Testosterone Replacement Therapy Guidelines

Introduction to Testosterone Replacement Therapy

Testosterone replacement therapy (TRT) with injectable formulations should be continued as long as benefits outweigh risks with ongoing monitoring for adverse effects, according to the American College of Physicians and American Urological Association guidelines 1
There is no specified maximum treatment duration for TRT, with a focus on regular monitoring of testosterone levels and ongoing assessment of benefits versus risks 1

Injectable testosterone provides small but significant improvements in sexual functioning and modest improvements in quality of life for men with documented hypogonadism 1, 2
Injectable testosterone provides less-than-small improvements in vitality, fatigue, and depressive symptoms for men with documented hypogonadism 1

Testosterone levels should be measured every 6-12 months once stabilized, and midway between injections for injectable testosterone, targeting 500-600 ng/dL 3
The initial dose for injectable formulations should be typically 50-150mg weekly, and adjusted based on testosterone levels and symptom response 3
True hypogonadism should be confirmed with at least two separate low testosterone measurements before initiating long-term testosterone therapy 3

Limited long-term safety data in clinical trials may contribute to misconceptions about the safety of long-term testosterone therapy, with concerns about potential risks including cardiovascular events and prostate effects 1, 2
However, studies show no increased cancer risk with long-term testosterone therapy 1, 2

Fertility implications should be considered in men of reproductive age before initiating testosterone therapy, with exogenous testosterone therapy not recommended for men trying to conceive due to significant suppression of spermatogenesis 4, 5
Fertility counseling and sperm banking/cryopreservation are strongly recommended for men of reproductive age before starting TRT 6, 7
Men with hypogonadism who wish to maintain fertility should consider human chorionic gonadotropin (hCG) therapy, and those who have been on testosterone therapy and wish to conceive should discontinue therapy at least 3-6 months before attempting conception 5, 6, 7, 8
Testosterone therapy should not be commenced for 3-6 months after the most recent cardiac event in patients with a history of cardiovascular events, and monitoring for cardiovascular effects with supraphysiological testosterone levels is crucial 4
High-dose testosterone therapy is not recommended, and compounded testosterone products should be avoided in favor of commercially manufactured products 4
Alkylated oral testosterone is associated with liver toxicity and should not be prescribed 4
Transgender individuals undergoing gender-affirming hormone therapy and anabolic steroid users should be counseled on fertility preservation options before starting treatment, according to the World Professional Association for Transgender Health and other organizations 6, 7