Essential Hormone Tests for Men Over 65
Routine hormone screening is not recommended for men over 65 years; however, testosterone testing (total testosterone measured in the morning) should be performed only in men with specific symptoms suggestive of hypogonadism, such as low libido or unexplained anemia 1.
When to Test Testosterone
The Endocrine Society explicitly recommends against routine screening of the general male population for hypogonadism 1. For men over 65 specifically, testing should be reserved for those with:
- Low libido or sexual dysfunction (decreased frequency/ability to perform sexual activity, reduced morning erections)
- Unexplained anemia
- Sarcopenia or significant muscle weakness 2
- Osteoporosis or low bone mineral density
These symptoms must be present before initiating any hormonal workup, as age-related testosterone decline alone without symptoms does not warrant testing or treatment 1.
The Diagnostic Algorithm
Step 1: Initial Testing
When symptoms are present, measure:
- Total testosterone - drawn in the morning (before 10 AM) when levels are highest
- This should be repeated on a separate occasion to confirm consistently low levels 1
The diagnostic threshold is a total testosterone <10-13 nmol/L (approximately 300 ng/dL), though this should be interpreted alongside clinical symptoms 3, 4.
Step 2: Confirmatory Testing (If Total Testosterone is Low)
Once low testosterone is confirmed, the following tests are essential to distinguish primary from secondary hypogonadism and identify underlying causes 1:
- Luteinizing hormone (LH)
- Follicle-stimulating hormone (FSH)
- Prolactin (to exclude prolactinoma)
- Sex hormone-binding globulin (SHBG) - to calculate free testosterone when total testosterone is borderline or when SHBG alterations are suspected (obesity, liver disease, aging) 3
Critical distinction:
- Primary hypogonadism = Low testosterone + elevated LH/FSH (testicular failure)
- Secondary hypogonadism = Low testosterone + normal or low LH/FSH (hypothalamic-pituitary dysfunction)
This distinction is crucial because secondary hypogonadism in obese older men may be reversible with weight loss 5, while primary hypogonadism is generally irreversible and may warrant testosterone replacement 5.
What NOT to Test Routinely
- Do not screen asymptomatic men - even if they are over 65 1
- Do not routinely measure other hormones (thyroid, cortisol, vitamin D) unless there are specific clinical indications unrelated to age alone 6
- Vitamin D testing is not recommended routinely in healthy adults under 75 years 6
Common Pitfalls to Avoid
- Testing at the wrong time: Testosterone must be measured in the morning due to diurnal variation; afternoon values are unreliable
- Single measurement: One low value is insufficient - confirmation with a second morning sample is required 1
- Ignoring SHBG: In obese men or those with conditions affecting SHBG, total testosterone alone may be misleading - calculate free testosterone 3
- Missing secondary causes: Failing to measure LH/FSH means missing potentially reversible causes (obesity, medications like opioids/corticosteroids, systemic illness) 5
- Testing without symptoms: Research shows only 7.8% of men with testosterone results had SHBG measured, and proper follow-up testing occurred in only 30-46% of hypogonadal men 3 - this represents inadequate diagnostic workup
Monitoring Before Treatment Consideration
If testosterone replacement is being considered, baseline assessment must include 1:
- Prostate-specific antigen (PSA) - contraindicated if PSA >4 ng/mL or >3 ng/mL with high prostate cancer risk
- Hematocrit - contraindicated if elevated
- Digital rectal examination - to exclude palpable prostate nodules
The evidence shows that in primary care, only 19.1% of men with confirmed hypogonadism actually received testosterone replacement 3, suggesting either appropriate caution or potential undertreatment depending on symptom severity.