Testosterone Testing Indication for Older Males
Testosterone testing in older men is indicated when they present with specific sexual symptoms—particularly decreased libido or erectile dysfunction—combined with clinical suspicion of hypogonadism, not simply based on age alone. 1
Primary Indications for Testing
Sexual Symptoms (Strongest Indication)
- Decreased libido (reduced sexual desire) is the most specific symptom warranting testosterone testing and should prompt evaluation 1
- Erectile dysfunction, especially when phosphodiesterase-5 (PDE5) inhibitor therapy has failed, is a reliable indicator requiring testosterone measurement 1
- Decreased spontaneous or morning erections are considered "more specific" for hypogonadism compared to other symptom categories 1
Physical Findings
- Reduced bone mineral density or low-trauma fractures warrant testing 1
- Testicular atrophy is an objective physical finding that justifies testing 1
- Decreased vigorous activity and significant physical function limitations may support testing when combined with other symptoms 1
Special Populations
- In men with diabetes who have symptoms or signs of low testosterone (hypogonadism), a morning total testosterone level should be measured using an accurate and reliable assay 2
What NOT to Test For
The American College of Physicians specifically recommends against initiating testosterone treatment—and by extension, testing—to improve energy, vitality, physical function, or cognition alone. 1 This is critical because:
- Nonspecific symptoms like fatigue, decreased motivation, or mild depression alone do not justify testing 1
- Age itself is not an indication for testing; do not test testosterone in asymptomatic older men simply because of age 1
- Testing should prioritize sexual symptoms and objective physical findings over nonspecific complaints 1
Proper Testing Protocol
Initial Testing Requirements
- Measure morning total testosterone between 8 AM and 10 AM in men presenting with symptoms of hypogonadism 1
- Free testosterone by equilibrium dialysis and sex hormone-binding globulin (SHBG) should also be measured, especially in men with obesity 1
- Prior to initiating any testosterone therapy, confirm the diagnosis by ensuring that serum testosterone has been measured in the morning on at least two separate days and that these concentrations are below the normal range 3
Follow-up Testing
- If testosterone levels are subnormal, they should be repeated, and serum LH and FSH should be measured to distinguish primary from secondary hypogonadism 1
- This is particularly important because normal total testosterone with low free testosterone can occur in 17.2% of men with erectile dysfunction, especially those over 60 years with elevated SHBG 4
Critical Caveats
Age-Related Considerations
- Approximately 20% of men older than 60,30% of those older than 70, and 50% of those older than 80 years have low testosterone levels, but this alone does not warrant testing or treatment 1
- In men over 60 years presenting with erectile dysfunction, 26.3% may have normal total testosterone but low free testosterone due to elevated SHBG, making free testosterone measurement essential 4
Common Pitfalls to Avoid
- Do not obtain testosterone levels in women in nonresearch settings 1
- Do not test based solely on nonspecific symptoms of aging such as fatigue, decreased energy, or mild cognitive changes 2, 1
- Safety and efficacy of testosterone therapy in men with "age-related hypogonadism" have not been established 3
Mortality and Morbidity Context
Given the association between low testosterone and increased cardiovascular and all-cause mortality, the more liberal testing approach in men with erectile dysfunction appears justified from a morbidity and mortality perspective 1. However, this does not extend to asymptomatic screening.
Contraindications to Testing/Treatment
Even if symptoms are present, do not pursue testosterone therapy in men with: