- Bioidentical Form, Produces Very Stable Testosterone Levels
- Easy Topical Application (no injections)
- Typically Applied Twice per Day
- Has Less of an Effect on Cholesterol Levels
- Unlikely to Cause Skin Reactions
- Can be Transferred to Others
- Slightly More Expensive
- Not Bioidenticial, Tends to Produce More Peaks and Valleys
- Must be Injected
- More Convenient: Injected 1-2 Times per Week
- May Lower Good Cholesterol Slightly
- Occasional Injection Site Reactions are Possible
- Cannot be Transferred to Other People
- A Less Expensive Option
Testosterone creams have the distinct advantage of producing very stable testosterone levels. This means the cream can mimic the natural testosterone levels that our bodies typically produce. They are also bioidentical, which means they tend to have fewer of the negative effects other forms of testosterone can have.
Testosterone injections tend to produce sharp spikes in testosterone levels, which gradually come down over time, before the next injection is done. Some men will may notice that their symptoms worsen, as testosterone levels fall below the therapeutic range. We typically recommend injecting twice per week to help avoid more severe peaks / valleys in testosterone levels.
Testosterone Cream vs Injection
Since testosterone creams produce stable testosterone levels, they also tend to have lower likelihood of side effects.
The two major side effects of testosterone that we are concerned about are changes in “good” cholesterol levels (HDL) and an increase in red blood cell concentration (hemoglobin levels). The large spikes in testosterone levels produced by injections, have the potential to lower HDL (so called good cholesterol). This can sometimes be countered by injecting more often, such as 2-3 times per week.
In some men the spikes can also stimulate the overproduction of red blood cells (RBC’s) in some men. If the RBC levels climb too high it can cause problems with increased blood pressure and headaches in some men. There is also some controversy in the medical field whether increased RBC’s can cause the blood to become too “thick” and could potentially increase the risk of blood clots.
This is why we perform frequent blood work when you first start therapy. Your clinician will keep a close eye out for any side effects and if any present, they will suggest methods to get things back in line.
Good Cholesterol & Hemoglobin Levels with Testosterone Injections
The major downside to testosterone creams is that they have the potential to be transferred to other individuals. This can occur when a patient fails to wash his hands after application. If any of the cream remains on the hands it can easily transfer to anyone the patient touches, including children. Men must be diligent in following the application instructions.
Transfer can also occur during sexual intercourse. Since the cream is often applied to the scrotal skin for better absorption, the potential for transfer to a sexual partner is high. The recommendation is to wait 4 hours after application to engage in intercourse.
Is testosterone cream the same as gel? I heard that the gels do not work well.
No, creams and gels are different. The gels (like AndroGel), may have problems with absorption through the skin. This leads to ineffective testosterone levels, and many men on gels complain that their symptoms do not improve.
The newer testosterone creams are specially made by compounding pharmacies, with the goal of better absorption. This is achieved by putting the testosterone in more effective “base” that allows better absorption. The “base” goes by the name of Versabase or Lipoderm. These are specially formulated to allow better absorption through the skin, which leads to effective testosterone absorption.
The cream also allows the pharmacist to add higher doses of testosterone per gram than gels. For example the cream can contain up to 200 mg of testosterone per gram, while Adrogel only has 10 and 20 mg per gram.
Do you offer bioidentical testosterone?
Yes, the topical cream is considered “bioidentical”, but there is more to that story:
Bioidentical hormone therapy has become a bit of an industry buzz-word. It has become fashionable for some clinics to market their hormone therapy as bioidentical.
Here is the truth: Bioidentical hormones became popular after it was found that certain forms of estrogen therapy caused cancer, heart disease and other problems. This is because the estrogen women were taking was harvested from horses and contained several other forms of estrogen, that do not naturally occur in a woman’s body. It was later found that these other ‘unnatural’ forms of estrogen sometimes caused major problems for the women who took them. Research showed that the natural or ‘bioidentical’ form of estrogen (aka. estradiol), did not cause these problems and was actually very healthy for women to use. This gave rise to the term “bioidentical”, which was soon hijacked and applied to men’s hormones as well.
The truth is that, testosterone injections contain a slightly altered form of testosterone. This allows the injection to be absorbed more slowly. Once the T is injected, the body cuts the small molecule that was attached to the testosterone and at that point the testosterone looks exactly like the testosterone our body produces. So, once the testosterone reaches the bloodstream, it can be considered bioidentical.
Hopefully this clears up some of the confusion around this term.
Do some patients respond differently to testosterone creams vs. injections?
Yes, some men may feel better on testosterone injections, while other men may have better results on topical cream. There is no way to predict which will work better for you. Typically, a trial period of a few months is needed to determine which one works best. Your clinician has received specific training on this issue and will guide you.
Our patients are always welcome to try different methods, whenever they like. We will keep a close eye on your health markers to be sure your overall health is improving.
Is it common for testosterone injections to cause problems with cholesterol levels?
No. Every patient is unique when it comes to how their body will react to testosterone injections.
The research has shown that some men will have a minor, insignificant drop in their HDL (good cholesterol), when they start testosterone replacement. Typically, HDL levels will stabilize after the first month, and men should not see any further decrease. If the decrease in HDL is minor then no changes to the medication regimen need to be done. However, some men can experience a more severe drop in their HDL level. Since HDL is thought to protect against heart disease, your clinician may suggest techniques or medications to bring HDL levels back in line.
Other men will see an improvement in their good cholesterol after the start testosterone therapy.
As always, we want to be sure that we are improving your overall health with testosterone therapy. We work with each patient closely, to be sure your health is maintained.
How does testosterone effect the thickness of my blood?
Testosterone is well known to increase the number of red blood cells (RBC’s). This happens in just about every patient. It is not a problem until the RBC concentration becomes too high (which is fairly rare). Logically, the more RBC’s in the blood the thicker the blood becomes. In theory, this can be problematic, as the thicker blood may have a more difficult time moving through blood vessels. This could predispose a patient to a blood clot, however this risk is not backed up by the research and it remains a very controversial issue.
Many studies have been done to test whether patients on testosterone therapy are at an increased risk of clots. The vast majority of the studies have shown no increased risk of clots in men on testosterone. However, a few studies have shown an increased risk, especially during the first 6 months of therapy.
What is known is that if you have a genetic clotting disorder, testosterone therapy can increase your risk of developing a clot. Studies have shown that somewhere between 3-8% of the population has a clotting disorder.
This is why we recommend very close follow up during the first year of therapy. This allows us to learn how your body is reacting to the testosterone and keep any risk to an absolute minimum. Your blood will be frequently tested for RBC concentration (a measure called hemoglobin & hematocrit).
Typically if your hemoglobin is climbing too high, it is because the testosterone dose is too high and needs to be lowered. Another technique is to do more frequent injections. Your clinician will work with you closely and develop an individualized plan, to be sure your testosterone therapy is done as safe as possible.
How often does the increase in red blood cells become a problem?
The increase in red blood cells (RBC’s) with testosterone therapy is very common. Most men will see a slight increase in the number of RBC’s over the first 3-6 months of therapy. Typically levels then stabilize and do not increase further. This is why it is important to track blood levels frequently when first starting therapy.
The research has shown that about 5-10% of men will have problematic increases in the number of RBC’s. Since we live at elevation, this number percentage is likely higher in Colorado. There are several techniques that can be employed if the RBC number climbs too high. Your provider will review these options with you, if needed. We have the capability of testing RBC concentration directly in our office without sending blood to a lab. Using testosterone in a safe and sustainable way is our number one priority.
How long will it take to notice the effects of TRT?
Since every individual is different, it is difficult to say exactly when you will feel improvement. It can take up to 3 months to figure out your correct dose. Once the dose is at the correct level we typically see improvement within 3-6 months. In addition, each symptom of low T has its own unique timetable to improvement. While energy and sleep typically improve quickly, low libido can take much longer. Your clinician is experienced in these issues and will guide you as your symptoms improve. We also employ regular symptom screening questionnaires, which help us to track symptom improvement.
An article from the European Journal of Endocrinology has two very helpful charts. The first chart, maps the time to changes in strength and body composition. The second chart, maps changes in sexual symptoms. These can be very helpful in managing our expectation of therapy. Patience is key during testosterone therapy.