madman
Super Moderator
EFFECT OF TESTOSTERONE PROPIONATE ON A POST-PUBERAL EUNUCH (1937)
Very little is on record about the action of testosterone propionate in man and our knowledge of the dosage required for substitution therapy is based entirely on animal experiments. Hamilton’s interesting account (1937) of the treatment of a medical student with hypogonadism finds a useful parallel in the following case:-
CASE RECORD
The patient, a man aged 38, a foreman electrician, had been severely wounded in the thigh and scrotum by shrapnel at Givenchy during the late war; he was then 19 years of age. The lacerated remains of his testicles were removed but his penis was unharmed. When I saw him in 1937 his apparent age was 24-28; and his body was soft and non-muscular and almost female in type, with narrow shoulders, wide hips, and slight genu valgum (Fig. 1). The distribution of fat on breasts, abdomen, and hips was female. There was no hair on his chest and the pubic hair was also female in type (Fig. 2). The face was youthful but the voice was normally male ; he had never shaved more than on alternate days. His development appeared to have been arrested at the age of 19, and he had been subject to flushes for several years. The penis was normal and well developed (9 em. long, 9 cm. in circumference around the glans and 9-5 cm. at the base), but the prostate was very small. Before castration in 1918 he had been a normal active youth, with a strong libido and sexual function, but since the removal of his testicles, no erections had been possible. Nevertheless, he had married in 1923, although it had been pointed out to him that he would be impotent. Slight turgidity took place at rare intervals and attempts at intromission were made, but the occasions became fewer and several years apart. The desire was almost negligible, attempts only being made for his wife’s satisfaction. In the last few years, however, the frequency had increased slightly (once every 2-3 months).
The reasons leading up to his treatment with male hormone were as follows. In 1935 he had had recurrent attacks of an eruption on the face confined to the cheeks and beard area and nose, with coexisting conjunctivitis and oedema of lids. This was diagnosed as eczema madidans in November 1935, and later as an exposure dermatitis in May 1936. There was a recurrence in June 1936, also in August and December of the same year. Further attacks occurred in February, April, May, and June 1937. The condition was not difficult to treat and cleared up in about a fortnight, but it seemed almost cyclical in its appearance. He was sent once more for a second opinion and the case was diagnosed as dermatitis venenata, taking 17 days to clear.
The almost cyclical recurrence led me to give testosterone propionate, on the analogy that oestradiol benzoate was of use in oestrin deficiency dermatoses of the menopause. Daily injections of 20 mg. Testoviron (Schering) was given with exactly the same local treatment (plain lotio calamine suited him best) starting on July 13th, 1937. By July 19th the skin was clear. On the 21st he came to me for his injection as usual but implored me to postpone it for a while. He said he had not slept all night owing to persistent and painful priapism which was not relieved at all by coitus; detumescence did not occur. To obviate any effect of suggestion I had not questioned him previously about the influence of the injections on his sexual function and he thought these were given only for his skin condition. He told me then that ever since the first injection erection had been more ready and that he had had coitus nightly. After the fifth injection erections’ were rapid and prolonged and coitus failed to relieve him. A good orgasm was enjoyed without any ejaculation, although there was a feeling of ejaculation. The libido was considerably increased, as evidenced by nightly coitus. Injections of testosterone propionate were still continued twice weekly but the skin condition recurred nevertheless. As soon as this was noticed, injections were given again daily, but the painful and persistent priapism was not seen this time. Erection was rapid and he said he was now normal again in sexual function.
By Sept. 3rd erection was frequent both day and night, and coitus occurred nearly every night. He had been taking Androstin tablets (Ciba) for four days (2 tablets t.d.s.) as well as injections but found little difference except that lateral tumescence was perhaps more marked. The glans was not absolutely turgid but erection lasted half an hour; libido was almost excessive. Now he was only having injections every 2-4 days and the effect was still very powerful, but more normal. On Oct. 7th full normal power was evidenced following a weekly injection of 40 mg. of testosterone propionate. Libido was almost excessive, coitus took place regularly twice a week and intromission was easy. He obtained a good erotic sensation and felt that he wanted to ejaculate, but there was no secretion of any kind. The erect penis measured 15 cm. in length, 11 cm. in circumference at the glans, and 11-5 cm. at the base. Previously his wife had never obtained any erotic sensation and his return to sexual power had enabled him to satisfy her completely. Seen on Oct. 15th he said he had recently noticed the growth of a few fair hairs on his chest and stronger growth of beard, although lie still only shaves on alternate days. During twelve weeks’ treatment his weight increased from 10 st. 10 lb. to 11 st. 12 lb. and all his clothes became too small; whereas originally lie wore size l4i in collars, size 15! are now too tight. On Oct. 29th erection had been impossible for the last eight days, following cessation of injections.
DISCUSSION
Hamilton (1937) during the first period of treatment gave his patient 550 mg. of testosterone acetate in one month (an average dose of 40 mg. three times a week) and penile erections were noticed after sixty hours. After six days erection reached a state of priapism- a development arising in my case rather more strikingly after seven daily injections of 20 mg. testosterone propionate. This excessive effect was lessened on the reduction of dosage to 20 mg. twice weekly and was not found to recur so forcibly when the dosage was increased again. Libido, however, was noticeably increased and desire for coitus was felt both by day and by night.
The improvement in the mental and physical condition noticed in Hamilton’s case was evident in my patient too. He was not morbid or depressed before, but after treatment, he realized that he was more virile and able to satisfy his wife for the first time since their marriage; also he had increased in weight and development as shown by an increase of 1 st. 2 lb. in twelve weeks. During this period of treatment in which he has been given 940 mg. in 108 days (see Table), he has felt no ill effects from the injections, which are painless, and normal sexual function has been maintained by weekly injections of 40 mg. Further reduction of dosage to 20 mg. weekly seemed hardly adequate for erection was not so spontaneous and coitus was only just possible once a week.
Judging from the two cases it appears that a substitution dosage of 100-140 mg. is necessary to restore sexual function-which is the true indication of successful therapy-and that afterward, a maintenance dose of 20-40 mg. per week is adequate. The dosage required for reversal of oestrogen imbalance as suggested in the treatment of early prostatic hypertrophy would presumably be greater than these substitution doses. Experiences (unpublished) in the treatment of about 20 cases of enlarged prostate with testosterone propionate have led me to. believe that dosage such as 40-50 mg. daily is at first necessary. For these prostatic cases, my original dosage was based on the monkey and human experiments of Zuckerman and Greene (1936) and was 40 mg. weekly, but soon I found out that better results were obtained when 50 mg. was given daily for a fortnight and then at increasing intervals. In many of these men, the power of erection was regained or increased only when the larger doses were given daily for some days.
SUMMARY
(1) A post-pubertal eunuch has been treated with testosterone propionate. (2) Sexual function and libido returned almost immediately. (3) A total of 140 mg. testosterone propionate was given over seven days was followed by persistent priapism. (4) Full libido and ability to perform the sexual act was maintained by weekly injection of 40 mg. (5) A later increase in dosage did not cause a return of priapism. (6) There was an increase in the weight of 16 lb. in twelve weeks. (7) Substitution dosage with testosterone propionate is probably between 100-140 mg., with smaller weekly maintenance doses. (8) Treatment doses are likely to be greater in cases of senility or prostatic syndrome.
Very little is on record about the action of testosterone propionate in man and our knowledge of the dosage required for substitution therapy is based entirely on animal experiments. Hamilton’s interesting account (1937) of the treatment of a medical student with hypogonadism finds a useful parallel in the following case:-
CASE RECORD
The patient, a man aged 38, a foreman electrician, had been severely wounded in the thigh and scrotum by shrapnel at Givenchy during the late war; he was then 19 years of age. The lacerated remains of his testicles were removed but his penis was unharmed. When I saw him in 1937 his apparent age was 24-28; and his body was soft and non-muscular and almost female in type, with narrow shoulders, wide hips, and slight genu valgum (Fig. 1). The distribution of fat on breasts, abdomen, and hips was female. There was no hair on his chest and the pubic hair was also female in type (Fig. 2). The face was youthful but the voice was normally male ; he had never shaved more than on alternate days. His development appeared to have been arrested at the age of 19, and he had been subject to flushes for several years. The penis was normal and well developed (9 em. long, 9 cm. in circumference around the glans and 9-5 cm. at the base), but the prostate was very small. Before castration in 1918 he had been a normal active youth, with a strong libido and sexual function, but since the removal of his testicles, no erections had been possible. Nevertheless, he had married in 1923, although it had been pointed out to him that he would be impotent. Slight turgidity took place at rare intervals and attempts at intromission were made, but the occasions became fewer and several years apart. The desire was almost negligible, attempts only being made for his wife’s satisfaction. In the last few years, however, the frequency had increased slightly (once every 2-3 months).
The reasons leading up to his treatment with male hormone were as follows. In 1935 he had had recurrent attacks of an eruption on the face confined to the cheeks and beard area and nose, with coexisting conjunctivitis and oedema of lids. This was diagnosed as eczema madidans in November 1935, and later as an exposure dermatitis in May 1936. There was a recurrence in June 1936, also in August and December of the same year. Further attacks occurred in February, April, May, and June 1937. The condition was not difficult to treat and cleared up in about a fortnight, but it seemed almost cyclical in its appearance. He was sent once more for a second opinion and the case was diagnosed as dermatitis venenata, taking 17 days to clear.
The almost cyclical recurrence led me to give testosterone propionate, on the analogy that oestradiol benzoate was of use in oestrin deficiency dermatoses of the menopause. Daily injections of 20 mg. Testoviron (Schering) was given with exactly the same local treatment (plain lotio calamine suited him best) starting on July 13th, 1937. By July 19th the skin was clear. On the 21st he came to me for his injection as usual but implored me to postpone it for a while. He said he had not slept all night owing to persistent and painful priapism which was not relieved at all by coitus; detumescence did not occur. To obviate any effect of suggestion I had not questioned him previously about the influence of the injections on his sexual function and he thought these were given only for his skin condition. He told me then that ever since the first injection erection had been more ready and that he had had coitus nightly. After the fifth injection erections’ were rapid and prolonged and coitus failed to relieve him. A good orgasm was enjoyed without any ejaculation, although there was a feeling of ejaculation. The libido was considerably increased, as evidenced by nightly coitus. Injections of testosterone propionate were still continued twice weekly but the skin condition recurred nevertheless. As soon as this was noticed, injections were given again daily, but the painful and persistent priapism was not seen this time. Erection was rapid and he said he was now normal again in sexual function.
By Sept. 3rd erection was frequent both day and night, and coitus occurred nearly every night. He had been taking Androstin tablets (Ciba) for four days (2 tablets t.d.s.) as well as injections but found little difference except that lateral tumescence was perhaps more marked. The glans was not absolutely turgid but erection lasted half an hour; libido was almost excessive. Now he was only having injections every 2-4 days and the effect was still very powerful, but more normal. On Oct. 7th full normal power was evidenced following a weekly injection of 40 mg. of testosterone propionate. Libido was almost excessive, coitus took place regularly twice a week and intromission was easy. He obtained a good erotic sensation and felt that he wanted to ejaculate, but there was no secretion of any kind. The erect penis measured 15 cm. in length, 11 cm. in circumference at the glans, and 11-5 cm. at the base. Previously his wife had never obtained any erotic sensation and his return to sexual power had enabled him to satisfy her completely. Seen on Oct. 15th he said he had recently noticed the growth of a few fair hairs on his chest and stronger growth of beard, although lie still only shaves on alternate days. During twelve weeks’ treatment his weight increased from 10 st. 10 lb. to 11 st. 12 lb. and all his clothes became too small; whereas originally lie wore size l4i in collars, size 15! are now too tight. On Oct. 29th erection had been impossible for the last eight days, following cessation of injections.
DISCUSSION
Hamilton (1937) during the first period of treatment gave his patient 550 mg. of testosterone acetate in one month (an average dose of 40 mg. three times a week) and penile erections were noticed after sixty hours. After six days erection reached a state of priapism- a development arising in my case rather more strikingly after seven daily injections of 20 mg. testosterone propionate. This excessive effect was lessened on the reduction of dosage to 20 mg. twice weekly and was not found to recur so forcibly when the dosage was increased again. Libido, however, was noticeably increased and desire for coitus was felt both by day and by night.
The improvement in the mental and physical condition noticed in Hamilton’s case was evident in my patient too. He was not morbid or depressed before, but after treatment, he realized that he was more virile and able to satisfy his wife for the first time since their marriage; also he had increased in weight and development as shown by an increase of 1 st. 2 lb. in twelve weeks. During this period of treatment in which he has been given 940 mg. in 108 days (see Table), he has felt no ill effects from the injections, which are painless, and normal sexual function has been maintained by weekly injections of 40 mg. Further reduction of dosage to 20 mg. weekly seemed hardly adequate for erection was not so spontaneous and coitus was only just possible once a week.
Judging from the two cases it appears that a substitution dosage of 100-140 mg. is necessary to restore sexual function-which is the true indication of successful therapy-and that afterward, a maintenance dose of 20-40 mg. per week is adequate. The dosage required for reversal of oestrogen imbalance as suggested in the treatment of early prostatic hypertrophy would presumably be greater than these substitution doses. Experiences (unpublished) in the treatment of about 20 cases of enlarged prostate with testosterone propionate have led me to. believe that dosage such as 40-50 mg. daily is at first necessary. For these prostatic cases, my original dosage was based on the monkey and human experiments of Zuckerman and Greene (1936) and was 40 mg. weekly, but soon I found out that better results were obtained when 50 mg. was given daily for a fortnight and then at increasing intervals. In many of these men, the power of erection was regained or increased only when the larger doses were given daily for some days.
SUMMARY
(1) A post-pubertal eunuch has been treated with testosterone propionate. (2) Sexual function and libido returned almost immediately. (3) A total of 140 mg. testosterone propionate was given over seven days was followed by persistent priapism. (4) Full libido and ability to perform the sexual act was maintained by weekly injection of 40 mg. (5) A later increase in dosage did not cause a return of priapism. (6) There was an increase in the weight of 16 lb. in twelve weeks. (7) Substitution dosage with testosterone propionate is probably between 100-140 mg., with smaller weekly maintenance doses. (8) Treatment doses are likely to be greater in cases of senility or prostatic syndrome.
