Many men with hypogonadism wonder whether using two sachets of Testogel daily is safe and appropriate. Testogel (testosterone gel) is a licensed hormone replacement therapy for male testosterone deficiency, available in the UK as 50 mg sachets. Whilst the standard starting dose is one sachet daily, some patients require dose escalation to achieve adequate testosterone levels. Using two sachets daily—equivalent to 100 mg of testosterone—is within the licensed maximum dose and may be prescribed when blood tests confirm insufficient testosterone replacement with a single sachet. Dose adjustments must always be guided by a healthcare professional based on biochemical monitoring and clinical response, never self-initiated.

Understanding Testogel Dosing and Sachet Strength

Testogel (testosterone gel) is a transdermal hormone replacement therapy licensed in the UK for treating male hypogonadism—a condition where the body produces insufficient testosterone. The gel is absorbed through the skin, delivering testosterone directly into the bloodstream. In the UK, Testogel is available in two primary formulations: Testogel 50 mg (1% gel in 5 g sachets) and Testogel 16.2 mg/g gel (primarily supplied as a pump dispenser).

Each Testogel 50 mg sachet contains 50 mg of testosterone in 5 g of gel. The standard starting dose recommended by the MHRA and outlined in the Summary of Product Characteristics (SmPC) is typically one sachet daily, applied to clean, dry, intact skin on the shoulders, arms, or abdomen. This delivers testosterone systemically to achieve physiological levels. However, testosterone requirements vary significantly between individuals based on factors including age, body weight, baseline testosterone levels, and the severity of hypogonadism.

Some patients do not achieve adequate testosterone levels with a single sachet. In such cases, clinicians may increase the dose in a stepwise manner. Using two sachets daily (equivalent to 100 mg of testosterone) is within the licensed dosing range and is a recognised therapeutic option. The maximum recommended daily dose according to the SmPC is 100 mg of testosterone (two sachets of Testogel 50 mg, or 10 g of gel). Dosing decisions should always be individualised and based on biochemical monitoring and clinical response, never self-adjusted without medical guidance.

Important safety considerations include that Testogel is contraindicated in known or suspected prostate or breast cancer, and the gel is flammable until dry (avoid flames or smoking during application).

When Two Sachets of Testogel May Be Prescribed

Dose escalation to two sachets daily is typically considered when a patient's serum testosterone levels remain suboptimal despite consistent use of a single sachet for an adequate trial period. Symptoms of persistent hypogonadism, such as fatigue, reduced libido, erectile dysfunction, low mood, and decreased muscle mass, may also prompt dose adjustment if biochemical testing confirms inadequate testosterone replacement.

Clinicians follow a stepwise titration approach as recommended by endocrinology guidelines. After initiating treatment with one sachet, testosterone levels are measured—ideally in the morning and at steady state (typically after 2-3 months of consistent use). If levels fall below the target therapeutic range (typically the mid-normal range for the specific laboratory's reference interval), and the patient remains symptomatic, the dose may be increased to two sachets daily. This approach aligns with NICE Clinical Knowledge Summary guidance on testosterone deficiency and British Society for Sexual Medicine (BSSM) recommendations on testosterone replacement.

Certain patient groups may be more likely to require dose adjustments. These include men with severe hypogonadism (very low baseline testosterone), those with higher body mass index (as adipose tissue can affect hormone metabolism), and individuals with primary testicular failure rather than secondary (hypothalamic-pituitary) causes. These factors may influence individual testosterone requirements and response to treatment.

It is important to emphasise that two sachets daily is a legitimate, licensed dose when prescribed by a qualified healthcare professional. Patients should never increase their dose independently, as this can lead to supraphysiological testosterone levels, increased side effects, and potential long-term health risks. Any dose adjustment must be guided by blood test results and clinical assessment.

How to Apply Multiple Testogel Sachets Safely

When using two sachets of Testogel daily, proper application technique is essential to maximise absorption, minimise side effects, and prevent accidental transfer to others. The gel should be applied once daily, preferably in the morning to mimic the body's natural circadian testosterone rhythm. Both sachets can be applied during the same application session, but the gel should be spread over a larger skin area to facilitate absorption.

For Testogel 50 mg sachets (1% gel), application sites include the shoulders, upper arms, and abdomen. The gel must be applied to clean, dry, intact skin—never to the genital area, as this increases the risk of local irritation and is not an approved application site. When using two sachets, distribute the gel across a wider surface area rather than applying both to the same small patch of skin. For example, apply one sachet to each shoulder and upper arm. This approach optimises transdermal absorption and reduces the likelihood of skin irritation.

After application, allow the gel to dry completely (typically 3–5 minutes) before dressing. Wash your hands thoroughly with soap and water immediately after application to prevent accidental transfer. Cover the application site with clothing once dry, particularly if you will have close skin-to-skin contact with others, especially women and children. Testosterone can transfer to others through direct skin contact with the application site, potentially causing virilisation in women and children.

Avoid swimming, showering, or vigorous exercise for at least 6 hours after application to allow adequate absorption, as advised in the SmPC. Patients should maintain a consistent daily routine for application to ensure stable testosterone levels and optimal therapeutic effect. Remember that the gel is flammable until dry, so avoid smoking or naked flames during application and drying time. If close skin contact with others is anticipated, wash the application site thoroughly with soap and water beforehand.

Monitoring Testosterone Levels with Higher Doses

Regular biochemical monitoring is essential when using two sachets of Testogel daily to ensure testosterone levels remain within the therapeutic range and to detect potential adverse effects early. UK guidelines recommend measuring serum testosterone levels around 2-3 months after initiating treatment or changing dose, then at 6-12 month intervals once stable levels are achieved.

Blood samples for testosterone measurement should ideally be taken in the morning (before 11:00 am when possible) and before applying that day's dose to obtain a trough level. However, with transdermal testosterone, levels are relatively stable throughout the day compared to injectable formulations. The target therapeutic range should aim for the mid-normal range of your laboratory's specific reference interval. Levels consistently above the upper limit may indicate over-replacement and warrant dose reduction.

In addition to testosterone levels, monitoring should include:

• Full blood count (FBC): Testosterone stimulates erythropoiesis (red blood cell production), and higher doses increase the risk of polycythaemia (elevated haematocrit). This should be checked at baseline, after 3-6 months, then annually. Haematocrit levels above 0.54 require dose reduction or temporary treatment cessation and further investigation.

• Prostate-specific antigen (PSA) and digital rectal examination: Recommended for men over 40 or those with prostate cancer risk factors, as testosterone replacement is contraindicated in prostate cancer. Any abnormal findings should prompt specialist referral.

• Liver function tests and lipid profile: May be checked based on individual risk factors and comorbidities, particularly in patients with pre-existing conditions.

Patients should attend all scheduled monitoring appointments and report any new symptoms promptly. If testosterone levels remain suboptimal despite two sachets daily, alternative formulations (such as testosterone injections or implants) may be considered. Conversely, if levels exceed the normal range, dose reduction is necessary to prevent adverse effects.

Risks and Side Effects of Using Two Testogel Sachets

Using two sachets of Testogel daily increases the dose of testosterone delivered, which proportionally increases the risk and severity of certain adverse effects. While many men tolerate higher doses well, awareness of potential side effects is crucial for patient safety.

Common side effects associated with testosterone replacement therapy include:

• Skin reactions at the application site: erythema (redness), pruritus (itching), dry skin, or acne. Using a larger application area when applying two sachets may help reduce localised irritation.

• Polycythaemia: Elevated red blood cell count and haematocrit, which increases blood viscosity and the risk of thrombotic events (blood clots). This is more common with higher doses and requires regular monitoring.

• Prostate effects: Benign prostatic hyperplasia (BPH) symptoms may worsen, including urinary frequency, urgency, or difficulty urinating. Testosterone replacement therapy is contraindicated in known or suspected prostate cancer. Current evidence does not show increased prostate cancer incidence in appropriately selected and monitored men, but regular PSA monitoring and digital rectal examination are required.

• Mood and behavioural changes: Some men experience increased irritability, aggression, or mood swings, particularly if testosterone levels become supraphysiological.

• Gynaecomastia: Breast tissue enlargement due to peripheral conversion of testosterone to oestradiol.

• Sleep apnoea: Testosterone may worsen obstructive sleep apnoea in susceptible individuals.

• Oedema: Fluid retention may occur, particularly in those with severe cardiac, hepatic or renal insufficiency.

Serious risks requiring immediate medical attention include signs of blood clots related to polycythaemia (leg pain/swelling, chest pain, breathlessness), severe allergic reactions, or sudden changes in vision or speech. Patients should contact their GP or seek urgent medical advice if they experience these symptoms.

Transfer to others remains a significant concern. Women and children exposed to testosterone through skin contact may develop signs of virilisation. Patients must take precautions to prevent transfer, including covering application sites and washing hands thoroughly. If accidental transfer occurs, the affected person should wash the area immediately with soap and water and seek medical advice if symptoms develop.

Patients should never exceed the prescribed dose or use Testogel without medical supervision. Always read the Patient Information Leaflet and report suspected side effects via the MHRA Yellow Card Scheme (yellowcard.mhra.gov.uk or via the Yellow Card app).

Frequently Asked Questions