Should primary care providers manage testosterone therapy?

Primary Care Management of Testosterone Therapy

Primary care providers should not routinely manage testosterone therapy, as this treatment requires specialized monitoring and expertise typically found in specialty care settings. 1

Rationale for Specialty Management

• Testosterone therapy requires complex diagnostic evaluation to determine the underlying cause of hypogonadism, including measurement of luteinizing hormone and follicle-stimulating hormone levels to differentiate between primary and central hypogonadism 1
• Testosterone treatment requires precise dosing adjustments to achieve total testosterone levels in the middle tertile of the normal reference range (450-600 ng/dL), which demands specialized expertise 1
• Regular monitoring is necessary every 6-12 months while on testosterone therapy to ensure appropriate therapeutic levels are maintained 1
• The American Urological Association (AUA) guidelines emphasize the need for specialized expertise in managing testosterone deficiency, with recommendations that include specialists in urology, cardiology, and other fields 1

Diagnostic Complexity

• Diagnosis requires confirmation of low testosterone with repeat testing due to variability in assays 1
• Free testosterone determination may be needed using reliable assays (such as equilibrium dialysis) when alterations in binding proteins are suspected 1
• Primary care providers may consider obtaining morning serum total testosterone measurements in male patients with symptoms like fatigue, weight loss, loss of libido, erectile dysfunction, or reduced bone mineral density, but further management should involve specialty consultation 1

Treatment Considerations

• Testosterone therapy has shown only small improvements in sexual functioning and quality of life, with little to no effect on physical functioning, depressive symptoms, energy, vitality, or cognition 1
• Long-term efficacy and safety of testosterone therapy remain unknown, as few trials exceed one year in duration 1
• Specialized knowledge is required for selecting appropriate testosterone formulations:
  • Commercially manufactured testosterone products should be prescribed rather than compounded testosterone 1
  • Alkylated oral testosterone should not be prescribed due to liver toxicity 1
  • Different formulations (intramuscular vs. transdermal) require different monitoring approaches 1

Safety Concerns

• Testosterone therapy is contraindicated in men trying to conceive due to interruption of normal spermatogenesis 1
• Treatment should not be commenced for 3-6 months in patients with a history of cardiovascular events 1
• Specialized monitoring is needed for potential adverse effects including polycythemia, elevated prostate-specific antigen levels, increased blood pressure, and other complications 1
• Testosterone therapy may increase the risk of cardiovascular events, prostate cancer, and thromboembolic disease, though evidence is limited 1

Limited Role for Primary Care

• Primary care providers may play a role in initial identification of patients with potential testosterone deficiency 2, 3
• Primary care providers can consider obtaining morning serum testosterone measurements in men with specific symptoms 1
• However, once testosterone deficiency is suspected, referral to specialists is appropriate for comprehensive evaluation and management 2, 4
• While some research suggests protocols can facilitate safe prescribing in primary care settings, these require specialized training and structured protocols not widely implemented 5

When to Refer

• Patients with confirmed low testosterone levels should be referred to specialists (typically urologists or endocrinologists) for further evaluation and management 1
• Men with hypogonadism desiring to maintain fertility require specialized approaches using aromatase inhibitors, human chorionic gonadotropin, or selective estrogen receptor modulators 1
• Patients with abnormal luteinizing hormone or follicle-stimulating hormone levels require further specialized evaluation 1

In conclusion, while primary care providers play an important role in identifying potential testosterone deficiency, the complex nature of diagnosis, treatment decisions, monitoring requirements, and potential risks associated with testosterone therapy make this a treatment best managed by specialists with appropriate expertise.