What questions to ask a 45-year-old male patient with hypogonadism (low testosterone)?

From the Guidelines

For a 45-year-old male with low testosterone, the most critical questions to ask are about his symptoms, medical history, and lifestyle factors, as these will guide the diagnosis and treatment of hypogonadism, with the ultimate goal of improving morbidity, mortality, and quality of life. When evaluating a patient with low testosterone, it is essential to inquire about symptoms such as fatigue, decreased libido, erectile dysfunction, reduced muscle mass, increased body fat, depression, and cognitive difficulties, as recommended by the American College of Physicians 1. The timing and progression of these symptoms should also be explored.

Medical history questions should cover chronic conditions like diabetes, obesity, sleep apnea, kidney or liver disease, and pituitary disorders, as these can impact testosterone levels and overall health. Medication use, particularly opioids, glucocorticoids, and psychiatric medications, which can affect testosterone levels, should be discussed 1. Previous testosterone levels, if tested, family history of hypogonadism, and lifestyle factors including exercise habits, sleep patterns, stress levels, and alcohol consumption should also be explored.

Physical examination findings like testicular size and body fat distribution should be noted, as they can provide valuable information about the patient's hormonal status. Laboratory confirmation is essential, with morning total testosterone measurements (ideally between 8-10 AM) on two separate occasions, along with luteinizing hormone, follicle-stimulating hormone, prolactin, and possibly estradiol levels, as recommended by the American Urological Association 1. These questions and tests help determine if hypogonadism is primary (testicular) or secondary (pituitary/hypothalamic) and guide appropriate treatment options, which might include testosterone replacement therapy, lifestyle modifications, or addressing underlying conditions.

Key points to consider when evaluating a patient with low testosterone include:

• The diagnosis of low testosterone should be made only after two total testosterone measurements are taken on separate occasions with both conducted in an early morning fashion 1.
• The clinical diagnosis of testosterone deficiency is only made when patients have low total testosterone levels combined with symptoms and/or signs 1.
• Clinicians should consider measuring total testosterone in patients with a history of unexplained anemia, bone density loss, diabetes, exposure to chemotherapy, exposure to testicular radiation, HIV/AIDS, chronic narcotic use, male infertility, pituitary dysfunction, and chronic corticosteroid use even in the absence of symptoms or signs associated with testosterone deficiency 1.
• The use of validated questionnaires is not currently recommended to either define which patients are candidates for testosterone therapy or monitor symptom response in patients on testosterone therapy 1.

By following these guidelines and considering the patient's individual symptoms, medical history, and lifestyle factors, clinicians can provide personalized care and improve outcomes for patients with low testosterone.

From the FDA Drug Label

INDICATIONS AND USAGE Males Testosterone Enanthate Injection, USP is indicated for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone. Primary hypogonadism (congenital or acquired) – Testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, or orchidectomy Hypogonadotropic hypogonadism (congenital or acquired) – Gonadotropin or luteinizing hormone‑releasing hormone (LHRH) deficiency, or pituitary-hypothalamic injury from tumors, trauma, or radiation. Safety and efficacy of Testosterone Enanthate Injection, USP in men with age-related hypogonadism have not been established.

To assess a 45-year-old male patient with low testosterone, you should ask about:

• Medical history: Any history of testicular problems, pituitary-hypothalamic injury, or other conditions that may be associated with hypogonadism.
• Symptoms: Presence of symptoms such as low libido, fatigue, or erectile dysfunction.
• Previous treatments: Any previous treatments for low testosterone or related conditions.
• Family history: Any family history of delayed puberty or hypogonadism. It is also important to note that testosterone replacement therapy may be considered for patients with primary hypogonadism or hypogonadotropic hypogonadism, but safety and efficacy in men with age-related hypogonadism have not been established 2.

From the Research

Patient Assessment

To assess a 45-year-old male patient with low testosterone, the following points should be considered:

• The patient's serum total testosterone level should be measured, with a level of less than 300 to 350 ng/dL on two separate morning blood samples considered low 3.
• The patient's symptoms and medical history should be evaluated to determine if they meet the criteria for hypogonadism, which is defined as a low testosterone level and signs or symptoms of hypogonadism 3.
• The patient's age and comorbidities should be taken into account, as the decline in testosterone with age may be related to comorbidities that develop in many aging men 4.

Treatment Options

The following treatment options should be considered:

• Testosterone replacement therapy (TRT) may be recommended for patients with hypogonadism, with various formulations available, including topical gels and intramuscular injections 3, 5.
• Nonhormonal pharmacotherapies may be considered for patients who wish to avoid exogenous hormones or are not candidates for TRT 3.
• The selection of treatment should be individualized to address the patient's needs and goals, with counseling and shared decision-making regarding risks, benefits, and expectations 3.

Monitoring and Follow-up

The following monitoring and follow-up procedures should be considered:

• Patients receiving TRT require close monitoring to minimize the risks and maximize the benefits of treatment 3, 6.
• The patient's testosterone levels, symptoms, and overall health should be regularly evaluated to adjust the treatment plan as needed 5, 6.
• The patient should be informed about the potential benefits and risks of TRT, including the impact on fertility and sexual function 5, 7.