Do you treat a 50-year-old male with a low testosterone level of 140 nanograms per deciliter (ng/dL)?

Management of Low Testosterone Level of 140 ng/dL in a 50-Year-Old Male

Testosterone replacement therapy (TRT) is indicated for a 50-year-old male with a testosterone level of 140 ng/dL, as this value is well below the diagnostic threshold of 300 ng/dL and likely contributes to clinical symptoms of hypogonadism. 1

Diagnostic Confirmation

Before initiating treatment:

• Confirm hypogonadism with a second morning testosterone measurement between 8-10 AM 1
• Ensure measurements are taken on two separate days 2
• Assess for symptoms of hypogonadism (sexual dysfunction, fatigue, decreased muscle mass)
• Measure luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to determine if primary or secondary hypogonadism 1
• Consider measuring prolactin levels, especially with low/normal LH levels 1

Treatment Decision Algorithm

1. Testosterone level < 300 ng/dL (confirmed twice) + symptoms = Treat

   • A level of 140 ng/dL is significantly below the threshold of 300 ng/dL used by most guidelines 1, 2
   • This level meets criteria for treatment according to the American Urological Association and Endocrine Society guidelines 1

2. Pre-treatment assessment:

   • Assess cardiovascular risk factors
   • Check hematocrit/hemoglobin (baseline)
   • Evaluate prostate health (PSA, digital rectal exam if indicated)
   • Discuss fertility desires (TRT suppresses spermatogenesis) 1
   • Rule out contraindications: prostate cancer, breast cancer, severe sleep apnea, uncontrolled heart failure, recent cardiovascular events 1

Treatment Options

First-line: Testosterone Replacement Therapy

• Starting dose: 40.5 mg testosterone gel applied topically once daily to shoulders and upper arms 2
• Target testosterone level: 450-600 ng/dL (mid-tertile of normal range) 1
• Formulation options:
  • Transdermal preparations (gels/patches): Provide stable day-to-day levels 1
  • Injectable testosterone: Less expensive but causes fluctuating levels 1
  • Implantable pellets: Longer-term option but requires implantation procedure 1

Alternative options (if fertility is desired or contraindications to TRT exist):

• Aromatase inhibitors: Can increase endogenous testosterone production in men with normal pituitary function 1
• Lifestyle modifications: Weight loss and physical activity can improve testosterone levels in overweight men 1

Monitoring Protocol

1. Initial follow-up:

   • Check testosterone levels 2-3 months after starting treatment 1
   • Adjust dose according to levels (see table below)

2. Dose adjustment criteria: 1, 2

   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%

3. Long-term monitoring:

   • Once stable, check testosterone levels every 6-12 months 1
   • Monitor hematocrit/hemoglobin (risk of erythrocytosis: 2.8-17.9%) 1
   • Assess cardiovascular status, especially in older patients 1
   • Monitor for other adverse effects: peripheral edema, emotional lability 1

Expected Benefits

• Improved sexual functioning and quality of life (though effect sizes may be small) 3
• Increased lean mass and decreased fat mass 1
• Improved body composition and potentially insulin sensitivity 1

Important Caveats

• TRT has little to no effect on physical functioning, depressive symptoms, energy/vitality, or cognition in most studies 3
• Long-term safety data regarding cardiovascular outcomes and prostate cancer risk are limited 3
• FDA approval is specifically for conditions associated with deficiency of endogenous testosterone, not specifically for "age-related hypogonadism" 2

A testosterone level of 140 ng/dL in a 50-year-old male is significantly below normal range and warrants treatment if accompanied by symptoms of hypogonadism, after proper confirmation with a second morning measurement.