Testosterone Therapy

The mainstay of testosterone treatment is different formulations of Bioidentical testosterone. Bioidentical testosterone comes in one of three forms (injectable, topical, or oral). In addition to Bioidentical Testosterone, Selective Estrogen Receptor  Modulators (SERMs) can be used in patients who are low in testosterone but still desire fertility. The above-mentioned medications are dosed as follows:

1. Injectable testosterone dosed every 1-2 weeks
2. Topical testosterone in the form of a gel, cream, or patch dosed daily
3. Twice daily oral testosterone
4. Selective Estrogen Receptor Modulators (SERMS) - daily oral medication that increases testosterone production by stimulating the testicles' natural testosterone production, thus preserving fertility.
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The risks of Testosterone therapy are an area of controversy, with many believing they are overstated. Potential risks include the following:

- Heart Disease/High blood pressure: Older studies have demonstrated a slightly increased risk in heart attacks in patients older than 65. To put it in perspective, if you treated 1000 men with Testosterone for 1 year, you would expect to see an addition 1-5 heart attacks. A more recent (and better-designed trial) called the TRAVERSE Trial, failed to show an increased risk of heart attacks in patients treated with testosterone. Of note, transdermal/topical preparations of testosterone have lower incidences of heart disease than injectable testosterone.


- Prostate Cancer - there is a theoretical risk for the increase of prostate cancer in males treated with testosterone. To date, no trials have demonstrated an increased risk, however, it is recommended that patients on testosterone be screened annually for prostate cancer.

- Prostate enlargement (unrelated to cancer) may increase in some patients on testosterone therapy

- Increased Red Blood Cell (RBC) counts: Testosterone therapy naturally increases the production of RBCs. Too many RBC's can lead to issues such as blood clots, strokes, and heart attacks. For this reason, we monitor blood cell counts regularly in patients on testosterone therapy. If RBC counts become too high, the options are to either discontinue therapy or to donate blood.

- Decreased Fertility - patients receiving Bio-identical testosterone therapy frequently experience a reduction in sperm production and infertility. In most cases, fertility returns somewhere between 18-24 months after stopping therapy, however, persistent infertility has been reported

- Blood Clots - A  2020 publication in the Journal of the American Medical Academy (JAMA), demonstrated an up to 2 fold increase in blood clots in patients (with or without hypogonadism) on testosterone therapy.

- local irritation from injections or topical medications

It is important to note that these risks noted above are based on studies in which the subjects were undergoing testosterone therapy with a formal diagnosis of male hypogonadism (symptoms + repeated Testosterone levels < 300ng/dl). As a result, this data on risk may not be entirely applicable in those with "normal testosterone levels" but with significant hypogonadal symptoms.

1. Topical testosterone
a. pros - easy to apply, reduced risk of heart disease, less hormonal peaks and valleys
b. Cons - application site irritation; messy; the potential of transference to family members/close acquaintances; difficulty in getting accurate monitoring lab testing as testing timing is critical, yielding inaccurate results.

2. Injectable testosterone
a. Pros - well studied for many years, weekly to biweekly dosages. easy to monitor. very cost-effective.
b. Cons - reduces sperm production and fertility; shots can be painful or overwhelming to some patients. Longer dosing intervals can lead to peaks in valleys of testosterone levels.

3. Oral Testosterone
a. Pros - easy administration, similar benefits to other forms of Testosterone, lower risk of prostate enlargement
b. Cons - relatively expensive, BID dosing. Older forms of oral Testosterone are associated with liver toxicity.

4. Clomophene/Enclomophene
a. Pros - easy to dose. Predictable increases in testosterone. No increased estrogen levels. Can be used in patient's desiring fertility. Long term safety promoted
b. Cons - some studies show greater improvement in Low-T symptoms on Testosterone when compared to clomophene/Enclomophene.

The diagnosis of male low testosterone is based on symptoms of low testosterone and repeated morning lab values below 300ng/dl of Total Testosterone. This one-size-fits-all approach does fail to consider that "normal testosterone" levels are highly dependent upon age and other factors. Our approach is to individually optimize your testosterone levels for maximal relief of low-test symptoms while avoiding supratherapeutic (or superhuman) levels to minimize the possibility of side effects and harm.

Not every patient with low testosterone will experience a benefit from treatment. Most who do, will experience improved symptoms in 3-6 months. For those who do not feel the benefits of improved testosterone, it is reasonable to stop the medication. At Valuemed, we have no contracts so you can cancel your service anytime.

Contraindications to androgen replacement therapy include a history of breast cancer, prostate cancer, uncontrolled heart failure, myocardial infarction or cerebrovascular accident within the past six months, untreated obstructive sleep apnea, having a hematocrit over 48%, men planning fertility, having a palpable undiagnosed prostate nodule, an elevated PSA (prostate-specific antigen) above 4 ng/mL, or an elevated PSA level above 3 ng/mL in high-risk patients including African Americans and men with a first-degree relative with prostate cancer.