Do we treat male hypogonadism (low testosterone levels) in patients over 65 years old?

Treatment of Male Hypogonadism After Age 65

Testosterone treatment in men over 65 with age-related low testosterone should only be initiated for sexual dysfunction (decreased libido, erectile dysfunction) after a shared decision-making discussion, and should NOT be prescribed to improve energy, vitality, physical function, or cognition. 1, 2

When to Consider Treatment

The Only Valid Indication

• Initiate testosterone only if ALL three criteria are met: 1, 2
  • Documented low morning testosterone levels (measured on at least two occasions between 8-10 AM) 3
  • Presence of specific sexual symptoms (decreased libido, erectile dysfunction, reduced morning erections) 1, 3
  • Patient actively desires improvement in sexual function 1

What NOT to Treat

The American College of Physicians explicitly recommends against initiating testosterone for: 1, 2

• Fatigue or low energy
• Decreased vitality
• Physical function decline or weakness
• Cognitive symptoms or memory concerns
• Muscle mass loss alone
• General "aging" symptoms

This is a conditional recommendation based on low-certainty evidence showing no meaningful benefit for these outcomes. 1

Treatment Algorithm

Step 1: Confirm Diagnosis

• Measure morning total testosterone (8-10 AM) on two separate occasions 3
• Document specific sexual symptoms—not just vague complaints of "feeling old" 1, 3
• Exclude secondary causes: medications, chronic illness, obesity, diabetes 1

Step 2: Shared Decision-Making Discussion

Must include: 1

• Potential benefits: modest improvement in sexual function only 1
• Harms: prostate monitoring burden, potential cardiovascular risks (uncertain), cost 1
• Lack of long-term safety data, especially in men >75 years 1, 2
• FDA labeling states testosterone is approved only for hypogonadism due to known medical causes, not age-related decline 1, 4

Step 3: If Treatment Initiated

• Prefer intramuscular over transdermal formulations due to dramatically lower cost ($156 vs $2,135 annually) with similar efficacy and safety 1
• Target mid-normal testosterone range 2
• Reevaluate at 12 months: discontinue if no improvement in sexual function 1, 2
• Monitor periodically thereafter if continuing 1

Critical Context for Men Over 65

Epidemiology

• 20% of men >60,30% of men >70, and 50% of men >80 have low testosterone levels 1, 2
• Low testosterone is common with aging but does NOT automatically warrant treatment 2, 3

Evidence Limitations

• Most trials had <12 months follow-up; only 3 studies extended to 36 months 1
• Mean age across trials was 66 years, with 8 studies restricted to ≥65 years 1
• Long-term safety data in men >75 is severely limited 1, 2
• Evidence on mortality and major cardiovascular events remains inconclusive due to low event rates and short follow-up 1

Common Pitfalls to Avoid

Do Not Treat Based On:

• Testosterone level alone without symptoms 2, 3
• Nonspecific symptoms like fatigue, decreased motivation, or mild depression 3
• Patient or family expectations for "anti-aging" benefits 1, 2
• Comorbid conditions (obesity, diabetes, metabolic syndrome) unless sexual symptoms present 1

Safety Monitoring

The FDA warns of increased risks in geriatric patients: 4

• Prostatic hypertrophy and potential prostate cancer (though conclusive evidence lacking) 4
• Edema and heart failure exacerbation in those with pre-existing cardiac disease 4
• Hypercalcemia in immobilized patients 4

Discontinuation Rates

• 30-62% of men discontinue testosterone therapy, often due to lack of perceived benefit 1
• This high discontinuation rate underscores the importance of realistic expectations and 12-month reassessment 1

Nuances in the Evidence

The American College of Physicians guideline (2020) represents the most authoritative and recent guidance, endorsed by the American Academy of Family Physicians. 1 While some older literature and specialty society guidelines are more permissive about testosterone use in aging men 5, 6, 7, the ACP's conservative approach prioritizes patient safety given the lack of long-term outcome data on morbidity and mortality. 1

The evidence base shows modest improvements in sexual function but no consistent benefits for physical function, cognition, or quality of life—outcomes that matter most for morbidity and mortality in this age group. 1 Recent meta-analyses have raised concerns about increased prostate-related events in testosterone-treated elderly men, warranting caution. 8

In men over 65, the burden of proof for benefit must outweigh potential harms, and current evidence supports treatment only for the narrow indication of sexual dysfunction with documented low testosterone. 1, 2