Table 2.
Managing Testosterone Therapy in Specific Patient Populations: Recommendations Based on the Authors’ Experience
| Patients | Potential Formulations | Starting Dose(s) | Key Safety and Outcomes Measures to Monitor | Key Considerations for Follow-Up Care |
|---|---|---|---|---|
| Patient wishing to maintain fertility | ● Therapy should maintain endogenous testosterone production ● Consider SERM (eg, clomiphene citrate) if low or normal gonadotropins ● Gonadotropin therapy (eg, hCG, FSH) ● Low suppressive testosterone therapy (intranasal testosterone) ● Aromatase inhibitors if elevated estradiol |
● Clomiphene citrate 25 mg every other day ● Anastrozole 0.5 mg weekly ● hCG 500 IU SC every other day ● Intranasal testosterone gel (1 pump [5.5 mg] per nostril 3 times daily) |
● Evaluate for changes in symptoms: fatigue, weight gain, hot flashes (seen in estradiol changes) ● Changes from baseline semen parameters |
● If inability to achieve pregnancy with unprotected intercourse is observed for >12 months, or after 6 months when the female partner is aged >35 years, refer to reproductive urologist |
| Patient with a steady lifestyle/predictable schedule | ● Patient preference drives therapy ● Daily topical 1% testosterone gel ● Intranasal gel ● Weekly or biweekly IM or SC injection ● Consider SC pellets |
● IM dose: testosterone cypionate 200 mg/mL per week ● 1% testosterone topical gel: 50 mg daily ● Pellets: six 75 mg pellets ● Intranasal gel: 1 pump (5.5 mg) per nostril 3 times daily |
● Resolution of symptoms ● Polycythemia ● Changes in skin and hair patterns ● Changes in lipid patterns ● Changes in PSA or DRE |
● Desire for fertility ● Anticipated close contact with other individuals: switch from topical |
| Patient with high hematocrit | ● Avoid depot formulations ● Daily application is encouraged |
● 1% testosterone topical gel: 50 mg daily ● Intranasal gel: 1 pump (5.5 mg) per nostril 3 times daily |
● Resolution of symptoms ● Polycythemia ● Changes in skin and hair patterns ● Changes in lipid patterns ● Changes in PSA or DRE |
● Low threshold to halt therapy ● Consider therapeutic phlebotomy ● Obtain appropriate imaging if suspected DVT or VTE |
Abbreviations: DRE, digital rectal examination; DVT, deep vein thrombosis; FSH, follicle-stimulating hormone; hCG, human chorionic gonadotropin; IM, intramuscular; IU, international unit; PSA, prostate-specific antigen; SC, subcutaneous; SERM, selective estrogen receptor modulator, VTE, venous thromboembolism.