What is known about testosterone therapy options and barriers to treatment
The symptoms associated with hypogonadism, also known as testosterone deficiency, are not specific to low testosterone levels; the same symptoms also occur with aging, obesity and other comorbidities. For example, erectile dysfunction can be a marker of coronary heart disease. Therefore, initial management of symptomatic men should include lifestyle changes with the goal to achieve weight loss and reduced waist size by increasing physical activity, improving food choices and reducing alcohol consumption. Nevertheless, while lifestyle changes and weight loss may increase endogenous testosterone levels and confer overall health benefits, it is commonly not enough for achievement of resolution of symptoms associated with hypogonadism.2,3
The major barrier to testosterone therapy is failure to consider the diagnosis of hypogonadism by general practitioners, and specialists who feel that treatment of hypogonadism is not their responsibility. Although general practitioners are ideally placed to provide care for men with hypogonadism, they have received no training in how to diagnose hypogonadism, and may be reluctant to take on the burden of long-term follow-up for a potentially large number of men. Furthermore, while accumulating evidence confirms the safety of testosterone therapy, common myths about increased risk of prostate cancer or cardiovascular events have not been completely dispelled and concern still exists amongst healthcare professionals.
The British Society for Sexual Medicine (BSSM) guideline on testosterone deficiency management provides evidence-based guidelines that help healthcare professionals diagnose and manage men with hypogonadism.4 Evidence reviewed by the BSSM shows that testosterone therapy consistently improves sexual function and preserves lean mass in men with hypogonadism; studies also show increases in bone mass, improvements in lipid profile and anemia, attenuation of insulin resistance, improved mood and increased exercise capacity.4,5 The BSSM recommends initiating testosterone therapy only in conjunction with weight-loss advice and lifestyle modification, so this should be discussed with patients.4
New data on adherence to testosterone therapy
Testosterone therapy in symptomatic men with hypogonadism should aim to restore testosterone levels and target a serum total testosterone level of 15-30 nmol/mL.4 A prerequisite for successful testosterone therapy is that this therapeutic target level of testosterone is maintained long-term in order for symptom resolution and health benefits to occur. This is why adherence to testosterone therapy is critical.
The most commonly used testosterone preparations for the treatment of hypogonadism are transdermal (gel) and injectable testosterone preparations. While transdermal preparations are easy to use, some people may find the need for daily gel application to the skin burdensome. Adherence rates with gels are disappointingly low, falling to 52% after 3 months6, 35% after 6 months7 and as low as 15-17% after 1 year.7,8
In contrast, a survey of 150 general practitioner practices in the UK showed that 58% of patients who were started on treatment with testosterone undecanoate injections stayed on treatment after 1 year, see figure. After 2-3 years, 40–44% of patients continued, and after 4–5 years about one-third were still being treated with testosterone undecanoate injections.9 Figure 1 shows the proportion of 2299 men prescribed intramuscular testosterone undecanoate who continued treatment, 2012–17.9 Adherence to treatment with long-acting testosterone undecanoate injections is also higher than the adherence rates reported with short-acting testosterone injections.6,9