Muscles and physical strength grow under testosterone treatment and the patient develops a more vigorous appearance (e.g. Wittert etal. 2003). Due to its anabolic effects body weight increases by about 5%. Therefore, accurate recording of body weight under comparable conditions is part ofthe routine control of the patient. The increase in lean body mass at the expense of body fat can be measured. Originally this was only possible by sophisticated equipment in the framework of clinical research (Young etal. 1993), but can now be done conveniently by equipment measuring bioimpedance (Rolf etal. 2002). Moreover, the distribution of subcutaneous fat that shows feminine characteristics in hypogonadism (hips, lower abdomen, nates) may change with increasing muscle mass. In particular, testosterone appears to reduce abdominal fat (Rebuffe-Scrive etal. 1991).

The appearance and maintenance of a male sexual hair pattern is a good parameter for monitoring testosterone replacement (see Chapter 6). In particular, beard growth and frequency of shaving can easily be recorded. Hair growth in the upper pubic triangle is an important indicator of sufficient androgen substitution. While women, boys and untreated hypogonadal patients have a straight frontal hairline, androgenization is accompanied by temporal recession of the hairline and - if a predisposition exists - by the development of baldness. The pattern of male sexual hair is of greater importance than the intensity of hair growth since no correlation could be found between the intensity of body hair growth and serum testosterone levels in the normal range (Knussmann etal. 1992). A well-substituted patient may have to shave daily. However, if there is no genetic disposition for dense beard growth, additional testosterone will not increase facial hair.

Sebum production correlates with circulating testosterone levels and hypogo-nadal men may suffer from dry skin. In an early phase of treatment patients may even complain about the necessity of shampooing more frequently; they have to be informed that this is a part of normal maleness. The occurrence of acne may be a sign of supraphysiological testosterone levels and the dose should be reduced accordingly.

Gynecomastia may be caused by increased estradiol levels during testosterone therapy, especially under testosterone enanthate injections. After initiation of androgen therapy and consecutive decrease of estradiol serum levels, gynecomastia usually disappears. If gynecomastia preexists due to an increased estradiol/ testosterone ratio in hypogonadal men, it may decrease during adequate testosterone therapy. However, in severe cases mastectomy by an experienced plastic surgeon maybe required.

Patients who have not undergone pubertal development will experience voice mutation soon after initiation of testosterone therapy. During normal pubertal development the voice begins to break when serum testosterone levels reach about 10 nmol/l and SHBG drops (Pedersen et al. 1986). Mutation of the voice is very assuring for the patient and helps him to adjust to his environment by closing the gap between his chronological and biological age. It is specifically important for the patient to be recognized as an adult male on the phone. Once the voice has mutated it is no longer a useful parameter for monitoring replacement therapy since the size of the larynx, the vocal chords and thus the voice achieved will be maintained without requiring further androgens.

In prepubertal patients penis growth will be induced by testosterone treatment and normal erectile function will develop. Since penile androgen receptors diminish during puberty, growth will cease even under continued testosterone treatment (Shabsigh 1997; see also Chapter 11).

Patients who did not undergo puberty before the onset of hypogonadism may also develop eunuchoidal body proportions because of retarded closure of the epiphyseal lines of the extremities. Testosterone treatment will briefly stimulate growth, but will then lead to closure of the epiphyses and will arrest growth. In these patients, an X-ray of the left hand and distal end of the lower arm should be made before treatment to determine bone age. The epiphyseal closure may be followed by further X-rays during the course of treatment. In addition, body height and arm span - as measured from the tip of the right to the tip of the left middle finger - should be measured until no further growth occurs. Continued growth, in particular of the arm span, indicates inadequate androgen substitution.

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