Related resources:
NHS Somerset Menopause webpage for information on testosterone
British Society for Sexual Medicine guidelines on adult testosterone deficiency
See Gender Identity Clinic – Alternatives when there are HRT shortages
Hypogonadism due to testosterone defiency in men – Monitoring testosterone therapy
After starting testosterone therapy, people should be evaluated at 3, 6 and 12 months, then annually thereafter, to monitor:
Serum testosterone – aim for a therapeutic target in the mid to upper range (15-30nmol/L), for an optimal response.
Haematocrit – levels should remain <54%. Dose reductions or preparation changes may be required to keep haematocrit levels within range. If they remain high, consider stopping therapy and reintroducing it at a lower dose.
PSA – prostate health should have been assessed via DRE and PSA prior to starting treatment. After initiating therapy, a PSA increase >1.4ng/mL over a 1-year period, or a PSA velocity >0.4ng/mL/year during sequential measurements over >2 years warrants urological evaluation and more intensive surveillance for prostate cancer thereafter.
Cardiovascular risk factors – should be assessed prior to staring treatment.
Symptomatic improvement – failure to benefit within a reasonable time frame (defined as 6 months for libido, sexual function, muscle function & improved body fat) should prompt treatment discontinuation and investigation for other causes of the symptoms.
| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments |
|---|---|---|---|
| Testosterone | Testosterone propionate, phenylpropionate, isocaproate and decanoate as Sustanon® | 250mg/ml solution for injection amp: £2.45 (1 ml) | Hypogonadism due to testosterone defiency in men - 250mg administered by deep intramuscular injection every 2-4 weeks. |
| Testosterone Enantate | 250mg/ml solution for injection amp: £87.73 (3 x 1ml) | Hypogonadism due to testosterone defiency in men - 250mg Testosterone Enantate intramuscularly every 3-6 weeks. | |
| Testosterone Undecanoate as Nebido® | 250mg/ml solution for injection amp: £87.11 (4ml) | Hypogonadism due to testosterone defiency in men - The injection interval should be within the recommended range of 10-14 weeks. | |
| Premature puberty and genital enlargement have been reported in children who were in close physical contact with an adult using topical testosterone and who were repeatedly accidentally exposed to this medicine. To reduce these risks, advise patients to wash their hands after application of topical testosterone, cover the application site with clothing once the product has dried, and wash the application site before physical contact with another adult or child. See MHRA Drug Safety Update (January 2023) for Topical testosterone (Testogel): risk of harm to children following accidental exposure. | |||
| Testavan® | 20mg/g Transdermal gel (23mg per actuation) pump: £25.22 (85.5g) | Hypogonadism due to testosterone defiency in men - The recommended starting dose is 23 mg (one pump actuation) applied once daily. The serum testosterone level should be measured 2-4 hours after dosing approximately 14 days and 35 days after starting treatment or after a dose adjustment. If the serum testosterone concentration is below 17.3 nmol/L the daily Testavan dose may be increased by 1 pump actuation. If the serum testosterone concentration exceeds 36.4 nmol/L the daily Testavan dose may be decreased by 1 pump actuation. Do not prescribe the pump for low sexual desire in postmenopausal women as dose cannot be accurately measured. |
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| Testogel® | 16.2mg/g Transdermal gel (20.25mg per actuation) pump: £31.11 (88g) | Hypogonadism due to testosterone defiency in men - The recommended dose is two pump actuations of gel (i.e. 40.5 mg of testosterone) applied once daily. The daily dose should not exceed four pump actuations or 81 mg testosterone per day. The adjustment of posology should be achieved by increments of one pump actuation of gel. Steady state blood testosterone levels are reached usually by the 2nd day of treatment. Do not prescribe the pump for low sexual desire in postmenopausal women as dose cannot be accurately measured. |
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| Testogel® | 40.5mg/2.5g Transdermal gel sachet: £31.11 (30) | Hypogonadism due to testosterone defiency in men - The entire contents of one sachet should be applied once daily at about the same time, preferably in the morning. The daily dose should be adjusted up or down by the physician depending on the clinical or laboratory response in individual patients, not exceeding 81 mg of testosterone per day (2 sachets i.e. 5 g of gel). The adjustment of posology should be achieved by approximately 1.25 g of gel (half sachet) steps. Steady state plasma testosterone concentrations are reached approximately on the 2nd day of treatment with this medicine. In order to adjust the testosterone dose, serum testosterone concentrations must be measured in the morning before application from the 3rd day on after starting treatment (one week seems reasonable). Second line for low sexual desire in postmenopausal women (off label) - 1/10th of a sachet daily, seal with a clip between uses. Apply a small pea sized amount once daily to lower abdomen, buttock, or outer thigh. Rotate site of application daily. Use at the same time each day. Seal sachet with a clip between uses. One sachet should last for 10 days. |
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| Tostran® | 2% Transdermal gel (10mg per application) multidose container £28.63 (60g) | Hypogonadism due to testosterone defiency in men - The recommended starting dose of Tostran is 3 g gel (60 mg of testosterone) applied once daily. Third line for low sexual desire in postmenopausal women (off label) - Apply one metered dose three times a week or on alternate days to lower abdomen, buttock, or outer thigh. Rotate site of application daily. Use at the same time each day. 60g pump container delivers 120 metered doses, each cannister should last 240 days. |
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