What is the initial workup for a male with hyperandrogenism (elevated testosterone)?

Initial Workup for Male with Hyperandrogenism (Elevated Testosterone)

The initial workup for a male with elevated testosterone should include measurement of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin levels to determine the etiology of hyperandrogenism, as this will guide appropriate treatment and prevent potential complications related to morbidity and mortality. 1

Primary Evaluation Components

Laboratory Testing

• Measure serum luteinizing hormone (LH) levels to help establish the etiology of testosterone elevation 1
• Measure follicle-stimulating hormone (FSH) to assess reproductive health status and spermatogenesis 1
• Check serum prolactin levels, especially if LH levels are low or low/normal 1
• Measure serum estradiol, particularly if the patient presents with breast symptoms or gynecomastia 1
• Consider measuring sex hormone binding globulin (SHBG) to calculate free testosterone levels 2
• Measure dihydrotestosterone (DHT) levels, as elevated DHT can cause specific clinical manifestations like androgenic alopecia 2

Clinical Assessment

• Perform a thorough physical examination with particular attention to:
  • Secondary sex characteristics and body habitus 1
  • Presence of gynecomastia 3
  • Androgenic manifestations (acne, alopecia) 2
  • Testicular examination (size, consistency, presence of masses) 1, 3
  • Digital rectal examination to assess prostate size and consistency 1

Differential Diagnosis Based on Laboratory Findings

Pattern 1: Elevated Testosterone with Elevated LH

• Suggests testicular resistance to androgens 1
• Consider testicular pathology 3

Pattern 2: Elevated Testosterone with Normal/Low LH

• Suggests autonomous testosterone production 1
• Consider:
  • Testicular tumors (including those without Leydig cell involvement) 3
  • Adrenal pathology (evaluate DHEAS levels) 4, 3
  • Exogenous testosterone use 5

Pattern 3: Elevated Testosterone with Elevated SHBG

• May not represent true hyperandrogenism as free testosterone may be normal 2
• Consider:
  • Age-related changes (more common in older men) 2
  • Medications with estrogenic effects 4
  • Hyperthyroidism 4
  • Liver disease 4

Additional Workup Based on Initial Findings

• If prolactin is elevated, repeat measurement to ensure it wasn't spurious 1
• For persistently elevated prolactin, consider pituitary MRI to rule out prolactinoma or other pituitary tumors 1
• If testosterone is very high (>twice upper limit of normal) with normal SHBG, consider adrenal imaging to rule out adrenal tumors 4, 3
• If testicular abnormalities are found on physical exam, obtain testicular ultrasound 1, 3
• For men with very low LH and testosterone <150 ng/dL, consider pituitary MRI regardless of prolactin levels 1

Clinical Patterns and Manifestations

• Patients with elevated total testosterone and elevated SHBG tend to be older with larger prostate volumes but fewer acne complaints 2
• Patients with elevated total testosterone, normal SHBG, and elevated DHT typically have the most pronounced clinical manifestations of hyperandrogenism 2
• Patients with isolated DHT elevation with normal testosterone often present primarily with androgenic alopecia 2

Important Considerations

• True hyperandrogenism in men is uncommon and warrants thorough investigation 5, 3
• Elevated testosterone can sometimes mask underlying pathology such as testicular or adrenal tumors 3
• Consider fertility implications - if the patient desires fertility, avoid treatments that might impair spermatogenesis 1
• Monitor for cardiovascular risk factors in patients with hyperandrogenism 1
• If hyperandrogenism is confirmed and treatment is needed, commercially manufactured products are preferred over compounded preparations 1

Monitoring Recommendations

• For patients requiring treatment, measure testosterone levels every 6-12 months 1
• Monitor for symptoms of hyperandrogenism including prostate enlargement, sleep apnea, gynecomastia, and polycythemia 1
• Perform digital rectal examination and PSA testing to monitor for prostate complications 1