What is the appropriate management for an adult male with elevated testosterone levels not on testosterone supplementation?

Management of Elevated Testosterone in Men Not on Supplementation

Men with elevated endogenous testosterone levels (>800 ng/dL) who are not on testosterone supplementation rarely require intervention, as naturally elevated testosterone is not associated with clinically significant morbidity. 1

Initial Assessment

When encountering elevated testosterone in a man not on supplementation, the priority is to confirm the elevation and rule out pathologic causes:

• Repeat the testosterone measurement to confirm the elevation is persistent, as single measurements can be spuriously elevated 1
• Measure LH levels to distinguish between primary (testicular) and secondary (pituitary/adrenal) causes of elevation 2
• Check for exogenous testosterone use including topical preparations, supplements, or anabolic steroids that the patient may not have disclosed 2

Distinguishing Physiologic from Pathologic Elevation

If LH is Elevated or High-Normal:

This suggests a testosterone-secreting tumor (testicular or adrenal). Proceed with:

• Testicular examination for masses 2
• Adrenal imaging if testicular exam is normal
• Endocrinology referral for further evaluation 2

If LH is Low or Low-Normal:

This suggests secondary causes:

• Measure prolactin levels to screen for pituitary adenomas 2
• If prolactin is elevated, repeat measurement and obtain pituitary MRI 2
• Consider adrenal causes including congenital adrenal hyperplasia or adrenal tumors

Clinical Monitoring Without Intervention

For men with confirmed elevated endogenous testosterone (>800 ng/dL) without identified pathology:

Hematocrit monitoring is the primary concern, though clinically significant polycythemia is uncommon:

• Check baseline hematocrit 2
• Men with naturally elevated testosterone have modestly higher hematocrit (mean increase of 1.3%) but this rarely reaches clinically significant levels 1
• Monitor annually; intervention is only needed if hematocrit exceeds 54% 2

Other parameters to monitor:

• Liver function tests (AST/ALT) may be mildly elevated but are not clinically significant 1
• PSA and digital rectal exam in men over 40 years, following standard screening guidelines 2
• Sleep apnea symptoms, though no increased risk has been demonstrated 1

What NOT to Do

Do not attempt to lower naturally elevated testosterone levels unless a pathologic cause is identified. The evidence shows:

• No association with sleep disorders, urinary symptoms, or depression 1
• No increased cardiovascular risk 1
• No clinically significant adverse effects even at levels >800 ng/dL 1

Do not use aromatase inhibitors in men with elevated endogenous testosterone, as these are only indicated for managing elevated estradiol in men receiving exogenous testosterone therapy 3, 4

Key Pitfalls to Avoid

• Missing occult exogenous testosterone use: Directly ask about use of testosterone gels, patches, injections, or "supplements" that may contain androgens 5
• Failing to measure LH: This is essential to distinguish benign elevation from tumor-related causes 2
• Over-treating based on laboratory values alone: Elevated endogenous testosterone without symptoms or identified pathology does not require treatment 1
• Confusing management of elevated endogenous testosterone with management of testosterone therapy: The latter requires monitoring for polycythemia, prostate issues, and estradiol elevation, while the former rarely causes problems 2, 1

When to Refer to Endocrinology

Refer when:

• Persistently elevated prolactin levels are identified 2
• LH is elevated suggesting a testosterone-secreting tumor 2
• Baseline estradiol is elevated (though this is uncommon without exogenous testosterone) 2
• Any pituitary or adrenal mass is identified on imaging 2