dromlakhani Guide shared decision-making for testosterone therapy selection
STEP 1 — Gather Information
Collect patient's medical history (thrombotic risk, liver disease, prostate status, allergies), lifestyle (dosing frequency preference, ability for clinic visits), insurance/formulary coverage, and prior experience with testosterone formulations.
Action: Summarize factors influencing formulation choice.
STEP 2 — Rule In / Rule Out
Rule out formulations with absolute contraindications (e.g., transdermal if severe skin allergy, oral if active liver disease, injectable if bleeding disorder or severe thrombophilia, pellets if unwilling for minor procedure).
Action: Eliminate unsuitable routes.
STEP 3 — Classify or Stratify
Stratify remaining options by safety, efficacy, tolerability, availability, preference, and cost; prioritize those aligning with patient values and clinical safety (e.g., steady-state agents for adherence concerns, cost-effective generics if covered).
Action: Create a shortlist of suitable formulations.
STEP 4 — Decide
Select the preferred formulation in shared decision-making, discuss expected benefits, risks, monitoring plan, and obtain consent.
Action: Prescribe chosen testosterone therapy and arrange follow-up.
Clinical Guardrails / Mimics / Pitfalls
Do not ignore patient preference or cost; avoid assuming one-size-fits-all; do not overlook adherence barriers (e.g., frequent dosing, clinic visits); never initiate without discussing monitoring for hematocrit, PSA, and symptoms; avoid transdermal in partners pregnant or trying to conceive due to transfer risk.
Concrete Clinical Example
A 52-year-old man with newly diagnosed hypogonadism (total testosterone 9 nmol/L, low libido, fatigue) prefers once-weekly dosing, has no skin allergies, insurance covers generic testosterone cypionate injection, and is comfortable with IM injections. After discussion, he chooses testosterone cypionate 100 mg weekly IM.
Source: Male hypogonadism: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024), International Society for Sexual Medicine, 2025, DOI: 10.1093/sxmrev/qeaf036