What is the best approach for a patient with normal testosterone levels?

Counseling Patients with Normal Testosterone Levels Against Testosterone Therapy

Testosterone therapy should not be prescribed to patients with normal testosterone levels because treatment is only indicated when both biochemical deficiency (testosterone <300-350 ng/dL) AND clinical symptoms of hypogonadism are present—giving testosterone to men with normal levels provides no benefit and exposes them to significant risks including infertility, cardiovascular events, and polycythemia. 1, 2

Clear Diagnostic Criteria to Explain

When counseling your patient, explain that testosterone therapy has specific medical indications that they do not meet:

• Biochemical requirement: Two separate morning testosterone measurements must show levels below 300-350 ng/dL to even consider therapy 2, 3
• Clinical requirement: Even with low levels, symptoms of hypogonadism (decreased libido, erectile dysfunction, depressed mood, loss of muscle/bone mass) must be present 4
• Their situation: Since their testosterone is normal, they lack the fundamental indication for treatment 1

The American Urological Association guideline explicitly states that the goal of therapy is "normalization of total testosterone levels combined with improvement in symptoms"—if levels are already normal, there is nothing to normalize 1.

Concrete Risks to Emphasize

Frame the conversation around specific harms they would face:

Fertility Destruction

• Exogenous testosterone completely shuts down sperm production through negative feedback on the hypothalamic-pituitary-gonadal axis 1, 5
• The AUA provides a strong recommendation that "exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive" because it causes severe oligospermia or azoospermia 1
• This effect occurs even in men with normal baseline testosterone 5

Cardiovascular Concerns

• Patients must wait 3-6 months after any cardiovascular event before even considering therapy 1
• The current literature cannot definitively prove safety regarding major adverse cardiovascular events (MACE) 1, 2
• Men on therapy must report chest pain, shortness of breath, or dizziness immediately 1

Hematologic Complications

• Testosterone increases hemoglobin/hematocrit, with therapy withheld if hematocrit exceeds 50% 2
• Polycythemia risk requires regular monitoring and potential phlebotomy 1

Prostate Monitoring Burden

• Men over 40 require PSA monitoring with specific thresholds for biopsy: increases >1.0 ng/mL in the first year or >0.4 ng/mL per year thereafter mandate urologic evaluation 1, 2
• This creates an ongoing medical surveillance burden without any corresponding benefit in someone with normal levels 1

Alternative Approaches to Address Underlying Concerns

Redirect the conversation to evidence-based interventions:

• Lifestyle modifications are the primary recommendation: Weight loss and increased physical activity can increase testosterone levels in men who actually have deficiency 1
• If they have symptoms they attribute to "low testosterone" (fatigue, decreased libido, mood changes), these warrant evaluation for other causes rather than empiric hormone therapy 6
• High body mass index coupled with normal testosterone still warrants weight loss counseling for cardiovascular risk reduction, not testosterone therapy 1

The "No Benefit" Argument

The most compelling point: testosterone therapy aims to bring levels to 450-600 ng/dL (the middle tertile of normal) 1. If their levels are already in this range or higher, therapy cannot improve upon normal physiology and the risk-benefit ratio becomes entirely unfavorable.

The guideline explicitly states that "in the event that patients do not experience symptomatic relief after reaching the specified target testosterone levels...testosterone therapy should be stopped" 1. Starting with normal levels guarantees this scenario.

Common Pitfall to Avoid

Do not get drawn into debates about "optimizing" or "maximizing" testosterone within the normal range. The evidence supports treating deficiency to normal, not pushing normal to supraphysiologic 1. This is inappropriate use of a medication with real risks.