What is the appropriate approach for a primary care physician when a patient with normal total testosterone, normal free testosterone, and normal LH and FSH levels demands testosterone therapy and cites a relative who is a provider willing to prescribe it?

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Do Not Prescribe Testosterone Therapy

Your clinical decision to withhold testosterone therapy is correct and evidence-based—this patient does not meet diagnostic criteria for testosterone deficiency and should not receive treatment. 1, 2

Why This Patient Does Not Qualify for Treatment

Laboratory Values Are Normal

  • Total testosterone: 449 ng/dL and 354 ng/dL - Both values are well above the diagnostic threshold of <300 ng/dL required for diagnosis 1
  • Free testosterone: 17.7 pg/mL and 12.5 pg/mL - Both within normal range (6.8-21.5 pg/mL)
  • LH and FSH: Normal - No evidence of primary or secondary hypogonadism 3, 2
  • TSH and T4: Normal - Thyroid dysfunction excluded

The 2018 AUA Guideline explicitly states: "The clinical diagnosis of testosterone deficiency is only made when patients have low total testosterone levels combined with symptoms and/or signs" and defines low testosterone as "below 300 ng/dL as a reasonable cut-off" with measurements taken on two separate early morning occasions 1. This patient fails to meet the biochemical criteria on both measurements.

Guideline-Based Diagnostic Requirements Not Met

The Endocrine Society's 2018 guideline is unequivocal: "We recommend diagnosing hypogonadism in men with symptoms and signs of testosterone deficiency AND unequivocally and consistently low serum total testosterone and/or free testosterone concentrations" 2. The word "unequivocally" is critical here—this patient's testosterone levels are solidly within the normal range, not borderline.

How to Address This Situation

1. Document Your Clinical Reasoning

  • Record that the patient has normal testosterone levels on two separate occasions
  • Note that diagnostic criteria for testosterone deficiency are not met per AUA and Endocrine Society guidelines 1, 2
  • Document that you explained the lack of medical indication and potential harms

2. Educate the Patient on Actual Risks

Testosterone therapy in men with normal levels carries significant risks without proven benefits:

  • Cardiovascular concerns: The FDA issued warnings about potential cardiovascular risks 4
  • Prostate effects: Worsening of BPH symptoms, need for ongoing prostate cancer surveillance 2, 4
  • Hematologic complications: Erythrocytosis (hematocrit >50%) requiring treatment discontinuation 5, 2, 4
  • Fertility suppression: Testosterone therapy suppresses spermatogenesis and can cause infertility 2, 6
  • Secondary exposure risks: Risk of virilization in children and women through skin contact 4

3. Address Underlying Symptoms

If the patient has symptoms he attributes to "low testosterone," explore alternative causes:

  • Fatigue/low energy: Screen for depression, sleep apnea, anemia, thyroid dysfunction (already done), diabetes, cardiovascular disease
  • Sexual dysfunction: Evaluate for erectile dysfunction causes (vascular, psychological), relationship issues, medications
  • Mood changes: Consider depression screening, stress assessment
  • Body composition concerns: Discuss evidence-based approaches including resistance training and nutrition

The 2003 AACE guideline notes that "Many men have normal sexual function even if their testosterone levels decline into the age-adjusted lower normal range" 7. Symptoms are nonspecific and often multifactorial.

4. Explain Why the Relative Provider Is Wrong

The fact that a relative who is a provider would prescribe testosterone is concerning but irrelevant to appropriate medical care. The evidence shows that up to 25% of men receiving testosterone therapy do not meet diagnostic criteria 1—this represents inappropriate prescribing, not a difference in clinical judgment.

Key point: The 2006 Endocrine Society guideline explicitly states: "We recommend against a general clinical policy of offering testosterone therapy to all older men with low testosterone levels" 5. Even men with borderline low levels require careful consideration—this patient doesn't even have low levels.

5. Set Clear Boundaries

Be direct: "I understand you want this treatment, but prescribing testosterone when your levels are normal would be practicing outside evidence-based guidelines and could harm you. I cannot in good conscience prescribe a medication that is not medically indicated and carries real risks."

Common Pitfalls to Avoid

Do Not Order Testosterone "Just to See If It Helps"

The 2018 Endocrine Society guideline warns against this approach 2. Testosterone therapy requires:

  • Ongoing monitoring (testosterone levels, hematocrit, PSA, lipids) 5, 2
  • Long-term commitment once started
  • Suppression of endogenous production
  • Potential difficulty discontinuing due to secondary hypogonadism

Do Not Be Swayed by Direct-to-Consumer Marketing

The dramatic increase in testosterone prescriptions has been driven partly by aggressive marketing, not by an epidemic of hypogonadism 1, 8. The 2020 American College of Physicians evidence report notes that "much of the increase is in men with nonspecific symptoms" who don't meet diagnostic criteria 8.

Do Not Use Symptom Questionnaires Alone

The AUA guideline specifically states: "The use of validated questionnaires is not currently recommended to either define which patients are candidates for testosterone therapy or monitor symptom response" 1. Symptoms are too nonspecific.

If the Patient Insists or Threatens to Go Elsewhere

Document that you:

  1. Explained the lack of medical indication based on current guidelines
  2. Discussed potential harms of unnecessary treatment
  3. Offered to address underlying symptoms through appropriate means
  4. Provided patient education materials if available

You cannot prevent a patient from seeking care elsewhere, but you can ensure your medical record clearly documents appropriate, guideline-concordant care. If the patient obtains testosterone from another provider, this represents a failure of that provider to practice evidence-based medicine, not a failure on your part.

The 2006 Endocrine Society guideline emphasizes: "We recommend making a diagnosis of androgen deficiency only in men with consistent symptoms and signs and unequivocally low serum testosterone levels" 5. Your patient meets neither criterion.

References

2
Guideline

testosterone therapy in men with hypogonadism: an endocrine society clinical practice guideline.

The Journal of clinical endocrinology and metabolism, 2018

7
Guideline

american association of clinical endocrinologists medical guidelines for clinical practice for the evaluation and treatment of male sexual dysfunction: a couple's problem--2003 update.

Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologist, 2003

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.