Androgen Replacement Therapy

Testosterone therapy results in a more "male" phenotype, with increases in facial and pubic hair, muscle size and strength, libido, and bone mineral density, and improved mood (21,47,52,53). We recommend testosterone therapy beginning at the time of puberty to allow boys with KS to experience pubertal changes in tandem with their peers. In addition, this approach may allow for optimal enhancement of bone mineral density. Even if testosterone therapy is delayed until adulthood, it is still associated with beneficial improvements in mood, behavior, and sense of well-being (53). Testosterone therapy has no beneficial effect on infertility or gynecomastia, which is best treated with surgical resection if bothersome.

Testosterone therapy is safely and easily accomplished either by periodic intramuscular injection of testosterone esters or with newer (and more expensive) transdermal patches and gels described in detail elsewhere in this volume (see Chapter 18). Replacement doses for the intramuscular esters of testosterone are 100-200 mg intramuscularly every other week in adults, whereas adolescents are started at lower doses (e.g., 50-100 mg every 2-4 wk) and are gradually increased to adult doses over 2-3 mo (13). Testosterone therapy side effects include weight gain, mostly owing to increases in lean body mass, and acne. In older men, erythrocytosis is seen with some frequency. Induction or a worsening of sleep apnea has also been reported (52). In general, testosterone therapy is both beneficial and well-tolerated by individuals with KS, most of whom continue therapy long-term (54). Twenty-year follow-ups of cohorts of men with KS treated with testosterone have demonstrated marked improvements in mental health, working capacity, social adjustment, and interpersonal relationships that are similar to improvements seen in hypogonadal control cohorts (55). As a result, most health care providers believe that early diagnosis and treatment with testosterone is of great benefit to the long-term health and welfare of individuals with KS.

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