What is the recommended treatment for a 58-year-old male with hypogonadism (low testosterone), low bioavailable testosterone, and low free testosterone, with normal Dehydroepiandrosterone (DHEA) levels and elevated Follicle-Stimulating Hormone (FSH) levels?

Treatment for Hypogonadism in a 58-Year-Old Male with Elevated FSH

Testosterone replacement therapy (TRT) is recommended for this 58-year-old male with confirmed hypogonadism (low total, bioavailable, and free testosterone) with elevated FSH, as this presentation is consistent with primary hypogonadism requiring hormone replacement to improve quality of life and sexual function. 1, 2

Diagnosis Confirmation

The patient's laboratory profile shows:

• Low total testosterone
• Low bioavailable testosterone
• Low free testosterone
• Normal DHEA
• High FSH

This pattern strongly suggests primary hypogonadism (testicular failure), as evidenced by:

• Low testosterone levels with elevated gonadotropins (FSH) 2
• This is consistent with the FDA-approved indication for testosterone therapy in "primary hypogonadism (congenital or acquired): testicular failure" 2

Treatment Approach

First-Line Treatment

• Testosterone replacement therapy is indicated for this patient with confirmed primary hypogonadism 1, 2
• Target testosterone level: 450-600 ng/dL 3

Formulation Options

1. Topical testosterone gel (1.62%) - Convenient daily application with good absorption 3, 4
2. Injectable testosterone - Options include:
   • Short-acting formulations (every 1-2 weeks)
   • Long-acting formulations (every 10-14 weeks)

Monitoring Protocol

• Check testosterone levels 4-6 weeks after treatment initiation 3
• Continue monitoring every 3-6 months thereafter 3
• Monitor for:
  • Hematocrit/hemoglobin (risk of polycythemia)
  • PSA levels (prostate monitoring)
  • Blood pressure
  • Symptom improvement 3

Expected Benefits

Based on moderate to low-certainty evidence, TRT provides:

1. Sexual function improvements (moderate-certainty evidence):

   • Small but significant improvement in global sexual function (SMD 0.35 higher) 1
   • Small improvement in erectile function (SMD 0.27 higher) 1

2. Quality of life improvements (low-certainty evidence):

   • Small improvement in quality of life measures (SMD 0.33 lower on AMS scale) 1
   • Improvements in energy and vitality (SMD 0.17 higher) 1

3. Other potential benefits:

   • Small improvement in depressive symptoms (SMD 0.19 lower) 1
   • Potential improvements in body composition 3, 5

Potential Risks and Monitoring

Cardiovascular Risk

• Low-certainty evidence showed small to no difference in adverse cardiovascular events (Peto odds ratio 1.22) 1
• Use caution in patients with cardiovascular disease 3

Other Risks

• Polycythemia: Monitor hematocrit regularly; discontinue if >54% 3
• Prostate effects: Monitor PSA; contraindicated in prostate cancer 3
• Sleep apnea: May worsen existing sleep apnea 3
• Fluid retention: Monitor for peripheral edema 3

Fertility Considerations

• TRT suppresses spermatogenesis 6
• If fertility is desired, consider alternative treatments:
  • Selective estrogen receptor modulators (SERMs)
  • Aromatase inhibitors
  • Human chorionic gonadotropin (hCG) 3, 7, 6

Treatment Adherence

• Patients often discontinue TRT prematurely 4
• Discuss expectations and importance of long-term therapy
• Consider patient preference for administration route (topical vs. injectable) 1

Common Pitfalls to Avoid

• Not monitoring for adverse effects, particularly hematocrit elevation 3
• Discontinuing therapy prematurely before benefits are realized 4
• Using testosterone for "age-related hypogonadism" without clear pathology 2

Follow-up Recommendations

• Assess symptom improvement at 3 months
• Continue regular monitoring of testosterone levels, hematocrit, and PSA
• Evaluate for side effects at each visit
• Consider bone density testing if baseline osteopenia/osteoporosis is suspected