21 / 111
L
ate
-
onset
hypogonadism
or
ADAM:
treatment
R
ev
A
ssoc
M
ed
B
ras
2014; 60(5):404-414
409
Recommendation
There is strong evidence that testosterone replacement
improves the parameters of metabolic syndrome, espe-
cially if serum levels are maintained within normal limits.
We recommend maintaining serum testosterone levels
within a normal range to aid in the treatment of metabo-
lic syndrome.
H
ow
should
ART
be
administered
orally
?
Oral testosterone formulations have been developed to
replace injectable forms; however, some disadvantages
have been noted, such as variable absorption, low bioa-
vailability due to liver metabolism and the need for 2 to
3 daily doses (
D
).
41
Moreover, 17
a
-alkylated derivatives
are hepatotoxic (
A
)
1
(
D
)
41
and have already been withdrawn
from the American market (
A
).
19
Oral testosterone unde-
canoate (OTU), the only available oral formulation, is
preferably absorbed in chylomicrons, avoiding the pri-
mary hepatic passag (
D
)
41
and significantly reducing he-
patotoxicity (
A
).
17
Although most of the studies were fla-
wed due to the small number of participants or the
variability of the dose used, the effectiveness of oral ART
is questionable. Several authors have shown that the OTU,
even at appropriate doses (160 mg/day) was not effecti-
ve in improving sexual function, wellbeing, sleep distur-
bances, cognitive function, mood and quality of life in
men with ADAM(
A
).
17,19,20
The manufacturer’s recom-
mendation is for OTU to be taken during meals, yet the-
re is variability in absorption depending on the compo-
sition of the patient’s diet (
A
).
19
DHEA has been proposed as an alternative oral ART,
but the results are controversial. Morales et al.
19
demons-
trated that the ingestion of 50 mg of DHEA orally twi-
ce a day, although leading to satisfactory serum levels
did not improve the sexual function of men with ADAM
(
A
).
19
On the other hand, replacement with lower doses
of DHEA (75 mg/day) improved insulin resistance in the
individuals treated (
B
).
42
Another way to release testosterone orally is oral mu-
cosa patches which contain 30 mg of testosterone that
should be administered twice daily. In general, studies
show that this form of ART is capable of maintaining
physiological levels of serum testosterone, is safe and well
tolerated, and is an interesting option for ART in hypo-
gonadal men (
D
)
41
(
B
).
43,44
The underreported sublingual form of testostero-
ne administration should be used at a dose of 2.5 mg or
5 mg, 3 times a day. It is rapidly absorbed and metaboli-
zed, and it does not lead to a sustained increase in serum
levels of dihydrotestosterone (DHT) and estradiol (
D
).
41
Recommendation
Oral testosterone undecanoate does not present hepato-
toxicity; however, it has proved ineffective in maintaining
adequate serum testosterone levels, and has variable ab-
sorption between individuals. It is strongly recommen-
ded NOT to use oral formulations of testosterone and
other androgens as an alternative to TRT.
H
ow
should
ART
be
administered
transdermally
?
Transdermal administration of ART includes patches,
cutaneous gels and cutaneous solutions.
The patches may be non-scrotal or scrotal, which are
thinner and have more effective testosterone absorption
than the non-scrotal version. The first presentation of
transdermal testosterone was the scrotal patch with re-
lease of 4 or 6 mg testosterone/day. It should be applied
once daily on depilated scrotal skin (
D
).
41
The most com-
monly used patches are non-scrotal, releasing 5 mg/day
of testosterone and should be applied once a day on clean
and dry glabrous skin (
B
).
43
Due to the large number of patches on the interna-
tional market from different manufacturers, in the opi-
nions of the authors, the tolerability of patients is quite
variable due to local adverse effects. They are considered
large and uncomfortable to use, and some formulations
cause local reactions and exhibit low adhesion that ends
up causing low acceptability by patients (
B
).
43
There are
reports of patients who have discontinued treatment due
to allergic reactions at the application site, even when
using a local corticosteroid ointment (
B
).
44
On the other hand, the authors are unanimous re-
garding the efficacy and safety of this type of ART. The
transdermal patches available provide physiological and
constant levels of serum testosterone, and mimic the cir-
cadian rhythm. At a dose of 5 to 7.5 mg/day, changing
patches every 48 hours, they are capable of producing a
significant improvement in symptoms and quality of life
of patients with ADAM(
A
)
8
(
B
).
45-47
With respect to secu-
rity, Raynaud et al.
44,47
reported that the use of transder-
mal patches showed no negative impact on the hematocrit
and lipid profile of patients (
B
),
45
and does not contami-
nate other people or the environment (
B
).
47
Many patients prefer transdermal gels or solutions as
they are easy to apply, substantially free of local reactions
and do not require injections (
D
).
41
Testosterone gel for-
mulations available on the health market are available in
the concentration of 1% as “pumps”, so that each “puff ”
releases 1.25 g of product; individual 2.5 g and 5 g pac-
kages or single dose tubes containing 5 g of the product.