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What is testosterone replacement therapy?

Testosterone replacement therapy is rising in popularity across the world, desired by older men wanting to boost their naturally declining testosterone levels to feel better, and by younger men who want to maximise their T to pack on lean muscle mass, lose body fat and look and perform at their full potential. Here are the major TRT treatment options available and the major pros and cons of each one

Do you suffer from persistent fatigue, decreased libido, muscle weakness, and mood changes? There’s a chance you may be suffering from low testosterone levels and could benefit from testosterone replacement therapy, or TRT.

If you have any symptoms of low testosterone – which can range from loss of morning erections to ‘man boobs’ – your doctor can arrange blood tests. And if those tests do confirm a low testosterone diagnosis, you may be offered TRT.

There are several different types of TRT available, including injections (short-acting and long-acting), transdermal systems (such as gels and patches), implants and tablets. Sublingual treatments (a tablet placed under the tongue) and buccal treatments (a patch applied to the gum) are also available, but these are less common. Injections and transdermal treatments are the norm, depending on a man’s medical needs, health profile and preferences, according to the British Society for Sexual Medicine.

But be warned TRT is not without some side effects. Potential problems include a thickening of the blood, fertility issues or weight gain. So you’ll undergo a detailed assessment before and during treatment. And for some men – such as those currently trying for a baby – therapy may not be suitable. But for most men with medically low levels of testosterone, treatment can improve a whole range of symptoms, from erectile function and libido to muscle strength, vitality and bone strength. Here are the main pros and cons of each type of TRT.

Testosterone injections

Long-acting injections are the most common method of testosterone therapy. As an example, testosterone undecanoate – marketed in its injectable form through the brand name Nebido – can be administered every 12 weeks.

The issue with long‐acting injections is that you cannot just stop the treatment if you happen to get any side effects. Other short-acting injections can be used every 3-4 weeks instead, but they lead to greater fluctuations in testosterone levels, which can cause unwelcome variations in libido, energy and mood. And, of course, any injection can cause pain, and it usually requires a healthcare professional to administer the jab.

But the British Society for Sexual Medicine suggests that injections usually encourage very good compliance as, unlike tablets and gels, they don’t require daily administration. And long-acting injections also deliver a steady stream of testosterone, without any of those unhelpful fluctuations. That’s why they’re the popular choice.

Testosterone tablets

According to the British Society for Sexual Medicine, testosterone tablets are rarely prescribed in the UK because they require multiple doses: this can be annoyingly impractical and can easily lead to men forgetting to take the right dosage. But there are also some lingering fears about hepatotoxicity (chemical-driven liver damage). This is largely based on a link between an early tablet called Methyltestosterone and hepatotoxicity. However, research suggests that the latest tablets, such as testosterone undecanoate, are pretty safe and effective.

But men who take tablets still need to take several doses per day, preferably with an intake of fatty food. And as oral absorption is generally less effective, testosterone levels can fluctuate, leading to side effects.

Nevertheless, tablets can still be an excellent option for specific men, such as men with medical conditions which might make testosterone injections or gels inappropriate, or men who require only low doses of testosterone.

Testosterone implants

Subdermal testosterone implants are small pellets which contain testosterone. They are inserted under the skin into the lower abdominal wall or buttock by a doctor. According to the NHS, patients are usually given a local anaesthetic beforehand. Common brands include Testo-100.

As with any implant, there is always a risk of a minor infection or bleeding. And extrusion of the pellets – where the pellet works its way out – occurs in 5-10% of cases.

But the real advantage is that the hormone treatment lasts for 4-5 months. Research suggests they often tend to provide the longest duration of action, as well as a reliable steady-state delivery. And once implanted, they are usually hassle-free, with no daily pills or gel applications to worry about. They’re not the norm, but they’re another option to think about.

Testosterone gels and patches

Transdermal treatments are usually applied through a skin patch or as a gel. A single application usually delivers testosterone for around 24 hours. One brand used by the NHS is Testogel, which is simply rubbed on the shoulders, arms or abdomen. Handily, doses are adjustable to suit a patient’s needs.

Some men might get a mild skin irritation or dryness, and other men might give up on them when they get bored of the daily slathering routine. There is also a slight risk of transfer to other people. That is why the usual NHS advice is to not wear a shirt for 10 minutes after application, and to avoid sex, showering or swimming for four hours after application, in order to avoid any transfer to other people.

But the British Society for Sexual Medicine emphasises that this popular method offers a really quick delivery of testosterone, and a reliable steady‐state stream. According to research in the journal Therapeutics and Clinical Risk Management, advantages include ease of use and the maintenance of relatively uniform testosterone levels over time.

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