From the Guidelines
Testosterone levels should be checked in men who show symptoms of low testosterone, such as decreased libido, erectile dysfunction, fatigue, depression, reduced muscle mass, or increased body fat, particularly if they are over 40 years old, as recommended by the American College of Physicians 1.
Key Considerations
- Testing should be done in the morning when levels are naturally highest, with at least two separate measurements to confirm a diagnosis.
- The normal total testosterone range for adult men is 300 to 800 ng/dL in most laboratories, and levels below 300 ng/dL may indicate hypogonadism 1.
- Treatment options for low testosterone include testosterone replacement therapy (TRT), which comes in several forms: injections, topical gels, patches, pellets, or buccal tablets.
Treatment Options
- Injections (testosterone cypionate or enanthate, typically 50-100mg weekly or 100-200mg every 2 weeks) are a common form of TRT.
- Topical gels (AndroGel, Testim, 5-10g applied daily) and patches (Androderm, 2-6mg applied nightly) are also available, with the advantage of relatively stable testosterone levels from day-to-day.
- Pellets (Testopel, implanted every 3-6 months) and buccal tablets (Striant, 30mg applied to gums twice daily) are alternative options.
Monitoring and Safety
- Before starting TRT, men should undergo prostate screening and have hematocrit levels checked.
- During treatment, regular monitoring of testosterone levels, prostate-specific antigen, hematocrit, and lipid profiles is necessary.
- Lifestyle modifications like weight loss, regular exercise, adequate sleep, and stress reduction can also help improve testosterone levels naturally.
- TRT may have side effects, including acne, fluid retention, breast enlargement, worsening sleep apnea, and potentially increased cardiovascular risks, as noted by the FDA 1.
From the FDA Drug Label
Testosterone cypionate injection is indicated for replacement therapy in the male in conditions associated with symptoms of deficiency or absence of endogenous testosterone. Primary hypogonadism (congenital or acquired)-testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome; or orchidectomy. Hypogonadotropic hypogonadism (congenital or acquired)-idiopathic gonadotropin or LHRH deficiency, or pituitary-hypothalamic injury from tumors, trauma, or radiation. The FDA drug label does not answer the question.
From the Research
When to Check Testosterone Levels
Testosterone levels should be checked in men who exhibit symptoms of hypogonadism, such as:
- Reduced libido or erectile dysfunction
- Reduced muscle mass and strength
- Increased adiposity
- Osteoporosis or low bone mass
- Depressed mood
- Fatigue These symptoms can be found in men with idiopathic, metabolic, or iatrogenic conditions that result in testosterone deficiency 2.
Treatment Options for Low Testosterone
Treatment options for low testosterone include:
- Intramuscular injections
- Transdermal patches
- Transdermal gels
- Buccal patches
- Subcutaneous pellets These formulations are efficacious in establishing eugonadal testosterone levels in the blood and relieving symptoms 3. Testosterone treatment can improve libido, sexual function, and mood, reduce fat body mass, increase lean body mass, and improve bone mineral density 3, 4.
Diagnosis and Monitoring
Diagnosis of hypogonadism requires the presence of low serum testosterone levels and hypogonadal symptoms 3, 5. Measuring testosterone levels can be done in men across all age groups, but it is estimated that more than one-third of men 45 years and older have testosterone deficiency 5, 4. It is essential to determine which patients might benefit from therapy and to offer recommendations regarding the workup and initiation of treatment 5.
Special Considerations
In men with obesity, reduced serum testosterone is usually reversible upon amelioration of the underlying non-gonadal illness 6. Obesity-related reductions in serum testosterone are primarily responsible for measured reductions in testosterone, but obesity is not a cause of pathological hypogonadism 6. In the absence of pathological hypogonadism, testosterone treatment is less effective than a diet and lifestyle intervention to rectify the reversible conditions responsible for non-specific symptoms and associated reduced serum testosterone concentrations 6.