From the Guidelines
Starting testosterone therapy for this 59-year-old male with low libido may not be appropriate based on the laboratory values provided, as his total testosterone level of 368 ng/dL and free testosterone of 5.0 ng/dL are within normal limits for his age. According to the American College of Physicians (ACP) guideline on testosterone treatment in adult men with age-related low testosterone 1, the decision to initiate testosterone treatment should be based on a discussion of the potential benefits, harms, costs, and patient's preferences, particularly in men with sexual dysfunction who want to improve sexual function. The guideline suggests that clinicians consider intramuscular rather than transdermal formulations when initiating testosterone treatment to improve sexual function in men with age-related low testosterone, as costs are considerably lower for the intramuscular formulation and clinical effectiveness and harms are similar 1.
Before initiating testosterone replacement therapy, it would be essential to rule out other causes of decreased libido, such as:
- Depression
- Stress
- Relationship issues
- Other medications
- Medical conditions If testosterone therapy is being considered despite these borderline values, a trial of testosterone gel or testosterone cypionate injections could be considered, with careful discussion of potential risks, including:
- Cardiovascular effects
- Polycythemia
- Sleep apnea exacerbation
- Prostate issues The low PSA (0.4 ng/mL) is reassuring regarding prostate health, but monitoring would still be necessary if therapy is initiated. Testosterone therapy should be accompanied by follow-up testing of testosterone levels, complete blood count, and PSA at 3-6 month intervals initially, then annually, as recommended by the ACP guideline 1. Non-hormonal approaches to improving libido should be explored first given his borderline testosterone values.
From the Research
Testosterone Therapy Considerations
- The patient's testosterone serum level is 368, and free testosterone is 5.0, which may not be considered low enough to initiate testosterone therapy, as the normal range for total testosterone is typically between 300-1000 ng/dL 2.
- The patient's PSA level is 0.4, which is within normal limits, but it is essential to monitor PSA levels during testosterone therapy due to the potential risk of increasing prostate-specific antigen levels 2, 3.
- The patient's complaint of low libido may be a symptom of hypogonadism, but other causes should be ruled out before initiating testosterone therapy 2, 4.
- Testosterone therapy may improve libido, mood, and overall well-being, but the benefits and risks should be carefully considered, and patients should be counseled on the potential risks, including cardiovascular complications and polycythemia 2, 3, 5.
Initiating Testosterone Therapy
- According to the guidelines, testosterone therapy should be initiated only after two morning total serum testosterone measurements show decreased levels 2.
- The patient's current testosterone levels do not seem to be significantly low, and other factors contributing to low libido should be investigated before starting testosterone therapy 4, 6.
- If testosterone therapy is initiated, the patient should be monitored regularly to ensure testosterone levels rise appropriately, clinical improvement occurs, and no complications develop 2, 6.