Testosterone therapy: gel transfer, haematocrit, prostate checks and misuse

What testosterone therapy does and when it is avoided

Exogenous testosterone binds androgen receptors directly or after conversion to dihydrotestosterone, restoring libido, energy, muscle mass and secondary sex characteristics in men with confirmed low levels. It also suppresses the body's own production and sperm formation, so people hoping to father children need that discussed before starting.

Contraindications include prostate cancer and male breast cancer. Guidance also lists a high PSA, a raised baseline haematocrit, uncontrolled heart failure and recent cardiac events as reasons for caution or deferral. Gels and injections are common first options, and the nurse's role differs by route: application teaching for gels, technique and site care for injections.

Gel transfer is a boxed warning

Children exposed to a parent's testosterone gel have developed virilisation, such as enlarged genitals, early pubic hair, aggressive behaviour and advanced bone age. Women can also be affected. Teach the patient to apply gel only to the sites on the label, wash hands with soap and water straight away, and cover the dried site with clothing.

The site should be washed before skin-to-skin contact, and the label specifies a wait before showering or swimming. The gel is flammable until dry, so smoking or open flames should be avoided after application. If a child shows signs of early puberty in a household using testosterone, the nurse should ask about possible exposure.

Haematocrit, prostate, lipids and cardiovascular monitoring

Erythrocytosis is a common and important effect. A rising haematocrit thickens the blood and increases clotting risk, and therapy may be paused when it passes the threshold set by the prescriber. Teach patients to report headache, flushing, leg swelling or calf pain, chest pain or breathlessness, which could signal thrombosis.

PSA and prostate assessment are checked at baseline and during follow-up because testosterone can raise PSA and worsen benign prostatic hyperplasia symptoms. Lipids, blood pressure, weight and oedema are also trended, and sleep apnoea can worsen. Testosterone can increase anticoagulant effect and change insulin needs, so those patients need closer monitoring.

Injection technique and what to report

Intramuscular testosterone is given deep into a large muscle, with site rotation and correct technique for the oily solution. Follow the product's own instructions on site, volume and any observation period after the injection. Teach patients using subcutaneous or self-injected forms how to dispose of sharps safely.

Patients should report urinary difficulty, breast tenderness or enlargement, ankle swelling, worsening snoring or daytime sleepiness, mood changes and jaundice. Report a haematocrit or PSA result outside the prescriber's parameters before the next dose. Document the product, dose and site for injections, along with any lot number or controlled-substance record that local policy requires.

Controlled-substance handling, misuse and an original scenario

As a schedule III drug, testosterone in inpatient settings follows controlled-substance storage, counting and waste procedures. Misuse for performance or appearance occurs and can cause acne, testicular atrophy, infertility, mood changes and erythrocytosis. Ask non-judgementally about sources of hormones and supplements, and report suspected diversion through the proper channel.

In a hypothetical case, a man using testosterone gel says his four-year-old has developed pubic hair and he usually applies the gel after his morning shower before carrying her to nursery. Choices are reassurance about normal growth, advising him to switch arms, or reviewing application and covering, washing hands and notifying the prescriber and paediatrician. The last option addresses secondary exposure. Reassurance misses a recognised boxed-warning harm, and switching arms leaves the core problem of uncovered, unwashed skin in contact with the child. The child may need assessment, and the family needs a practical routine they can follow every morning.

Sources and further reading

StatPearls: Androgen Replacement. Indications, formulations, contraindications, baseline and follow-up PSA, haematocrit and lipid monitoring and gel transfer.

DailyMed: Testosterone gel 1.62% prescribing information. Schedule III status, secondary exposure boxed warning, application and washing instructions, flammability, PSA, thrombosis and interactions.

StatPearls: Anabolic Steroid Toxicity. Effects of exogenous testosterone or anabolic steroid misuse, including testicular atrophy, infertility, acne, mood change and erythrocytosis.