When is hypogonad (hypogonadism) testing recommended for individuals with symptoms like low libido, erectile dysfunction, fatigue, or infertility?

When to Test for Hypogonadism

Test for hypogonadism when men present with specific sexual symptoms—particularly decreased libido, erectile dysfunction, or reduced spontaneous/morning erections—combined with physical or psychological symptoms suggestive of testosterone deficiency. 1

Specific Symptoms That Warrant Testing

Sexual Symptoms (Most Specific)

• Reduced libido is the most specific symptom associated with hypogonadism and should prompt testosterone measurement 1
• Erectile dysfunction, especially when accompanied by decreased spontaneous or morning erections, warrants screening 1
• Reduced frequency of sexual intercourse or masturbation, though less specific, supports testing when combined with other symptoms 1

Physical Symptoms

• Decreased vigorous activity, difficulty walking >1 km, or decreased bending capacity suggest hypogonadism 1
• Hot flushes, decreased energy, and reduced physical strength/function/activity are supportive symptoms 1
• Diminished facial and body hair, muscle mass loss, fine facial wrinkles, gynecomastia, and testicular hypotrophy indicate long-standing hypogonadism 2

Psychological Symptoms

• Low mood/mood deflection, decreased motivation, and fatigue warrant consideration of testing 1
• Concentration difficulties, memory problems, and sleep disturbances are less specific but supportive 1

Special Populations Requiring Screening

Men with Diabetes

• Screen men with diabetes who have symptoms of hypogonadism with a morning serum testosterone level 1
• Mean testosterone levels are lower in diabetic men compared to age-matched controls, though obesity is a major confounder 1
• Further testing (LH and FSH) may be needed when total testosterone is near the lower limit, given expected decreases in sex hormone-binding globulin with diabetes 1

Men with Infertility

• Men presenting with infertility require testosterone testing as part of the comprehensive evaluation 1
• Approximately 36% of men seeking consultation for sexual dysfunction have hypogonadism 3

Men with Failed PDE5 Inhibitor Therapy

• Measure testosterone in all men with organic erectile dysfunction, especially those who failed PDE5 inhibitor therapy 3
• A minimal testosterone level is required for complete effect of PDE5 inhibitors, explaining treatment failures when testosterone is low 3

Diagnostic Confirmation Requirements

Initial Testing Protocol

• Measure morning total testosterone (between 8 AM and 10 AM) on at least two separate days to confirm hypogonadism, as single measurements are insufficient due to assay variability and diurnal fluctuation 3, 4
• Testosterone levels below 300-350 ng/dL indicate potential hypogonadism 3, 5

Additional Testing for Borderline Cases

• Measure free testosterone by equilibrium dialysis in men with obesity, diabetes, or borderline total testosterone levels 3
• Measure sex hormone-binding globulin (SHBG) to distinguish true hypogonadism from SHBG-related decreases in total testosterone 3
• SHBG levels increase with aging, hyperthyroidism, hepatic disease, smoking, and certain medications (anticonvulsants, estrogens, thyroid hormone) 1
• SHBG levels decrease with obesity, hypothyroidism, insulin resistance, metabolic syndrome, and type 2 diabetes 1

Distinguishing Primary from Secondary Hypogonadism

• If testosterone levels are subnormal on repeat testing, measure serum LH and FSH to distinguish primary (testicular) from secondary (pituitary-hypothalamic) hypogonadism 3, 5
• Elevated LH/FSH with low testosterone indicates primary hypogonadism 5
• Low or inappropriately normal LH/FSH with low testosterone indicates secondary hypogonadism 5
• This distinction is critical because secondary hypogonadism patients can potentially achieve both fertility and normal testosterone with gonadotropin therapy, while primary hypogonadism patients can only receive testosterone therapy, which compromises fertility 1, 5

Common Pitfalls to Avoid

• Never diagnose hypogonadism based on symptoms or screening questionnaires alone without confirmed biochemical testing, as symptoms lack specificity 3
• Do not test testosterone in men without specific symptoms, as approximately 20-30% of men over 60 have low-normal testosterone levels that do not constitute disease requiring treatment 3
• Avoid testing testosterone while patients are on exogenous testosterone therapy, as this will yield misleading results and prevent accurate diagnosis of the underlying type of hypogonadism 3
• Do not assume all symptomatic men with borderline testosterone require treatment—address reversible causes first, including obesity, sleep disorders, thyroid dysfunction, anemia, and vitamin D deficiency 3