Can you provide a checklist for evaluating a male patient with confirmed low testosterone who is seeking testosterone therapy?

Testosterone Therapy Pre-Treatment Checklist

Before initiating testosterone therapy, you must confirm BOTH biochemical hypogonadism (total testosterone <300 ng/dL on two separate early morning measurements) AND the presence of clinical symptoms, while systematically ruling out absolute contraindications. 1

PART 1: Confirm Diagnosis

Laboratory Requirements (MANDATORY)

• Two separate early morning (7-11 AM) total testosterone measurements <300 ng/dL 1

  • Must be fasting samples
  • Use same laboratory and methodology for both measurements
  • Measurements should be on different days

• Measure LH and FSH levels 2, 1

  • Low/normal LH = secondary (central) hypogonadism
  • Elevated LH = primary (testicular) hypogonadism
  • This determines etiology and guides further workup

Clinical Symptoms Assessment (MUST HAVE AT LEAST ONE)

Document presence of:

• Sexual symptoms: Reduced libido, erectile dysfunction
• Physical symptoms: Reduced energy/endurance, diminished work performance, fatigue, reduced muscle mass
• Psychological symptoms: Depression, reduced motivation, poor concentration, impaired memory, irritability 1

Physical Examination Findings

Document:

• Body mass index or waist circumference
• Gynecomastia (present/absent)
• Testicular size and consistency
• Body hair pattern in androgen-dependent areas
• Prostate examination findings 1

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PART 2: Screen for ABSOLUTE CONTRAINDICATIONS

If ANY of the following are present, DO NOT prescribe testosterone: 2

Cancer-Related (STOP if present)

• ❌ Breast cancer (current or history)
• ❌ Prostate cancer (current or history)
• ❌ Palpable prostate nodule or induration on exam
• ❌ PSA >4 ng/mL
• ❌ PSA >3 ng/mL + high risk features for prostate cancer (without urologic evaluation first)

Hematologic (STOP if present)

• ❌ Elevated hematocrit (>50%)
• ❌ Known thrombophilia

Cardiovascular (STOP if present)

• ❌ Myocardial infarction within last 6 months
• ❌ Stroke within last 6 months
• ❌ Uncontrolled heart failure

Other (STOP if present)

• ❌ Severe untreated obstructive sleep apnea
• ❌ Severe lower urinary tract symptoms (IPSS >19)
• ❌ Planning fertility in near term (testosterone suppresses spermatogenesis)

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PART 3: Baseline Laboratory Panel

Before starting therapy, obtain:

• PSA level (mandatory for prostate cancer screening)
• Hematocrit/hemoglobin (testosterone increases red blood cell production)
• Lipid panel (monitor metabolic effects)
• Liver function tests (baseline for monitoring)
• Consider: HbA1c if diabetic, bone density if osteoporosis risk 2

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PART 4: Special Populations - Additional Considerations

Men >65 Years Old

• Do NOT routinely prescribe to all older men with low testosterone 2
• Only offer therapy if:
  • Consistently and unequivocally low morning testosterone
  • Clear symptoms (low libido, unexplained anemia)
  • After explicit discussion of risks/benefits on individualized basis

High-Risk Conditions (Consider testing even without symptoms)

Screen testosterone in patients with: 1

• Unexplained anemia
• Bone density loss/osteoporosis
• Type 2 diabetes
• HIV/AIDS
• History of chemotherapy or testicular radiation
• Chronic opioid use
• Chronic corticosteroid use
• Pituitary dysfunction
• Male infertility

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PART 5: Patient Counseling Documentation

Document discussion of:

• Expected benefits: Improved sexual function, energy, body composition, bone density
• Potential adverse effects: Polycythemia, acne, gynecomastia, testicular atrophy, infertility, fluid retention 3
• Monitoring requirements: Labs at 3 months, then every 6-12 months
• Cardiovascular and prostate safety profile
• Patient preference for formulation (gel vs injection vs other)
• Cost and treatment burden 2

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DECISION ALGORITHM

1. Two morning testosterone <300 ng/dL? 
   NO → Do not treat
   YES → Continue to #2

2. Clinical symptoms present?
   NO → Do not treat
   YES → Continue to #3

3. Any absolute contraindications present?
   YES → Do not treat (or defer until resolved)
   NO → Continue to #4

4. Baseline labs acceptable (PSA, hematocrit)?
   NO → Address abnormalities first
   YES → Continue to #5

5. Patient counseled and agrees to monitoring?
   NO → Do not treat
   YES → INITIATE THERAPY

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Critical Pitfall to Avoid

The most common error is prescribing testosterone based on symptoms alone without confirming biochemical hypogonadism with two separate early morning measurements. Up to 25% of men receiving testosterone do not meet diagnostic criteria. 1 Additionally, nearly half of treated men never have follow-up testosterone levels checked, which is substandard care.