be started with long-acting agents such as testosterone enanthate or cypionate in doses of 50 mg intramuscularly, initially every 4, then every 3, and finally every 2 weeks, with each change taking place at 3-month intervals. The dose is then doubled to 100 mg every 2 weeks until maturation is complete. Finally, it is changed to the adult replacement dose of 200 mg at 2-week intervals.
Testosterone propionate, though potent, has a short duration of action and is not practical for long-term use. Testosterone undecanoate can be given orally, administering large amounts of the steroid twice daily (eg, 40 mg/d); however, this is not recommended because oral testosterone administration has been associated with liver tumors. Testosterone can also be administered transdermally; skin patches or gels are available for scrotal or other skin area application. Two applications daily are usually required for replacement therapy. Implanted pellets and other longer-acting preparations are under study. The development of polycythemia or hypertension may require some reduction in dose.
B. Gynecologic Disorders
Androgens are used occasionally in the treatment of certain gynecologic disorders, but the undesirable effects in women are such that they must be used with great caution. Androgens have been used to reduce breast engorgement during the postpartum period, usually in conjunction with estrogens. The weak androgen danazol is used in the treatment of endometriosis (see above).
Androgens are sometimes given in combination with estrogens for replacement therapy in the postmenopausal period in an attempt to eliminate the endometrial bleeding that may occur when only estrogens are used and to enhance libido. They have been used for chemotherapy of breast tumors in premenopausal women.
C. Use as Protein Anabolic Agents
Androgens and anabolic steroids have been used in conjunction with dietary measures and exercises in an attempt to reverse protein loss after trauma, surgery, or prolonged immobilization and in patients with debilitating diseases. Evidence to support this use of androgens is poor except when hypogonadism is also present.
D. Anemia
In the past, large doses of androgens were employed in the treatment of refractory anemias such as aplastic anemia, Fanconi’s anemia, sickle cell anemia, myelofibrosis, and hemolytic anemias. Recombinant erythropoietin has largely replaced androgens for this purpose.
E. Osteoporosis
Androgens and anabolic agents have been used in the treatment of osteoporosis, either alone or in conjunction with estrogens. With the exception of substitution therapy in hypogonadism, bisphosphonates have largely replaced androgen use for this purpose.
F. Use as Growth Stimulators
These agents have been used to stimulate growth in boys with delayed puberty. If the drugs are used carefully, these children will probably achieve their expected adult height. If treatment is too vigorous, the patient may grow rapidly at first but will not achieve full predicted final stature because epiphyseal closure is accelerated. It is difficult to control this type of therapy adequately even with frequent x-ray examination of the epiphyses, since the action of the hormones on epiphyseal centers may continue for many months after therapy is discontinued.
G. Anabolic Steroid and Androgen Abuse in Sports
The use of anabolic steroids by athletes has received worldwide attention. Many athletes and their coaches believe that anabolic steroids—in doses 10–200 times larger than the daily normal physiologic production—increase strength and aggressiveness, thereby improving competitive performance. Such effects have been unequivocally demonstrated only in women. Furthermore, the adverse effects of these drugs clearly make their use inadvisable. As a result, most sports organizations have developed extremely sensitive assays, conduct random testing, and apply strong penalties if drugs are detected.
H. Aging