A number of testosterone replacement modalities are in use in the United States. Each has a unique profile that may determine its appropriateness for your patient. A 76-year-old man with primary testicular failure secondary to war trauma sustained 40 years ago reports dissatisfaction with his testosterone replacement therapy (TRT). For many years, he has been using testosterone enanthate (TE) 200 mg IM every 2 weeks. He was doing relatively well with the treatment until recently, after his wife passed away. Now he is bothered by the mood swings and the lethargy that he feels shortly before his next injection is due. Although these symptoms are not new, he says he has recently been feeling low and is, therefore, more sensitive to them.

The patient recalls that, while using TE, he had a healthy libido despite some erectile dysfunction. He is, however, no longer interested in continuing the treatment for this goal. He has no problem voiding, reports no excessive daytime sleepiness, and has no history of fractures or height loss, though he has never had a dual energy X-ray absorptiometry (DEXA) bone scan. Past medical history includes dyslipidemia, for which he is currently taking simvastatin 20 mg daily. In addition, he takes aspirin 81 mg daily to lower his risk of clot-related events. A cardiac catheterization performed within the past few years showed some blockage.

Recent blood work reveals the following levels: hemoglobin (Hb), 16.2 g/dL (normal, 13.8 to 17.2); hematocrit (Hct), 49.2% (normal, 42% to 52%); low-density lipoprotein (LDL) cholesterol, 65 mg/dL (normal, less than 100 mg/dL); high  density lipoprotein (HDL) cholesterol, 52 mg/dL (normal, above 40 mg/dL); triglycerides, 104 mg/dL (normal, less than 150 mg/dL); prostate-specific antigen (PSA), 0.8 ng/mL (normal, below 4 ng/mL); total testosterone, 369 ng/dL (normal, 280 to 800 ng/dL); luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, undetectable (normal, 2 to 12 mIU/mL and 1 to 12 mIU/mL, respectively). He also has been told he has elevated blood glucose levels and has, therefore, reduced his carbohydrate intake and lost some weight.

On physical exam, the patient appears to be healthy and in no distress. His vital signs are within the normal range. He has a nontender, Tanner stage II gynecomastia on the left side, which he says developed recently. Genitourinary examination reveals no palpable testis in the left scrotal sack, and an atrophic right testis measuring approximately 7 mL. Digital rectal exam (DRE) reveals a nonenlarged prostate with no nodules. Body hair, virilization, and all other aspects of his physical examination are normal.