Is testosterone supplementation appropriate for a 54-year-old male with fatigue, borderline low total testosterone (hypogonadism) and free testosterone levels?

Testosterone Supplementation for a 54-Year-Old Male with Fatigue

Testosterone supplementation is not clearly indicated based on your current values alone, as your total testosterone of 366 ng/dL falls within the normal range for men over 40 years old, and the evidence shows only minimal benefit for fatigue even when testosterone is definitively low. 1, 2

Diagnostic Confirmation Required Before Any Treatment Decision

You need additional testing before considering testosterone therapy:

• Repeat morning total testosterone measurement on a separate day to confirm whether levels are consistently below 300 ng/dL, as two measurements are required for diagnosis 2
• Verify the free testosterone measurement using equilibrium dialysis (not analog methods), as most local laboratory methods have limited reliability 2
• Measure serum luteinizing hormone (LH) to establish whether this is primary or secondary hypogonadism 2
• Check sex hormone-binding globulin (SHBG), as it is often low in older men and can lower total testosterone while free testosterone remains normal 2
• Measure serum prolactin if LH is low or low-normal, as hyperprolactinemia can cause secondary hypogonadism 2

Critical Context: Your Testosterone May Be Normal for Your Age

• For men 40-44 years old, the normal middle tertile range is 350-473 ng/dL, with a cutoff for low testosterone at 350 ng/dL 3
• Your total testosterone of 366 ng/dL falls within the normal range for your age group, making the diagnosis of testosterone deficiency questionable 3

Rule Out Other Causes of Fatigue First

Before attributing fatigue to testosterone, evaluate for:

• Anemia (complete blood count with hemoglobin/hematocrit) 2
• Thyroid dysfunction (TSH and free T4) 1, 2
• Diabetes or prediabetes (hemoglobin A1C or fasting glucose) 1, 2
• Cardiac dysfunction, mood disorders, sleep disturbance, and pain 4, 2

Expected Benefits Are Minimal for Fatigue

Even if testosterone deficiency is confirmed, the evidence for fatigue improvement is weak:

• Testosterone treatment results in only a "less-than-small" improvement in vitality and fatigue (SMD 0.17), with low-certainty evidence 1, 5
• The improvement in quality of life is small (SMD -0.33), and depressive symptoms show only a less-than-small improvement (SMD -0.19) 1, 5
• The primary benefits of testosterone therapy are for sexual function, not fatigue 5

Safety Screening Required Before Treatment

If testosterone deficiency is confirmed and treatment is considered, screen for absolute contraindications:

• Prostate or breast cancer 6
• Elevated PSA without urologic evaluation 6
• Hematocrit >50% 6
• Untreated severe obstructive sleep apnea 2
• Severe heart failure 2
• Cardiovascular disease risk, as some studies show increased risk of myocardial infarction and stroke with testosterone therapy 6

Treatment Approach If Deficiency Is Confirmed

• Re-evaluate symptoms within 12 months and discontinue treatment if no improvement in sexual function occurs 5
• Topical gel/cream is preferred by 71% of patients for convenience and ease of use 5
• Intramuscular formulation is significantly lower in cost ($156.24 annually vs. $2,135.32 for transdermal) with similar effectiveness 5
• Monitor hematocrit every 6-12 months for polycythemia and PSA annually in men over 40 2

Common Pitfall to Avoid

The most critical error would be starting testosterone therapy without confirming true testosterone deficiency with repeat testing and without ruling out other treatable causes of fatigue, especially given that your current total testosterone level may be normal for your age and the expected benefit for fatigue is minimal 1, 2, 3.