Clinical Hypogonadism and Androgen Replacement Therapy: An Overview

Dana A. Ohl; Susanne A. Quallich

Disclosures

Urol Nurs. 2006;26(4):253-259,269. 

In This Article

Types of Testosterone Replacement Therapy

Different preparations of testosterone are used for replacement therapy (see Table 4 ). While there are advantages and disadvantages to each type of replacement therapy, there are also other important issues.

First, oral agents really have no place in hormone therapy in men. There is a first pass effect after absorption into the portal system that allows the liver to metabolize the drug, leading to a very small amount of hormone entering the circulation. The resultant down-regulation of GnRH and LH will result in very little change in circulating levels of testosterone in all men except those with a profound decline in testosterone. The first pass absorption of oral agents through the liver causes the highest degree of toxicity of all the replacement therapy options. These include lowering of HDL cholesterol (Bagatell & Bremner, 1995) and liver toxicity (Yoshida, Erb, Scudamore, & Owen, 1994). An exception to this discussion of oral agents is testosterone undecanoate, which is absorbed via lymphatics and must be taken four times per day. It is available outside of the United States, and there are no plans to pursue FDA approval.

Injectable agents are more often used for replacement therapy. The testosterone esters in these compounds are put in depot injections that leach hormone out over a period of weeks. The average dosage is 100 mg per week. Injections are formulated such that a person may receive 200 mg every 2 weeks or 300 mg every 3 weeks, etc. There is an initial peak in testosterone level right after an injection. If this level rises above the normal range, increased adverse events such as those described in the following section may be seen. There may also be a drop of the testosterone level below the normal range shortly before the next injection, leading to increased symptoms. This cyclical nature of highs and lows can be minimized by shortening the interval between injections, and lowering the dose. A target of 200 mg every 2 weeks is usually a good compromise between toxicity and beneficial effects.

Topical or transdermal delivery for testosterone replacement is also available. Since these agents are administered daily in low dose, the risk of supraphysiological or subtherapeutic levels is minimized. The use of topical agents is thought to minimize adverse events. Indeed, in most series examining the toxicity of topical agents, adverse events are nearly nonexistent (Steidle et al., 2003). The main disadvantage of the topical agents are their high cost ($100 to $150 per month), substantially higher than self-administered injection therapy ($30 per month). Specific disadvantages of individual agents are listed in Table 4 .

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