Evaluation for low testosterone involves a simple blood test. If low testosterone is diagnosed in a man with some of the aforementioned symptoms, consideration for testosterone replacement therapy is in order. The goal is to restore testosterone to normal levels and to treat the symptoms and signs of low testosterone with better libido and erectile function and improved energy, body composition (reduced fat, increased muscle) and increased bone mineral density. There are a variety of different means of testosterone replacement therapy (TRT). Oral replacement is not used because of erratic absorption and liver toxicity.
Injections are generally not the first-line means of TRT because of wide fluctuations in testosterone levels and injection site reactions. There are a number of gel formulations that are commonly prescribed including: Androgel; Testim; Axiron; Fortesta; additionally, many pharmacies will compound testosterone in gel or cream formulation at a fraction of the cost of the commercially available products. With the gels and creams, one needs to beware of skin-to-skin contact with the potential exposure of testosterone to others. There are scrotal patches: Testoderm and non-scrotal patches: Androderm, both of which can cause skin irritation. There is another formulation in the form of pellets that are injected into the fatty tissue of the buttocks: Testopel, advantageous in terms of its long-term efficacy (3-6 months) but disadvantageous in terms of the need for the minor procedure for implantation. There is a buccal formulation that is placed in the inner cheek or gum: Striant, a simple means of administration, but one that can cause gingivitis, interference with eating, drinking and dental hygiene.
Men on TRT need to be carefully followed to ensure that the testosterone is effective, adverse effects are minimal, and blood levels are in-range. Periodic digital rectal exams are important to check the prostate and in addition to testosterone levels, other blood tests are obtained including a complete blood count and PSA. Side effects of TRT may include the following:
- Oily skin; acne
- Sleep apnea
- Breast growth
- Increased red blood cell count
- Lipid profile changes
- Infertility—testosterone can be viewed as a male contraceptive
- Testes atrophy