What is the appropriate management for an elderly male with low Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH) levels?

Management of Low FSH and LH in an Elderly Male

An elderly male with low FSH and LH requires immediate evaluation for secondary (hypogonadotropic) hypogonadism, with measurement of morning total testosterone, prolactin, and consideration of pituitary imaging to exclude structural lesions, followed by referral to endocrinology for potential gonadotropin replacement therapy if fertility is desired or testosterone replacement if not. 1

Initial Diagnostic Workup

When an elderly male presents with low FSH and LH levels, this indicates secondary (hypogonadotropic) hypogonadism rather than primary testicular failure, which would show elevated gonadotropins. 1

Essential Laboratory Tests

• Morning total testosterone (8-10 AM): Must be measured to confirm hypogonadism, as low gonadotropins alone don't establish clinical significance. 1
• Repeat testosterone measurement: If initial level is low, confirm with a second morning measurement using an accurate assay. 1
• Serum prolactin: Mandatory in all patients with low testosterone combined with low/low-normal LH and FSH to screen for hyperprolactinemia and prolactinomas. 1
• Free testosterone: If total testosterone is 200-400 ng/dL (borderline), measure free testosterone by equilibrium dialysis or calculate using total testosterone, SHBG, and albumin. 1

Critical Red Flags Requiring Imaging

• Pituitary MRI is indicated if: 1
  • Total testosterone <150 ng/dL with low/low-normal LH
  • Persistently elevated prolactin levels (repeat to confirm)
  • Visual field defects (bitemporal hemianopsia)
  • Other signs of pituitary dysfunction

Clinical Assessment

Symptoms to Evaluate

Document presence of: 1

• Reduced libido and erectile dysfunction
• Decreased energy, endurance, and physical performance
• Fatigue and reduced motivation
• Depression, poor concentration, impaired memory
• Loss of muscle mass and strength
• Infertility (if relevant)
• Anosmia (suggests Kallmann syndrome even in elderly)

Physical Examination Findings

Assess for: 1

• Body habitus and BMI/waist circumference
• Virilization status (body hair patterns in androgen-dependent areas)
• Gynecomastia
• Testicular size, consistency, and presence
• Signs of other pituitary hormone deficiencies

Etiology Determination

Common Causes in Elderly Males

Low FSH/LH with low testosterone indicates hypothalamic-pituitary dysfunction: 1

• Pituitary adenomas (prolactinomas or non-secreting)
• Medications: Chronic opioid use, corticosteroids
• Obesity-related: Increased aromatization of testosterone to estradiol causing negative feedback 1
• Chronic illness: HIV, diabetes, hemochromatosis
• Prior radiation or trauma to hypothalamic-pituitary region
• Idiopathic hypogonadotropic hypogonadism (can present later in life)

Age-Related Considerations

Normal aging causes primary testicular insufficiency (elevated LH/FSH with low testosterone), not secondary hypogonadism. 2, 3 Therefore, low gonadotropins in an elderly male suggest an acquired pathological process requiring investigation, not simple aging.

Treatment Approach

If Fertility is Desired

Refer to endocrinology or male reproductive specialist for gonadotropin therapy: 1

• hCG injections initiated first to normalize testosterone
• FSH or FSH analogues added after testosterone normalization to optimize spermatogenesis
• Pulsatile GnRH is an alternative option
• Never use exogenous testosterone in men desiring fertility, as it suppresses gonadotropin secretion and causes azoospermia 1

If Fertility is Not a Concern

Testosterone replacement therapy is appropriate after excluding contraindications: 1, 4, 5

Pre-Treatment Safety Screening

• Prostate-specific antigen (PSA) and digital rectal exam
• Hemoglobin and hematocrit (baseline)
• Exclude prostate cancer and severe BPH
• Cardiovascular risk assessment (testosterone replacement associated with increased coronary plaque volume in some studies) 1

Testosterone Formulations

• Transdermal preparations (gel, patch): Provide stable daily levels but risk transfer to others via skin contact 1
• Intramuscular injections (enanthate, cypionate): Given every 2-4 weeks, avoid daily administration, lower cost 4, 5
• Starting dose: Use conservative doses in elderly, especially with suspected heart disease 1, 4

Monitoring During Treatment

• Serum testosterone: Measure to ensure levels reach mid-normal range
• Hemoglobin/hematocrit: Check periodically for polycythemia 4
• PSA and prostate exam: Monitor for prostate changes
• Serum TSH: Recheck every 6-12 months as testosterone therapy goal is to maintain TSH in normal range 1

Alternative: Selective Estrogen Receptor Modulators (SERMs)

Clomiphene or tamoxifen may be considered in men with low testosterone and low-normal LH who wish to preserve fertility, though benefits are limited: 1

• Not FDA-approved for this indication
• Acts by increasing endogenous testosterone production
• Preserves spermatogenesis unlike exogenous testosterone

Common Pitfalls to Avoid

• Do not assume age-related decline: Low gonadotropins suggest pathology, not normal aging 2, 3
• Do not give testosterone without checking prolactin: May miss treatable prolactinoma 1
• Do not use testosterone in men desiring fertility: Causes suppression of spermatogenesis 1
• Do not screen asymptomatic elderly men: Testosterone replacement in age-related hypogonadism lacks safety/efficacy data 1, 4
• Do not over-replace: Risk of anxiety, muscle wasting, osteoporosis, and atrial fibrillation 4

Specialist Referral Indications

Endocrinology referral is strongly recommended for: 1

• All cases of confirmed hypogonadotropic hypogonadism
• Elevated prolactin levels
• Total testosterone <150 ng/dL with low LH
• Men desiring fertility
• Suspected pituitary or hypothalamic disease