Taking Testosterone Without Testosterone Deficiency
Testosterone therapy should not be initiated in men without a documented testosterone deficiency, which requires both consistently low testosterone levels (<300 ng/dL on two separate morning measurements) AND clinical symptoms of hypogonadism. 1, 2
Why This Practice is Inappropriate
The American Urological Association explicitly identifies this as a widespread problem: approximately 25% of men currently receiving testosterone therapy do not meet diagnostic criteria for testosterone deficiency. 1 This represents inappropriate prescribing that exposes patients to unnecessary risks without established benefits.
Diagnostic Requirements That Must Be Met
Before testosterone therapy can be considered appropriate, ALL of the following criteria must be documented:
Two separate morning testosterone measurements (between 8-10 AM) showing total testosterone <300 ng/dL, using the same laboratory and methodology 1, 3, 4
Presence of clinical symptoms including reduced libido, erectile dysfunction, decreased energy, fatigue, reduced muscle mass, depressed mood, poor concentration, or impaired memory 1, 3, 4
Physical examination findings consistent with testosterone deficiency, such as decreased body hair in androgen-dependent areas, gynecomastia, or reduced testicular size 1, 4
The FDA labeling for testosterone cypionate specifically states the indication is "for replacement therapy in the male in conditions associated with symptoms of deficiency or absence of endogenous testosterone." 2 This clearly excludes use in men with normal testosterone levels.
Significant Safety Risks
Using testosterone without deficiency exposes patients to serious adverse effects without any proven benefit:
Cardiovascular Risks
- Testosterone therapy should not be initiated within 3-6 months of myocardial infarction or stroke 3, 5
- Men with uncontrolled heart failure are contraindicated from receiving testosterone 6, 5, 7
- The relationship between testosterone therapy and cardiovascular events remains a concern, though not definitively established 1
Hematologic Complications
- Erythrocytosis occurs in up to 43.8% of men on injectable testosterone formulations 4
- Hematocrit >54% requires immediate dose reduction or discontinuation 4
- Increased blood viscosity can aggravate coronary, cerebrovascular, or peripheral vascular disease 4
- Therapy is contraindicated in men with baseline hematocrit >50% 3, 5
Reproductive Consequences
- Exogenous testosterone suppresses spermatogenesis and causes infertility 3, 4
- This effect makes testosterone therapy absolutely contraindicated in men attempting to conceive 3, 5
- Recovery of fertility after discontinuation is not guaranteed
Prostate Concerns
- Testosterone therapy is contraindicated in men with prostate cancer, palpable prostate nodules, or PSA >4 ng/mL (or >3 ng/mL in high-risk men) 3, 6, 5
- Ongoing monitoring of PSA is mandatory during treatment 3, 4
What Happens When Normal Men Take Testosterone
In eugonadal men (those with normal testosterone levels), exogenous testosterone provides no established benefit for:
- Muscle mass or strength beyond normal physiologic levels
- Sexual function (which is already normal)
- Energy or mood (symptoms likely have other causes)
- Cognitive function
Instead, the body's negative feedback mechanisms will:
- Suppress endogenous testosterone production
- Reduce or eliminate sperm production
- Potentially cause testicular atrophy
- Create dependence on exogenous testosterone
The Correct Clinical Approach
When Symptoms Exist But Testosterone is Normal
If a patient has symptoms commonly attributed to low testosterone (fatigue, low libido, erectile dysfunction) but testosterone levels are normal (>300 ng/dL), the American Urological Association and European Association of Urology recommend against testosterone therapy. 3, 4
Instead, evaluate for:
- Obesity and metabolic syndrome - weight loss can improve symptoms and modestly increase testosterone 4, 6
- Depression or anxiety disorders - these cause identical symptoms
- Sleep disorders including obstructive sleep apnea
- Chronic medical conditions - diabetes, cardiovascular disease, chronic pain
- Medication side effects - opioids, corticosteroids, certain antidepressants
- Relationship or psychological factors affecting sexual function
Lifestyle Modifications First
The Endocrine Society recommends that obese men with borderline testosterone levels should attempt:
- Weight loss through caloric restriction - can improve testosterone levels and symptoms 4, 6
- Regular physical activity - provides modest testosterone increases (1-2 nmol/L) 4
- Addressing modifiable cardiovascular risk factors 4
Common Pitfalls to Avoid
Do not measure testosterone at random times of day. Afternoon or evening measurements will be physiologically lower and lead to false-positive diagnoses of deficiency. 4 Only morning measurements (8-10 AM) are valid. 1, 3, 4
Do not rely on a single testosterone measurement. The diagnosis requires two separate confirmatory tests. 1, 3, 4
Do not use screening questionnaires to diagnose testosterone deficiency. The American Urological Association explicitly recommends against using validated questionnaires to define candidates for testosterone therapy. 1
Do not prescribe testosterone for "anti-aging" or performance enhancement in eugonadal men. This represents off-label use without evidence of benefit and with documented risks. 1
Monitoring Requirements If Therapy Were Appropriate
Even in men with documented deficiency, testosterone therapy requires intensive monitoring that nearly half of treated men do not receive: 1