My patient is a man in his early 70s who complains of lack of strength. His testosterone level is low, and his B12 level is low-normal.
My patient is a man in his early 70s who complains of lack of strength. His testosterone level is low, and his B12 level is low-normal. An endocrinologist recommended B12 injections and testosterone. Because the patient also has erectile dysfunction (ED) that has not responded to sildenafil or vardenafil, testosterone therapy is an appealing option. He has mild benign prostatic hyperplasia and a normal prostate-specific antigen level. However, he also has a history of coronary artery disease (CAD): he takes 3 antihypertensive medications, a statin, ezetimibe, aspirin, and clopidogrel. How safe is it to administer testosterone in this setting-and if it is safe, what dosage is recommended?
----- Percy Kepfer, MD
Fort Pierce, Fla
Many of the symptoms of male hypogonadism, such as your patient's lack of strength, are nonspecific. Other symptoms, such as ED, have many possible causes. Therefore, it is difficult to determine whether testosterone replacement is indicated. One of the main difficulties in determining whether a man has hypogonadism is that the available assays do not adequately assess free testosterone levels. With the exception of a free testosterone by dialysis assay (which is usually used only in research settings), free testosterone assays are limited and can be inaccurate. I therefore recommend measuring total testosterone. If you confirm hypogonadism with total testosterone measurements on 2 separate mornings, then testosterone replacement can be considered-provided there are no contraindications. However, if your patient is obese, I would recommend calculating the bioavailable testosterone level to confirm hypogonadism. Unfortunately, we do not have good data on the effects of long-term testosterone replacement on CAD or prostate cancer. If your patient has problems with congestive heart failure as a result of his CAD or an American Urological Association/International Prostate Symptom Score greater than 19, I would recommend against testosterone replacement. If he does not have these problems and has no other contraindications to testosterone replacement, you may consider this therapy once you discuss the possible risks and benefits with him. The testosterone gels are well tolerated and are the form of testosterone replacement preferred by most patients. The typical starting dosage is 5 g/d, and the goal testosterone level in this man's age group is 400 ng/dL. With regard to safety monitoring, I would recommend following the Endocrine Society Clinical Practice Guideline published in 2006.1
----- Maria Yialamas, MD
Instructor in Medicine
Division of Endocrinology, Diabetes, and Hypertension
Brigham and Women's Hospital
1. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2006;91:1995-2010.