Testosterone Therapy Guidelines

Introduction to Testosterone Therapy

The American Urological Association (AUA) recommends counseling patients that it cannot be stated definitively whether testosterone therapy increases or decreases cardiovascular events, and untreated low testosterone levels are associated with increased risk of major adverse cardiovascular events 1
The AUA provides clear guidance regarding prostate health, including the absence of evidence linking testosterone therapy to the development of prostate cancer, and the need for caution in patients with a history of prostate cancer 1

Clinicians should inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer 1
For patients with a history of prostate cancer, there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy 1
Caution is recommended when considering testosterone therapy in men with in-situ prostate cancer on active surveillance or previously treated prostate cancer 1
Regular PSA monitoring is recommended on the same schedule as men without testosterone deficiency 1

The relationship between testosterone therapy and cardiovascular risk remains controversial, but current evidence suggests testosterone therapy is noninferior to placebo regarding major adverse cardiovascular events in men with hypogonadism and preexisting or high risk of cardiovascular disease 1
Monitor cardiovascular symptoms (chest pain, shortness of breath, dizziness) 1

Risk of erythrocytosis varies by administration route: 3-18% with transdermal administration, up to 44% with injections 2
Regular monitoring of hematocrit is required 2

Fluid retention (rarely of clinical significance) 2
Sleep apnea (infrequent) 2
Gynecomastia (rare, usually reversible) 2
Skin reactions (varies by administration method) 2
Testicular atrophy or infertility (common, especially in young men; usually reversible) 2

Counsel patients about potential risks and benefits before initiating treatment 1, 2
Discuss lifestyle modifications (weight loss, increased physical activity) as these can increase testosterone levels naturally 1
Adjust testosterone therapy dosing to achieve total testosterone levels in the middle tertile of the normal reference range (450-600 ng/dL) 1
Monitor PSA levels regularly 1
Monitor hematocrit to detect erythrocytosis 2