What is the process for testing and diagnosing andropause (male menopause)?

Testing and Diagnosing Andropause (Late-Onset Hypogonadism)

The diagnosis of andropause requires both biochemical confirmation with two early morning total testosterone measurements showing levels consistently <300 ng/dL AND the presence of specific symptoms such as decreased libido, erectile dysfunction, reduced energy, or loss of morning erections. 1

Required Laboratory Testing

Primary Hormone Measurements

• Measure serum total testosterone on two separate occasions, both drawn in the early morning (before 10 AM), preferably using the same laboratory and methodology 1

  • The diagnostic threshold is consistently <300 ng/dL on both measurements 1
  • Morning timing is critical because testosterone levels decline throughout the day 1

• Measure serum luteinizing hormone (LH) in all patients with confirmed low testosterone 1

  • Low or inappropriately normal LH with low testosterone indicates secondary (central) hypogonadism 1, 2
  • Elevated LH with low testosterone indicates primary (testicular) hypogonadism 2

• Measure serum prolactin if LH is low or low-normal 1

  • Elevated prolactin can suppress testosterone production and requires evaluation for pituitary disorders 1
  • Persistently elevated prolactin of unknown etiology mandates endocrine evaluation 1

Additional Testing Considerations

• Measure follicle-stimulating hormone (FSH) to assess testicular function and spermatogenesis, particularly if fertility is a concern 3, 2

• Consider measuring free testosterone or calculating free androgen index if total testosterone is borderline or clinical suspicion remains high despite normal total testosterone 4, 2

Clinical Symptom Assessment

Key Symptoms to Document

• Sexual symptoms: Reduced libido, erectile dysfunction, loss of morning penile tumescence 5, 6
• Physical symptoms: Reduced energy, decreased endurance, fatigue, diminished work/physical performance 1
• Cognitive/mood symptoms: Depression, reduced motivation, poor concentration, impaired memory, irritability 1
• Body composition changes: Decreased muscle mass, increased fat mass 2, 6

Physical Examination Findings

• Evaluate body habitus, body mass index or waist circumference 1
• Assess virilization status by examining body hair patterns in androgen-dependent areas 1
• Check for gynecomastia 1
• Perform testicular examination including presence, size, consistency, and masses 1
• Assess for varicocele 1
• Evaluate prostate size and morphology 1

High-Risk Populations Requiring Screening

Even without symptoms, measure testosterone in men with: 1

• Unexplained anemia
• Bone density loss or osteoporosis
• Diabetes mellitus
• History of chemotherapy exposure
• History of testicular radiation
• HIV/AIDS
• Chronic narcotic use
• Male infertility
• Pituitary dysfunction
• Chronic corticosteroid use

Important Caveats and Pitfalls

Questionnaires Are Not Diagnostic

• Do not use validated questionnaires as screening tools or to determine candidacy for testosterone therapy 1
• Questionnaires have variable sensitivity and specificity and should not replace comprehensive evaluation and laboratory testing 1

Assay Method Matters

• Use liquid chromatography-tandem mass spectrometry (LC-MS/MS) when available for superior accuracy in testosterone measurement 1, 7
• Direct immunoassays have lower accuracy and may produce inconsistent results 1, 7
• If immunoassay results are inconsistent with clinical presentation, recheck using LC-MS/MS 1, 7

Diabetes and Metabolic Factors

• Andropause occurs earlier and more frequently in diabetic men 5
• Duration of diabetes and HbA1c levels negatively impact testosterone levels 5
• Diabetic patients with low testosterone often have secondary hypogonadism (low LH) rather than primary testicular failure 5
• Obesity is a major confounder that can lower testosterone independent of age 8, 2

Fertility Considerations

• Never prescribe testosterone replacement to men desiring fertility, as it suppresses spermatogenesis 8
• For men wishing to preserve fertility with low testosterone and low/normal LH, consider selective estrogen receptor modulators instead 1

Diagnostic Algorithm Summary

1. Document specific symptoms of hypogonadism (sexual, physical, cognitive) 1, 6
2. Obtain two early morning total testosterone measurements on separate days 1
3. If both values <300 ng/dL, measure LH 1
4. If LH is low or low-normal, measure prolactin 1
5. If prolactin elevated, repeat measurement and consider pituitary imaging if persistently elevated 1
6. Perform targeted physical examination focusing on virilization, body composition, testicular size, and prostate 1
7. Screen high-risk populations even without symptoms 1