2. An J, Cheetham TC, Van Den Eeden S. PS336: testosterone replacement therapy patterns for aging males in a managed care setting. Clin Med Res. 2013;11(3):141.

3. Carnegie C. Diagnosis of hypogonadism: clinical assessments and laboratory tests. Rev Urol. 2004;6(suppl 6):S3S8.

4. Seftel A. Male hypogonadism. Part II: etiology, pathophysiology, and diagnosis. Int J Impot Res. 2006;18(3):223228.

5. Kalyani RR, Gavini S, Dobs AS. Male hypogonadism in systemic disease. Endocrinol Metab Clin North Am. 2007;36(2):333348.

6. Zarotsky V, Huang MY, Carman W, et al. Systematic literature review of the epidemiology of nongenetic forms of hypogonadism in adult males. J Hormones. 2014. http://dx.doi.org/10.1155/2014/190347. Accessed March 3, 2017.

7. Smith HS, Elliott JA. Opioid-induced androgen deficiency (OPIAD). Pain Physician. 2012;15(3 suppl):ES145ES156.

8. Basaria S. Male hypogonadism. Lancet. 2014;383(9924):12501263.

9. Bhasin S, Cunningham GR, Hayes FJ, et al.; Task Force, Endocrine Society. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010;95(6):25362559.

10. Emmelot-Vonk MH, Verhaar HJ, Nakhai-Pour HR, Grobbee DE, van der Schouw YT. Low testosterone concentrations and the symptoms of testosterone deficiency according to the Androgen Deficiency in Ageing Males (ADAM) and Ageing Males' Symptoms rating scale (AMS) questionnaires. Clin Endocrinol (Oxf). 2011;74(4):488494.

11. Morales A, Bebb RA, Manjoo P, et al.; Canadian Men's Health Foundation Multidisciplinary Guidelines Task Force on Testosterone Deficiency. Diagnosis and management of testosterone deficiency syndrome in men: clinical practice guideline. CMAJ. 2015;187(18):13691377.

12. Huo S, Scialli AR, McGarvey S, et al. Treatment of men for low testosterone: a systematic review. PLoS One. 2016;11(9):e0162480.

13. Boloa ER, Uraga MV, Haddad RM, et al. Testosterone use in men with sexual dysfunction: a systematic review and meta-analysis of randomized placebo-controlled trials. Mayo Clin Proc. 2007;82(1):2028.

14. Snyder PJ, Bhasin S, Cunningham GR, et al.; Testosterone Trials Investigators. Effects of testosterone treatment in older men. N Engl J Med. 2016;374(7):611624.

15. Giltay EJ, Tishova YA, Mskhalaya GJ, Gooren LJ, Saad F, Kalinchenko SY. Effects of testosterone supplementation on depressive symptoms and sexual dysfunction in hypogonadal men with the metabolic syndrome. J Sex Med. 2010;7(7):25722582.

16. Jones TH, Arver S, Behre HM, et al.; TIMES2 Investigators. Testosterone replacement in hypogonadal men with type 2 diabetes and/or metabolic syndrome (the TIMES2 study). Diabetes Care. 2011;34(4):828837.

17. Gianatti E, Dupuis P, Hoermann R, Zajac JD, Grossmann M. Effect of testosterone treatment on constitutional and sexual symptoms in men with type 2 diabetes in a randomized, placebo-controlled clinical trial. J Clin Endocrinol Metab. 2014;99(10):38213828.

18. Alhathal N, Elshal AM, Carrier S. Synergetic effect of testosterone and phophodiesterase-5 inhibitors in hypogonadal men with erectile dysfunction: a systematic review. Can Urol Assoc J. 2012;6(4):269274.

19. Buvat J, Montorsi F, Maggi M, et al. Hypogonadal men nonresponders to the PDE5 inhibitor tadalafil benefit from normalization of testosterone levels with a 1% hydroalcoholic testosterone gel in the treatment of erectile dysfunction (TADTEST study). J Sex Med. 2011;8(1):284293.

20. American Urological Association: ten things physicians and patients should question. February 21, 2013. http://www.choosingwisely.org/societies/american-urological-association/. Accessed September 5, 2016.

21. Fink HA, Ewing SK, Ensrud KE, et al. Association of testosterone and estradiol deficiency with osteoporosis and rapid bone loss in older men. J Clin Endocrinol Metab. 2006;91(10):39083915.

22. Isidori AM, Giannetta E, Greco EA, et al. Effects of testosterone on body composition, bone metabolism and serum lipid profile in middle-aged men: a meta-analysis. Clin Endocrinol (Oxf). 2005;63(3):280293.

23. Kenny AM, Kleppinger A, Annis K, et al. Effects of transdermal testosterone on bone and muscle in older men with low bioavailable testosterone levels, low bone mass, and physical frailty. J Am Geriatric Society. 2010;58(6):11341143.

24. Snyder PJ, Kopperdahl DL, Stephens-Shields AJ, et al. Effect of testosterone treatment on volumetric bone density and strength in older men with low testosterone: a controlled clinical trial JAMA Intern Med. 2017;177(4):471479.

25. Hildreth KL, Barry DW, Moreau KL, et al. Effects of testosterone and progressive resistance exercise in healthy, highly functioning older men with low-normal testosterone levels. J Clin Endocrinol Metab. 2013; 98(5): 18911900.

26. Srinivas-Shankar U, Roberts SA, Connolly MJ, et al. Effects of testosterone on muscle strength, physical function, body composition, and quality of life in intermediate-frail and frail elderly men: a randomized, double-blind, placebo-controlled study. J Clin Endocrinol Metab. 2010; 95(2):639650.

27. Travison T, Basaria S, Storer T, et al. Clinical meaningfulness of the changes in muscle performance and physical function associated with testosterone administration in older men with mobility limitation. J Gerontol A Biol Sci Med Sci. 2011;66(10):10901099.

28. Fleurence R, Williamson R, Jing Y, et al. A systematic review of augmentation strategies for patients with major depressive disorder. Psychopharmacol Bull. 2009;42(3):5790.

29. Shamlian NT, Cole MG. Androgen treatment of depressive symptoms in older men: a systematic review of feasibility and effectiveness. Can J Psychiatry. 2006;51(5):295299.

30. Zarrouf FA, Artz S, Griffith J, Sirbu C, Kommor M. Testosterone and depression: systematic review and meta-analysis. J Psychiatr Pract. 2009; 15(4):289305.

31. Pope HG Jr, Amiaz R, Brennan BP, et al. Parallel-group placebo-controlled trial of testosterone gel in men with major depressive disorder displaying an incomplete response to standard antidepressant treatment. J Clin Psychopharmacol. 2010;30(2):126134.

32. Lu PH, Masterman DA, Mulnard R, et al. Effects of testosterone on cognition and mood in male patients with mild Alzheimer disease and healthy elderly men. Arch Neurol. 2006;63(2):177185.

33. Kenny AM, Bellantonio S, Gruman CA, Acosta RD, Prestwood KM. Effects of transdermal testosterone on cognitive function and health perception in older men with low bioavailable testosterone levels. J Gerontol A Biol Sci Med Sci. 2002;57(5):M321M325.

34. Huang G, Wharton W, Bhasin S, et al. Effects of long-term testosterone administration on cognition in older men with low and low-to-normal testosterone concentrations: a prespecified secondary analysis of data from the randomised, double-blind, placebo-controlled TEAAM trial. Lancet Diabetes Endocrinol. 2016;4(8):657665.

35. Tong SF, Ng CJ, Lee BC, et al. Effect of long-acting testosterone undecanoate treatment on quality of life in men with testosterone deficiency syndrome: a double blind randomized controlled trial. Asian J Androl. 2012;14(4):604611.

36. Hackett G, Cole N, Bhartia M, Kennedy D, Raju J, Wilkinson P. Testosterone replacement therapy with long-acting testosterone undecanoate improves sexual function and quality-of-life parameters vs. placebo in a population of men with type 2 diabetes. J Sex Med. 2013;10(6): 16121627.

37. Basaria S, Harman SM, Travison TG, et al. Effects of testosterone administration for 3 years on subclinical atherosclerosis progression in older men with low or low-normal testosterone levels: a randomized clinical trial. JAMA. 2015;314(6):57081.

38. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA cautions about using testosterone products for low testosterone due to aging; requires labeling change to inform of possible increased risk of heart attack and stroke with use. March 3, 2015. http://www.fda.gov/Drugs/DrugSafety/ucm436259.htm. Accessed March 12, 2015.

39. Finkle WD, Greenland S, Ridgeway GK, et al. Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men. PLoS One. 2014;9(1):e85805.

40. Vigen R, O'Donnell CI, Barn AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels [published correction appears in JAMA. 2014; 311(9):967]. JAMA. 2013;310(17):18291836.

41. Xu L, Freeman G, Cowling BJ, Schooling CM. Testosterone therapy and cardiovascular events among men: a systematic review and meta-analysis of placebo-controlled randomized trials. BMC Med. 2013;11:108.

42. Basaria S, Coviello AD, Travison TG, et al. Adverse events associated with testosterone administration. N Engl J Med. 2010;363(2):109122.

43. Haddad RM, Kennedy CC, Caples SM, et al. Testosterone and cardiovascular risk in men: a systematic review and meta-analysis of randomized placebo-controlled trials. Mayo Clin Proc. 2007;82(1):2939.

44. Corona G, Maseroli E, Rastrelli G, et al. Cardiovascular risk associated with testosterone boosting medications: a systematic review and meta-analysis. Exp Opin Drug Saf. 2014;13(10):13271351.

45. Sharma R, Oni OA, Gupta K, et al. Normalization of testosterone level is associated with reduced incidence of myocardial infarction and mortality in men. Eur Heart J. 2015;36(40):27062715.

46. Baillargeon J, Urgan RJ, Kuo YF, et al. Risk of myocardial infarction in older men receiving testosterone therapy. Ann Pharmacother. 2014; 48(9): 11381144.

47. Shores MM, Smith NL, Forsberg CW, Anawalt BD, Matsumoto AM. Testosterone treatment and mortality in men with low testosterone levels. J Clin Endocrinol Metab. 2012;97(6):20502058.

48. Muraleedharan V, Marsh H, Kapoor D, Channer KS, Jones TH. Testosterone deficiency is associated with increased risk of mortality and testosterone replacement improves survival in men with type 2 diabetes. Eur J Endocrinology. 2013;169(6):725733.

49. Morgentaler A, Miner MM, Caliber M, Guay AT, Khera M, Traish AM. Testosterone therapy and cardiovascular risk: advances and controversies. Mayo Clin Proc. 2015;90(2):224251.

50. Calof OM, Singh AB, Lee ML, et al. Adverse events associated with testosterone replacement in middle-aged and older men: a meta-analysis of randomized, placebo-controlled trials. J Gerontol A Biol Sci Med Sci. 2005; 60(11):14511457.

51. Fernndez-Balsells MM, Murad MH, Lane M, et al. Clinical review 1: adverse effects of testosterone therapy in adult men: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2010;95(6):25602575.

52. Kang DY, Li HJ. The effect of testosterone replacement therapy on prostate-specific antigen (PSA) levels in men being treated for hypogonadism: a systematic review and meta-analysis. Medicine (Baltimore). 2015;94(3):e410.

53. Gray H, Seltzer J, Talbert RL. Recurrence of prostate cancer in patients receiving testosterone supplementation for hypogonadism. Am J Health Syst Pharm. 2015;72(7):536541.

54. Kohn TP, Mata DA, Ramasamy R, Lipshultz LI. Effects of testosterone replacement therapy on lower urinary tract symptoms: a systematic review and meta-analysis. Eur Urol. 2016;69(6):10831090.

55. Roy CN, Snyder PJ, Stephens-Shields AJ, et al. Association of testosterone levels with anemia in older men: a controlled clinical trial. JAMA Intern Med. 2017;177(4):480490.

56. U.S. Food and Drug Administration. FDA adding general warning to testosterone products about potential for venous blood clots. June 19, 2014. http://www.fda.gov/Drugs/DrugSafety/ucm401746.htm. Accessed March 12, 2016.

57. Baillargeon J, Urban RJ, Morgentaler A, et al. Risk of venous thromboembolism in men receiving testosterone therapy. Mayo Clin Proc. 2015; 90(8):10381045.

58. Sharma R, Oni OA, Chen G, et al. Association between testosterone replacement therapy and the incidence of DVT and pulmonary embolism: a retrospective cohort study of the Veterans Administration database. Chest. 2016;150(3):563571.

59. The use of testosterone and the aging male. Pharmacist's Letter/Prescriber's Letter. October 2015. http://pharmacistsletter.therapeuticresearch.com/pl/Browse.aspx?cs=amp;&s=PLamp;&pt=2amp;&fpt=31amp;&dd=320411&pb=PLamp;&cat=3658amp;&segment=9574 (login required). Accessed February 10, 2015.

60. Lexicomp Online. http://online.lexi.com/action/home (login required). Accessed March 20, 2016.

61. U.S. Preventive Services Task Force. Prostate cancer screening. May 2012. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening. Accessed March 14, 2017.

62. Burger HG. Androgen production in women. Fertil Steril. 2002;77 (suppl 4):S3S5.

63. Simpson ER. Aromatization of androgens in women: current concepts and findings. Fertil Steril. 2002;77(suppl 4):S6S10.

64. Elraiyah T, Sonbol M, Wang Z, et al. Clinical review: the benefits and harms of systemic testosterone therapy in postmenopausal women with normal adrenal function: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2014;99(10):35433550.

65. Wierman ME, Arlt W, Basson R, et al. Androgen therapy in women: a reappraisal: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(10):34893510.

66. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guidelines. J Clin Endocrinol Metab. 2017;102(11):38693903.

67. Margo K, Winn R. Testosterone treatments: why, when, and how? Am Fam Physician. 2006;73(9):15911598.

More here:
Testosterone Therapy: Review of Clinical Applications ...

Testosterone

Testosterone is a male steroid hormone that does a lot more for men than just promote a healthy sex drive. The hormone affects several other factors in your health, including body fat, muscle mass, bone density, red blood cell count, and mood.

Normal testosterone levels are between 300 and 1,000 ng/dL. If a blood test shows that your levels are far below the norm, your doctor may suggest testosterone injections. These are a form treatment called testosterone replacement therapy.

Testosterone injections are most often given by your doctor. The injection site is typically in the gluteal muscles in the buttocks. However, your doctor may allow you to self-administer the injections. In that case, the injection site would be in your thigh muscles.

Men naturally start losing some of their testosterone when they hit their 30s or 40s. A more rapid decline in testosterone levels may indicate a problem called low testosterone (low T). Common symptoms of low T include:

Some men may also have changes in the size of their penis and testicles. Others may have breast swelling.

Some men may want to diagnose themselves with low T. The problem with self-diagnosis is that many of the symptoms of low T are normal parts of aging, so using them for diagnosis isnt reliable. A doctor-ordered testosterone level test is the only way to find out if your testosterone levels are too low.

When you see your doctor, they will take a thorough health history and do a physical exam. In addition to a blood test to measure your testosterone levels, youll also likely have a test that measures your red blood cell count. Testosterone injections can increase your red blood cell count, so this test is done to make sure you arent at risk of a dangerous increase in these cells.

If your exam and tests reveal that you have low T, your doctor may suggest testosterone injections.

The purpose of testosterone injections is to help regulate male hormone levels to help address problems related to low T. For men with low T, the benefits of these injections can include:

Men generally have less body fat than women. This is partly related to testosterone, which regulates fat distribution and muscle maintenance in your body. With low T, youll likely notice an increase in body fat, especially around your midsection.

Your hormones also help regulate muscle growth. So, with low T, you may feel like youre losing muscle size or strength. However, this only occurs if your low T is prolonged and severe.

Testosterone shots can help regulate fat distribution, but you shouldnt expect significant weight changes from hormone therapy alone. As for muscle maintenance, testosterone therapy has been found to help increase muscle mass, but not strength.

Low sperm count is a common side effect of low T. This problem can make it difficult if you and your partner are trying to get pregnant. However, if low T is to blame for problems with conception, dont count on testosterone injections to help. Testosterone therapy can itself lead to reduced sperm counts, especially at high doses.

According to GoodRx.com, the cost of 1 mL (200 mg/mL) of Depo-Testosterone is about $30. The same amount of testosterone cypionate, the generic version of that drug, runs about $12$26. The Depo-Testosterone label states that shots should be given every two to four weeks. Considering that dosage varies by patient, the cost could run anywhere from less than $24 per month to more than $120 per month.

These estimates only cover the drug itself, and not all possible costs of treatment. For instance, if you receive the injections from your doctor, theres a cost for the office visits. This is in addition to the cost of office visits for monitoring, as your doctor will likely monitor your condition carefully to check for side effects and to make sure the injections are working properly. If you give yourself the injections, you may also need to buy needles and syringes.

Testosterone therapy doesnt cure the cause of low T, it just raises testosterone levels up to a normal range. Therefore, injections could be a lifelong treatment if you continue to need them.

Some insurance companies cover portions of the costs, but youll want to check your coverage in advance. If you have questions about the costs, talk to your doctor.

Testosterone shots can help many men with low T. Still, this doesnt mean that these powerful injections are safe for all men. Be sure to tell your doctor about all health conditions you have before starting testosterone therapy.

You will likely need extra monitoring from your doctor if you have heart disease, sleep apnea, or a high red blood cell count. And you should not use testosterone injections at all if you have breast cancer or prostate cancer.

Testosterone shots may also increase your risk of certain health problems, such as:

Testosterone injections can be helpful, but only if you actually have low T. If youre wondering if these injections might be right for you, talk to your doctor. They can test you for low T. If they diagnose you, you can discuss whether these injections would be a good choice for you.

If you dont end up having low T but still feel like your hormone levels might be off, keep in mind that good nutrition, regular exercise, and avoiding smoking could help you feel better. If those dont help, be sure to talk to your doctor.

Go here to read the rest:
Testosterone Injections: Are They Right for You?

Masculinizing hormone therapy, also known as transmasculine hormone therapy, or female-to-male (or FTM) hormone therapy, is a form of hormone therapy and gender affirming therapy which is used to change the secondary sexual characteristics of transgender people from feminine or androgynous to masculine. It is a common type of transgender hormone therapy (another being feminizing hormone therapy), and is predominantly used to treat transgender men and other transmasculine individuals. Some intersex people also receive this form of therapy, either starting in childhood to confirm the assigned sex or later if the assignment proves to be incorrect.

The purpose of this form of therapy is to cause the development of the secondary sex characteristics of the desired sex, such as voice deepening and a masculine pattern of hair, fat, and muscle distribution. It cannot undo many of the changes produced by naturally occurring puberty, which may necessitate surgery and other treatments to reverse. The medications used for FTM therapy include, mainly, androgens (namely testosterone) and GnRH analogues.

While the therapy cannot undo the effects of a person's first puberty, developing secondary sex characteristics associated with a different sex can relieve some or all of the distress and discomfort associated with gender dysphoria, and can help the person to "pass" or be seen as their gender. Introducing exogenous hormones into the body impacts it at every level and many patients report changes in energy levels, mood, appetite, etc. The goal of the therapy, and indeed all somatic treatments, is to provide patients with a more satisfying body that is more congruent with their gender identity.

Several contraindications to androgen therapy exist.[1] An absolute medical contraindication is pregnancy.

Relative medical contraindications are:

Hormone therapy for transmasculine individuals has not been adequately studied. Two recent studies indicate the potential for elevated risk of cardiovascular events. Nota, et al (2019) found that transgender men taking testosterone had an increased risk of cardiovascular events compared to cisgender women, with 11 vs. 3 cardiovascular events per 100,000 person-years, though the risk was less than that of cisgender men. Researchers were not able to control for smoking status or stressors.[2]Another recent study (Alzahrani, 2019) found elevated risk of heart attacks among self-identified transgender menwhich persisted even after adjusting for age, diabetes mellitus, chronic kidney disease, smoking, hypertension, hypercholesterolemia, and exercisethough the study did not include data about whether the subjects were undergoing hormone therapy and did not control for stressors. The study found that transgender men have a >4-fold and 2-fold increased odds of having a myocardial infarction when compared with cisgender women and cisgender men, respectively.[3] Since testosterone for transgender men is intended to be used over an individual's entire lifespan, the full range of risks of such lengthy testosterone administration is not yet known.

Testosterone is metabolized by the cytochrome P450 enzyme system (specifically CYP3A isoforms) in the liver. There are certain drugs that increase or decrease the activity of cytochrome P450 enzymes and may cause increased or decreased levels of testosterone:

Testosterone can also alter the effects of other drugs:

Because of these interactions, it is advised that trans men make their healthcare providers aware of their hormone therapy when this is relevant to their treatment for other medical issues.

Medications used in hormone therapy for transgender men include androgens and anabolic steroids like testosterone (by injection and other routes) to produce masculinization, suppress estrogen and progesterone levels, and prevent/reverse feminization; GnRH agonists and antagonists to suppress estrogen and progesterone levels; progestins like medroxyprogesterone acetate to suppress menses; and 5-reductase inhibitors to prevent/reverse scalp hair loss.

The elimination half-life of testosterone in the blood is about 70 minutes, so it is necessary to have a continuous supply of the hormone for masculinization.

'Depot' drug formulations are created by mixing a substance with the drug that slows its release and prolongs the action of the drug. The two primarily used forms in the United States are the testosterone esters testosterone cypionate (Depo-Testosterone) and testosterone enanthate (Delatestryl or Xyosted) which are almost interchangeable. Testosterone enanthate is purported to be slightly better with respect to even testosterone release, but this is probably more of a concern for bodybuilders who use the drugs at higher doses (2501000mg/week) than the replacement doses used by transgender men (50100mg/week). These testosterone esters are mixed with different oils, so some individuals may tolerate one better than the other. Testosterone enanthate costs more than testosterone cypionate and is more typically the one prescribed for hypogonadal males in the US. Testosterone cypionate is more popular in the US than elsewhere (especially amongst bodybuilders). Other formulations exist but are more difficult to come by in the US. A formulation of injected testosterone available in Europe and the US, testosterone undecanoate (Nebido, Aveed)[13][14] provides significantly improved testosterone delivery with far less variation outside the eugonadal range than other formulations with injections required only four times yearly. However, each quarterly dose requires an injection of 4mL of oil which may require multiple simultaneous injections. Testosterone undecanoate is also much more expensive as it is still under patent protection. Testosterone propionate is another testosterone ester that is widely available, including in the US, Canada, and Europe, but it is very short-acting compared to the other testosterone esters and must be administered once every 2 or 3days, and for this reason, is rarely used.

The adverse side effects of injected testosterone esters are generally associated with high peak levels in the first few days after an injection. Some side effects may be ameliorated by using a shorter dosing interval (weekly or every ten days instead of twice monthly with testosterone enanthate or testosterone cypionate). 100mg weekly gives a much lower peak level of testosterone than does 200mg every two weeks, while still maintaining the same total dose of androgen. This benefit must be weighed against the discomfort and inconvenience of doubling the number of injections.

Injectable forms of testosterone can cause a lung problem called pulmonary oil microembolism (POME). Symptoms of POME include cough, shortness of breath, tightening of the throat, chest pain, sweating, dizziness, and fainting.[15][16] A postmarketing analysis by the manufacturer of Aveed (testosterone undeconate injection) found that POME occurred at a rate of less than 1% per injection per year for Aveed.[17]

Injected testosterone esters should be started at a low dose and titrated upwards based on trough levels (blood levels drawn just before your next shot). A trough level of 500ng/dL is sought. (Normal range for a cisgender male is 290 to 900ng/dL).

Both testosterone patches, creams and gels are available. Both approximate normal physiological levels of testosterone better than the higher peaks associated with injection. Both can cause local skin irritation (more so with the patches).

Patches slowly diffuse testosterone through the skin and are replaced daily. The cost varies, as with all medication, from country to country, it is about $150/month in the US, and about 60 in Germany.

Transdermal testosterone is available throughout the world under the brand names Andromen Forte, Androgel, Testogel and Testim. They are absorbed quickly when applied and produce a temporary drug depot in the skin which diffuses into the circulation, peaking at 4 hours and decreasing slowly over the rest of the day. The cost varies, as with all medication, from country to country, from as little as $50/month to about $280/month.

Transdermal testosterone poses a risk of inadvertent exposure to others who come in contact with the patient's skin. This is most important for patients whose intimate partners are pregnant or those who are parents of young children as both of these groups are more vulnerable to the masculinizing effects of androgens. Case reports of significant virilization of young children after exposure to topical androgen preparations (both prescription and 'supplement' products) used by their caregivers demonstrates this very real risk.

Implants, as subcutaneous pellets, can be used to deliver testosterone (brand name Testopel). 6 to 12 pellets are inserted under the skin every three months. This must be done in a physician's office, but is a relatively minor procedure done under local anesthetic. Pellets cost about $60 each, so the cost is greater than injected testosterone when the cost of the physician visit and procedure are included. The primary advantages of Testopel are that it gives a much more constant blood level of testosterone yet requires attention only four times yearly.

Oral testosterone is provided exclusively as testosterone undecanoate. It is available in Europe and Canada, but not in the US. Once absorbed from the gastrointestinal tract, testosterone is shunted (at very high blood levels) to the liver where it can cause liver damage (albeit very rarely) and worsens some of the adverse effects of testosterone, like lower HDL cholesterol. In addition, the first-pass metabolism of the liver also may result in testosterone levels too low to provide satisfactory masculinization and suppress menses. Because of the short terminal half-life of testosterone, oral testosterone undecanoate must be administered two to four times per day, preferably with food (which improves its absorption).

In 2003, the FDA approved a buccal form of testosterone (Striant). Sublingual testosterone can also be made by some compounding pharmacies. Cost for Striant is greater than other formulations (US$180210/month). Testosterone is absorbed through the oral mucosa and avoids the first-pass metabolism in the liver which is the cause of many of the adverse effects of oral testosterone undecanoate. The lozenges can cause gum irritation, taste changes, and headache but most side effects diminish after two weeks. The lozenge is 'mucoadhesive' and must be applied twice daily.

Synthetic androgens/anabolic steroids (AAS), like nandrolone (as an ester like nandrolone decanoate or nandrolone phenylpropionate), are agonists of the androgen receptor (AR) similarly to testosterone but are not usually used in HRT for transgender men or for androgen replacement therapy (ART) in cisgender men. However, they can be used in place of testosterone with similar effects, and can have certain advantages like less or no local potentiation in so-called androgenic tissues that express 5-reductase like the skin and hair follicles (which results in a reduced rate of skin and hair-related side effects like excessive body hair growth and scalp hair loss), although this can also be disadvantageous in certain aspects of masculinization like facial hair growth and normal body hair growth). Although many AAS are not potentiated in androgenic tissues, they have similar effects to testosterone in other tissues like bone, muscle, fat, and the voice box. Also, many AAS, like nandrolone esters, are aromatized into estrogens to a greatly reduced extent relative to testosterone or not at all, and for this reason, are associated with reduced or no estrogenic effects (e.g., gynecomastia). AAS that are 17-alkylated like methyltestosterone, oxandrolone, and stanozolol are orally active but carry a high risk of liver damage, whereas AAS that are not 17-alkylated, like nandrolone esters, must be administered by intramuscular injection (via which they act as long-lasting depots similarly to testosterone esters) but have no more risk of liver damage than does testosterone.

For the sake of clarification, the term "anabolicandrogenic steroid" is essentially synonymous with "androgen" (or with "anabolic steroid"), and that natural androgens like testosterone are also AAS. These drugs all share the same core mechanism of action of acting as agonists of the AR and have similar effects, although their potency, pharmacokinetics, oral activity, ratio of anabolic to androgenic effects (due to differing capacities to be locally metabolized and potentiated by 5-reductase), capacity for aromatization (i.e., conversion into an estrogen), and potential for liver damage may all differ.

Dihydrotestosterone (DHT) (referred to as androstanolone or stanolone when used medically) can also be used in place of testosterone as an androgen. The availability of DHT is limited; it is not available in the United States or Canada, for instance, but it is available in certain European countries, including the United Kingdom, France, Spain, Belgium, Italy, and Luxembourg.[18] DHT is available in formulations including topical gel, buccal or sublingual tablets, and as esters in oil for intramuscular injection.[19] Relative to testosterone, and similarly to many synthetic AAS, DHT has the potential advantages of not being locally potentiated in so-called androgenic tissues that express 5-reductase (as DHT is already 5-reduced) and of not being aromatized into an estrogen (it is not a substrate for aromatase).

In all people, the hypothalamus releases gonadotropin-releasing hormone (GnRH) to stimulate the pituitary to produce luteinizing hormone (LH) and follicle-stimulating hormone (FSH) which in turn cause the gonads to produce sex steroids. In adolescents of either sex with relevant indicators, GnRH analogues, such as leuprorelin can be used to suspend the advance of sex steroid induced, inappropriate pubertal changes for a period without inducing any changes in the gender-appropriate direction. GnRH analogues work by initially overstimulating the pituitary gland then rapidly desensitizing it to the effects of GnRH. Over a period of weeks, gonadal androgen production is greatly reduced. There is considerable controversy over the earliest age, and for how long it is clinically, morally and legally safe to do this. The Harry Benjamin International Gender Dysphoria Association Standards of Care permits treatment from Tanner stage 2, but do not allow the addition of gender-appropriate hormones until 16, which could be five or more years. The sex steroids do have important other functions. The high cost of GnRH analogues is often a significant factor.

Antiestrogens (or so-called "estrogen blockers") like aromatase inhibitors (AIs) (e.g., anastrozole) or selective estrogen receptor modulators (SERMs) (e.g., tamoxifen) can be used to reduce the effects of high levels of endogenous estrogen (e.g., breast development, feminine fat distribution) in transgender men. In addition, in those who have not yet undergone or completed epiphyseal closure (which occurs during adolescence and is mediated by estrogen), antiestrogens can prevent hip widening as well as increase final height (estrogen limits height by causing the epiphyses to fuse).

5-Reductase inhibitors like finasteride and dutasteride can be used to slow or prevent scalp hair loss and excessive body hair growth in transgender men taking testosterone.[20] However, they may also slow or reduce certain aspects of masculinization, such as facial hair growth, normal male-pattern body hair growth, and possibly clitoral enlargement.[20][21] A potential solution is to start taking a 5-reductase inhibitor after these desired aspects of masculinization have been well-established.[20]

Progestogens can be used to control menstruation in transgender men. Depot medroxyprogesterone acetate (DMPA) may be injected every three months just as it is used for contraception. Generally after the first cycle, menses are greatly reduced or eliminated. This may be useful for transgender men prior to initiation of testosterone therapy.

In those who have not yet started or completed epiphyseal closure, growth hormone can be administered, potentially in conjunction with an aromatase inhibitor or a GnRH analogue, to increase final height.

The main effects of HRT of the FTM type are as follows:[22]

Many transgender men are unable to pass as cisgender men without hormones. The most commonly cited reason for this is that their voice may reveal them.

Facial changes develop gradually over time, and sexual dimorphism (physical difference between the sexes) tends to increase with age. Within a population of similar body size and ethnicity:

Frequently the first sign of endometrial cancer is bleeding in post-menopausal women. Transgender men who have any bleeding after the cessation of menses with androgen therapy should be evaluated for age appropriate causes of abnormal uterine bleeding as per cisgender female guidelines.[23]

A number of skeletal and cartilaginous changes take place after the onset of puberty at various rates and times. Sometime in the late teen years epiphyseal closure (in other words, the ends of bones are fused closed) takes place and the length of bones is fixed for life. Consequently, total height and the length of arms, legs, hands, and feet are not affected by HRT. However, details of bone shape change throughout life, bones becoming heavier and more deeply sculptured under the influence of testosterone. Many of these differences are described in the Desmond Morris book Manwatching.

The psychological changes are harder to define, since HRT is usually the first physical action that takes place when transitioning. This fact alone has a significant psychological impact, which is hard to distinguish from hormonally induced changes. Most trans men report an increase of energy and an increased sex drive. Many also report feeling more confident.

While a high level of testosterone is often associated[how?] with an increase in aggression, this is not a noticeable effect in most trans men. HRT doses of testosterone are much lower than the typical doses taken by steroid-using athletes, and create testosterone levels comparable to those of most cisgender men. These levels of testosterone have not been proven to cause more aggression than comparable levels of estrogen.

Some transgender men report mood swings, increased anger, and increased aggressiveness after starting androgen therapy. Studies are limited and small scale, however, based on self reporting over a short period of time (7 months). In a study by Motta et al, trans men also reported better anger control.[26] Many transgender men, however, report improved mood, decreased emotional lability, and a lessening of anger and aggression.[citation needed]

During HRT, especially in the early stages of treatment, blood tests should be consistently done to assess hormone levels and liver function.

Gianna Israel and colleagues have suggested that for pre-oophorectomy trans men, therapeutic testosterone levels should optimally fall within the normal male range, whereas estrogen levels should optimally fall within the normal female range. Before oophorectomy, it is difficult and frequently impractical to fully suppress estrogen levels into the normal male range, especially with exogenous testosterone aromatizing into estrogen, hence why the female ranges are referenced instead. In post-oophorectomy trans men, Israel and colleagues recommend that both testosterone and estrogen levels fall exactly within the normal male ranges. See the table below for all of the precise values they suggest.[31]

The optimal ranges listed for testosterone only apply to individuals taking bioidentical hormones in the form of testosterone (including esters) and do not apply to those taking synthetic AAS (e.g., nandrolone) or dihydrotestosterone.

Original post:
Masculinizing hormone therapy - Wikipedia

OverviewWhat is low testosterone (male hypogonadism)?

Low testosterone (male hypogonadism) is a condition in which the testes (testicles, the male reproductive glands) do not produce enough testosterone (a male sex hormone).

In men, testosterone helps maintain and develop:

Low testosterone affects almost 40% of men aged 45 and older. It is difficult to define normal testosterone levels, because levels vary throughout the day and are affected by body mass index (BMI), nutrition, alcohol consumption, certain medications, age and illness.

As a man ages, the amount of testosterone in his body gradually drops. This natural decline starts after age 30 and continues (about 1% per year) throughout his life.

There are many other potential causes of low testosterone, including the following:

Symptoms of low testosterone depend on the age of person, and include the following:

Other changes that occur with low testosterone include:

Low testosterone is diagnosed by measuring the amount of testosterone in the blood with a blood test. It may take several measurements to determine if a patient has low testosterone, since levels tend to change throughout the day. The highest levels of testosterone are generally in the morning, near 8 a.m. This is why doctors prefer to measure testosterone levels in the early morning.

Low testosterone is treated with testosterone replacement therapy, which can be given in several different ways:

(Oral testosterone is not approved for use in the United States.)

Potential benefits of testosterone replacement therapy may include:

The side effects of testosterone replacement therapy include:

Laboratory abnormalities that can occur with testosterone replacement include:

If you are taking hormone replacement therapy, regular follow-up appointments with your physician are important.

Guidelines suggest discussing the potential risk vs. benefit of evaluating prostate cancer risk and prostate monitoring. The doctor and patient will decide together regarding prostate cancer monitoring. For patients who choose monitoring, clinicians should assess prostate cancer risk before starting testosterone treatment, and 3 to 12 months after starting testosterone:

Testosterone replacement therapy may cause the prostate to grow. If a man has early prostate cancer, there is concern that testosterone may stimulate the cancer's growth. Therefore, men who have prostate cancer should not take testosterone replacement therapy. It is important for all men considering testosterone replacement therapy to undergo prostate screening before starting this therapy.

Other men who should not take testosterone replacement therapy include those who have:

There are no known ways to prevent low testosterone that is caused by genetic conditions or damage to the testes or pituitary gland.

A healthy lifestyle that includes good nutrition, exercise, weight management, and that avoids excessive use of alcohol and drugs can help keep testosterone levels normal.

Here is the original post:
Low Testosterone (Low T): Causes, Symptoms, Diagnosis ...