Three Grandchildren and a Needle He Won't Use
A 61-year-old with confirmed hypogonadism, a genuine needle aversion, and grandchildren who visit weekly — testing which testosterone formulation actually fits a specific household, not an abstract ranking of routes.
Harold P. retired from thirty years in commercial insurance underwriting two years ago and now spends most Wednesdays and Saturdays with his three grandchildren, ages four through nine, who live fifteen minutes away and treat his house as a second home. That detail became directly relevant the moment his testosterone deficiency — fatigue, decreased muscle mass, low libido, confirmed on two morning draws at 211 ng/dL — moved from diagnosis to treatment discussion, because a topical gel, the most commonly prescribed formulation, carries a real risk of transferring to a child's skin on contact and causing inappropriate virilization in a young girl or premature puberty in a young boy.
He was equally direct about a second constraint: he has an established, longstanding needle aversion, not a mild preference, that he disclosed unprompted before any formulation discussion began, which effectively removes intramuscular injection from consideration regardless of its other merits. That leaves oral testosterone undecanoate and subcutaneous pellet implantation as the two routes that avoid both problems at once — the gel's transfer risk and the injection's needle. Pellets require a minor in-office surgical insertion every three to four months, which he tolerated as a one-time procedure but which is its own barrier for a man who has already said needles concern him.
The oral route has a real, recent history worth naming directly: oral testosterone undecanoate products carried a boxed warning for blood pressure elevation from their 2019 approval until the FDA removed it in July 2025, following the same TRAVERSE-informed review that removed the older, broader cardiovascular boxed warning from the entire testosterone class. What remains, rather than a boxed warning, is a standard monitoring recommendation — blood pressure should be checked periodically, since oral formulations still produce a measurable systolic increase in the 3 to 5 mmHg range in trial data, smaller than a boxed warning implies but not zero. Harold's own blood pressure today is 122/78, unremarkable and without a personal or family history that would make that increase concerning at his baseline. His hematocrit, at 49%, sits closer to the upper edge of normal than most first-time TRT candidates, which is the one number that argues against the erythrocytosis risk of injectable dosing regardless of the needle question, and modestly favors either oral or topical over pellet: Pastuszak’s comparative series put erythrocytosis at 35% with pellets against 13% with gels, though no high-quality trial has compared pellets against oral undecanoate head to head.
Clinic, matching the drug to the household
He told us the needle concern before we asked, and he has three grandchildren treating his living room as their own most weeks. Those aren't soft preferences to work around — they rule out injection and make a gel genuinely risky in his specific home. Oral testosterone undecanoate is now a real first option since the FDA removed its blood-pressure boxed warning in July 2025, following the same TRAVERSE review that cleared the whole testosterone class. It avoids both problems at once.
I agree oral solves the needle and the transfer risk together, and I'm not arguing for a gel in his house. What I want on the record before we finalize is his hematocrit — 49%, already toward the upper end of normal before we've started anything. Pellets carry the highest erythrocytosis risk of the three routes still on the table, so I'd rule that one out on those numbers alone, separate from the needle question entirely.
The boxed warning coming off oral products addressed blood pressure specifically; it says nothing about hematocrit, which oral formulations still raise, just less than injectable or pellet dosing does in the comparative data.
Putting his own numbers next to each route: no needle rules out injection outright. Grandchildren in the house weekly rules out gel on transfer-risk grounds specifically for him, independent of how manageable that risk is for other patients. A hematocrit already at 49% argues against pellet, the highest-erythrocytosis route among what's left. That converges on oral testosterone undecanoate as the formulation his own specific facts point toward, not oral as a generically preferred first choice — with blood pressure and hematocrit both checked at the standard follow-up interval regardless.
Agreed within the visit: oral testosterone undecanoate started at the standard titration dose, with blood pressure and hematocrit both rechecked at six to twelve weeks per label guidance. Harold left with a formulation that fit his household and his own stated limits, not simply the most commonly prescribed option.
The reasoning behind ruling out pellet and gel was carried forward explicitly in his chart, not just the final choice, so a future prescriber revisiting this decision inherits the actual facts — his hematocrit and his household — rather than a bare formulation preference with no context attached.