I am often asked by patients which form of testosterone is best. “Should I use a cream, gel, pellets or injection?” The answer is that it depends. Each has its own advantages and disadvantages. Let me go through them with so you are better equipped to make that decision with your doctor.
Topical Cream: Advantage is you can use very high doses vs gels. In a standard lipoderm cream we can use up to 200mg/gram. Compare that to androgel which only has 10mg/gram or 20mg/gram. Creams will also provide very stable levels daily. Creams tend to have a more positive effect on cholesterol profile (specifically increasing HDL) than do the injections. So for patients who have increased risk for cardiovascular disease it makes more sense to use a cream.
The downside to creams is that we see variable absorption. Some patients get excellent levels but others do not. It is difficult to predict who will absorb them better so it can be frustrating for a patient who is applying the cream daily and not feeling the effects. In those patients we simply switch to IM injection. The other downside with the creams is that they are dosed twice daily making compliance difficult. Patients using injectable testosterone can inject once or twice weekly which is easier. Also, testosterone cream can be transferred to your spouse. So the evening dose becomes tricky if the man thinks he will have sex with his wife. You have to sit and wait and see if it is going to happen and then apply if it doesn’t or wait until you are done. I have had patients fall asleep waiting and miss their dose. So patients have to be careful about washing their hands and making sure they do not have sex with their wife within 4 hours of applying the cream.
Injectable: Testosterone can be injected once per week, twice per week or daily. Most commonly patients inject 1ml of 200mg/ml every week. The advantage is that patients will get great levels and there really is no problem with absorption like you have with the creams. You avoid having to think about it daily and there is no chance of transferring it to your spouse.
The down side to injections is that it can be uncomfortable (sore) for a few days. Injections also provide very high levels initially and then they slowly decline throughout the week. The downside to this is that men who are fat will over-convert testosterone to estradiol which can cause some nipple tenderness and breast swelling. I see this in about 3% of patients. What patients can do if this happens is break the injections up into twice weekly IM or even daily sub-Q (the best) Secondly, injectable testosterone does not seem to have a positive effect on lipids like the creams do. It can also increase hsCRP slightly which the creams tend to lower. CRP is a marker for inflammation in the body. However you have to balance this out with the increase in exercise that men with optimal testosterone levels will perform daily.
Currently I use a 200mg/gram lipoderm cream and I rub 1 gram on my upper inner thigh only in the morning. This seems to give me adequate levels and improve my symptoms.