in vein clots.
  • At this time, there is no strong evidence that TT either increases or decreases the risk of cardiovascular events. However, while you are on TT, you should call your doctor right away if you have signs or symptoms of stroke or heart attack.