Recommended Workup for Starting Testosterone Therapy
Prior to initiating testosterone therapy, clinicians should perform a comprehensive evaluation including hemoglobin/hematocrit, PSA (for men over 40), and assessment of cardiovascular risk factors to ensure safe and effective treatment. 1
Initial Laboratory and Clinical Assessment
- Measure morning total testosterone levels between 8-10 AM on at least two separate occasions to confirm testosterone deficiency 1
- Measure free testosterone by equilibrium dialysis and sex hormone-binding globulin, particularly in obese patients 1
- Measure luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to distinguish between primary and secondary hypogonadism 1
- Obtain baseline hemoglobin/hematocrit (withhold therapy if hematocrit exceeds 50%) 1
- Measure PSA in men over 40 years of age to exclude occult prostate cancer 1
- Assess for cardiovascular disease risk factors (both fixed and modifiable) 1
Fertility Considerations
- Perform testicular examination to evaluate size, consistency, and descent 1
- Measure serum FSH to assess underlying reproductive health status 1
- Consider semen analysis for patients interested in preserving fertility 1
- Offer reproductive genetic testing (karyotype and Y-chromosome microdeletion analysis) for patients with severe oligospermia (<5 million sperm/mL) or non-obstructive azoospermia 1
- Counsel patients that testosterone therapy will impair spermatogenesis and should not be used in men actively trying to conceive 1
Additional Evaluations Based on Clinical Presentation
- For patients with low testosterone and low LH/FSH (secondary hypogonadism), consider measuring serum prolactin and iron saturation 1
- Consider pituitary function testing and MRI of the sella turcica in cases of secondary hypogonadism 1
- For patients with history of cardiovascular events, consider delaying testosterone therapy for 3-6 months after the most recent event 1
Patient Counseling Prior to Initiation
- Discuss potential benefits: improvements in erectile function, libido, anemia, bone mineral density, lean body mass, and depressive symptoms 1
- Inform about potential risks: polycythemia (especially with injectable forms), sleep apnea exacerbation, and effects on fertility 1
- Counsel that current evidence cannot definitively state whether testosterone therapy increases or decreases cardiovascular risk 1
- Advise on lifestyle modifications (weight loss, physical activity) as adjunctive treatment 1
- Discuss the variable time course for recovery of spermatogenesis after cessation of therapy for patients interested in future fertility 1
Common Pitfalls and Caveats
- Avoid alkylated oral testosterone preparations due to hepatotoxicity risk 1
- Be aware that injectable testosterone is associated with the greatest treatment-induced increases in hemoglobin/hematocrit 1
- For patients with elevated PSA at baseline, obtain a second PSA test to rule out spurious elevation before proceeding 1
- Monitor for polycythemia during treatment; hematocrit >54% warrants dose reduction or temporary discontinuation 1
- Recognize that testosterone therapy should target levels in the middle tertile of the normal reference range (450-600 ng/dL) 1
Following this comprehensive workup will help ensure appropriate patient selection for testosterone therapy while minimizing potential risks and optimizing treatment outcomes.