Hypogonadism is a condition associated with low serum testosterone levels and symptoms such as fatigue, decreased libido, weakness, and weight gain. It is known to occur with aging, as most men have declining testosterone levels beginning in their 30’s. Low testosterone levels have been associated with decreased muscle mass and strength, osteoporosis, depression, decreased cognition, ED, and metabolic syndrome. Testosterone replacement therapy (TRT) has been shown to increase lean body mass, improve bone mineral density, increase cognitive performance, and improve sexual function.
Currently, there is no single consensus statement regarding diagnosis and management of hypogonadism. In general, the diagnosis requires a low serum testosterone level coupled with at least one clinical symptom of low testosterone. Absolute ranges of normal testosterone levels are difficult to establish. Therefore, treatment is generally geared toward improvement of clinical symptoms rather than an absolute serum testosterone level.
Historically, the concern for TRT was its effect on the prostate. Despite evidence that the prostate does enlarge slightly on TRT, no studies have shown any significant worsening of urinary symptoms while on therapy. Studies have also demonstrated no significant change in PSA while on therapy. An increasing PSA while on TRT may indicate underlying malignancy and warrants evaluation. There has been no increased risk of prostate cancer demonstrated with TRT. Additionally, studies have demonstrated no increased risk of recurrence in men on TRT after undergoing treatment for prostate cancer. Small studies of men with active prostate cancer have shown no progression of disease on TRT.
There are many options for TRT, each of which has its benefits and disadvantages. The decision about which one is right for you will depend on your personal preferences and a discussion with your physician. In some cases, different insurance companies may cover one option and not another, which may also be taken into consideration. If the desired effects are not achieved with your initial choice, a different option can be tried to see if it is a better fit for you. A summary of the most commonly used TRT options is provided below.
- Topical Gels: Advantages include more constant levels with daily dosing, high patient satisfaction, and avoidance of needles. Disadvantages include increased cost compared to injectables, the potential for transference of the gel to others (e.g., spouses and young children) through contact with your skin or clothes, messiness of gel application, and potential skin irritation.
- Injectables: Advantages include efficacy and patient satisfaction, weekly to biweekly dosing, and low cost. Disadvantages include increased fluctuation (peaks and valleys) in testosterone levels compared to daily dosing options and the requirement for needles and self-injection.
- Implantable: The advantages of this therapy include convenience and decreased frequent of dosing. As this requires a short office procedure, there are risks including bleeding, infection, and pellet extrusion in less than 1% of cases.
Regardless of the type of testosterone replacement therapy chosen, you will need to be monitored at regular intervals (usually every 3-6 months); both to confirm good control of your symptoms and to ensure that there are no potentially dangerous side effects. The follow-up regimen usually consists of the following:
- Physical examination, including digital rectal exam to rule out prostate nodules (yearly).
- Routine blood work for testosterone levels and other hormones (every 3-6 months)
- Routine blood work for lipids, hemoglobin and hematocrit, and PSA (prostate-specific antigen) (every 6 months).