Over the past few years, the FDA (Federal Drug Administration) has approved several new testosterone replacement therapy (TRT) products. Patients now have several options to choose from. Treatment can be applied to the skin via a gel or patch, injected into a muscle, placed in the mouth and allowed to absorb through the gums or inserted under the skin by their provider.
There is no right or wrong choice. TRT modalities are numerous, and all have advantages and disadvantages in terms of safety, convenience, efficacy, ability to mimic physiologic levels, and adverse effects. Choice of treatment must take into account the patient’s age, existing medical conditions, previous and current response to treatment, and preference, as well as cost.
Topical Therapy: The topical class is the one we typically start patients on. They are easy to use and the dosage can be adjusted easily to reach goal levels. There are 4 approved agents in this class. There is similar efficacy between the products. The differences between products is where and how much to apply. All products need to be applied daily. We find that about 20% of patients will not get good testosterone levels with the topicals due to absorption problems, no matter which of the 4 products is used. These patients will need to use another delivery system to reach goal levels. One of the risks of the topical medications is the accidental transfer of the medication to partner or child. It is important to wash the area before having skin to skin contact with anyone.
A patch, which has been approved for years, is also available. It is applied daily to the body. There is no risk of transfer with the patch however some patients will experience a rash. The patch needs to be applied daily as well.
Testosterone injections have been around for years. The medication is injected deep into a muscle where it gets absorbed. The medication is injected once a week or once every two weeks. In order to monitor levels, patients will typically have their levels checked between injections. Injections provide a bolus of medication and thus patients will typically feel better after an injection but may become symptomatic a day or two before their next dose. There is also an increased risk of polycythemia (an increased hematocrit level which can increase your risk for blood clots).
Testosterone pellets get inserted under the skin during an office procedure. The pellets get absorbed over the course of 3-4 months. There is no risk of transfer and absorption of the medication is good. Testosterone pellets are a good option for patients who have difficulty reaching goal levels with the topical products, are tired or are poor at applying a medication daily or patients who want to decrease the risk of transferring the product to their partner or child. There is a chance of pellet extrusion or infection although these risks are low. Also, you cannot make quick changes to dose.
A buccal formulation exists. It adheres to the gum tissue above the incisors, transbuccal testosterone is absorbed slowly, as it is hydrated by the buccal mucosa. It is taken twice a day. Associated adverse effects are mild to moderate and include gum or mouth irritation or tenderness and bitter taste. Other potential concerns include inadvertent swallowing of the tablet resulting in decreased blood levels of testosterone and transfer of salivary testosterone to the partner.
It is important you work with someone who is knowledgeable with all treatment options as this will give you the best chance of success.