What is the recommended treatment for an elderly male with low Luteinizing Hormone (LH) levels and suspected hypogonadism?

Management of Low LH in an Elderly Male

In an elderly male with low LH and low testosterone (secondary hypogonadism), testosterone replacement therapy should only be considered if the patient has documented sexual dysfunction symptoms and desires improvement in sexual function—not for improving energy, vitality, physical function, or cognition. 1, 2

Understanding the Clinical Context

Low LH in an elderly male indicates secondary (hypogonadotropic) hypogonadism, where the pituitary-hypothalamic axis fails to adequately stimulate testicular testosterone production. 3 This differs from primary hypogonadism where LH is elevated in response to testicular failure. 4

• Secondary hypogonadism in aging men is strongly associated with obesity (BMI ≥30 kg/m²) and comorbidities, rather than age alone. 4
• This form of hypogonadism accounts for approximately 11.8% of older men with testosterone deficiency. 4
• Men with secondary hypogonadism show lower muscle mass, bone mineral density, hemoglobin, and poorer general health compared to eugonadal men. 5

Diagnostic Confirmation Required

Before considering any treatment, confirm the diagnosis with:

• Morning testosterone measurements on at least two separate days, both showing levels below the normal range. 1, 3
• Document specific symptoms, particularly sexual dysfunction (decreased libido, erectile dysfunction, reduced ejaculate volume). 6
• Rule out classical causes of secondary hypogonadism including pituitary tumors, trauma, radiation, or LHRH deficiency. 3

Treatment Decision Algorithm

Step 1: Assess Indication for Treatment

Only proceed with testosterone therapy if ALL of the following are present: 1, 2

• Confirmed low morning testosterone on two occasions
• Presence of sexual dysfunction symptoms
• Patient explicitly desires improvement in sexual function
• Absence of contraindications (prostate cancer, breast carcinoma, pregnancy in partner) 3

Step 2: Do NOT Treat For These Indications

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

• Improving energy or vitality
• Enhancing physical function or muscle mass
• Improving cognitive function
• General "anti-aging" purposes

The FDA requires labeling that testosterone products are approved only for low testosterone due to known medical causes, not age-related decline. 2, 3

Step 3: If Treatment Is Initiated

Formulation selection: 1, 2

• Prefer intramuscular testosterone over transdermal formulations due to significantly lower cost with similar clinical effectiveness and safety profiles.

Dosing approach for transdermal (if used): 3

• Starting dose: 40.5 mg testosterone daily (2 pump actuations or one 40.5 mg packet)
• Apply to clean, dry, intact skin of shoulders and upper arms only—never to abdomen, genitals, chest, armpits, or knees
• Dose range: 20.25 mg to 81 mg daily

Target testosterone levels: 7, 3

• Aim for mid-normal range testosterone levels
• Measure pre-dose morning testosterone at approximately 14 days and 28 days after initiation
• Adjust dose based on these measurements

Step 4: Mandatory Reassessment

Reevaluate symptoms within 12 months and periodically thereafter. 1, 2, 8

• Discontinue testosterone treatment if there is no improvement in sexual function. 1, 2
• This is a critical decision point—continuing therapy without symptomatic benefit exposes patients to risks without benefit.

Monitoring Requirements

Baseline and ongoing monitoring should include: 7, 3

• PSA levels at each visit (discontinue if PSA >4.0 ng/mL or increases ≥1.0 ng/mL within 12 months) 7
• Hematocrit/hemoglobin for erythrocytosis risk 7, 3
• Digital rectal examination 7
• Testosterone levels every 6-12 months during maintenance 7
• Assessment for sleep apnea symptoms 3

Critical Safety Considerations

Important warnings for elderly patients: 3

• Venous thromboembolism (DVT, PE) has been reported with testosterone therapy
• Postmarketing studies suggest increased risk of myocardial infarction and stroke
• Monitor for worsening benign prostatic hyperplasia symptoms
• Evidence for long-term safety in men over 75 is limited 2

Secondary exposure prevention: 3

• Patients must wash hands immediately with soap and water after application
• Cover application sites with clothing after gel dries
• Wash application site thoroughly before any skin-to-skin contact with others
• Children must avoid contact with unwashed or unclothed application sites

Common Pitfalls to Avoid

• Do not treat based solely on low testosterone levels without specific sexual dysfunction symptoms. The correlation between nonspecific symptoms (fatigue, decreased energy) and testosterone levels is weak. 9
• Do not continue therapy indefinitely without reassessing symptom improvement. 1, 2
• Do not measure testosterone at random times—always use morning measurements. 7, 3
• Do not ignore the underlying cause—obesity and comorbidities are strongly associated with secondary hypogonadism and should be addressed. 4