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Injectable Testosterone cypionate/enanthate

Mood fluctuations or changes in libido Pain at injection site Erythrocytosis

Testosterone undecanoatea

Low incidence of pain at injection site

Treatment options

Several types of testosterone treatment are on the market today and in development, including topical, transdermal, transbuccal, intramuscular injection, and subcutaneous implants, each with specific dosing recommendations, potential adverse effects, and general pros and cons (Table 6).22 The ideal formulation is safe, effective at providing physiologic levels of testosterone, convenient, and cost-effective.

A novel, long-acting intramuscular injectable formulation, testosterone undecanoate, is being evaluated in the United States. It has been approved and launched in more than 80 countries in Europe and Asia in a dosage of 1000 mg in castor oil administered up to every 12 weeks.46 This dosing regimen requires only 4 injections per year, eliminating adherence issues and thereby improving patient outcomes.

Table 6. Testosterone Therapy and Formulation-Specific Adverse Events22 Formulation

Adverse Effect

Topical Topical gel Patch system Buccal system

Adapted with permission.

Potential infections or expulsion

Skin-to-skin transference Skin irritation

Alterations in taste and irritation of gums and oral mucosa


Any time after patient has received treatment for at least 1 wk 3-12 h after application of patch Immediately before application of fresh system

Injectable Testosterone cypionate or enanthate

Midway between injections; if >700 ng/dL or <350 ng/dL, adjust dose or frequency

Testosterone undecanoate

Before each injection, adjust dosing interval to maintain testosterone level in mid-normal range

Implants Testosterone pellets

A key benefit of injectable testosterone is that monitoring is easier because patients have to return to the office

Ajay Nehra, MD

Monitoring recommendations

Because testosterone is delivered via different mechanisms depending on the route of administration, the ideal time to get an accurate measure of

testosterone varies (Table 7).22 As accurate measurement is an important component of monitoring patients for efficacy and safet , it is important for primary care clinicians to be aware of these differences.

When monitoring the effects of testosterone therap , it is necessary to measure testosterone but equally important to assess the efficacy of treatment with regard to the signs and symptoms of low testosterone. Because testosterone affects various organs and tissues, men receiving testosterone therapy should be evaluated at baseline and at follow-up visits, generally at 3, 6, and 12 months after the initiation of therapy and yearly thereafter.1

Topical Topical gel Patch system

Table 7. Monitoring Testosterone Levels: When to Measure Based on Formulation22 Formulation

When to Measure Testosterone Level

Buccal Buccal system


In development in the United States.

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