What is the recommended treatment for late-onset hypogonadism (andropause)?

Treatment of Late-Onset Hypogonadism (Andropause)

Testosterone replacement therapy is the recommended treatment for late-onset hypogonadism in men with both clinical symptoms and confirmed low testosterone levels. 1

Diagnostic Criteria

Before initiating treatment, proper diagnosis is essential:

• Clinical symptoms must be present, particularly:

  • Sexual symptoms: Reduced libido, erectile dysfunction, decreased morning erections
  • Physical symptoms: Decreased physical activity/strength, difficulty walking, fatigue
  • Psychological symptoms: Low mood, decreased motivation, fatigue 1

• Laboratory confirmation is required:

  • Morning total testosterone levels <200 ng/dL indicate definite hypogonadism
  • Levels between 200-400 ng/dL require repeat testing and free testosterone measurement
  • Sex hormone binding globulin (SHBG) levels should be considered as they affect free testosterone 1

Treatment Algorithm

1. First-line: Lifestyle modifications

   • Weight loss for obese patients (can reverse obesity-associated secondary hypogonadism)
   • Regular physical activity
   • Limiting alcohol consumption
   • Addressing metabolic disorders 1

2. Testosterone replacement therapy (TRT)

   • Target: Total testosterone levels between 500-900 ng/dL 2
   • Formulations:
     • Transdermal gels (lower risk of erythrocytosis compared to injectables)
     • Injectable testosterone (cypionate or enanthate)
     • Transdermal patches
     • Buccal tablets 3, 4

3. Monitoring during TRT:

   • Total testosterone: 3-6 months after initiation, then annually
   • Hematocrit: Baseline, 3-6 months, then annually (discontinue if >54%)
   • PSA: Baseline, 3-6 months, then according to guidelines for prostate cancer screening
   • Bone mineral density: In hypogonadal patients 1, 2

Contraindications for TRT

• Active prostate or breast cancer
• Hematocrit >50%
• Severe untreated sleep apnea
• Severe lower urinary tract symptoms
• Uncontrolled heart failure
• Desire for current or future fertility 2, 3, 4

Potential Side Effects and Management

• Erythrocytosis: Most common side effect (2.8-43.8% depending on formulation)

  • Injectable testosterone has highest risk (43.8%)
  • Consider dose reduction or therapeutic phlebotomy if hematocrit >54% 2

• Prostate effects: Monitor PSA

  • Consider biopsy if PSA >4.0 ng/mL or increases >1.0 ng/mL/year 2, 3

• Cardiovascular risk: Regular assessment of lipid profiles and blood pressure 2

• Fertility suppression: TRT can suppress spermatogenesis 3

• Other potential side effects:

  • Edema (caution in cardiac, renal, or hepatic disease)
  • Gynecomastia
  • Sleep apnea exacerbation (especially in obese patients)
  • Changes in lipid profile 3, 4

Common Pitfalls to Avoid

1. Treating based on age alone without confirming both symptoms and low testosterone levels

   • Only 2% of men aged 40-80 have true LOH by strict criteria 5

2. Overlooking modifiable causes of hypogonadism

   • Obesity is a more common cause of low testosterone than age itself 5
   • Address metabolic disorders, obesity, and other comorbidities first 1

3. Ignoring contraindications to testosterone therapy

   • Particularly important for prostate cancer risk, erythrocytosis, and cardiovascular disease 3, 4

4. Inadequate monitoring during treatment

   • Regular assessment of testosterone levels, hematocrit, PSA, and symptom response is essential 2

Remember that late-onset hypogonadism is a clinical and biochemical syndrome requiring both symptoms and laboratory confirmation for diagnosis and treatment. Indiscriminate testosterone prescribing without proper diagnosis should be avoided 6.