Management of Proportionate Testosterone Imbalance
For patients with testosterone deficiency, the goal of testosterone therapy should be to achieve total testosterone levels in the middle tertile of the normal reference range (450-600 ng/dL) using the minimal dosing necessary. 1
Diagnostic Evaluation
- Diagnosis of testosterone deficiency should be made only in men with symptoms and signs consistent with testosterone deficiency and confirmed with at least two separate morning testosterone measurements 1
- Clinicians should measure serum luteinizing hormone (LH) levels in patients with low testosterone to establish the etiology of testosterone deficiency 1
- Serum prolactin levels should be measured in patients with low testosterone combined with low or low/normal LH levels 1
- Patients with persistently high prolactin levels should undergo evaluation for endocrine disorders 1
- Men with total testosterone levels <150 ng/dL in combination with low or low/normal LH should undergo pituitary MRI regardless of prolactin levels 1
Pre-Treatment Assessment
- Prior to offering testosterone therapy, clinicians should:
Treatment Options
FDA-Approved Testosterone Preparations
- Intramuscular injections:
- Transdermal preparations (gels, patches):
Alternative Therapies for Men Desiring Fertility
- Clinicians may use aromatase inhibitors, human chorionic gonadotropin, selective estrogen receptor modulators, or a combination in men with testosterone deficiency desiring to maintain fertility 1
- Exogenous testosterone therapy should NOT be prescribed to men who are currently trying to conceive 1
Dosing and Administration
- Target testosterone levels in the middle tertile of the normal reference range (450-600 ng/dL) 1
- Transdermal testosterone preparations (gel, patch) are generally favored over intramuscular injections due to more stable day-to-day testosterone levels 1
- Testosterone injections offer the benefit of avoiding daily administration 1
- Commercially manufactured testosterone products should be prescribed rather than compounded testosterone 1
- Clinicians should NOT prescribe alkylated oral testosterone due to risk of liver toxicity 1
Monitoring During Treatment
- Monitor testosterone levels every 6-12 months once stable levels are confirmed 1
- For patients receiving testosterone injections, levels should be measured midway between injections, targeting a mid-normal value (500-600 ng/dL) 1
- For patients receiving transdermal preparations, levels can be measured at any time 1
- Monitor prostate-specific antigen (PSA):
- Urologic referral for possible biopsy is recommended for patients with an increase in PSA of more than 1.0 ng/mL during the first six months of treatment or more than 0.4 ng/mL per year thereafter 1
Special Considerations
- Cardiovascular risk: Testosterone therapy should not be commenced for a period of three to six months in patients with a history of cardiovascular events 1
- Prostate cancer risk: Men over 40 should have PSA monitoring during treatment 1
- Fertility concerns: Exogenous testosterone can interrupt normal spermatogenesis and can result in severely oligospermic or azoospermic states 1
Contraindications
- Exogenous testosterone therapy should not be used in:
Treatment of Hyperandrogenism
- For patients with hyperandrogenism (testosterone levels consistently above the normal physiologic range), anti-androgen therapy is recommended as first-line treatment 5
- Options include Spironolactone (100-200 mg daily) or Flutamide (250 mg daily, though less commonly used due to hepatotoxicity risk) 5