Medical necessity for testosterone replacement involves men with a documented low testosterone level traditionally coupled with some sort of symptom (s) such as low libido, erectile dysfunction, weakness, loss of muscle tone, body-fat gain, fatigue, and/or depression. In most men, testosterone levels fade with age. Of course, testosterone can be lowered by a number of other conditions as well. Particularly common in my practice are those individuals with a history of anabolic steroid abuse. Once a patient’s low level is correctly identifed by a physician, options for testosterone replacement fall into three categories: topical applications, injections, or pellets.
The first and perhaps most common involve THE TOPICAL APPLICATIONS. One of the most often prescribed is Andro-Gel. Perhaps the greatest physiologic benefit of this option is that the topical applications are “bio-identical” to the testosterone that your own body produces and not a synthetic testosterone-like hormone. As a result, there seem to be fewer side effects with the topical applications, such as elevated red blood cells and thickening of the blood.
The downsides with the topical applications are the fact that they can come of on your lover or your kids if they snuggle up to you. The gels will also come off on your skin and onto your clothes. Although there are testosterone patches as well, which contain the same medication in the gel targeting a specific area under the patch, they still have the annoyance of having to be applied each day. Then there’s also the added adhesive issue for the patches, which can be sticky, annoying, and irritate the underlying skin over time.
THE INJECTABLE VERSIONS, like the commonly used “testosterone enanthate,” can be given once per week or even less frequently in some cases. In fact, there is even the recently approved ultra-long-acting testosterone preparation called Aveed, which only requires once-per-month administration. The main issue I tend to cite when advising against the injectable application is that the injectable versions are not bio-identical. As a result of not being the same testosterone as that which our own male bodies produce, side effects seem more prevalent. In particular, hematocrit rises. The hematocrit represents the amount of red blood cells floating around our arteries and veins. If the number gets too high, vascular occlusion and even stroke can result. So for those patients who prefer injectable testosterone, blood testing must be done. If the hematocrit gets dangerously high, I often recommend that phlebotomy (removing a portion of the blood) be done either in my clinic or at a blood donation site.
Finally, there are the testosterone pellets. Currently the only FDA-approved testosterone pellet is Testopel. It’s a grain-size pellet of 75mg of bio-identical testosterone. THE PELLET OR PELLETS are implanted only once every three to six months. The pellets are bio-identical testosterone so hematocrit issues are far less common. There is no risk of topical transmission to partners or children. There is no burden of daily dosing, no need to refill a prescription every month, no need to travel with supplies, and no risk of missing or skipping a dose. The only drawback is the procedure itself, which can be uncomfortable and a little painful to endure each time. In addition, there is the soreness and occasional temporary hematoma (bruising) that results from each procedure. But compared with the alternatives, these drawbacks are increasingly being looked at as relatively minor when compared with the issues patients experience using the other options.
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