Ask Dr. H: Testosterone gel preferred to pill

Tubes of Testim testosterone gel are seen at the Auxilium Pharmaceuticals Inc. packing facility in Norristown, Pa., Friday May 16, 2003. The gel is aimed at alleviating low energy levels and loss of sex drive, strength and bone density that can affect men with declining testosterone levels, while avoiding some problems that testosterone injections or patches can involve. (AP Photo/Jacqueline Larma)

Question: I have low testosterone treated with Androgel applied once a day to my shoulder and upper chest area. It does seem to help, but I find the gel pretty messy. I know this is the most popular way low testosterone is treated, but why couldn't I just take testosterone pills instead?

Answer: If it were only that easy! The problem is that testosterone in pill form just doesn't work well to correct a low testosterone level. When swallowed, it's absorbed in the digestive tract and sent to the liver, where not only is it heavily broken down, but it also exerts a direct toxic effect on the tissues of the liver before it has a chance to exert its desired effect on the rest of the body. Also, because of the rapid metabolism of testosterone pills, they would need to be taken several times a day.

While testosterone pills are used in other countries, the FDA doesn't consider them to be a particularly safe or effective treatment of low testosterone in adult males - especially when compared with testosterone gels (Androgel, Testim), testosterone patches (Androderm), or even twice-daily testosterone (Striant) placed in the mouth between the cheek and gum. A testosterone injection administered every few weeks is another option, although periodic bursts of testosterone are far less helpful than daily treatments of smaller amounts. When first-line options fail, there's now Testopel, a long-lasting implantable testosterone option of multiple rice-sized pellets approved by the FDA.

Q: I use Cialis for treatment of ED (erectile dysfunction). It works fair, but I wish sometimes it would work better than it does. I have been seeing a lot of advertising that recommends testing for low testosterone. Do you think taking testosterone would help me?

A: Probably not. Although the erectile dysfunction and low testosterone often occur at the same time, they really are two separate conditions. Many folks who have difficulty having an erection still have a healthy desire for sex. Folks who have a low testosterone typically have a markedly decreased desire for sex, as well as decreased strength, stamina, and normal male aggressiveness. Men with low testosterone don't necessarily have erectile dysfunction, but they often do.

A study in the Nov. 20 issue of the Annals of Internal Medicine found that testosterone supplementation given to men ages 40 to 70, with low testosterone and already using Viagra for erectile dysfunction, did not improve that condition better than a placebo. It did not improve any aspect of sexual function, frequency of sexual encounters, vitality, ED-related quality of life, or marital intimacy.

I'd suggest discussing additional treatment options with a urologist, as well as evaluating whether or not any of your medications could be to blame.

Mitchell Hecht specializes in internal medicine. Send questions to him at: "Ask Dr. H," Box 767787, Atlanta, Ga. 30076. Due to the large volume of mail received, personal replies are not possible.