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Class: Androgens
VA Class: HS100
CAS Number: 58-18-4
Brands: Android, Estratest, Methitest, Testred


Special Alerts:

[Posted 10/25/2016]

AUDIENCE: Patient, Endocrinology, Internal Medicine

ISSUE: FDA approved class-wide labeling changes for all prescription testosterone products, adding a new Warning and updating the Abuse and Dependence section to include new safety information from published literature and case reports regarding the risks associated with abuse and dependence of testosterone and other AAS.

The Anabolic Steroids Control Act of 1990 placed AAS, including testosterone, in Schedule III of the Controlled Substances Act. Testosterone and other AAS are abused by adults and adolescents, including athletes and body builders. Abuse of testosterone, usually at doses higher than those typically prescribed and usually in conjunction with other AAS, is associated with serious safety risks affecting the heart, brain, liver, mental health, and endocrine system. Reported serious adverse outcomes include heart attack, heart failure, stroke, depression, hostility, aggression, liver toxicity, and male infertility. Individuals abusing high doses of testosterone have also reported withdrawal symptoms, such as depression, fatigue, irritability, loss of appetite, decreased libido, and insomnia.

The new Warning will alert prescribers to the abuse potential of testosterone and the serious adverse outcomes, especially those related to heart and mental health that have been reported in association with testosterone/AAS abuse. In addition to the new Warning, all testosterone labeling has been revised to include information in the Abuse and Dependence section about adverse outcomes reported in association with abuse and dependence of testosterone/AAS, and information in the Warning and Precautions section advising prescribers of the importance of measuring serum testosterone concentration if abuse is suspected.

BACKGROUND: Prescription testosterone products are FDA-approved as hormone replacement therapy for men who have low testosterone due to certain medical conditions. Examples of these conditions include failure of the testicles to produce testosterone because of genetic problems, or damage to the testicles from chemotherapy or infection.

RECOMMENDATION: Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA's MedWatch Safety Information and Adverse Event Reporting Program:

  • Complete and submit the report Online:, available at: ,

  • Download form, available at: , or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178

For more information visit the FDA website at: and .


A synthetic androgenic anabolic steroid hormone.b

Uses for Methyltestosterone

Pending revision, the material in this section should be considered in light of more recently available information in the MedWatch notification at the beginning of this monograph.

Male Hypogonadism

Management of congenital or acquired primary hypogonadism such as that resulting from orchiectomy or from testicular failure caused by cryptorchidism, bilateral torsion, orchitis, or vanishing testis syndrome.b e

Management of congenital or acquired hypogonadotropic hypogonadism such as that resulting from idiopathic gonadotropin or gonadotropin releasing hormone (luteinizing hormone releasing hormone) deficiency or from pituitary-hypothalamic injury caused by tumors, trauma, or radiation.b e

If any of these conditions occur before puberty, replacement therapy will be necessary during adolescence for the development of secondary sexual characteristics.b Will require prolonged therapy to maintain these characteristics in pubertal males or postpubertal males who develop testosterone deficiency.b e

May be used to stimulate puberty in carefully selected males with delayed puberty (family history of delayed puberty not secondary to a pathologic disorder).b e Brief treatment with conservative doses occasionally may be justified if patients do not respond to psychologic support.b e

Safety and efficacy of methyltestosterone therapy in men with low testosterone concentrations related to aging (i.e., late-onset hypogonadism) not established.104 118 119 Further study needed to elucidate the role of testosterone replacement therapy in treatment of this condition.105

Breast Cancer

Palliative treatment of androgen-responsive, advanced, inoperable, metastatic (skeletal) breast cancer in women who are 1–5 years postmenopausal and in premenopausal women who have benefited from oophorectomy and are considered to have a hormone-responsive tumor.a b

Poorly tolerated (see Virilization under Cautions); other hormonal agents (e.g., tamoxifen, anastrozole, letrozole, exemestane) currently are preferred for this use.k l


Used in combination with estrogens for the short-term management of moderate to severe vasomotor symptoms associated with menopause in patients who do not respond adequately to estrogens alone.b d However, the FDA is reexamining the efficacy of estrogen/androgen combinations for this use.100 101

Misuse and Abuse

Has been misused and abused by athletes, bodybuilders, weight lifters, and others to enhance athletic performance and physique.b

Medical and sports experts (e.g., International Olympic Committee) consider such use to be inappropriate and unacceptable because of known adverse effects and potential for long-term sequelae.b j Such use by athletes is contrary to the rules and ethical principles of athletic competition.b j

Methyltestosterone Dosage and Administration


  • Confirm diagnosis of male hypogonadism by laboratory testing prior to initiation of therapy.104 118 119

  • Measure serum testosterone concentrations in the morning on at least 2 separate days.104 118 119 To confirm diagnosis, measurements must be consistently below the normal range.104 118 119 Serum testosterone concentrations may be low later in the day in men with or without hypogonadism; avoid measuring testosterone concentrations later in the day.104

  • Individualize dosage according to the condition being treated, the severity of symptoms, and the patient’s age, gender, and history of prior androgenic therapy.b e

  • Adjust dosage carefully according to individual response and appearance of adverse effects.a c e

Delayed Puberty

  • Take into consideration the chronological and skeletal ages of the patient, both in determining the initial dosage and in adjusting the dosage.a b c e

  • Perform radiographic examination of the hand and wrist at 6-month intervals to determine the rate of bone maturation and to assess the effect of therapy on the epiphyseal centers.b e (See Pediatric Use under Cautions.)

Breast Cancer

  • Administer only under supervision of a qualified clinician experienced in the treatment of breast cancer.a c e

  • Occasionally may appear to accelerate progression of the disease; monitor patients closely.a c e


Administer orally,e usually in divided daily doses.b


Pending revision, the material in this section should be considered in light of more recently available information in the MedWatch notification at the beginning of this monograph.

Pediatric Patients

Male Hypogonadism

For development of secondary sexual characteristics during adolescence: 10–50 mg daily.a b c e Prolonged therapy is required to maintain sexual characteristics.a b c e

Delayed Puberty

Use dosages in the lower end of the usual range for replacement (i.e., 10 mg daily) for 4–6 months.b e

Some clinicians recommend lower dosages initially, followed by gradual increases in dosage as puberty progresses; subsequently, the dosage may or may not be decreased to maintenance levels.b c e Other clinicians state that higher dosages are required initially to induce pubertal changes and lower dosages can then be used for maintenance therapy after puberty.b c e


Male Hypogonadism

Usual dosage: 10–50 mg daily; prolonged therapy is required to maintain sexual characteristics.a b c e

Breast Cancer

Usual dosage: 50–200 mg daily.a b e


Usual dosage: 0.625–1.25 mg of esterified estrogens and 1.25–2.5 mg of methyltestosterone in fixed combination.d Administer cyclically (3 weeks on and 1 week off); repeat the regimen as necessary.d Should make attempts to reduce dosage or discontinue the drugs at 3- to 6-month intervals.d

Cautions for Methyltestosterone


Pending revision, the material in this section should be considered in light of more recently available information in the MedWatch notification at the beginning of this monograph.

  • Males with breast cancer or known or suspected prostate cancer.a b c d e

  • Known or suspected pregnancy.a b

  • Some manufacturers state that methyltestosterone is contraindicated in patients with cardiac, renal, or hepatic decompensation; hypercalcemia; impaired liver function; and in patients who are easily sexually stimulated.b



Fetal/Neonatal Morbidity

May cause fetal harm; dose-related virilization of the external genitalia (e.g., clitoral hypertrophy, labial fusion of the external genital fold to form a scrotal-like structure, abnormal vaginal development, persistence of a urogenital sinus) of female fetus reported, particularly when exposure to androgens occurs during the 1st trimester.a b If used during pregnancy or patient becomes pregnant, apprise of potential fetal hazard.b

Hepatic Effects

Potentially serious and/or life-threatening adverse hepatic effects (e.g., peliosis hepatitis, hepatic adenomas, hepatocellular carcinoma) associated with prolonged use of high dosages of androgens.a b Discontinuance of androgen therapy following development of hepatocellular carcinoma does not always result in regression of the tumor.a b

If cholestatic jaundice or hepatitis occurs, or if liver function test results become abnormal during therapy, discontinue the drug and investigate the etiology of these disorders.a d Drug-induced jaundice usually is reversible following discontinuance of the drug.a b

Periodic liver function evaluation recommended.a b

GU Effects

Priapism or excessive sexual stimulation possible, especially in geriatric men.a Oligospermia and decreased ejaculatory volume also may occur in men receiving excessive dosage or prolonged administration.a If any of these adverse effects occur, discontinue the drug temporarily.b If therapy is restarted, use lower dosages.b

Possible increased risk for the development of prostatic hyperplasia and prostate cancer, particularly in geriatric patients.a b c e

Possible increased or decreased libido.a b

Gynecomastia frequently develops and occasionally persists in patients being treated for hypogonadism.e

Cardiovascular Effects

Cardiovascular events (e.g., MI, stroke) reported with methyltestosterone therapy.118 119 (See Advice to Patients.)

Long-term safety studies not conducted to date to determine the cardiovascular effects of testosterone replacement therapy in men.118 119 Epidemiologic data and results from randomized, controlled clinical trials inconclusive to date for determining risk of serious adverse cardiovascular events (i.e., nonfatal MI, nonfatal stroke, death) with testosterone use compared with nonuse.118 119

Based on review of data, FDA concluded that testosterone therapy is associated with possible increased risk of serious adverse cardiovascular events.104 106 107 108 109 110 111 112 Inform patients of this potential increased cardiovascular risk when deciding whether to use or continue to use therapy.118 119

Unclear whether potential cardiovascular risk is confined to a certain subset of patients; some experts suggest that clinicians use testosterone therapy with caution in patients at high risk for cardiovascular disease (e.g., older men, those with diabetes mellitus or obesity).105 Additional evidence needed to further elucidate the cardiovascular risk associated with testosterone use.104 105

Venous thromboembolism (i.e., PE, DVT) reported during postmarketing experience with testosterone preparations, including methyltestosterone.117 118 119 Evaluate patients reporting symptoms of pain, edema, warmth, erythema in a lower extremity for DVT, or presenting with acute shortness of breath for PE.118 119 If venous thromboembolism suspected, discontinue drug and institute appropriate evaluation and management.118 119

Fluid Retention

Edema, with or without CHF, possible as a result of sodium and water retention and may be a serious complication in patients with preexisting cardiac, renal, or hepatic disease.b d (See Contraindications under Cautions.) If edema occurs and is considered a serious complication, discontinue the drug and, if necessary, initiate diuretic therapy.a b c e

Retention of potassium and inorganic phosphates also has occurred.c d e


Possible hypercalcemia resulting from osteolysis, especially in immobile patients and women with metastatic breast cancer.a b d In patients with cancer, hypercalcemia may indicate progression of metastases to the bone.a d f Monitor urine and serum calcium concentrations frequently during the course of androgen therapy in women with metastatic breast cancer.a b c e If hypercalcemia occurs, discontinue the drug.a d f

Misuse and Abuse

Potential for serious adverse effects (e.g., increased aggression, antisocial behavior, manic episode, depression, changes in libido, increased risk of cardiovascular disease, hepatotoxicity) associated with misuse and abuse of androgens (see Misuse and Abuse under Uses); methyltestosterone preparations currently subject to control under the Federal Controlled Substances Act of 1970, as amended by the Anabolic Steroids Control Act of 1990 and 2004 as schedule III (C-III) drugs.b j

General Precautions


Virilization, including deepening of the voice, hirsutism, menstrual irregularities, and clitoral enlargement, occurs commonly in females receiving high-dose methyltestosterone therapy; these changes may not be reversible following discontinuance of the drug.a b e

Monitor women receiving methyltestosterone therapy for signs of virilization.a If virilization occurs, discontinue therapy.b e

Hematologic Effects

Possible polycythemia, especially with high dosages of androgens.a b Perform periodic hemoglobin and hematocrit determinations in patients receiving high dosages of methyltestosterone.a b

Use of Fixed Combination

When used in fixed combination with estrogens, consider the cautions, precautions, and contraindications associated with estrogens.b

Specific Populations


Category X.c (See Fetal/Neonatal Morbidity and also Contraindications, under Cautions.)


Not known whether methyltestosterone is distributed into milk.a b Use not recommended.a b

Pediatric Use

May accelerate bone maturation without producing compensatory gain in linear growth, possibly resulting in compromised adult stature.a b The younger the child, the greater the risk of methyltestosterone compromising final mature stature.e Use with extreme caution in children and only under the supervision of a specialist who is aware of the adverse effects of methyltestosterone on bone maturation.a b Perform radiographic examination of the hand and wrist every 6 months to determine the rate of bone maturation and to assess the effect of treatment on the epiphyseal centers.b e

Geriatric Use

Possible increased risk of developing prostatic hypertrophy and carcinoma during androgen therapy.a b

Males, especially geriatric patients, may become overly sexually stimulated during therapy and such stimulation may be a sign of excessive dosage.a Carefully monitor males for the development of excessive sexual stimulation.a b

Common Adverse Effects

Males: Gynecomastia, frequent or persistent penile erections.a b

Females: Amenorrhea, other menstrual irregularities, inhibition of gonadotropin secretion, virilization (e.g., deepening of the voice, clitoral enlargement).e

Interactions for Methyltestosterone

Specific Drugs and Laboratory Tests

Drug or Test



Anticoagulants, oral

May potentiate the action of oral anticoagulants and decrease anticoagulant requirementsa c e

Monitor closely when androgen therapy is initiated or discontinued in patients receiving oral anticoagulants and adjust anticoagulant dosage as neededa c e


May decrease blood glucose concentrations in patients with diabetesa c e

May require dosage reduction of insulin


Possible increased serum concentrations of oxyphenbutazonea c e

Tests for thyroid function

Possible decreased thyroxine-binding globulin concentrations, resulting in decreased total serum thyroxine (T4) concentrations and increased resin uptake of triiodothyronine (T3) and T4a b c e

Free thyroid hormone concentrations remain unchangedb e

May decrease protein-bound iodine (PBI) concentrationsb

No clinical evidence of thyroid dysfunctiona b c e

Decrease in PBI concentrations does not appear to be clinically importantb

Methyltestosterone Pharmacokinetics



Rapidly absorbed following oral administration, with peak serum concentrations usually attained within a mean of 1.04 hours.i



Metabolized in the liver to various hydroxysteroids.h Methylation at the 17 position is associated with less hepatic metabolism following oral administration compared with testosterone.b h


Averages 2.29 hours.i





Tight, light-resistant containers at 15–30°C; protect from moisture and heat.a

Store methyltestosterone in fixed combination with esterified estrogens at 15–30°C.d


25°C (may be exposed to 15–30°C).c e


  • Replaces diminished or absent endogenous testicular hormone in hypogonadal males.a b c e

  • Endogenous androgens are essential hormones that are responsible for the normal growth and development of the male sex organs and for maintenance of secondary sex characteristics.b c

  • Responsible for the growth spurt that occurs during adolescence and for the eventual termination of linear growth that results from fusion of the epiphyseal growth centers.b e

  • Methylation at the 17 position (methyltestosterone) enhances pharmacologic activity compared to testosterone.b e

  • Produces retention of nitrogen, potassium, sodium, and phosphorus; increases protein anabolism; and decreases amino acid catabolism and urinary calcium concentrations.b e

  • Stimulates the production of erythrocytes, apparently by enhancing the production of erythropoietic stimulating factor.b e

  • Inhibits the release of endogenous testosterone via feedback inhibition of pituitary luteinizing hormone.b e

  • Large doses of androgens may suppress spermatogenesis.b e

Advice to Patients

Pending revision, the material in this section should be considered in light of more recently available information in the MedWatch notification at the beginning of this monograph.

  • Risk of MI or stroke.104 Contact clinician if symptoms suggestive of MI or stroke (e.g., chest pain, shortness of breath, unilateral weakness, difficulty talking) occur.104

  • Risk of virilization in females.a b Advise female patients to contact their clinician if they notice hoarseness, acne, menstrual changes, or the growth of facial hair.a b

  • Risk of priapism; importance of males informing clinicians if too frequent or persistent penile erections occur.a b

  • Importance of discussing the potential for adverse effects on bone maturation in prepubertal males prior to initiation of therapy.a b

  • Importance of informing clinicians if nausea, vomiting, changes in skin color, or ankle swelling occurs.a b

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs as well as any concomitant illnesses.e

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.c

  • Importance of informing patients of other important precautionary information.e (See Cautions.)


Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Most methyltestosterone-containing preparations are subject to control under the Federal Controlled Substances Act of 1970, as amended by the Anabolic Steroids Control Act of 1990 and 2004, as schedule III (C-III) drugs.102 However, manufacturers of certain preparations containing androgenic anabolic steroids (principally combinations that also include estrogens) have applied for and obtained for their product(s) an exemption from the record-keeping and other regulatory requirements of the Federal Controlled Substances Act.102 103 Because regulatory requirements for a given preparation containing an androgenic anabolic steroid may be subject to change under the provisions of the Act, the manufacturer should be contacted when specific clarification about a preparation’s status is required.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name



Dosage Forms


Brand Names




10 mg

Android (C-III)


Testred (C-III)



10 mg*

Methitest (C-III; scored)


methylTESTOSTERone Combinations


Dosage Forms


Brand Names




1.25 mg with Esterified Estrogens 0.625 mg

Covaryx H.S. (with parabens and povidone)


2.5 mg with Esterified Estrogens 1.25 mg

Covaryx (with parabens and povidone)


AHFS DI Essentials. © Copyright 2017, Selected Revisions October 25, 2016. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.


Only references cited for selected revisions after 1984 are available electronically.

100. Food and Drug Administration. Certain estrogen-androgen combinations drugs; drugs for human use; drug efficacy study implementation; amendment and opportunity for hearing. [Docket nos. 78N-0377 and 98P-1041; DESI 7661] Fed Regist. 2003; 68:17953-7.

101. Food and Drug Administration. FDA revises finding on estrogen/androgen combination products in the treatment of hot flashes. FDA Talk Paper. Rockville, MD; 2003 Apr 10. Correction. 2003 Apr 11. From the FDA web site . Accessed 2003 Jun 9.

102. Drug Enforcement Administration (DEA), Department of Justice. Implementation of the Anabolic Steroid Control Act of 2004. Fed Regist. 2005; 241:74653-8.

103. Drug Enforcement Administration (DEA), Office of Diversion Control. Exempt Anabolic Steroids (December 31, 2003). From the DEA web site.

104. Food and Drug Administration. FDA Drug Safety Communication: FDA cautions about using testosterone products for low testosterone due to aging; requires labeling change to inform of possible increased risk of heart attack and stroke with use. Rockville, MD; 2015 Mar 3. From the FDA website.

105. Summary minutes of the joint meeting of the bone, reproductive and urologic drugs advisory committee and the drug safety and risk management advisory committee, Sept 17, 2014. From FDA website.

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107. Vigen R, O'Donnell CI, Barón AE et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA. 2013; 310:1829-36. [PubMed 24193080]

108. Muraleedharan V, Marsh H, Kapoor D et al. Testosterone deficiency is associated with increased risk of mortality and testosterone replacement improves survival in men with type 2 diabetes. Eur J Endocrinol. 2013; 169:725-33. [PubMed 23999642]

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117. Food and Drug Administration. Testosterone products: FDA/CDER statement - risk of venous blood clots. Rockville, MD; 2014 Jun 20. From the FDA website. Accessed 2015 Sept 18.

118. Valeant Pharmaceuticals. Android (methyltestosterone) prescribing information. Bridgewater, NJ; 2015 Apr.

119. Valeant Pharmaceuticals. Testred (methyltestosterone) prescribing information. Bridgewater, NJ; 2015 Apr.

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c. Valeant Pharmaceuticals International. Testred (methyltesosterone) capsules prescribing information. Costa Mesa, CA; 1999 May.

d. Solvay Pharmaceuticals. Estratest and Estratest H.S. (esterified estrogens and methyltestosterone) tablets prescribing information. marietta, GA; 2004 Feb.

e. ICN Pharmaceuticals. Android (methyltestosterone) capsules prescribing information. Costa Mesa, CA; 2001 Sep.

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g. Phillips EH, Ryan S, Ferrari R et al. Estrest and Estratest HS (esterified estrogens and methyltestosterone) therapy: a summary of safety surveillance data, January 1989 to August 2002. Clin Ther. 2003; 23:3027-43.

h. Schanzer W. Metabolism of anabolic androgenic steroids. Clin Chem. 1996; 42:1001-20. [PubMed 8674183]

i. Shinohara Y, Baba S, Kasuya Y et al. Stable-isoptope methodology in the bioavailability study of 17 α-methyltesosterone using gas chromatography-mass spectrometry. J Pharm Sci. 1986; 75:161-4. [PubMed 3958925]

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