Which male hormone treatment to choose? (Erectile dysfunction & male menopause)

The two major diseases related to male sexual function are erectile dysfunction and male menopause. Testosterone drugs used for the treatment of male menopause have been developed similarly to those used to treat erectile dysfunction.

The most important principle of andropause treatment is that it should be started only when a decrease in serum testosterone is confirmed in a patient complaining of androgenic symptoms. In testosterone supplementation therapy, the most ideal hormonal agent is a drug that maintains the blood testosterone concentration as close to the physiological state as possible.

To date, formulations with various routes of administration, such as subcutaneous insertions, intramuscular injections, oral formulations, gel formulations, and oral formulations, have been developed, and each formulation has various pharmacokinetic properties. So, what are the pros and cons of each formulation?

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First, injections every 2-3 weeks are not expensive, but require frequent visits to the hospital, and immediately after injection, the concentration rises above the physiological level, which increases the risk of thrombosis in patients with chronic obstructive respiratory disease or congestive heart failure. . Therefore, caution is required for use in the elderly or patients with cardiovascular disease. Injections that last for 3 months are convenient, but there may be some people who are expensive or complain of pain during injection. It is an appropriate drug for patients with primary hypogonadism who need to continue testosterone supplementation during the life span.

Since the testosterone gel is administered daily, it has the advantage that it can be closest to the physiological concentration, and it is possible to immediately stop the administration when side effects occur. However, there are concerns that the gel applied to the body does not fit well with the lifestyle of the elderly in Korea, who like to wear underwear in winter, has to wait for absorption after application, and that it can spread through skin contact to the other person.

The gel formulation applied to the nose is known to have relatively little effect on the hypothalamus-pituitary-gonad axis while maintaining the testosterone level in the human body at a physiological concentration. Since it is applied to the nasal mucosa, it is evaluated as an improved treatment in that there is no risk of transmission through skin contact to the partner during sexual intercourse.

So, which testosterone treatment is best?

Based on my experience and treatment guidelines, I would suggest starting with a short-term injection or gel formulation to check the effect in the patient and determine whether side effects occur. If the effect is confirmed after treatment and there are no side effects, consider switching to a long-acting injection that is suitable for long-term treatment and can maintain blood testosterone levels close to physiological concentrations. For elderly patients who are concerned about side effects due to excessive increase in blood concentration, it is recommended to apply a gel formulation to the nose that can control the dosage and maintain stable blood concentration.

Written By: Hyunjoon Park, Professor, Department of Urology, Pusan ​​National University Hospital

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