Concerns that TRT increases risk of cardiovascular events have been raised in some studies. It is reasonable to convert older adolescents totestosterone gel preparations at adult dosages when their IM dosage has reached the equivalent of 100 to 200 mg every 2 weeks. It is reasonable to convert older adolescents to deficiency receive long-acting testosterone enanthate or testosterone cypionate at a dose that is increased gradually over 18 to 24 months, every 1 to 2 weeks. Older adolescents withtestosterone deficiency receive long-acting testosterone enanthate or testosterone cypionate at a dose that is increased gradually over 18 to 24 months, every 1 to 2 weeks.
For patients who choose monitoring, clinicians should assessprostate cancer risk before starting testosterone treatment and 3 to 12 months after starting testosterone. 2.1 We recommend testosterone therapy in hypogonadal men to induce and maintain secondarysex characteristics and correct symptoms of testosterone deficiency. It is important to consider treating symptomatic patients and not leave them untreated because of anxiety over possible adverse events from testosterone replacement therapy, after discussing with them the potential benefits and risks of treatment. One of the striking things about a study published in 2007 was that physicians’ number one fear about initiating testosterone therapy was their perception that it increases the risk of prostate cancer. Because testosterone therapy may worsen sleep apnoea in some patients, there is a need to ask patients and their partners about any sleep apnoea symptoms, such as excessive snoring or daytime tiredness, they may have before they start treatment. Studies with hypogonadal men have demonstrated that once testosterone levels are restored to a stable normal range, there is an improvement in libido, sexual function, mood and energy levels relatively early in the course of treatment (78,84–86).
Total testosterone represents the total of free, SHBG-bound, and albumin-bound testosterone. Most hospital laboratories can provide total testosterone measurements of good accuracy and reliability. Serum total testosterone is the easiest and most straightforward measurement to take for the first measurement. In our opinion, screening for at-risk patients is therefore worthy of consideration. Screening tools can be helpful in identifying patients with a high probability of having low testosterone.
An age-related guideline for referral if PSA levels exceed 2.5 ng/ml in males under 60 years or 4 ng/ml in men over 60 years is often used (97). Bone mineral density measurement should also be carried out at baseline because hypogonadism is an important cause of male osteoporosis. Elevated haematocrit values above 54% require action – usually therapy should be stopped until the values decrease to a safe level. Any significant increase in PSA deserves a referral to a urologist and treatment should be discontinued until evaluated. AEs, adverse events; BMD, bone mineral density; DRE, digital rectal examination; PSA, prostate-specific antigen.
‡After 3 months, perform in accordance with guidelines for prostate cancer screening, depending on the age and race of the patient. Men using a testosterone gel should be advised by their healthcare provider on the ways of minimising the risk of testosterone transfer to women and children. Some studies have shown that insulin resistance may also improve following testosterone treatment (87,88). Testosterone pellets currently are the only long-acting testosterone treatment approved for use in the United States. This risk can be minimised by having patients wash their hands with soap and water after applying the gel, by covering the site of application with clothing after the gel has dried, and by washing the application site when skin-to-skin contact is expected.
These risks, however, are often exaggerated and should not outweigh the benefits of testosterone treatment. There are a number of formulations available for testosterone therapy including intramuscular injections, transdermal patches, transdermal gels, buccal patches and subcutaneous pellets. The symptoms are non-specific enough that men normalise them for years. Once low testosterone is confirmed, the next step is measuring LH (luteinising hormone) → the signal from the brain that tells the testes to produce testosterone.
Although serum free testosterone more accurately reflects functional testosterone levels, its measurement requires equilibrium dialysis, which is technically difficult and not widely available. The normal range for total testosterone is 300 to 1000 ng/dL (10.5 to 35 nmol/L). Elevation of serum FSH with normal levels of serum testosterone and LH often occurs when spermatogenesis is impaired but testosterone production is normal. Levels of FSH and LH also help determine whether hypogonadism is primary or secondary. Some syndromes of hypogonadism have both primary and secondary causes (mixed hypogonadism). Any acute systemic illness can cause temporary secondary hypogonadism.
The Endocrine Society recommends that the diagnosis of testosterone be made in men who have both consistent signs and symptoms and low total testosterone levels. A recent study showed that supervised diet and exercise increased testosterone levels in hypogonadal men with metabolic syndrome and newly diagnosed type 2 diabetes. The withdrawal of testosterone therapy in hypogonadal patients that had been stabilised on this therapy leads to an increase in insulin resistance within 2 weeks and prior to significant weight gain (59). C-reactive protein, a marker for systemic inflammation, has been found to be markedly elevated in patients with secondary hypogonadism and type 2 diabetes. The Massachusetts Male Ageing Study (MMAS) measured a combination of testosterone levels and hypogonadal symptoms and found between 6% and 12% of men had symptomatic androgen deficiency (21).

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