Information Re Changing Testosterone Preparations
The aim of this document is to respond to queries around changing the formulation of testosterone an individual is receiving. Increasingly, we are seeing shortages of different testosterone preparations with requirements to change between preparation. This information is to provide a framework to help health professionals navigate these changes and increase confidence with hormone prescribing.
Types of Testosterone; Initiating and Up titrating:
Testosterone is normally started in a short acting formulation such as a gel or injectable (Sustanon/Enanthate) with initial monitoring at 4-6 months and with dose titrations up to target range. For risks of testosterone therapy, please see detailed information available on our consent forms for testosterone which are located on our health professional hormone support hub on our website.
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| 1ml injection IM Avoid in peanut/ soya allergy | | 4ml IM injection into buttock |
| | | May have second dose at 6 weeks then third dose at 12 weeks when initiating.<br>8-26 weeks maintenance dosing frequency. |
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| 16.2mg/g topical gel (20.25 mg per actuation) | 40.5mg/g topical gel (50mg per sachet) | 20 mg/1g topical gel (10 mg per actuation) | | |
| 1-2 actuations daily (20.25-40.5 mg) | Half to one sachet daily (20.25-40.5mg) | 1-2 actuation daily (10-20mg) | | |
| Apply to clean, dry, healthy skin of both inner thighs or abdomen. | | | | |
| 1-4 pumps (40.5-81mg) once daily | Half-2 sachets (20.25-81mg) once daily | 2-8 pumps daily (20-80mg) once daily | 1-3 pumps (23-69mg) once daily | |
*YGES do not routinely recommend these products but if other options are not available it may be appropriate for a period of time.
| | | | Tostran gel pump 20mg/g 2% | Testavan gel pump 20mg/g (2%) | | Testogel pump 16.2mg/g (1%) |
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You can do a direct switch between any of the testosterone preparations although there is no formal advice on switching between testosterone injections or equivalent dosing. Any changes are inexact and would require further monitoring and dose adjustments as detailed below.
| Sustanon or Testosterone Enanthate250mg IM every 2-6 weeks | Testosterone GelTestogel pump/sachets, Tostran etc- see next table for guidance | Nebido 1g IM every 8-26 weeks |
Switching To... Sustanon or Testosterone Enanthate 250mg IM every 2-6 weeks | Direct switch between Sustanon and Testosterone Enanthate | Stop Sustanon/enanthate and start gel on the day the next Sustanon/Enanthate is due. If was using Sustanon/Enanthate every 4-6 weeks use a low dose of Testosterone gel. If was using Sustanon/Enanthate every 2-3 weeks use a medium dose of Testosterone gel | Stop Sustanon/enanthate and start nebido on the day the next Sustanon/Enanthate is due. Give a second injection at 6 weeks then at 12 weeks. Take blood tests a further 6 weeks after this third injection. If levels are in range continue every 12 weeks. If high or low adjust dosing accordingly by 2 weeks. If receiving Sustanon/enanthate more frequently than every 2-3 weeks, it is appropriate to give the second injection at 4 weeks and then at 8 weeks with appropriate monitoring and adjustment as needed. |
Switching To... Testosterone GelTestogel pump/sachets, Tostran etc-see next table for guidance | Stop Gel and start Sustanon/Enanthate the next day. Start at every 3-4 weeks and recheck levels after third to fourth dose. If have been on >40g of gel, start at 3 weekly. | See table above for equivalent dosing of Testosterone gels | Start Nebido and continue the gel for the first 4 weeks. Give a second injection at 12 weeks then take blood tests a further 6 weeks after this second injection. If levels are in range continue every 12 weeks. If high or low adjust dosing accordingly by 2 weeks. |
Switching To... Nebido 1g IM every 8-26 weeks | Stop Nebido and start Sustanon/Enanthate the on the day the next Nebido is due. Start at every 4 weeks and recheck levels after third to fourth dose. | Stop Nebido and start gel on the day the next Nebido is due. If was using Nebido every 14-26 weeks use a low dose of Testosterone gel. If was using Nebido every 8-14 weeks use a medium dose of Testosterone gel | |
All monitoring should be undertaken 4-6 months after a change in dose. We recommend that the following blood tests (Testosterone, Estradiol, LFTs, FBC, Lipid profile including Triglycerides) be done six monthly for a year and then annually.
Sustanon/Enantate: Trough level (immediately before injection or if not possible within two days prior to injection), 4-6 months after changing dose. Testosterone levels should be in the lower third of the reference range immediately before the Sustanon or Enantate injections. The lower third of the male reference range is usually around 8-12 nmol/L but does depend on the normal range for the local assay as these vary.
Nebido: Mid-way between injections, 4-6 months after changing dose depending on which preparation the individual has been switched from. Testosterone levels should be in the middle third of the reference range on Nebido (for samples taken mid-way between injections). We more commonly dose on mid point levels but if trough levels are logistically easier, we aim for levels in the lower third of the reference range immediately before Nebido injections. The middle third of the male reference range is usually around 15-22 nmol/L but does depend on the normal range for the local assay as these vary. The lower third of the male reference range is usually around 8-12 nmol/L but does depend on the normal range for the local assay as these vary.
Gel: Ideally bloods are taken 4 to 6 hours after application of gel if applied in morning first thing in the morning if gel applied in evening (ideally under 10 hours from application of gel). Testosterone should be in the middle third reference range on gel which is usually around 15-22 nmol/L but does depend on the normal range for the local assay as these vary.
Up-titration: If outside target range, increase/decrease as appropriate:
· injection frequency by 1 week for Sustanon/Enanthate
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| Usually aim for less than 400 pmol/L with suppression of menstruation, however if no periods there is no evidence that higher levels are a concern. |
| Blood pressure may increase. The clinician can diagnose and treat hypertension as appropriate. |
| Can cause polycythaemia (a high concentration of red blood cells in the blood). Testosterone should be withheld if haematocrit (PCV) > 54% (0.54) and/or haemoglobin > 18 g/L and ongoing treatment immediately discussed with specialist. |
| Refer back to specialist if ALT three times greater than upper limit of normal reference range. Lipids Full lipid screen including fasting triglycerides. Treat raised triglycerides as per local guidance. |
| If diabetes or pre-diabetes. |
| Can rarely cause hypercalcaemia – refer to specialist if greater than upper limit of reference range. |
| Attendance for routine cervical screening tests should remain the same as per the NHS Cervical Screening Programme recommendations, however the invitation process and informing of results are outside the NHS Cervical Screening Programme process and should now be organised within your GP practice. If you have not already done so, and your patient is registered as male, with a new NHS number, you should liaise directly with the screening lead for cervical screening who will advise on further action. There are challenges regarding recalls for cervical screening and we know that there is poor uptake of cervical screening in this group. Consideration should be made of what may make the individual more comfortable and less concerned about this procedure including the use of vaginal Estradiol. There is further information on our website for health care professionals regarding cervical screening. |
| Anyone who has not had bilateral mastectomies from the ages of 50 to 70. If the individual is registered as male with their GP they will NOT be automatically invited. If they have not had surgery to remove the breasts (bilateral mastectomy) and male chest reconstruction and would like to take part in screening, then they can organise their mammogram by visiting their GP or booking an appointment at a screening service. If they notice any changes that are not normal for them, they should talk to their GP. |
If there is ongoing vaginal bleeding, please see the separate information leaflet on ‘How to approach vaginal
bleeding in transmen on testosterone treatment’
