Testosterone Replacement:

So say that we have mutually decided you are indeed testosterone deficient and suffer from such.  (Congratulations, as only 5% of men with hypogonadism actually undergo treatment.  This is mostly to because patients and their doctors don't know what the current rules are concerning testosterone safety, when or how to diagnose it, or how to give it in the first-place and what's the proper monitoring).  Great, you are one of a few.  Where do we go from here?  Well, there are many concerns and options.  I will review them below along with the benefits and risks.

First of all, Testosterone shouldn't be replaced orally in a man, as the doses typically used in a man would be hepatotoxic, causes damage to your liver.  So forget about any pill.  Secondly, some tout sub lingual testosterone as an option.  The problem is a lot of the testosterone is still ingested thereby still causing hepatotoxicity from the "first pass effect."  (I have seen sub lingual testosterone promoted more as an option for women for libido and sexual dysfunction conditions).  Since sub lingual testosterone is usually short acting, and other problems would be obtaining consistent optimal levels at a making sure you're not supraphysiological in the thereby exposing yourself to unnecessary risks and side effects.

Next, would be the topical gels or patches.  For some reason, the latter is usually put on the scrotum, which I would consider quite a logistical problem.  Topical usually works well, and is easier for those who doesn't like weekly shots or if such shots are a logistical problem.  Clinically though, the topical delivery methods may not increase the levels high enough if the patient is moderately to severely androgen deficient.  The increased amount of a gel needed, two or more packets, can create quite a mess on one's chest.  Also, the topicals depend a lot on how and when applied.  For example, if applied immediately after a shower on wet skin, and then clothing put on, this would diminish the amount absorbed.  Or, if they sweated a lot after applying the gel. This may also diminish results.  Lastly, you must be careful not to expose your fertile female partner to topical testosterone because of possible effects on the developing fetus. 

For many reasons, I just don't see consistency in testosterone levels in those using topical TRT. Additionally, there is some research suggesting increased conversion of Testosterone to Di-Hydro-Testosterone, DHT, and Estrogen because of the higher exposure to subcutaneous tissue.  The former is associated with Benign Prostatic Hypertrophy, BHP, and baldness.  The latter is associated with enlarged breasts and possibly increased risk for prostate cancer.  However, it is still a very favorable option because of the ease-of-use, and also because some insurances will reimburse for testosterone gel.  If not, topical gels are quite expensive.  Again, it depends on what you and your physician are comfortable with.

There is also TRT via intramuscular shots.  These are usually given weekly, although it may depend on which testosterone compound is used, for me it's usually testosterone cypionate.  The up side here is I find levels are quite consistent resulting in reaching optimal levels and subsequently optimal clinical results, which are very important goals.  A vastly important decision factor in determining how testosterone is replaced depends on the age of the patient and the functioning of the pituitary gland, usually measured by lab work.  As a rule of thumb, if a male is below the age of 65, we assume his testes work, just that they are a little bit, well… lazy.  If you remember they feedback loop presented earlier, the pituitary increases LH levels in response to lower testosterone.  Generally, as men at age, this feedback loop becomes less sensitive.  Early on, we may see increased LH levels in that to further stimulate the testes to make more testosterone, but in middle-age or later, we may see relatively improperly low LH levels. 

And, since the testes work, we should use them, right?  So for a younger man his lab work usually shows the testes do work, but are a bit lazy, so we use a natural hormone to stimulate them in order to produce optimal physiological testosterone levels.  The hormone is beta-hCG, and I like to give it in twice per week subcutaneous injection.  Beta-HCG it is very similar in composition to LH and fortunately has the same end organ effect of stimulating the testes to produce testosterone.  I believe this is generally the best way to increase testosterone in a man younger than 65 years old, mainly because of less side effects.  Usually baseline LH levels are in the normal range, (which is actually sub optimal or relatively low since we would expect them to be elevated thereby trying to stimulate the testes to make more testosterone). Again appropriate baseline lab work should be performed in the doctor should know how to interpret them correctly.

If you use direct testosterone replacement, either topical or injection, the main side effect is testicular atrophy and infertility.  These effects can be permanent.  Now, most guys enjoy having their testes around. It gives them something to play with and look at when no one is around.  They wouldn't want the friend they have had since they were young to suddenly shrink and disappear.  Therefore, using beta-hCG will achieve optimal testosterone levels without testicular atrophy.  The usual dosing is by subcutaneous injection, usually about 4000 to 7000 units divided twice per week.  This is based on the research that compared various dosing of hCG and its half-life in the body.  It doesn't have the immediate bang that direct testosterone shots can have in the first week, as it may take about six weeks about to effectively stimulate the testes because of the feedback loop mechanism.  That is usually no big deal.  Even in men above 65, I may use some beta-hCG once per week to maintain testicular size.  This is especially important and men that model, wear tight clothes or beachwear, or participate in weightlifting competition are such. 

I must emphasize though the necessity of individualized approaches in finding what is right for the patient.  What specifically is the hormonal status, is it primary or secondary failure?  What are the patient's goals, are they realistic and obtainable?  What are they willing to do to obtain such?  Are they fully aware of the benefits and the risks of TRT?  And, only going to be compliant with the necessary routine follow-up lab work and prostate examinations?  These and more needs to be satisfactorily reviewed in order to have patient compliance and a long-term successful relationship.  You need to see a doctor that specializes in these modalities as they are not without risks and need frequent routine monitoring.