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July 14, 2014

Which Testosterone Gel is Right for Me?

testosterone gel
Testosterone Replacement Therapy (TRT) using testosterone gel. Hypogonadism concept.

Which Testosterone Gel is Right for You?

With so many testosterone gels on the market, which testosterone gel is right for you? And, is there any real difference among these commercial products?

The short answer is I don’t think any of these products are better than the others. Each may have an edge in very specific situations, but in the end they all work about the same and have the same side effect profiles related to the properties of testosterone and transdermal application, not the product itself.

Testosterone Gel Cost

I’m partial to prescribing testosterone injections as it is always possible to raise testosterone levels into the optimal range. Getting optimal levels with transdermal gels isn’t always possible. But, some men are fearful of injecting themselves (not as tough as women).

So I end up prescribing a lot of testosterone gels because of men not wanting injections, plus financial reasons. At least one commercially available testosterone gel is usually covered by a patient’s insurance. And, at the end of the day, which product I prescribe depends on insurance coverage. Where I practice insurance tends to cover AndroGel and Testim to a greater degree than the other testosterone products.

Names of Testosterone Gels

Below are the names of testosterone gels in alphabetical order:

  • AndroGel
  • Axiron
  • Fortesta
  • Testim

How Testosterone Gels Work

Healthy male adults make 5 to 10 mg of testosterone a day. In general, about 10% of a testosterone gel is absorbed by the skin. So it becomes necessary to apply 50 mg to 100 mg of a testosterone gel a day in order to deliver 5 to 10 mg to the bloodstream. Commercial testosterone gels are fairly dilute containing 1% to 2% testosterone. So one downside of commercial testosterone gels is that it becomes necessary to apply a large amount of testosterone gel to the skin. And, that creates some problems.

There is a risk of transferring the testosterone gel to another person through physical contact, but also by the handling of clothes that may have some residual gel on them. The more skin surface that a testosterone gel is applied to the higher is this risk of transference.

Some of the testosterone we naturally make gets converted to DHT or dihydrotestosterone. DHT is great for libido, but if too high, can contribute to male pattern baldness, and plays a role in prostate enlargement (not prostate cancer) which can cause urinary flow problems for men. The enzyme that converts testosterone to DHT exists in high concentrations in the skin, especially skin covered by hair. So the more skin that one applies testosterone to the more likely DHT levels are to rise – sometimes too high.

Testosterone gels are designed to raise testosterone levels reaching a peak typically 2 to 4 hours after application and then slowly dwindling over the day. In that sense, testosterone gels mimic the body’s natural circadian rhythm. Normally testosterone levels are highest in the morning and slowly decline over the day, though strenuous exercise (heavy weight lifting or high intensity interval training) can cause stimulation of testosterone production, as does sex and even sexual thoughts.

Testosterone gels are safe and effective. Three-quarters of men will obtain a testosterone level within the reference range (300 ng/dl to 1,050 ng/dl) using testosterone gels.

Differences Between Testosterone Gels

testosterone gelFirst, all testosterone gels mentioned here are in an alcohol base, and therefore potentially flammable. It’s important to avoid smoking, flames, and fires until the gel dries on the skin. It is recommended that men avoid swimming or showering the first two hours after applying a testosterone gel as some gel will be washed away. The risk of transferring testosterone to another person (or even animal) is greatest the first two hours after applying. Wearing clothing over the application site is recommended once the gel is dry. It’s also recommended that application sites be washed with soap and water prior to physical contact with another person.

Of the four testosterone gels mentioned here, Axiron is unique in that it is applied to the armpits potentially reducing the chance of transferring testosterone to another person. Though it has been shown that even through T-shirts a small amount of testosterone can be transferred to women at two hours from application of Axiron.

The other testosterone gels are applied to either the shoulders and upper arms or the thighs. Axiron can even be applied over deodorant. In fact, it is recommended that the deodorant be applied first, wait 2 minutes, then apply Axiron to the armpits. But if you read the fine print you will find that applying it over deodorant can reduce testosterone exposure up to 33% which means you might need a higher dose.

The important point with any of the gels is to be consistent in the way you apply it. Apply it the same time every day. Take the necessary time to really work the gel into the skin. Applying a testosterone gel after a shower helps absorption, too. Also, applying sunscreen lotion or moisturizing lotion one hour after applying a testosterone gel increases testosterone levels about 15%.  These lotions are in bases that probably help the absorption of testosterone.

A few words on the other testosterone gels.

AndroGel

AndroGel comes in two concentrations, 1%, and 1.62%. It also comes in single application packets and in a pump dispenser. Either way, the gel is placed on the hands and then rubbed into the shoulders and upper arms. I exclusively write for the 1.62% concentration. Each pump dispenses 20.25 mg of testosterone and up to four pumps is recommended. Each packet of 1.62% AndroGel contains 40.5 mg of testosterone and up to two packets is the recommended dose.

Testim

Testim comes in single-use tubes. Like AndroGel it’s applied to the shoulders and upper arms. Each tube contains 50 mg of Testim and up to two tubes is recommended.

Fortesta

Fortesta comes in a pump dispenser that dispenses 10 mg of testosterone per pump. One to seven pumps is recommended. The smaller amount with each pump allows for fine tuning of the dose. The gel is applied to the thighs.

In the end, these products are very similar. When it comes to transdermal testosterone, though, I prefer to send patients to a compounding pharmacy. A compounding pharmacy can compound a 20% concentration of testosterone in a lipodermal base which is better absorbed by the skin. In addition, a much smaller amount is all that needs to be applied (one-tenth to one-twentieth the amount of the commercials gels), or about the amount of toothpaste you would put on a toothbrush. This reduces the amount of skin testosterone needs to be applied to reducing the risk of transference, reducing the chances of elevated DHT levels, and the lipodermal base allows for better absorption and potentially higher testosterone levels.

Compounded creams tend to more costly, though not that much more (compounding pharmacies are becoming more cost competitive with commercial products), and insurance will sometimes cover part of the cost. But, many patients are cost-sensitive these days and commercial testosterone gels provide a suitable alternative for men with low testosterone.

What Are The Symptoms Of Low Testosterone?

Before you can decide if testosterone gel is right for you, you first have to determine if the problem is low testosterone. Most of the time, the symptoms are hard to detect and go unnoticed. If you’re unsure if you have low T, take a look at the symptoms below:

Low Sex Drive

A decrease in sex drive is one of the primary indicators that there’s a change in your testosterone levels. You might notice a reduction in libido as you age, which directly influences your desire to have sex. 

Reduced Semen Volume

Your testosterone is a huge factor in the production of semen. However, men who have low T usually notice a reduction in the amount of semen they produce during ejaculation.

Weight Gain

Low testosterone level can lead to increased body fat. Furthermore, some men experience enlarge breast tissue, which happens as a result of an imbalance between testosterone and estrogen within the body.

Mood Swings

Changes in mood are often associated with menopause in women. However, emotional highs and lows can happen within men as well. Testosterone not only effects the physical aspect of the body, but the mental and emotional as well. Some men deal with frustration, depression, and a lack of focus due to low T.

Memory Loss

It’s natural for memory to reduce with age, and it’s usually a result of low testosterone. Luckily, studies show that some supplementation can help increase memory.

Smaller Testicles

If you have low T, it can result in smaller testicles. The body needs testosterone to form the penis and testicles, but a lack of it can cause undersized testicles.

What Causes Low Testosterone?

There are two primary causes of Low T, which are called primary and secondary hypogonadism.

Primary Hypogonadism

Generally, underactive testes is the reason for primary hypogonadism. If they’re the testes are performing at normal capacity, it doesn’t produce proper levels of testosterone for optimal growth. The underdevelopment might be an inherited trait or it can be caused by an accident or illness. Here a few of the inherited conditions:

Klinefelter’s Syndrome: An disorder in which a male is born with an X,X, and Y chromosome.

Hemochromatosis: If a guy has too much iron in his blood, it can lead to testicular failure or pituitary damage.

Undescended Testicles: This happens when the testicles don’t descend from the abdomen prior to birth.

Injury Causes Of Primary Hypogonadism

Cancer Treatment: Unfortunately, chemo can damage the testicles.

Mumps Orchitis: Mumps can stunt the development of the testicles and hinder testosterone.

Physical Injury: If there’s trauma to the testicles it can also affect testosterone levels.

Secondary Hypogonadism

Secondary hypogonadism is a result of damage to the pituitary gland or the hypothalamus. Both of these are areas of the brain that control hormone production. Below are the inherited or illness causes:

Pituitary Disorders: This is caused by drugs, small tumors or kidney failure.

Inflammatory Disease: Conditions such as tuberculosis, histiocytosis, and sarcoidosis have a direct impact on the pituitary gland and the hypothalamus.

HIV/AIDS: Diseases like aids can affect the testes, pituitary gland, and the hypothalamus.

Other Causes Of Secondary Hypogonadism

Aging: It’s normal for testosterone levels to drop with age.

Medication: Pain medications and steroids can hinder hypothalamus and pituitary gland functions.

Obesity: A high body fact impacts hormone production and testosterone levels.

Final Thoughts On Testerone Gel

If your testosterone levels drop, it’s nice to know there’s a solution available. If you have problems taking pills or are have a sensitive system, gels are perfect. The important thing is to use them consistently, so they’re effective. After reading this article, do you think testosterone gels are right for you?

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Dr. Joe Jacko


Dr. Joe is board certified in internal medicine and sports medicine with additional training in hormone replacement therapy and regenerative medicine. He has trained or practiced at leading institutions including the Hughston Clinic, Cooper Clinic, Steadman-Hawkins Clinic of the Carolinas, and Cenegenics. He currently practices in Columbus, Ohio. Read more about Dr. Joe Jacko

  1. I am nervous about starting trt
    Gels but my endocrinologist
    Thinks I should, axiron vs. Androgel

    1. AndroGel is probably easier to use. Axiron is used in the armpit and can be a little messy. Often it is an insurance issue. AndroGel, at least in my area, is covered by more insurance companies than Axiron. Both should work equally as well, though. Hope that helps.

  2. How long does FORTESTA stay in one’s system after stopping? Meaning the metabolites. Thanks.

    1. Topical testosterones have a half-life about 7-10 days. It takes 3 half-lives for 97% plus of drug to be eliminated from the body. So figure on about a month, though the biologics effects may last longer.

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