What is the best course of action for a 45-year-old male with low free testosterone (7.8 pg/mL), anemia, Crohn's disease, and bilateral sciatic pain, who is experiencing increased fatigue and has a history of testosterone therapy?

Management of Low Testosterone in a 45-Year-Old Male with Crohn's Disease and Anemia

This patient requires confirmatory early morning total testosterone testing before any treatment decision, mandatory psychiatric evaluation despite his resistance, and comprehensive workup of his anemia and psychosocial stressors—testosterone therapy should NOT be initiated until these critical steps are completed. 1

Immediate Diagnostic Requirements

Testosterone Confirmation Testing

• A single free testosterone measurement of 7.8 pg/mL is insufficient for diagnosis—the AUA guideline mandates two separate early morning total testosterone measurements (not free testosterone) before making any treatment decision 1
• The diagnostic threshold is total testosterone consistently <300 ng/dL on at least two measurements, preferably using the same laboratory and methodology 1
• Free testosterone alone should not be used as the primary diagnostic test; morning total testosterone is the initial required test 1

Mandatory Additional Testing Before Treatment

• Measure serum luteinizing hormone (LH) levels to establish the etiology of testosterone deficiency (primary vs. secondary hypogonadism) 1
• If LH is low or low-normal, measure serum prolactin levels to screen for hyperprolactinemia and potential pituitary pathology 1
• This patient has unexplained anemia, which is a specific indication for testosterone measurement even without symptoms, but also requires independent evaluation 1

Critical Red Flags Requiring Immediate Attention

Psychiatric Concerns Take Priority

• The patient's presentation strongly suggests major depression: sleeping 10-18 hours daily, recent job loss, impending fatherhood stress, irritability, verbal aggression toward his wife, and fixation on testosterone as the sole solution 1
• His symptoms began 6 months ago and intensified 2 months ago—temporally related to psychosocial stressors, not testosterone levels 1
• Verbal aggression and irritability during the visit are concerning behavioral changes that require psychiatric evaluation regardless of testosterone status 1
• Depression itself can cause fatigue, low energy, and reduced libido—symptoms that overlap with hypogonadism 1

Anemia Workup is Essential

• This patient has documented anemia with a history of Crohn's disease—the anemia must be fully evaluated as it can independently cause severe fatigue 1
• Crohn's disease-related anemia (iron deficiency, chronic disease, B12/folate deficiency) is a more likely primary cause of his fatigue than borderline-low free testosterone 1
• Interestingly, testosterone therapy may improve Crohn's disease activity and inflammatory markers in hypogonadal men with Crohn's disease, but this is not the primary indication here 2

Testosterone Treatment Decision Framework

When Treatment Should NOT Be Initiated

Do not start testosterone therapy in this patient at this visit because: 1

• Diagnosis is not confirmed (only one free testosterone measurement, not two morning total testosterone levels) 1
• Psychiatric evaluation has not been completed despite clear indicators of depression 1
• Anemia has not been adequately investigated as the primary cause of fatigue 1
• The patient is actively smoking one pack daily—smoking cessation should be prioritized as it affects cardiovascular risk 1
• Urinalysis shows crystals and turbidity—requires further evaluation before initiating therapy 1

If Testosterone Deficiency is Confirmed

After proper workup, if two morning total testosterone levels are <300 ng/dL with documented symptoms: 1

• The ACP recommends discussing whether to initiate testosterone treatment specifically for sexual dysfunction improvement, including potential benefits, harms, costs, and patient preferences 1
• For this 45-year-old male, testosterone therapy does not increase stroke risk according to the 2024 AHA/ASA guideline, which found no increased stroke risk in men 45-80 years with confirmed hypogonadism 1
• The ACP found only small improvements in sexual function (SMD 0.35) and quality of life (SMD 0.33), with little to no improvement in physical function or energy 1, 3

Treatment Monitoring if Initiated

• Reevaluate symptoms within 12 months—discontinue testosterone if no improvement in sexual function 1
• Monitor PSA levels (he's 45 years old, approaching the age threshold), hematocrit (especially important given his anemia history), and symptom response 3, 4
• Hematocrit monitoring is critical—intervention necessary if Hct >54% to prevent polycythemia 3
• Consider intramuscular formulations over transdermal due to significantly lower cost with similar efficacy and safety 1

Specific Action Plan for This Patient

1. Refuse testosterone prescription today and explain the need for proper diagnostic workup 1
2. Order two early morning total testosterone levels (7-11 AM) on separate days, LH, and prolactin 1
3. Mandate psychiatric evaluation before any testosterone consideration—frame this as standard medical care for his symptom complex, not optional 1
4. Complete anemia workup: iron studies, B12, folate, reticulocyte count, and assess Crohn's disease activity 1
5. Address smoking cessation with pharmacotherapy and counseling 1
6. Evaluate urinalysis findings (crystals, turbidity) with urine culture and metabolic panel 1
7. Assess for intimate partner violence risk given verbal aggression toward wife during visit

Common Pitfalls to Avoid

• Do not treat based on patient demand alone—testosterone is not indicated for non-specific fatigue without confirmed biochemical hypogonadism 1
• Do not use free testosterone as the sole diagnostic test—total testosterone is the required initial and confirmatory test 1
• Do not overlook psychiatric comorbidity—depression is a more likely primary cause of his symptoms given the clinical context 1
• Do not ignore the anemia—it independently explains his fatigue and requires treatment regardless of testosterone status 1
• Do not expect testosterone to improve energy or physical function—evidence shows little to no benefit for these outcomes 1