Improvement of Attention Deficit/Hyperactivity Disorder (ADHD) in Three Adult men During Testosterone Treatment

A Case Series

Ane Rogne; Bjørnar Hassel

J Med Case Reports. 2022;16(425)

Abstract and Introduction

Abstract

Background: Attention deficit/hyperactivity disorder (ADHD) entails inattention, impulsivity, and restlessness at a disabling level. The pharmacological treatment of ADHD rests on the use of centrally acting stimulants, such as methylphenidate and D-amphetamine. In some patients, these drugs cause side effects that preclude their use.

Case Presentation: We present three adult male, Caucasian, ADHD patients (24, 37, and 43 years old) whose ADHD symptoms improved during treatment with testosterone. The first patient experienced loss of libido during treatment with methylphenidate; for this, he was offered a trial of testosterone. Unexpectedly, his ADHD symptoms improved with testosterone treatment, and this effect continued with testosterone as monotherapy. The two other patients, who also had side effects from centrally acting stimulants, received testosterone monotherapy with similar results. The effect has now continued for 4.5–5 years at the same doses: 10–60 mg testosterone/day, administered as a skin gel. Prior to testosterone treatment, the patients had serum levels of testosterone in the low–normal range: 12–16 nmol/L (age-specific reference range: 10.4–32.6 nmol/L). The testosterone/sex hormone-binding globulin ratio was low in two patients (0.32 and 0.34; age-specific reference range: 0.38–1.1), suggesting low free serum levels of testosterone. Serum testosterone levels and testosterone/sex hormone-binding globulin ratios increased with testosterone treatment in all patients, but remained within reference values.

Conclusion: These cases suggest that a moderately reduced serum level of free testosterone may contribute to the ADHD symptoms of some adult male ADHD patients, and that testosterone treatment may be of value for these patients.

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Table 1. Testosterone/SHBG ratios and serum levels of hormones and SHBG before and during testosterone treatment
	Patient 1	Patient 2	Patient 3
Testosterone/SHBG (ref.: 0.38–1.1)	0.32 → 0.48	0.34 → 0.60	0.50 → 0.65
Serum testosterone (ref.: 10.4–32.6 nmol/L)	12 → 15	16 → 21	14 → 24
Serum SHBG (ref.: 13.5–57.4 nmol/L)	37 → 31	47 → 35	28 → 37
LH (ref 1.9–9.7 U/L)	3.2 → 2.7	3.1 → 2.8	3.2 → 0.1
FSH (1.5–10.3 U/L)	3.6 → 3.0	3.8 → 3.9	3.6 → 0.4
Testosterone dose	10 mg/day	60 mg/day	50 mg/day

Three adult men with ADHD underwent treatment with a testosterone skin gel as monotherapy. Arrows indicate changes from pretreatment levels to levels after 4–12 months of treatment. Reference values are for healthy men in their thirties from the Nordic countries [7]. Testosterone doses are mg testosterone applied to the skin in the form of a gel each morning [9]. Please note that although serum levels of testosterone and SHBG are within the reference values, the fact that serum testosterone is low whereas SHBG levels are medium, the ratio between them (the testosterone/SHBG ratio) falls below the reference range in Patients 1 and 2
FSH: follicle-stimulating hormone, LH: luteinizing hormone, SHBG: sex hormone-binding globulin, U/L: units/liter