This leaflet answers some of the queries you have about testosterone replacement therapy (TRT). The reasons for the treatment, benefits of testosterone therapy, potential side effects,  commonly used formulations of testosterone and the required monitoring regime whilst you are on testosterone replacement are explained in the leaflet.

What is testosterone replacement therapy?

Hypogonadism is the medical term for testosterone deficiency, which means having a low testosterone level. The condition happens when the testes do not produce an adequate level of testosterone.

This can be due to a problem in the testes, where testosterone is produced, or a problem in the pituitary gland that controls the testicular production of testosterone.

Low testosterone can happen in men of any age. Furthermore, there is a progressive decline in testosterone level as men get older.

Testosterone can be lower than the reference range in people who had taken anabolic steroids/ testosterone injections previously and people who consume excess alcohol, who are overweight/ obese, or on certain medications (opiates).  Once you address the underlying cause, the testosterone level usually normalises.

If your own body does not make enough testosterone and reversible causes are excluded, you may benefit from having supplemental testosterone.  If indicated, testosterone replacement therapy will be initiated by your Endocrinologist.

Why do I need testosterone replacement?

If you have been having symptoms of low testosterone and blood testing carried out in the morning (preferably following overnight fasting) has shown that your testosterone is low, at least on two occasions, you may be advised to start testosterone replacement therapy.

Symptoms of low testosterone may include

• Fatigue

• Depression /anxiety

• Irritability/ mood changes

•Low libido, subfertility and erectile dysfunction

• Reduced exercise tolerance and strength

• Excessive sweating / night sweats

• Poor concentration or memory issues

• Needing to shave less often or hair loss

However, it is important to know that other conditions can also cause some of the above-described symptoms.  Therefore, testosterone replacement may not necessarily improve some of the symptoms described above.

Benefits of testosterone treatment
  • Induce and complete secondary sexual characteristics
  • Improve sex drive and sexual function
  • Improve mood and well being
  • Improve muscle mass and strength
  • Improve and restore facial and body hair
  • Maintain bone strength and prevent osteoporosis
  • Improve red cell mass and anaemia
Side effects of testosterone treatment
  • Headache
  • Acne
  • Irritability/ aggressiveness
  • Mood swings/depression
  • Weight gain and oedema
  • Painful and prolonged erections
  • Gynaecomastia (breast enlargement)
  • Male pattern baldness
  • Increase in red cell mass/haematocrit
  • Prostate enlargement
  • Effects of testosterone treatment in cardiovascular risk is controversial.  However it is known to cause an increased risk of venous thrombosis especially in overweight/ obese individuals
 Various testosterone formulations you may be prescribed

Your Endocrinologist may prescribe you a formulation of testosterone if indicated. The decision about the formulation depends on the risks and the benefits, your lifestyle and the preference.

Testosterone transdermal gel (Tostran®, Testogel®, Testavan®, Testim®)

  • This is a clear gel applied once daily preferably in the morning to clean, dry unbroken skin (stomach/ arms). The gel should not be applied around the genital area.
  • Wash your hands after applying the gel
  • Avoid swimming/ shower within 6 hours of application.
  • Skin- skin transfer  can happen within 6 hours of application
  • Usually well tolerated and occasional skin irritation can happen. If you develop skin irritation, it can be treated with moisturising cream.
Dose titration
  • The dose is titrated to acquire the mid reference range after 2-6 hrs of application
  • The testosterone level should be checked 2-6 hr after the application and avoid the application site for blood drawing.
Testosterone intramuscular injections
  • These are oily preparations hence allow absorption over a long period of time
  • Usually the injections are given by the GP or Practice Nurse
  • Causes high levels of testosterone (peaks) soon after injection. Therefore some patients may experience symptoms related to high and low levels of testosterone- i.e.- mood changes, fluctuation of energy
Intramuscular preparations your Endocrinologist may prescribe
  • Combination of testosterone esters (Sustanon®)-250mg/ml
    • Given as an  intramuscular injection every 3-4 weeks
    • Can be self-administered as a subcutaneous injection (following appropriate training), which has the same effectiveness and tolerability to intramuscular injections.
  • Testosterone Undecanoate ( Nebido® )
    • Typically given every 10-14 weeks. Sometimes longer intervals may be required.
    • Should be warmed and injected slowly into gluteal muscle.
    • First and second injection can be given 6-8 weeks apart if required.
    • 3rd injection should be  given 12 weeks later from the 2nd injection
    • Testosterone and Full Blood Count( FBC) should be measured just before the 3rd injection
    • The Trough testosterone level to be achieved towards the lower end of reference range
    • Check testosterone (trough blood) every 3-5 injections or annually once steady state is achieved.
Monitoring the testosterone replacement

It is important to monitor the appropriateness of testosterone treatment and development of side effects whilst you are on testosterone treatment. Usually, once established on testosterone treatment, you will be monitored annually if no adverse effects were identified.

  • Your Endocrinologist will consider other factors such as bone density, haematocrit /red cell count, adverse effects and clinical wellbeing before and following starting on a testosterone formulation.
  • You will be advised to have blood tests annually which includes Full blood Count( FBC), liver function tests( LFT) Testosterone level and Prostate Specific Antigen ( PSA)
  • If your red cell count/ haematocrit goes up, you may be advised to stop testosterone, have less frequent injections or change to transdermal testosterone preparations depending on the results and the risks.
  • If haematocrit/ red cell count remains elevated persistently, testosterone therapy will be discontinued. 
  • You may be advised to discontinue testosterone if the PSA goes up or if prostate cancer is suspected.

 

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