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Sublingual Testosterone — Why We Almost Always Prescribe Testosterone as Injections or Topicals

People with testosterone deficiency typically have several treatment options when it comes to improving their testosterone profile, but sublingual testosterone is not one that we recommend.

Sublingual testosterone may come in pills like these — white capsules on a wooden surface

You might find it difficult to determine which option may be best suited to meet your needs, but, based on our experience, we almost always recommend injectable testosterone.

The medical professionals at Testosterone Centers of Texas collectively have well over 100,000 patient encounters specific to Testosterone Replacement Therapy (TRT), which is not something we say to brag, but rather to convey that we’ve “seen it all,” so to speak, in terms of the advantages and disadvantages of the various treatment options out there, and we still recommend injectible testosterone.

So let’s delve into the problems with sublingual testosterone (and other non-injectable forms of testosterone) so that we may ultimately help you determine a treatment option best suited to meet your specific needs.

Sublingual Testosterone — Too Many Problems Compared to Injectable Testosterone

Sublingual testosterone (under the tongue) or transbuccal testosterone (a pinch between the cheek and gum) is something we never prescribe to our patients.

The reasons are simple: injections and topical preparations have been proven to be safe and effective, and sublingual testosterone, while an interesting idea, just doesn’t have the science behind it that these older forms of testosterone have.

Sublingual testosterone is also only available from compounding pharmacies, which, given the low level of regulation of compounding pharmacies in the U.S., means that it is very hard to guarantee the quality of the drug that you receive.

Another problem with sublingual testosterone is that there’s almost no way to keep it from being absorbed orally — if you’re putting testosterone in your mouth, hoping it will be absorbed under the tongue, it’s essentially assured that you’re going to swallow some of it as it becomes mixed with saliva.

We know that, with sublingual testosterone, testosterone levels will typically spike rather quickly. A worrisome consequence to this is that these quick spikes are typically accompanied by rapid conversion of testosterone into estradiol, which as you probably know, is a type of estrogen; for men to benefit the most from any form of testosterone replacement, we want to get a wide ratio between levels of testosterone and estradiol.

And, to borrow an old adage, what goes up must come down.

With oral forms of testosterone, including sublingual testosterone, not only do we see a rapid spike in testosterone levels, but we also see them plummet relatively quickly. Also, we know that oral forms of testosterone can have harmful effects on the liver.

Therefore this form of TRT is definitely not recommended for people with a history of liver problems and, as we’ll get into a little later, oral forms of testosterone can even cause problems in people who start with a healthy liver.

Intramuscular Injections of Testosterone Allow Precise Dosing, Avoid Serious Complications of Topicals

When given the choice between testosterone injections and topical preparations, we prefer intramuscular (IM) injections.

The reasoning for this is also pretty simple — first, we don’t advise a “shotgun blast” approach to optimizing your testosterone levels; we prefer precision.

With an injection, it’s relatively easy to increase or decrease your maintenance dose by 10 mg or 20 mg. This allows us to put and keep your testosterone level in the “sweet spot,” so to speak.

With topicals, it’s extremely difficult to modify a maintenance dose by a ¼ or ⅓ of a pump actuation.

Then, there is the unpredictable nature of transdermal absorption (that is, absorption through the skin) and the risk of skin irritation (dermatitis). The medical literature is filled with incidents of accidental transference of topical medications to a spouse or child, and we’ve even seen it ourselves.

For instance, I know an individual (who was being treated by another medical provider) who was on a topical and who reported a small growth of pubic hair in his daughter.

His daughter was less than 2 years old.

This unnatural change in his very young daughter was the result of testosterone absorption — when he was holding his daughter, she was absorbing the testosterone medication that was still on his skin.

In more severe cases, there have been reports of changes to the genitalia of little ones.

These risks are real, and they’re not even just risks for men! We often recommend against topical testosterone preparations for women as well.

But there’s an even simpler reason why men, whether they have children or not, might want to avoid topical preparations of testosterone — topical preparations have a high risk of failure.

As far as topical preparations are concerned, some studies have suggested a failure rate of approximately 50% in men using topical forms of testosterone; that is, these men simply aren’t happy with the results of their treatment because the medication is not working in the way that it should.

Another concern that often flies under the radar is something that medical professionals and patients alike should consider — expense. Brand name topicals tend to be very costly.

But topicals aren’t the only form of testosterone on the market — many patients who consider sublingual testosterone also ask us about pellet therapy.

Testosterone pellets are hardened pellets that are implanted under the skin and are meant to stay in your body for 4–6 months. Not only are they often uncovered by insurance, but they also come with a host of problems of their own, which is why we recommend against them.

Testosterone Replacement Pellets Do Not Work as Advertised

The main problem with testosterone replacement pellets is that these pellets don’t work the way they’re supposed to.

They’re supposed to be the answer to patient compliance issues, but, because they have such high failure rates, along with risks of infection and pellet extrusion (they come out of your body), we avoid them.

These testosterone replacement pellets were originally conceived to help with patient compliance — compliance basically means taking the medication the way you’re supposed to take it.

The idea was simple — create a time-release testosterone product and implant it in the body. Unfortunately, this hasn’t worked well in practice, and we find that the “time-release” mechanism does not perform as expected.

Instead, what you see with pellets is that patients often find themselves on a roller coaster from a symptomatic standpoint; that is, there are high-highs and low-lows.

So, what does that mean? It means your testosterone goes far above what it should be and far below what it should be during the course of a single pellet treatment.

Your testosterone levels will typically peak well above what’s considered to be a physiologic level of testosterone; that is, a level of testosterone that the human body might normally produce.

When testosterone levels are too high, we begin to worry more about side effects, like blood thickening, high estradiol levels, fluid retention, mood swings, and the like. Again, our preferred approach is not to simply normalize your testosterone levels 24 hours a day, 7 days a week, but rather, through precise and individualized dosing mechanisms, to optimize your levels to where they were when you were a younger adult.

Because it’s so important to keep your hormone levels as stable as possible and to avoid as little fluctuation as possible, we recommend against testosterone replacement pellets.

A final problem with pellets is that some insurance carriers will not cover them unless an individual has “failed” two other forms of treatment (and note that this only applies to the FDA-approved form of testosterone pellets, Testopel — BioTE pellets are not FDA approved and will not be covered by insurance).

The catch there is that, if indeed one is symptomatic from testosterone deficiency, it’s not likely that one is going to “fail” injection therapy. That’s not to say an injection of testosterone will cure all that ails you, but it should provide improvement of symptoms directly related to a low testosterone level.

Which brings us back to sublingual testosterone, which may seem like an excellent alternative to pellets — however, those compliance issues I mentioned above apply even more to sublingual testosterone than they do to other forms of therapy.

Sublingual Testosterone — Side Effects Are Not as Concerning as Compliance Issues

Although taking testosterone sublingually can theoretically bypass the issues that you see with oral testosterone because it’s being absorbed directly into your bloodstream, thereby bypassing the digestive system, first, we know this isn’t the case — you’re likely to swallow some of the medication, and there’s really no avoiding this, which sets you up for possible liver damage.

But even beyond that, sublingual testosterone has one other major issue: it generally has to be taken multiple times a day.

It can be hard enough to get someone into our offices once a week to do an injection.

Even our patients who are given topical testosterone, which has to be administered daily, can find it troublesome to use because of the specific requirements of the medication, like keeping your skin dry beforehand, not being able to touch other people for a period of time after applying the medicine, or having to wait for the medicine to dry before engaging in certain activities.

In fact, they often forget to take their medication — and, with a daily medication, the time of day that the medication is taken is important.

These compliance issues are compounded in medications that are taken multiple times a day (sublingual testosterone may need to be taken up to three times a day, in some cases).

So compliance is a concern, but the main concerns are that these medications are produced by compounding pharmacies, which means the quality cannot be guaranteed, and the medication is likely to be swallowed, leading to potential liver problems.

So we see that there’s no clear reason to use it, especially when we know that injectible testosterone is safe and effective when managed properly.

What’s Most Important Is Finding a Solution That Works for You

Every patient is different, which means that every treatment plan needs to be different. What matters most is that we find a medication and a treatment schedule that works best for you and that treats your symptoms in the safest, most effective manner possible.

Contact us today and get a free consultation — we’ll talk about your symptoms, determine if indeed you are deficient of testosterone, and, if so, find a treatment plan that works best for you.

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(Bill) William J. White, PA-C

(Bill) William J. White, PA-C brings over 20 years of surgical experience to our practice. He is a decorated veteran of the United States Army where he served for nearly 6 years with duty assignments, both here and abroad.   During his military career, Bill was trained as a Certified Surgical Technologist, and following an Honorable Discharge from the Army, he attended Texas Tech University.   He graduated with a Bachelor of Science in Biology and went on to attend PA School at the University of Texas Southwestern Medical Center at Dallas. He spent the first 10 years of his career in Neurosurgery.

2 Comments

  1. Ariel on 06/27/2017 at 10:47 am

    I don’t see how topical is expensive. I use compounded testosterone cream and I pay $85 that lasts me 3 months plus my levels are closer to 800.
    In fact your clinic quoted me $65 for shots a week and that’s with insurance.

    Also the topical is dangerous when it’s wet but can you still transmit it when it’s dry?

    • William J. White, PA-C on 06/27/2017 at 11:33 am

      Hello Ariel and thank you for posting. I’m happy to hear that you have found an approach to TRT that works well for you both financially and biochemically.

      Some clinicians are hesitant to prescribe compounded forms of testosterone for a variety of reasons, primarily because compounded products are not regulated by the FDA. A prime example of this is noted in a recent lawsuit filed in California which is specific to a topical form of compounded testosterone:

      http://www.lexology.com/library/detail.aspx?g=58fc5f02-089d-401b-a24b-563938744648

      With regard to an individual’s cost of treatment within one of our facilities, it is based on your copayment which is a determination that is made specifically to your insurance plan and by your insurance company; i.e. it’s the amount your insurance tells us you pay for an office visit. As you might imagine, this varies widely from plan to plan.

      Topicals will typically not transfer from skin to skin contact once dried. However the application of any moisture to the skin from vectors such as sweating or high humidity can potentially cause problems.

      If you have found a modality that works well for you and you have been counseled to your satisfaction with regard to the potential risks, benefits and side effects, it’s doubtful that most clinicians would try and steer you in a different direction barring any medical concern.

      Thank you again for your post.

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