Testosterone Replacement Therapy

Testosterone is the male sex hormone. It is responsible for male sexual characteristics such as:

• deep voice
• muscle tone
• bone strength
• hair pattern (and balding)
• sex drive
• achieving and maintaining erections
• general sense of male well-being

How will my testosterone level be affected by an orchidectomy?

Having one testicle removed should not affect the overall testosterone level in the body, providing the remaining testicle is healthy. In some men such as those who have had, or are having chemotherapy, testosterone production can be reduced. This is usually not permanent, but it may take some time after treatment for testosterone levels to recover. 

Men who have had a bilateral orchidectomy (both testicles removed) will have a minimal level of testosterone and will need testosterone replacement therapy.

How will I know if my testosterone is low?

Possible symptoms of low testosterone include:

• Tiredness
• Low mood
• Confusion and feeling emotional.
• Hot flushes.
• Weight gain
• Loss of muscle strength.
• Loss of or difficulty in achieving normal erections on waking up in the morning
• Fall in sex drive (loss of libido)
• Difficulty in maintaining erections strong enough for masturbation or sexual intercourse. 
• Breast swelling (gynaecomastia)

Longer term

• Thinning of the bones (osteoporosis) 
• Increased risk of cardiovascular disease.

The blood test to measure testosterone levels.

Testosterone levels can be checked by a blood test. Testosterone levels are at their highest early in the morning, and this is when the blood test should be performed.

What is the normal level?

A normal level of testosterone is usually considered to be between approximately 9 – 30 nmol/L (nanomoles per litre). A level below 8 nmol/L is low, and the blood test should be repeated. If it is low on 2 occasions taken at the right time of the day, then men will usually benefit from starting testosterone replacement therapy. 

Borderline levels are between 9 – 12 nmol/L and will often be monitored. However, if men are displaying symptoms of low testosterone with a borderline level a trial of testosterone replacement therapy for 6- months can be tried to see if symptoms improve,

If a man is worried that they may have a low testosterone level, they should speak to their specialist team who can arrange a blood test and if necessary, refer them to a hormone specialist (endocrinologist).

Types of testosterone replacement

Type	Formulation	Side effects
Taken by mouth	Mucoadhesive Buccal tablets (Striant™ SR) These are tablets that are placed on the gum above the front teeth and dissolve gradually.   Capsules (Restadol®/Testocaps™) Three or four capsules are usually taken daily for the first 2 – 3 weeks, reduced to 1 – 3 capsules daily. They should be taken with a meal and swallowed not chewed.	Widely used with few side effects. Safe when used for a limited time.         These provide much lower levels of testosterone than other preparations so may not be recommended.
Injected into the buttock or arm	Injections (Nebido®, Sustanon 250®, Virormone®) Sustanon or Virormone are given as an injection into the muscle of the buttocks (or the thickest part of the leg) every 2 or 3 weeks. Nebido is an injection which will release testosterone into the body gradually. It is given deep into the muscle of the buttocks every 10 – 14 weeks.	The injections themselves can be uncomfortable and the vial should always be warmed up for a few minutes before the injection is given.   Possible skin irritation or soreness can occur around the site of the injections.   Other testosterone injections lead to a rapid rise for the first week then the levels usually fall, and men may feel it wear off completely before the next injection is due.   Short-acting injections can cause testosterone levels to vary, sometimes too high and sometimes too low. This may cause symptoms to appear and disappear during treatment.
Applied to the skin	Short-acting: transdermal testosterone patch or gel.   Long-acting: subdermal depot (patch injected under the skin releases medicine over 5–7 months).	These are applied daily usually after a shower or bath, and men need to wait at least 5 minutes before dressing afterwards. It is very important that men wash their hands before and after use to avoid any transfer to their wife or partner, or if someone else applies it for them, they need to wear gloves to stop testosterone being absorbed into their body. Short-acting treatment can cause skin to become irritated. Long-acting treatment can cause skin infection.

How do I know if the treatment is working?

Testosterone levels will be checked on a regular basis. Most people start to feel better within a few weeks of treatment, but it may take 3 months to feel the full effects. If testosterone replacement therapy improves symptoms, then it can be continued indefinitely. In some men who have had a unilateral orchidectomy, testosterone levels may eventually return to normal, and therapy can be discontinued.

Are there any side effects?

Although testosterone is commonly thought to cause aggression and hostility, it helps the body deal with challenging and stressful events or situations. Common side effects are oily skin and spots. Less often, people complain of headaches, nausea, excess sweating, tiredness, and mood changes.

Testosterone does not cause prostate cancer but can increase the size of the prostate. Testosterone actively “feeds” prostate cancer and treatment may not be started in people with active prostate cancer.

Men should never stop testosterone treatment without consulting their GP or specialist team.

Is there anything I can do to improve my testosterone levels?

• Physical exercise is very good for improving energy levels, reducing anxiety and low mood while increasing feelings of general well-being. A few seconds sprinting can increase testosterone levels, while exercise such as brisk walking or supervised cardiovascular training may also help.
• Sleep – a good night’s sleep can help increase testosterone levels naturally.
• Avoid stressful situations. Practice relaxation techniques such as deep breathing or other natural ways to reduce stress levels. Stress will lower testosterone levels.
• Avoid excessive alcohol intake. Alcohol can lower testosterone levels.
• Try and eat a healthy mixed diet and keep to a healthy weight. Being overweight leads to a fall in testosterone.

Reviewed 1/2024