When should testosterone levels be tested in older adults?

When to Test Testosterone in Older Adults

Test morning testosterone levels (between 8-10 AM) in older men presenting with specific sexual symptoms—particularly decreased libido, erectile dysfunction, or reduced spontaneous erections—as these are the most reliable indicators of hypogonadism. 1, 2

Primary Indications for Testing

Sexual Symptoms (Strongest Indication)

• Decreased libido (reduced sexual desire) is the most specific symptom warranting testosterone testing 1, 2
• Erectile dysfunction, especially in men where PDE5 inhibitor therapy has failed 1
• Decreased spontaneous or morning erections are considered "more specific" for hypogonadism compared to other symptom categories 2
• The Princeton III Consensus recommends measuring testosterone in all men with organic erectile dysfunction 1

Physical Symptoms

• Reduced bone mass or low-trauma fractures (osteoporotic changes) 1, 2
• Hot flashes or sweats 1
• Loss of body and facial hair 2
• Testicular or muscle atrophy on physical examination 1

Less Specific Symptoms (Consider Testing)

• Decreased vigorous activity and physical function 2
• Fatigue and decreased motivation 1, 2
• Depression or mood disturbances 1, 2

Special Populations

Men with Diabetes

• Check morning serum testosterone in diabetic men who have symptoms of hypogonadism, as androgen deficiency is associated with insulin resistance and metabolic syndrome 2

HIV-Infected Men

• Morning serum testosterone levels are recommended in adult HIV-infected men with decreased libido, erectile dysfunction, reduced bone mass, low trauma fractures, hot flashes, or sweats 1

Diagnostic Approach

Timing and Method

• Measure morning total testosterone between 8 AM and 10 AM 2
• Also measure free testosterone by equilibrium dialysis and sex hormone-binding globulin (SHBG), especially in men with obesity 2
• If testosterone levels are subnormal, repeat the test and measure serum LH and FSH to distinguish primary from secondary hypogonadism 2

Age-Related Context

The prevalence of low testosterone increases substantially with age: approximately 20% of men over 60,30% over 70, and 50% over 80 have low testosterone levels 2. However, testing should be symptom-driven, not age-driven 1.

Important Caveats

Do NOT Test Routinely

• Do not test testosterone in asymptomatic older men simply because of age 1
• Do not obtain testosterone levels in women in nonresearch settings 1
• The American College of Physicians specifically recommends against initiating testosterone treatment to improve energy, vitality, physical function, or cognition alone 1

Divergent Guidelines

There is some controversy in the literature. The Princeton III Consensus advocates testosterone measurement in all men with erectile dysfunction 1, while the American College of Physicians takes a more conservative approach, recommending testing only when specific symptoms of hormonal dysfunction are present 1. Given the association between low testosterone and increased cardiovascular and all-cause mortality 1, the more liberal testing approach in men with erectile dysfunction appears justified from a morbidity and mortality perspective.

Clinical Decision-Making

The decision to test should prioritize sexual symptoms (decreased libido, erectile dysfunction, reduced spontaneous erections) and objective physical findings (reduced bone mass, fractures, testicular atrophy) over nonspecific symptoms like fatigue or depression alone 1, 2.