ASK DR.K: No T, More T?

Updated: Mar 11, 2021

Dear Dr. K, my testosterone is low on my blood test. My doctor recommended testosterone replacement. What is the best way to do this?

Testosterone (T) replacement is currently available in several different ways: tablets, sublingual pills, topical creams, injections and pellets. There are advantages and disadvantages to each method. Tablets and pills are poorly absorbed, so they only deliver a relatively low dose to the bloodstream. Topical creams and ointments are absorbed erratically and, if a woman or child comes in contact with the area of application, the T may rub off on them, causing virilizing effects.

Injections and pellets offer the most reliable means for raising T levels. Injectable testosterone has been available for several decades and is relatively safe and well-tolerated. Several formulations of T are available for injection, the most commonly prescribed being testosterone cypionate. The medication is dispensed in an oily base, so it requires a larger caliber needle for injection. Injections are most often done in the upper quadrant of the buttocks, although the front of the thigh or the back of the deltoid may also be used. Men usually are instructed on how to do the injections themselves, or a partner may be willing to do the injections. The injections are usually done weekly. A smaller dose could be administered twice a week to keep a consistent blood level.

Having to have repeated injections is one of the disadvantages of this method. The second disadvantage is that drug must pass through the liver to become active. This can lead to a build-up of chemicals in the liver that may cause damage to the liver cells. Third, this method has the potential for abuse, especially by those who self-inject and take significantly higher doses-"if a little is okay, more is better. Right?" Not necessarily. Higher than physiological levels of T can lead to hepatic and circulatory problems as well as aggressive behavior-"roid rage."

Hormone replacement using bioidentical hormone pellets (BHRT) has been available for women for several decades. Using BHRT in men is somewhat newer but is gaining acceptance in the medical community. The testosterone is derived from plant hormones and is purified so that it is 100% pure. It is compressed into a pellet using an inert binding agent. The pellets are inserted in the upper outer aspect of the buttocks, under local anesthesia. The dosage is determined by blood levels of T both before and after insertions. The T is absorbed directly into the bloodstream and does not need to be activated by the liver. As the blood flows around the pellet the hormone is absorbed into the blood. The faster the bloodflow, i.e. exercise, the higher the level and the faster the pellet is absorbed. This patterns the natural physiology-exercise increases T levels naturally.

The advantages of BHRT are that (1) it is more physiological, (2) does not require metabolic activation, (3) is 100% identical to the T that your body produces, (4) lasts for 4 to 6 months, depending on the level of physical activity ("gym rats" will blast through them quicker), (5) negligible potential for abuse-very difficult to self-dose, and (6) rare reactions and/or complications.

The disadvantages are that the pellet insertion requires a minor surgical procedure with the risks of infection, bleeding, or pellet extrusion. These are rare, occurring in 1 out of 1000 insertions. There may be some bruising and swelling that my be noticeable for a week after insertion. The only restriction is any activity that requires flexing at the hip joint which could cause extrusion of the pellets.

Testosterone replacement will cause shrinkage in the size of the testicles since the cells producing T don't have to work. There also maybe so interference in sperm production, so if you are thinking about pregnancy, you should talk with your urologist about replacement therapy and have a sperm analysis performed.

After stopping hormone replacement it may take a lengthy period of time for your testicles to resume functioning and your T level may not return to pre-replacement levels. So, lifelong testosterone replacement may be necessary.