From the Guidelines
Testosterone level evaluation is necessary in a 60-year-old male patient with osteopenia, as it can help identify hypogonadism, a recognized risk factor for bone loss in men. According to the evidence-based guideline for the management of osteoporosis in men published in Nature Reviews Rheumatology in 2024 1, serum free or total testosterone levels should be measured as part of the investigatory work-up for osteoporosis in men. This is because testosterone therapy might be indicated in the case of symptomatic deficiency, and hypogonadal men with osteoporosis should usually be treated with an established anti-osteoporosis medication, regardless of whether testosterone therapy is instituted.
Key points to consider in the evaluation of testosterone levels in this patient include:
- Measuring morning total testosterone level, preferably drawn before 10 AM when levels are highest
- Repeating the test to confirm low levels, along with measuring free testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) to determine if the hypogonadism is primary or secondary
- Considering testosterone replacement therapy in men with confirmed testosterone deficiency and osteopenia, typically starting with testosterone gel, injections, or patches
- Initiating testosterone therapy only after careful consideration of potential risks, including prostate issues, cardiovascular effects, and erythrocytosis
It is also important to note that a comprehensive evaluation for osteopenia should include other laboratory tests, such as calcium, vitamin D, parathyroid hormone, and thyroid function tests, as multiple factors often contribute to bone loss in older men. The potential benefits of hormone replacement therapy on bone mineral density (BMD) in hypogonadal men, as demonstrated in the T-trial 1, support the assessment of serum total or free testosterone levels in men undergoing investigation for osteoporosis.
From the Research
Testosterone Level Evaluation in a 60-year-old Male Patient with Osteopenia
- The evaluation of testosterone levels in a 60-year-old male patient with osteopenia is a complex issue, with various studies providing insights into the relationship between testosterone and bone health 2, 3, 4, 5, 6.
- Testosterone has an important role in maintaining bone mineral density (BMD) among men, and a decrease in testosterone with age can lead to decreased BMD and increased risk of osteoporosis 2.
- However, the relationship between testosterone levels and osteoporosis development has been conflicting in human epidemiological studies, and more research is needed to fully understand this relationship 2.
- Testosterone replacement therapy (TRT) has been shown to be beneficial in improving BMD in hypogonadal men with osteopenia and osteoporosis, although its effects on preventing bone fractures are still unclear 2, 3, 5, 6.
- The diagnosis of hypogonadism in older men is a clinical syndrome complex that comprises both symptoms and biochemical testosterone deficiency, and a diagnosis of hypogonadism associated with borderline testosterone levels should only be made by an experienced clinician 4.
- Regular measurements of bone mineral density are necessary in hypogonadal men, as densitometric parameters should be accepted as an osteologic marker of androgenization of the male organism 3.
- Testosterone therapy has been shown to result in greater improvements in skeletal health in hypogonadal men with type 2 diabetes compared to their non-diabetic counterparts 6.
Key Considerations
- The evaluation of testosterone levels in a 60-year-old male patient with osteopenia should take into account the patient's overall health, symptoms, and medical history 4, 5.
- TRT should be considered as one of the treatment options to improve hypogonadal symptoms and BMD simultaneously in symptomatic hypogonadal men with osteopenia 2, 5.
- More research is needed to fully understand the relationship between testosterone levels and osteoporosis development, as well as the effects of TRT on preventing bone fractures 2, 3, 5, 6.