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Appropriate investigations to rule out contraindications before starting T therapy are DRE, determination of PSA, and possibly transrectal ultrasonography If, after 3 6 months, the signs and symptoms causing the initiation of therapy do not improve, androgen administration should be reconsidered The second annual Andropause consensus meeting recommended performing DRE and serum PSA before treatment, at three and six months, and yearly thereafter [215] In addition to that recommendation, a PSA level could be obtained one month after initiation of therapy to capture the patient with a previously undiagnosed prostate cancer that may be behaving in a very aggressive fashion following T-replacement ISSAM and WHO guidelines also recommend periodic hematologic assessment, ie
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Table 183 Available testosterone formulations Route Injectable Formulation T propionate in oil T cypionate in oil T enanthate in oil T undecanoate in oil T undecanoate* T undecanoate caps** Mesterolone T buccal system*** T patch T gel Crystalline T pellet Dose 10 25 mg 50 250 mg 50 250 mg 1000 mg 40 80 mg 40 80 mg 75 150 mg 30 mg (1 system) 5 mg (1 patch) 50 100 mg 600 mg
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Dosing frequency Twice a week Every 2 4 weeks Every 2 4 weeks Every 10 14 weeks 2 3 times a day Twice a day Once a day Twice a day Once or twice a day Once a day Every 16 26 weeks
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* in oleic acid; ** in a mixture of castor oil and propylene glycol laureate; *** to be stuck to gum Source: [75]
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usually observed 10 to 14 days after injection A regimen of T enanthate or cypionate results in highs and lows in serum T levels that are attended by similar changes in the patient s mood, sexual desire and activity, and energy level The advantages of this form of therapy include low cost and high peak serum levels of T The disadvantages include the pain of injection and the need for frequent medical visits for administration of the injections A new parenteral T preparation, T undecanoate, enables elimination of most of the shortcomings of these old preparations It has the advantage that the serum T levels resulting from each injection are much more stable and physiologic T undecanoate has been extensively investigated in hypogonadal men After two loading doses of 1000 mg T undecanoate at 0 and 6 weeks, repeated injections at 12week intervals are suf cient to maintain T levels in the reference range in the vast majority of eugonadal men, with intervals of up to 14 weeks in some men [216,217] Transdermal T is available in either a skin patch and more recently as gel preparations Daily application is required for each of these They are designed to deliver 5 10 mg of T per day The advantages include ease of use and maintenance of relatively uniform serum T levels over time [218,219] Skin
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irritation is a frequent adverse effect of T patches but is uncommon with gel preparations [30,220] Inadequate absorption through the skin may limit the value of transdermal preparations in some persons, or may require a doubling of the daily dose Table 184 provides a summary of T therapy
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Another potential method of the treatment of hypogonadism is the use of agents that increase the endogenous production of T in men with hypogonadotropic hypogonadism Shabsigh et al reported on a study on 36 men with hypogonadism de ned as serum T level less than 3 ng/mL Each patient was treated with a daily dose of 25 mg clomiphene citrate, and followed prospectively The mean age was 39 years with the mean pretreatment T and estrogen levels of 247 039 ng/mL and 323 109 pg/mL, respectively By the rst follow-up visit (four to six weeks), the mean T level rose to 61 178 ng/mL (P < 000001) Moreover, the T/E ratio improved from 87 to 142 (P < 0001) This therapy may represent an alternative to T therapy by stimulating the endogenous androgen production pathway [211], and allowed Guay et al to improve T secretion
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