From the Guidelines
For a young male with an elevated testosterone level not on testosterone supplementation, the initial workup should include a repeat measurement of total testosterone and sex hormone-binding globulin (SHBG) to confirm the elevation, as recommended by guidelines from the Endocrine Society and American Urological Association 1.
Initial Evaluation
It is recommended to check for symptoms of hyperandrogenism, such as acne, hirsutism, and male pattern baldness, and to perform a physical examination to look for signs of androgen excess, including testicular size and consistency.
Laboratory Tests
Laboratory tests should include:
- Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to evaluate for primary or secondary hypogonadism
- Prolactin to rule out prolactinoma
- 17-Hydroxyprogesterone to evaluate for congenital adrenal hyperplasia
- Dehydroepiandrosterone sulfate (DHEA-S) to assess adrenal androgen production
Imaging Studies
Imaging studies, such as testicular ultrasound or adrenal computed tomography (CT) scan, may be considered if an adrenal or testicular tumor is suspected, as noted in studies evaluating the efficacy and safety of testosterone treatment in men 1.
Medication Review
Medications that may cause elevated testosterone, such as anabolic steroids, should be discontinued if possible. If the patient is taking any medications that may interfere with testosterone levels, such as spironolactone or ketoconazole, these should be stopped or adjusted under medical supervision, as suggested by the American College of Physicians 1.
Referral to Specialist
In cases where the elevated testosterone is confirmed and the cause is not clear, referral to an endocrinologist for further evaluation and management is recommended, to ensure appropriate diagnosis and treatment of underlying conditions, such as hypogonadism or androgen excess disorders 1.
From the Research
Hyperandrogenism Workup
The workup for hyperandrogenism (elevated testosterone level) in a young male not on testosterone replacement therapy (TRT) involves several steps:
- Evaluating the patient's medical history and physical examination to identify any underlying conditions that may be contributing to the elevated testosterone level 2
- Measuring circulating testosterone, luteinising hormone (LH), and follicle-stimulating hormone (FSH) concentrations to confirm the diagnosis of hyperandrogenism 3
- Assessing for any signs or symptoms of hyperandrogenism, such as acne, hirsutism, or male pattern baldness 2
- Investigating the underlying cause of the hyperandrogenism, which may include:
- Considering further testing, such as:
Differential Diagnosis
The differential diagnosis for hyperandrogenism in a young male includes:
- Hypogonadism, which is characterized by low testosterone levels 5, 3, 4
- Hypergonadotropic hypogonadism, which is characterized by high LH and FSH levels and low testosterone levels 3
- Congenital or acquired conditions that disrupt the testis production of testosterone or signaling from the hypothalamic-pituitary-gonadal axis 4
- Anabolic steroid or illicit drug use 4
- Obesity, diabetes, or other metabolic disorders 4
Treatment
Treatment for hyperandrogenism in a young male depends on the underlying cause and may include:
- Lifestyle modifications, such as weight loss or exercise, to improve insulin sensitivity and reduce testosterone levels 6
- Medications, such as selective estrogen receptor modulators (SERMs) or aromatase inhibitors, to reduce testosterone levels or improve fertility 6
- Human chorionic gonadotropin (hCG) therapy to stimulate testicular production of testosterone 6
- Surgery, such as varicocelectomy, to improve testicular function and reduce testosterone levels 6