Pre-Testosterone Therapy Testing Requirements
Before deciding on a dosage for testosterone therapy in patients with high testosterone levels, comprehensive laboratory testing including total testosterone, hemoglobin/hematocrit, PSA (in men over 40), cardiovascular risk assessment, and fertility evaluation should be conducted. 1
Essential Baseline Tests
Hormone Profile
- Total testosterone levels - Mandatory baseline measurement to confirm diagnosis and establish reference point 1
- Free testosterone levels - Particularly important when total testosterone is borderline or when conditions affecting sex hormone-binding globulin exist 1
- Luteinizing hormone (LH) and Follicle-stimulating hormone (FSH) - To distinguish between primary and secondary hypogonadism 1
Hematologic Parameters
- Hemoglobin/hematocrit - Critical baseline measurement to assess risk of erythrocytosis 1, 2
- If hematocrit exceeds 50%, therapy should be withheld until etiology is investigated 1
- Testosterone therapy significantly increases hemoglobin (mean increase 0.80 g/dl) and hematocrit (mean increase 3.18%) 3
- Risk varies by administration route: injectable testosterone (43.8%), transdermal patches (15.4%), gels (2.8-17.9%) 1
Prostate Assessment
- Prostate-specific antigen (PSA) - Required for men over 40 years 1
- If elevated, a second test should be performed to rule out spurious elevation
- If two PSA levels raise suspicion for prostate cancer, consider reflex testing (4K or phi) and prostate biopsy with/without MRI before starting therapy
Cardiovascular Risk Assessment
- Lipid profile - Testosterone therapy may decrease HDL cholesterol (mean decrease 0.49 mg/dl) 3
- Blood pressure measurement
- Blood glucose/HbA1c - Androgens may decrease blood glucose in diabetic patients 2
- Assessment of modifiable risk factors - Dyslipidemia, hypertension, diabetes, current smoking 1
Fertility Considerations
- Testicular examination - To evaluate size, consistency, and descent 1
- Semen analysis - Consider if FSH is elevated or if fertility is a concern 1
- Genetic testing - Karyotype and Y-chromosome analysis for men with severe oligospermia or non-obstructive azoospermia 1
Additional Considerations
Contraindications to Assess
- Breast or prostate cancer - Absolute contraindication 4
- Palpable prostate nodule or induration - Requires urological evaluation 4
- Elevated PSA - >4 ng/mL or >3 ng/mL in high-risk men 4
- Severe obstructive sleep apnea - Should be treated before initiating therapy 4
- Recent cardiovascular events - MI or stroke within 6 months 4
- Thrombophilia - Increased risk with testosterone therapy 4
Dosage Considerations
- Target mid-normal testosterone values (350-600 ng/dL) to minimize risk of erythrocytosis 1
- Consider administration route based on individual risk profile for erythrocytosis 1
- For injectable testosterone, monitor for fluctuating levels which may increase cardiovascular risk 1
Monitoring Protocol After Initiation
- Check testosterone levels 2-3 months after treatment initiation and after any dose change 1
- Monitor hemoglobin/hematocrit 1-2 months after initiation, every 3-6 months during the first year, then annually 1
- Follow PSA according to standard prostate cancer screening guidelines 1
- If hematocrit becomes elevated, temporarily discontinue therapy until normalized and consider dose reduction when restarting 1
Common Pitfalls to Avoid
- Ignoring baseline hematocrit - Elevated levels increase risk of thromboembolic events 1, 2
- Overlooking fertility concerns - Testosterone therapy may suppress spermatogenesis 1, 5
- Inappropriate dosing - Higher doses (300 mg/week) are not more effective than moderate doses (100 mg/week) for suppressing LH/FSH but increase side effect risk 5
- Inadequate monitoring - Failure to check hemoglobin/hematocrit regularly can miss polycythemia 2
- Drug interactions - Testosterone may increase sensitivity to oral anticoagulants and affect blood glucose control in diabetics 2