What is the appropriate management for a patient with hypergonadism and normal FSH, LH, and prolactin levels?

Management of Hypergonadism with Normal Gonadotropins

This patient with markedly elevated testosterone (1187 ng/dL) and normal FSH, LH, and prolactin does not have a pituitary-driven disorder and requires investigation for exogenous testosterone use, testosterone-secreting tumors, or other causes of hypergonadism—not testosterone therapy, which is contraindicated in eugonadal men. 1

Critical First Steps

Rule Out Exogenous Testosterone

• Directly question the patient about testosterone supplementation, anabolic steroid use, or performance-enhancing substances, as this is the most common cause of elevated testosterone with normal gonadotropins 1
• Exogenous testosterone suppresses the hypothalamic-pituitary-gonadal axis, typically lowering FSH and LH, but the patient's normal gonadotropins suggest either recent cessation or an alternative etiology 1

Assess for Testosterone-Producing Tumors

• Evaluate for testicular masses through physical examination and scrotal ultrasound if exogenous use is denied 1
• Consider adrenal imaging (CT or MRI) to exclude testosterone-secreting adrenal tumors, particularly if clinical features suggest Cushing's syndrome or virilization 1
• Measure DHEA-S to help differentiate adrenal from testicular sources of androgen excess 1

What NOT to Do

Do not initiate testosterone therapy in this patient—testosterone therapy is strongly contraindicated in eugonadal men (those with normal or elevated testosterone levels). 1 The 2025 European Association of Urology guidelines explicitly state: "Do not use testosterone therapy in eugonadal men" as a strong recommendation. 1

The AUA guidelines define testosterone deficiency as total testosterone below 300 ng/dL, and this patient's level of 1187 ng/dL is nearly 4 times the upper limit of normal. 1

Monitoring and Follow-Up

If Exogenous Testosterone Confirmed

• Counsel on cessation of non-prescribed testosterone or anabolic steroids 1
• Explain risks including polycythemia (hematocrit >54% requires intervention), cardiovascular concerns, and suppression of endogenous testosterone production 1
• Monitor for recovery of the hypothalamic-pituitary-gonadal axis after cessation, which may take 3-6 months 1

If No Clear Etiology Identified

• Refer to endocrinology for comprehensive evaluation of hypergonadism 1
• Repeat testosterone measurement in 2-4 weeks to confirm persistent elevation and rule out laboratory error 1
• Assess for clinical signs of androgen excess: acne, aggressive behavior, erythrocytosis, or changes in libido 1

Common Pitfalls to Avoid

• Do not assume elevated testosterone is benign without investigation—while rare, testosterone-secreting tumors can have significant morbidity if undiagnosed 1
• Do not prescribe testosterone therapy based solely on symptoms when testosterone levels are elevated—approximately 25% of men receiving testosterone do not meet criteria for deficiency 1
• Do not overlook polycythemia risk—elevated testosterone increases hemoglobin/hematocrit, and baseline hematocrit >50% warrants investigation before any intervention 1