Management of Hypogonadism in a 50-Year-Old Male
Testosterone replacement therapy (TRT) is the recommended treatment for this 50-year-old male with confirmed hypogonadism (testosterone 6.7 nmol/L), decreased libido, and low energy, after confirming the diagnosis with a second morning testosterone measurement and appropriate laboratory workup. 1, 2
Diagnostic Confirmation
Before initiating treatment:
- Confirm hypogonadism with a second morning testosterone measurement between 8-10 AM 1, 3
- Measure:
- Free testosterone by equilibrium dialysis
- Sex hormone-binding globulin (SHBG)
- Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to distinguish primary from secondary hypogonadism
- Estradiol if gynecomastia is present
- Complete blood count (hemoglobin/hematocrit)
- Prostate-specific antigen (PSA) 2
Treatment Options
First-line: Testosterone Replacement Therapy
For confirmed hypogonadism with symptoms:
- Starting dose: 40.5 mg testosterone gel 1.62% applied topically once daily in the morning to shoulders and upper arms 3
- Target: Testosterone levels in mid-normal range (450-600 ng/dL) 2
- Dose adjustment: Based on pre-dose morning testosterone concentration at approximately 14 and 28 days 3
| Pre-Dose Morning Testosterone | Dose Adjustment |
|---|---|
| >750 ng/dL | Decrease daily dose by 20-25% |
| 350-750 ng/dL | No change |
| <350 ng/dL | Increase daily dose by 20-25% |
Alternative Formulations
- Transdermal preparations (gels, patches): Preferred for stable day-to-day levels 1, 2
- Injectable testosterone: Less expensive ($156.24 vs $2135.32 annually for transdermal) but may cause fluctuating levels 1
- Implantable pellets: Longer-term option but requires implantation procedure 1
Patient preference may influence choice - studies show 53% of patients prefer injectable testosterone (primarily due to cost), while 71% of those who tried both preferred topical gel for convenience and ease of use 1.
Fertility Considerations
If fertility is a concern:
- Avoid exogenous testosterone as it suppresses spermatogenesis 2
- Consider alternative treatments:
Contraindications to TRT
Absolute contraindications include:
- Prostate cancer
- Breast cancer
- Desire for near-term fertility
- Severe sleep apnea
- Uncontrolled heart failure
- Recent cardiovascular events 2, 3
Monitoring and Follow-up
- First follow-up: 1-2 months to assess efficacy 2
- Testosterone levels: Test 2-3 months after treatment initiation or dose change 2
- Once stable: Monitor every 6-12 months 2
- Regular assessment of:
Expected Benefits
TRT has demonstrated improvements in:
- Sexual function and libido 5
- Energy levels 5
- Body composition (increased lean mass, decreased fat mass)
- Insulin sensitivity
- Lipid profile
- Muscle strength 1, 2
In a placebo-controlled study, 73% of men using testosterone solution achieved normal testosterone levels with significant improvements in sexual drive and energy compared to placebo 5.
Potential Risks and Side Effects
- Erythrocytosis (dose-dependent: 2.8-17.9%)
- Suppression of spermatogenesis
- Peripheral edema
- Emotional lability
- Potential cardiovascular effects (though high-quality evidence suggests TRT does not increase stroke or heart attack risk in men 45-80 years old) 2
Lifestyle Modifications
Consider concurrent lifestyle modifications:
- Weight loss through low-calorie diets
- Increased physical activity
These changes can help reverse obesity-associated secondary hypogonadism and may enhance the benefits of TRT 2.
TRT has shown favorable results in men with obesity and hypogonadism, including improvements in weight, fasting glucose, insulin resistance, lipid profile, and body composition 1.