Testosterone replacement therapy

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Abstract Androgen replacement therapy is usually indicated for testicular and hypothalamopituitary disease. A decision to initiate testosterone treatment should be based on clinical symptoms supported by levels of total testosterone consistently in the hypogonadal (rather than low-normal) range. Free testosterone may be useful in situations in which sex hormone-binding globulin levels are altered. However, the usefulness of free testosterone measurement in the diagnosis of androgen deficiency remains unproven. Carcinoma of the prostate or breast is the main contraindication for androgen therapy. The efficacy and safety of androgen replacement for classical hypogonadism are well proven from extensive clinical experience. The choice of preparation depends on age, convenience, cost, availability and patient preference. Parenteral preparations are the mainstay of androgen replacement therapy. Newer formulations include transdermal patches and gels, depot intramuscular injections and buccal tablets; though more expensive, these offer the advantage of ease of administration, while avoiding the supraphysiological levels commonly seen with parenteral preparations. Short-acting preparations are preferred when rapid discontinuation is advantageous, as in older men. In recent years, there is increasing interest in the possible benefits of androgens in non-classical situations (e.g. ageing, erectile dysfunction, wasting disease such as HIV in men, female hypoactive sexual disorders). Translation of these areas of research into routine clinical practice will require more support from clinical trial data.