Quiz 9: Testosterone Replenishment Options

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Question 1 of 15

1. Question
Which form is NOT common for delivery of testosterone?
- Intranasal gel or spray
- Topical creams or gels
- Injectable testosterone esters
- Sublingual drops or troches
- Implantable pellets
- Patches
- Buccal lozenges
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Question 2 of 15

2. Question
Sublingual drops or troches are not recommended because:
- They result in spike levels of T
- Part is swallowed and part is absorbed sublingually
- They are quite expensive
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Question 3 of 15

3. Question
Implantable testosterone pellets are:
- Practical and effective
- Not recommended or beneficial
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Question 4 of 15

4. Question
Patches and buccal lozenges are:
- Practical and effective
- Not very effective
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Question 5 of 15

5. Question
What is NOT a major cause of patients’ failure to respond to replacement over time, or a remedy to address it?
- Saturation of androgen receptors from sustained, excess doses of testosterone, followed by down-regulation or receptors
- This happens with all forms of replacement
- Giving periodic “drug holidays” to let androgen receptors reactivate
- Using “pulse dosing” to achieve higher levels
- Adding Clomiphene or hCG Rx to testosterone replacement regimen
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Question 6 of 15

6. Question
What is UNTRUE of topical testosterone?
- Higher DHT levels occur with all topical applications due to skin 5 alpha reductase – the wider the application, the higher the DHT conversion
- Hairy areas such as the inner thigh, axilla, neck and particularly the scrotal area will have higher DHT conversion
- DHT in excess can cause male pattern baldness or acne
- It can be administered twice weekly, similar to the method of delivery of subQ testosterone
- Creams and gels at lower concentrations (25–50 mg/gm or cc) work well but require larger surface areas to apply and, therefore, higher DHT conversion – better to use 100 mg/cc in oil emulsion or lipoderm base cream
- Androgel and Testim are only 10 mg/gm and therefore require very large application areas as well as being quite expensive
- For some, higher DHT does confer increased libido and mental sharpness
- Be alert for patients that have history of acne or hair loss in their teen years having an increased propensity for DHT elevations
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Question 7 of 15

7. Question
What else is NOT true of topical testosterone?
- Testosterone in oils suspension 100 mg/cc/ DHEA 10 mg/cc works very well 0.5–1.0 cc daily
- Apply 0.3 cc to glans and shaft of the penis and the rest to the lateral abdomen once daily in the AM
- This gives more rapid absorption on penis and more delayed absorption on the abdomen
- It can be applied daily to the scrotum with specific advantage of not raising DHT
- Never use the forearm as it contaminates all blood testing
- Make sure to have patient wash penis before sexual activity since transmission to female may be excessive
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Question 8 of 15

8. Question
What is NOT true of sublingual boosting doses?
- Testosterone 25 mg/cc propylene glycol solution – 3–4 drops sl works well for some men for quick boosting doses before workouts, sex or for afternoon “low spells”
- Can be given sublingually for quick, “spike-like” activity
- If there is a recognizable symptom alleviating "boost" response from sublingual dose, your daily dose is demonstrated to be adequate
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Question 9 of 15

9. Question
What is UNTRUE of DHEA and pregnenolone?
- A favorite “anti-aging cocktail” is selegiline 3 mg/cc, DHEA 10 mg/cc, pregnenolone 10 mg/cc in an alcoholic gel – start 0.2 cc bid and increase every week by 0.05 bid – this may increase hypothalamic responses and mental clarity
- As these are precursors to gonadal steroid hormones, they can be used in place of testosterone replacement in select patients
- Selegiline increases dopamine
- DHEA 10–25 mg capsules bid or pregnenolone 10–25 mg bid can be used if DHEA or DHEA-S are low
- Excess pregnenolone may actually suppress libido over time due to conversion to progesterone in men
- DHEA in obese men may increase E1 and E2 levels
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Question 10 of 15

10. Question
What is UNTRUE of injectable testosterone?
- Older methods of high doses given IM every 2–3 weeks have high variability in benefits, high estrogen conversion
- Higher sustained doses of IM testosterone results in frequent “saturation failure”
- Saturation failure – original dosages that were adequate, no longer are, and call for an increase in dosage levels
- IM route has highly vascular depot spike and more rapid clearance
- High variable T and high variable E2 result in poor sexual effectiveness in most studies
- SubQ can be given with smaller needle and twice weekly
- SubQ has more steady and consistent dosing without significant spiking
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Question 11 of 15

11. Question
What is NOT true concerning injectable testosterone subcutaneously?
- Dr Neil Burman from South Africa pioneered the use of SQ low dose weekly T injections with excellent responses
- SubQ testosterone is more patient-compliant as it only has to be administered once every 2–3 weeks (depending on duration of symptom improvement)
- Testosterone cypionate or enanthate 100–200 mg/cc is given in small doses 60–120 mg weekly in abdominal or SQ fat above wallet. Also may easily be given IM in anterior thigh with 25 gauge 5/8” needle
- Lower frequent doses avoid the peak/valley effects of the older Q 2–3 weeks IM injections
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Question 12 of 15

12. Question
What is UNTRUE of subQ testosterone injections?
- The injections can be given weekly or biweekly (Monday/Thursday)
- Check blood tests after 3 weeks, 2 days after injections are given to obtain median testosterone levels
- Higher doses may be cautiously used in syndrome X or diabetes but require careful follow-up with Hb/Hct and T and E2 levels along with Insulin, FBS, HbA1C, and lipids
- Higher dosages can result in reduced estrogen levels and increased insulin resistance
- Reduction in sulfonylureas should be considered to avoid hypoglycemia
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Question 13 of 15

13. Question
What else is UNTRUE of subQ testosterone injections?
- Pharmacokinetics are much better than IM due to greatly reduced vascularity of fat vs muscle
- SQ doses give very stable repeatable levels that can be easily adjusted
- Because of stability, serum testosterone levels can be assessed on any day of the week
- Some individuals react to the alcohol preservative and can be switched to low dose IM
- E2 conversion seems to be much better (lower) with SQ due to lower peak levels
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Question 14 of 15

14. Question
What is NOT true of testosterone injections plus hCG?
- Testosterone injections may result in testicular atrophy
- Testicular atrophy is more likely to develop in older men on replacement than younger men
- hCG injections in low doses (250 units sq on Friday and Sat) may be added at the end of the week to give a “boost” when levels are declining
- This “boosting” may also offset suppression of FSH/LH and may prevent atrophy in those individuals who experience “shrinkage”
- This “boosting” may also result in improved libido and sexual responses
- Topical testosterone emulsion on weekends may help
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Question 15 of 15

15. Question
Which statement is INCORRECT?
- Pellets require a surgical procedure with special trocar to insert, with attendant risk of infection or expulsion and no pulsatility to the Rx
- Once surgically placed, pellets last for 3–4 months
- Lozenges, troches, capsules and patches are poor treatment options for full replacement
- Oral commercially available testosterone is the easiest, least expensive, and safest method of treating with testosterone
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