In my last blog, we examined signs, symptoms and tests that could indicate if someone had low testosterone levels. OK, so you’ve determined that your testosterone levels are low and have ruled out and/or addressed other causes that could contribute such as high conversion to estradiol, low DHEA or high cortisol. What do you do from here?
There are a number of options for testosterone replacement therapy including topical options (cream and gels), patches, troches, injections and pellet implantation. Each method has its advantages and disadvantages.
Creams and gels. Creams and gels are perhaps the most popular methods of testosterone replacement. There are a number of commercially available replacements available including Androgel® and Testim®. These products contain natural testosterone and they are relatively easy to use. Four disadvantages of commercial testosterone replacement gels are 1) they are expensive ($350/month), 2) they contain a fixed dosing which may or may not be an appropriate dose for you, 3) the amount of gel needed to be applied is large and often the whole torso needs to be covered for each application and 4) they contain large amounts of alcohol which may be irritating to some men. Compounded testosterone replacement is usually less expensive, has infinitely flexible dosing, does not contain alcohol and usually comprises a volume that can be easily applied to a small area, such as the inner thigh. One disadvantage to all creams applied to the skin is the skin itself. The skin is a formidable barrier to molecules both entering and leaving the body. This is the skin’s main purpose. Sometimes, no matter what we do to try to get drugs through the skin, we cannot overcome the barrier properties.
Patches. Androderm® patches are effective at administering testosterone across the skin. They contain penetration enhancers that overcome the barrier properties of the skin and deliver a consistent and constant delivery of testosterone. Three disadvantages of patches are 1) they tend to be very irritating to the skin, 2) they are only available in 2 and 4mg/day fixed dosing, 3) they are conspicuous when worn and are easily visible to others and 4) they are expensive ($360/month).
Troches. Unlike the skin, the mucosal lining of the mouth is more permeable to molecules entering the body. Sometimes, if application to the skin does not provide adequate testosterone levels, dissolving a waxy or gummy-bear like tablet (troche) between the cheek and gum or under the tongue will provide improved testosterone levels and will improve symptoms. The main disadvantage of troche delivery is that not the entire amount of testosterone is absorbed across the mucosa. Obviously, some is going to be swallowed with the saliva. When testosterone is swallowed, it is readily deactivated by the liver. In addition, orally administered testosterone can negatively impact lipid levels (cholesterol, triglycerides, etc.) If troches are chosen as the method of delivery, physicians should keep a close eye on blood chemistries to ensure that the swallowed component of a troche is not adversely affecting your body.
Injections. Injections can provide an efficient and cost-effective way to administer testosterone. Obviously, any molecule injected into the body will make its way into the blood stream. The main disadvantage of injectable testosterone replacement is the injection itself. Some men are capable of self-injecting, some are not. If not, this method of administration may necessitate multiple trips to the physician’s office for injections. Many physicians believe that testosterone cypionate, testosterone enanthate and testosterone propionate are long acting forms of testosterone and only need to be administered monthly. This is simply not true. These injections need to be administered multiple times per week and, at a minimum, one per week. Otherwise, the resulting high and low levels (called peaks and troughs) stimulate aromatase production and results in higher estrogen levels. The second disadvantage with injections is that the oil used as a carrier or vehicle can be irritating. Commercial products are made with cottonseed oil. Sometimes this oil is irritating to the tissues surrounding the injection sites. Keystone Pharmacy is compounding products with much gentler sesame oil to help alleviate this problem.
Pellets. Pellets are small waxy like rods that are inserted under the skin. In theory, they are designed to slowly release testosterone over the time of 3 to 9 months at which time, new pellets are inserted. This is a viable method of testosterone replacement but must be administered in a physician’s office, is relatively expensive and is irreversible if the therapy is poorly tolerated. Keystone Pharmacy does not make testosterone pellets. We have attempted them in the past but have found them too difficult to sterilize. If you choose pellet therapy, ensure that your doctors is obtaining them from a PCAB accredited pharmacy and as to see testing records that demonstrate that your lot of pellets is sterile and free from contaminants called endotoxins.
Next month, we’ll examine the safety of testosterone replacement therapy.
Keystone Pharmacy Owner and Chief Formulation Scientist