What is the current consensus on testing for testosterone levels in asymptomatic patients with normal physical examination and no symptoms of hypogonadism (testosterone deficiency)?

From the Guidelines

The current consensus does not recommend routine testing for testosterone levels in asymptomatic patients. Testing should only be performed when patients present with specific symptoms of testosterone deficiency, such as decreased libido, erectile dysfunction, fatigue, decreased muscle mass, or depressed mood. When testing is indicated, it should be done with a morning total testosterone measurement (between 8-10 AM when levels are highest), with at least two separate measurements to confirm low levels due to natural fluctuations. The threshold for low testosterone is generally considered to be below 300 ng/dL, though this can vary slightly between laboratories. This recommendation exists because testosterone levels naturally vary throughout the day and between individuals, and there is insufficient evidence that treating asymptomatic men with low testosterone improves health outcomes, as noted in the 2020 study by the American College of Physicians 1. Additionally, testosterone replacement therapy carries potential risks including cardiovascular events, polycythemia, sleep apnea, and prostate issues, which should be considered when assessing the risks and benefits of treatment, as highlighted in the 2020 standards of medical care in diabetes 1. Therefore, the risk-benefit ratio does not favor screening in the absence of symptoms.

Some key points to consider when testing for testosterone levels include:

• Measuring morning total testosterone levels using an accurate and reliable assay, as recommended in the 2018 standards of medical care in diabetes 1
• Checking sex hormone–binding globulin in men who have total testosterone levels close to the lower limit, as it is often low in diabetes and associated with lower testosterone levels 1
• Considering further testing, such as luteinizing hormone and follicle-stimulating hormone levels, to determine if the patient has hypogonadism 1
• Weighing the potential benefits of testosterone replacement therapy, including improved sexual function, well-being, muscle mass and strength, and bone density, against the potential risks, as discussed in the 2020 study by the American College of Physicians 1.

From the Research

Current Consensus on Testing for Testosterone Levels

The current consensus on testing for testosterone levels in asymptomatic patients is that it should not be routinely performed.

• According to 2, a diagnosis of hypogonadism should only be made in men with symptoms and signs consistent with testosterone deficiency and unequivocally and consistently low serum testosterone concentrations.
• The Endocrine Society recommends measuring fasting morning total testosterone concentrations using an accurate and reliable assay as the initial diagnostic test, and confirming the diagnosis by repeating the measurement of morning fasting total testosterone concentrations 2.
• The guidelines also recommend against starting testosterone therapy in patients who are planning fertility in the near term or have certain medical conditions, such as breast or prostate cancer, or untreated severe obstructive sleep apnea 2.

Diagnosis and Evaluation of Male Hypogonadism

The diagnosis and evaluation of male hypogonadism involve measuring testosterone levels, as well as other hormones such as luteinizing hormone and follicle-stimulating hormone.

• According to 3, hypogonadism in males is a clinical syndrome complex that comprises symptoms with or without signs, as well as biochemical evidence of testosterone deficiency.
• The study also notes that hypogonadal symptoms depend on the age at onset of hypogonadism, severity of the deficiency, its duration, and sensitivity to androgen action 3.
• Another study found that appropriate use of testosterone and gonadotropin levels in clinical practice, as recommended by guidelines, is suboptimal, increasing the possibility of overdiagnosis of male hypogonadism, underdiagnosis of secondary hypogonadism, and inappropriate testosterone therapy use and management 4.

Monitoring of Testosterone Therapy

The monitoring of testosterone therapy involves measuring serum testosterone concentrations, as well as evaluating symptoms, adverse effects, and compliance.

• According to 2, clinicians should monitor men receiving testosterone therapy using a standardized plan that includes evaluating symptoms, adverse effects, and compliance, measuring serum testosterone and hematocrit concentrations, and evaluating prostate cancer risk during the first year after initiating testosterone therapy.
• Another study found that only 46% of men had at least one follow-up testosterone measurement after initiating testosterone therapy, highlighting the need for improved monitoring of testosterone therapy 4.