From the Guidelines
The appropriate diagnostic workup for a 35-year-old male with hypogonadism is to measure a morning serum testosterone level using an accurate and reliable assay.
Diagnostic Approach
- The initial step in diagnosing hypogonadism is to assess symptoms such as decreased sexual desire (libido) or activity, or erectile dysfunction 1.
- A morning total testosterone level should be measured, as levels are typically highest in the morning 1.
- If the total testosterone level is close to the lower limit, it is reasonable to determine free testosterone concentrations either directly from equilibrium dialysis assays or by calculations that use total testosterone, sex hormone binding globulin, and albumin concentrations 1.
- Further testing, such as luteinizing hormone and follicle-stimulating hormone levels, may be needed to distinguish between primary and secondary hypogonadism and to determine the underlying cause of hypogonadism 1.
Considerations
- Obesity is a major confounder in the diagnosis of hypogonadism, as it can lower testosterone levels 1.
- The Endocrine Society Clinical Practice Guideline provides detailed recommendations for the diagnosis and evaluation of hypogonadism 1.
- It is essential to consider the potential benefits and risks of testosterone replacement therapy, including improved sexual function, well-being, muscle mass and strength, and bone density, as well as potential cardiovascular risks 1.
From the Research
Diagnostic Workup for Hypogonadism
The diagnostic workup for a 35-year-old male with hypogonadism involves:
- Clinical signs and symptoms consistent with androgen deficiency 2, 3, 4
- Laboratory confirmation via the measurement of low morning testosterone levels on two different occasions 2, 3, 4
- Serum luteinizing hormone and follicle-stimulating hormone levels to distinguish between primary (hypergonadotropic) and secondary (hypogonadotropic) hypogonadism 2
Laboratory Testing
- Total testosterone is considered the appropriate testosterone measurement in most situations in primary care 4
- Free testosterone is a more accurate marker and is indicated in some situations 4
- Measurement of serum testosterone levels to confirm an adequate replacement dosage 2
Additional Evaluations
- Digital rectal examination and prostate-specific antigen tests to monitor for prostate cancer 2, 4
- Measurement of hematocrit to detect polycythemia 2
- Serial measurement of bone mineral density during androgen therapy to confirm end-organ effects 2
- Evaluation of comorbidities such as metabolic syndrome and type 2 diabetes 4
- Assessment of overall health, including cardiovascular and chronic obstructive pulmonary disease, and frailty 5
Treatment Considerations
- Testosterone replacement therapy is a valid treatment option for men with testosterone deficiency accompanied by symptoms of hypogonadism 2, 3, 4, 5
- Contraindications to testosterone-replacement therapy include prostate and breast cancers, uncontrolled congestive heart failure, severe lower-urinary-tract symptoms, and erythrocytosis 3, 5