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M
artits
AM
et
al
.
410
R
ev
A
ssoc
M
ed
B
ras
2014; 60(5):404-414
The recommended dose for starting treatment is 5 g/day,
which can be increased up to 10 g/day (
D
).
48
Testosterone gel should be applied in the morning
on dry skin on the shoulders, arms or abdomen. Patients
should wash hands well after application and let the appli-
cation site dry before putting on clothes. It is recommen-
ded to wait 4 hours after application to bathe or swim.
The application site should be washed with soap and wa-
ter if there is direct contact with another person (
D
).
48
Testosterone gels at the recommended doses are able
to restore the physiological serum testosterone levels but
they do not mimic the circadian rhythm(
B
)
46
and promote
a significant improvement of sexual symptoms and qua-
lity of life for patients with ADAM(
B
).
13
Even at higher
doses (60 mg) applied once daily they promote testoste-
rone levels within the normal range in most patients (
B
).
49
The association of this type of ART with sildenafil at
the maximum dose (100 mg/day) improves erectile dys-
function in hypogonadal men who do not respond to treat-
ment with testosterone alone (
B
),
50
or sildenafil alone (
B
).
49
Transdermal testosterone solution at 2% for axillary
use is a new treatment option with characteristics simi-
lar to those described for gels (
B
).
51
A less frequently used form of transdermal ART is the
use of dihydrotestosterone gel. Few studies are available
for this type of ART. The dose of DHT gel is 70 mg/day
for 3 months in patients with ADAM proved to be safe,
but with limited effect on physical and cognitive func-
tions. A greater number of long-term studies with a grea-
ter numbers of patients are needed to confirm the safety
and efficacy of DHT as a treatment option for ART (
A
).
52
Recommendation
There is strong evidence that transdermal testosterone re-
placement (patches, gels or solution) is safe and effective
in addition to being the most physiological. Patches, in
turn, are capable of mimicking the circadian rhythm of
testosterone secretion; however, these pharmaceutical forms
are not available in our country. The use of transdermal
TRT is recommended for being the most physiological.
I
s
there
a
difference
between
the
commercial
gel
and
compound
gel
?
There are no scientific studies comparing commercial gels
and compound ones. Only two studies have compared
gels that are produced in two different countries that are
not widely available in the global market. The ointment
produced in Japan was used on 50 patients with ADAM
at a dose of 3 mg twice daily on the skin of the scrotum
for 12 weeks and caused a physiological increase in total
and free testosterone with no severe adverse effects (
B
).
53
The gel produced in Germany was applied both on scro-
tal and non-scrotal skin and removed after 10 minutes
in hypogonadal men. There was better tolerability than
the commercial gels, less chance of interpersonal trans-
fer due to early removal of the gel and an effective increa-
se in testosterone levels (
B
).
54
Recommendation
Studies with a good level of evidence using noncommer-
cial testosterone gel are still scarce. The use of a testoste-
rone gel preparation without proven efficacy and safety
is not recommended.
H
ow
should
ART
be
administered
using
subcutaneous
implants
?
Subcutaneous implants are composed of 1,200 mg of crys-
tallized testosterone, are generally more accepted by patients,
but require a surgical procedure and if not performed by ex-
perienced physicians may have high rates of extrusion (
B
).
43
The implants are changed every 3-6 months and are consi-
dered safe in long-term studies (
B
).
34
Experience with this
type of ART is still limited in the literature.
Recommendation
Studies with a good level of evidence for this form of TRT
are scarce and this pharmaceutical form is not available
in our country. We recommend not using subcutaneous
testosterone implants until a larger number of studies
on safety and efficacy can be found, as the extrusion rate
appears to be high.
H
ow
should
injectable
ART
be
administered
?
Injectable testosterone preparations have been widely
used for many years. They consist of various testostero-
ne esters, combined or otherwise, namely, propionate,
phenylpropionate, enanthate, cypionate, decanoate, iso-
caproate and undecanoate (
D
).
41
All formulations are avai-
lable in Brazil, except those containing testosterone enan-
thate (
B
).
55
All injections with testosterone esters have
short action, except for testosterone undecanoate depot
(TUD).
The short acting formulations must be injected every
14-21 days while the long acting ones should be applied
every 6 weeks at the start of the treatment and every 12
weeks thereafter (
D
)
41
(
B
).
55
Replacement therapy using
short acting testosterone for a short period of time has
proven effective and safe, improving sexual function in pa-
tients without increasing hematocrit or PSA (
D
)
41
(
B
).
55,56