Androgens
Testosterone should not be used for "male menopause" and should only be initiated following investigation by a consultant.
Testosterone intramuscular injection (IM)
(Testosterone propionate/ testosterone phenylpropionate/ testosterone isocaproate/ testosterone decanoate)
- Sustanon 250 solution for injection 250mg/1ml (£2.45 = 1ml amp)
Indications
Dose
- Usual therapy is 250mg IM injection every 3-4 weeks
- For patients who report large swings in their symptomatic response, an alternative dosing schedule of a lower dose more frequently, may be given
Notes
- Contains arachis oil and is contraindicated in patients allergic to peanuts or soya
Testosterone intramuscular injection (IM) (long-acting)
(Testosterone undecanoate)
- Nebido oily solution for injection 1000mg/4ml (£87.11 = 4ml vial)
Indications
Dose
- 1g every 10-14 weeks, to be given over 2 minutes by deep intramuscular injection. A second dose may be given after 6 weeks to achieve rapid steady state plasma testosterone levels and then every 10-14 weeks
Testosterone transdermal gel
- Testogel gel 16.2mg/g (£31.11 = 88g pump)
- One pump actuation delivers 1.25g gel containing 20.25mg testosterone
- Testogel gel 40.5mg/2.5g (£31.11 = 30 x 2.5g sachets)
- One 2.5g sachet contains 40.5mg testosterone
- Tostran gel 2% (£28.63 = 60g pump)
- One pump actuation delivers 0.5g gel containing 10mg testosterone
Indications
Dose
- Testogel 16.2mg/g pump:
- Apply 40.5mg (two actuations) once each morning. Increase dose in steps of 20.25mg (one actuation), according to response; maximum 81mg per day (four actuations)
- Testogel 40.5mg/2.5g sachet:
- Apply 40.5mg (1 x 2.5g sachet) once each morning. Increase dose in half sachet steps (1.25g of gel) according to response; max 81mg (2 x 2.5g sachet) per day
- Tostran 2% pump:
- Apply 60mg (six actuations) once each morning. Adjust dose according to response; max 80mg (eight actuations) per day
Notes
- Avoid skin contact with gel application sites to prevent testosterone transfer to other people, especially pregnant women and children—consult product literature and note 4.
- Refer to individual product literature for specific application directions.
- Do not apply to the genital areas
- MHRA Drug Safety Update (January 2023): Topical testosterone: risk of harm to children following accidental exposure
- Inform patients that accidental transfer to other people can lead to increased blood testosterone levels in the other person.
- Advise patients of the possible effects should accidental exposure occur in adult women (facial and/or body hair growth, deepening of voice, changes in menstrual cycle) or children (genital enlargement and premature puberty, including development of pubic hair).
- Counsel patients on methods to reduce the risks of accidental exposure, including washing their hands with soap and water after application, covering the application site with clean clothing (such as a t-shirt) once the gel has dried, and washing the application area with soap and water before physical contact with another person.
Testosterone cream
- Cream 5% (unlicensed preparation)
Notes
- For use in University Hospitals Plymouth NHS Trust only
Anti-androgens
Cyproterone acetate
- Tablets 50mg, 100mg (£132.57 = 300mg daily)
Indications
- Polycystic ovary disease
- Hirsutism in women
Notes
- Direct hepatic toxicity including jaundice, hepatitis and hepatic failure has been reported (usually after several months) in patients treated with cyproterone acetate 200-300mg daily. Liver function tests should be performed before treatment and whenever symptoms suggestive of hepatotoxicity occur-if confirmed cyproterone should normally be withdrawn
- In women of child bearing potential cyproterone must be used with cyclical oestrogen or in the form of co-cyprindiol. Please refer to chapter 13
- Cyproterone is contra-indicated in patients with a history of thrombo-embolic disorders
5 alpha-reductase inhibitors
Sexual dysfunction (decreased libido, ejaculation disorder, and impotence) and breast tenderness are reported in the first year of use for fewer than one in 10 men. Advise patients:
- Sexual dysfunction tends to improve with duration of treatment.
- Changes in breast tissue (lumps, pain, nipple discharge) should be promptly reported; cases of breast cancer have (rarely) been reported.
Finasteride
- Tablets 5mg (£1.38 = 28 tablets)
Indications and dose
Notes
- Finasteride can decrease PSA levels by approximately 50%. For men undergoing PSA monitoring: Recheck PSA levels after 6 months of treatment to establish a new PSA baseline. Any confirmed increase in PSA (even if values are within normal range) may indicate prostate cancer; careful interpretation is advised (see NICE CKS LUTS in men for further details).
- Finasteride can be absorbed through the skin and is excreted in semen; women of childbearing potential should avoid handling crushed or broken finasteride tablets; use of a condom is recommended if sexual partner is pregnant or likely to become pregnant.
- MHRA Drug Safety Update (April 2024): Finasteride: reminder of the risk of psychiatric side effects and of sexual side effects (which may persist after discontinuation of treatment)
- Finasteride has been associated with depression, suicidal thoughts and sexual dysfunction.
- 281 UK reports of finasteride and psychiatric dysfunction (depressed mood disorders, suicidal and self-injurious behaviours) and 426 UK reports of finasteride and sexual dysfunction (erectile dysfunction, decreased sex drive) were received from 1992 to 2024.
- Before prescribing finasteride, ask patients if they have a history of depression or suicidal ideation
- Advise patients prescribed finasteride 5mg (Proscar) for benign prostatic hyperplasia to consult their doctor for further medical advice as soon as possible if they develop depression or suicidal thoughts
- Monitor patients for psychiatric and sexual side effects
- Refer to the Drug Safety Update for advice to give to patients