Position
Statements
Use and Misuse
of Androgens
Key Messages
- Androgen
deficiency is a clinical diagnosis confirmed by hormone assays.
- Androgen
replacement therapy is usually life-long and should only be started
after proof of established androgen deficiency.
- Testosterone
rather than synthetic androgens should be used for androgen replacement
therapy.
- Oral 17a
-alkylated androgens are hepatotoxic and should not be use for
standard androgen replacement therapy. If used, they require monitoring
for hepatotoxicity.
- The therapeutic
goal of androgen replacement therapy is to maintain physiological
testosterone concentrations.
- Contraindications
to androgen therapy are prostate and breast cancer. Precautions
include lower starting doses may be required for older men and
induction of puberty, avoiding parenteral administration for men
with bleeding disorders, warning competitive athletes about risks
of disqualification, and androgen-sensitive epilepsy, migraine,
sleep apnea, polycythemia or fluid overload.
- Androgen
replacement therapy should be initiated with intramuscular injections
of testosterone esters, 250 mg per 2 weekly.
- Maintenance
of ART requires tailoring treatment modality to the patient's
convenience to ensure long-term therapeutic compliance. Modalities
currently available include testosterone injections, implants
or capsules. Choice depends on convenience, cost, availability
and familiarity.
- Androgen
deficiency protects against prostate disease and men receiving
androgen replacement therapy are not at higher risk of prostate
disease than eugonadal men of comparable age.
- Screening
for cardiovascular and prostate disease among men on ART should
be similar to, but no more intensive than, among eugonadal men
of similar age.
- Androgen
administration may invoke placebo effects. In the absence of significant
androgen deficiency, this can create transient symptomatic benefits
that may subsequently wane causing confusion and dissatisfaction
for patients and management difficulties for doctors.
- There is
no indication for androgen therapy in male infertility.
- Androgen
deficiency is an uncommon presenting cause of erectile dysfunction.
All men presenting with erectile dysfunction should be evaluated
for androgen deficiency. If androgen deficiency is confirmed,
an underlying pathological cause needs further investigation.
- At present,
there is no convincing evidence that, in the absences of proven
androgen deficiency, androgen therapy is effective and safe treatment
for (a) older men per se, (b) men with chronic non-gonadal disease
or (c) for treatment of non-specific symptoms. Until further placebo-controlled
clinical trials are available, such treatment cannot be recommended.
- There is
no a priori age limit for ART where androgen deficiency
is established. With appropriate monitoring, ART may be continued
indefinitely.
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