What is the recommended treatment for men with symptoms of Andropause (Late-Onset Hypogonadism)?

Treatment for Andropause (Late-Onset Hypogonadism)

Testosterone replacement therapy (TRT) is recommended for men with symptomatic hypogonadism to improve sexual function, quality of life, muscle mass, strength, and bone mineral density, but should not be used in eugonadal men or those with contraindications. 1

Diagnosis and Assessment

• Diagnosis of hypogonadism should only be made in men with consistent symptoms and unequivocally low serum testosterone levels 1
• Laboratory confirmation requires:
  • Morning total testosterone measurements on at least two separate occasions 1, 2
  • Free or bioavailable testosterone measurement when total testosterone is near the lower limit or when sex hormone-binding globulin abnormality is suspected 2
• Clinical evaluation should include:
  • Assessment of symptoms (decreased libido, erectile dysfunction, fatigue, decreased vitality) 1
  • Evaluation for potential causes (pituitary disorders, medications affecting HPG axis) 1
  • Physical examination including BMI and waist circumference 1
  • Screening for contraindications to therapy 1, 2

Treatment Recommendations

First-line Treatment: Lifestyle Modifications

• Weight loss through low-calorie diets can reverse obesity-associated secondary hypogonadism 1
• Physical activity shows benefits with results correlating to exercise duration and weight loss 1
• These interventions may increase testosterone levels by 1-2 nmol/L 1

Pharmacological Treatment

• Testosterone replacement therapy is indicated for men with:

  • Symptomatic hypogonadism 1, 3
  • Consistently low testosterone levels 2
  • Symptoms affecting quality of life 1

• Formulation options:

  • Transdermal preparations (gels, patches)
  • Intramuscular injections (testosterone cypionate, enanthate) 1, 3
  • Selection based on patient preference, pharmacokinetics, side effects, and cost 2

• Target testosterone levels:

  • Aim for mid-normal range during treatment 2
  • Adjust dosing based on clinical response and laboratory monitoring 2

Contraindications to Testosterone Therapy

• Absolute contraindications:
  • Active or treated male breast cancer 1
  • Planning fertility in the near term 1, 2
  • Prostate cancer 2
  • PSA >4 ng/mL or >3 ng/mL in high-risk men without urological evaluation 2
  • Elevated hematocrit 2
  • Untreated severe obstructive sleep apnea 2
  • Severe lower urinary tract symptoms 2
  • Uncontrolled heart failure 2
  • Recent myocardial infarction or stroke (within 6 months) 2

Monitoring During Treatment

• Regular follow-up with standardized monitoring plan:
  • Evaluate symptoms, adverse effects, and compliance 2
  • Measure serum testosterone and hematocrit 2
  • Assess prostate cancer risk (PSA, digital rectal examination) 1, 2

Expected Benefits and Limitations

• Benefits of testosterone therapy:

  • Improved sexual functioning and quality of life (small but significant improvements) 1
  • Increased muscle mass and strength 1
  • Improved bone mineral density 1, 4

• Limited or no benefit for:

  • Physical functioning 1
  • Depressive symptoms 1
  • Energy and vitality 1
  • Cognition 1
  • Weight reduction or cardiometabolic status 1

Important Considerations

• Testosterone therapy should not be used in eugonadal men 1
• Fertility concerns must be addressed before initiating therapy 1
• Testosterone testing should be avoided during acute illness 1
• Long-term efficacy and safety data are limited, particularly for cardiovascular outcomes and prostate cancer risk 1
• Combining lifestyle modifications with TRT may yield better outcomes in symptomatic patients 1