- Potential cardiovascular risk, liver dysfunction with oral formulations, and possible impact on fertility (spermatogenesis suppression).
- Contraindicated in prostate cancer, severe hepatic disease, or uncontrolled hypertension.
Monitoring
- Baseline PSA if age >40; periodic CBC for hematocrit; serum testosterone levels; assessment of symptoms.
4. Clinical Scenarios and Decision‑Making
Scenario Key Factors Recommendation
A 30‑year‑old male with mild fatigue, low libido, normal labs except low T (270 ng/dL) and slightly low LH Early hypogonadism; patient symptomatic. Start testosterone therapy (T 200 mg IM q4‑6 wk or daily gel). Reassess after 3–4 mo.
A 45‑year‑old male with erectile dysfunction, normal T but low FSH and high LH Possible secondary hypogonadism; consider pituitary evaluation. Refer to endocrinology; evaluate MRI of pituitary.
A 50‑year‑old male with infertility, normal T, but high inhibin B Consider testicular dysfunction; may need assisted reproduction. Fertility workup; IVF/ICSI if needed.
An elderly man (>70) with low T, mild depression, no sexual symptoms Evaluate risks vs benefits of TRT; consider psychological evaluation. Discuss lifestyle modifications; monitor for cardiovascular events.
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8. Practical Recommendations (for Clinicians)
Screen only patients who meet criteria in the "Indications" section.
Confirm diagnosis with two separate morning measurements.
Use a single, high‑dose testosterone injection (e.g., 200–400 mg intramuscularly) as the preferred modality; avoid low‑dose regimens that require frequent administration.
Educate patients about potential side effects and the importance of adherence to follow‑up appointments.
Document baseline labs, treatment plan, and schedule for repeat monitoring.
If a patient refuses or is ineligible for injections, consider alternative therapies (e.g., topical gels) only if they meet all eligibility criteria.
Summary
Do not use low‑dose testosterone creams/gels; they are ineffective at treating the symptoms you described and increase side‑effect risk.
Use a single, appropriately dosed intramuscular injection of testosterone (e.g., 200 mg/100 mL) to achieve therapeutic hormone levels.
Monitor with baseline and periodic lab checks for testosterone, hematocrit, liver enzymes, PSA, and lipid profile.
Eligibility: Confirm that the patient meets all inclusion criteria (age, testosterone level, health status, etc.) and no exclusion conditions apply.
Following these guidelines will ensure a safe, effective treatment plan tailored to your needs.
