What should a 37-year-old patient do after being started on testosterone therapy without proper testing and evaluation?

Immediate Evaluation and Management After Inappropriate Testosterone Initiation

This 37-year-old patient should immediately undergo comprehensive diagnostic testing to determine if testosterone therapy is actually indicated, and if not, the therapy should be discontinued with appropriate monitoring for recovery of endogenous testosterone production. 1

Step 1: Obtain Proper Diagnostic Testing Now

The patient requires the following baseline laboratory work while still on testosterone therapy to assess current status:

• Morning total testosterone levels on two separate occasions to establish if true hypogonadism exists (threshold <300 ng/dL) 1
• Serum luteinizing hormone (LH) to determine if hypogonadism is primary (testicular) or secondary (hypothalamic-pituitary) in origin 1, 2
• Serum prolactin if LH is low or low-normal, to screen for hyperprolactinemia and potential pituitary tumors 1, 2
• Hemoglobin/hematocrit to assess for polycythemia (intervention required if hematocrit >54%) 1, 2
• Follicle-stimulating hormone (FSH) if the patient has any interest in current or future fertility 1, 2
• Estradiol only if the patient has breast symptoms or gynecomastia 1, 3

Step 2: Assess Clinical Symptoms and Signs

Document whether the patient actually has symptoms consistent with testosterone deficiency, as diagnosis requires both low testosterone levels and clinical manifestations 1:

Key symptoms to assess: 1

• Reduced libido and erectile dysfunction
• Decreased energy, endurance, and physical performance
• Fatigue and reduced motivation
• Depression, poor concentration, and impaired memory
• Changes in body composition (decreased muscle mass, increased adiposity)

Physical examination findings: 1

• Body habitus and virilization status (body hair patterns in androgen-dependent areas)
• Body mass index or waist circumference
• Gynecomastia presence
• Testicular size, consistency, and presence of masses
• Prostate size and morphology

Step 3: Decision Algorithm Based on Testing Results

If Testing Confirms True Hypogonadism:

Continue testosterone therapy if both criteria are met: 1

• Two morning testosterone levels <300 ng/dL on separate occasions
• Presence of consistent symptoms and/or signs

Adjust monitoring: 1, 2

• Measure follow-up testosterone levels approximately 14 days after any dose adjustment to ensure levels are in the normal range (300-1,000 ng/dL) 4
• Monitor hemoglobin/hematocrit at 3-6 months, then annually 2
• Check testosterone levels every 6-12 months 1

If Testing Does NOT Confirm Hypogonadism:

Discontinue testosterone therapy immediately if: 1

• Testosterone levels are consistently ≥300 ng/dL, OR
• Patient lacks consistent symptoms/signs of testosterone deficiency

Post-discontinuation management: 1

• Counsel the patient that recovery of endogenous testosterone production is highly variable in timing and degree
• Recheck morning testosterone levels 3-6 months after discontinuation to assess recovery of the hypothalamic-pituitary-gonadal axis
• If fertility is a concern, consider semen analysis as exogenous testosterone suppresses spermatogenesis through feedback inhibition 1, 2

Step 4: Address Fertility Concerns Immediately

Critical consideration at age 37: Exogenous testosterone suppresses spermatogenesis and can cause infertility 1. If the patient has any interest in future fertility:

• Obtain semen analysis now to assess current reproductive status 1, 2
• Consider discontinuing testosterone and switching to alternative therapies that preserve fertility, such as human chorionic gonadotropin (hCG), selective estrogen receptor modulators, or aromatase inhibitors 1
• Counsel that time to sperm recovery after testosterone cessation is highly variable and unpredictable 1

Step 5: Evaluate for Underlying Risk Factors

Assess whether the patient has conditions associated with increased risk of hypogonadism that may have prompted inappropriate treatment: 1

• Unexplained anemia
• Bone density loss
• Diabetes
• History of chemotherapy or testicular radiation
• HIV/AIDS
• Chronic narcotic use
• Pituitary dysfunction
• Chronic corticosteroid use

Critical Pitfalls to Avoid

Do not rely on questionnaires alone – validated questionnaires are not appropriate tools to diagnose testosterone deficiency or monitor treatment response 1

Do not continue therapy without documented benefit – if the patient achieves target testosterone levels (300-1,000 ng/dL) but experiences no symptom improvement after 3-6 months, discontinue therapy as there is no utility in continuing 1

Avoid compounded testosterone preparations – commercially manufactured FDA-approved products should be prescribed when possible due to quality and potency concerns with compounded formulations 1

Monitor for polycythemia aggressively – injectable testosterone formulations carry the highest risk of treatment-induced increases in hemoglobin/hematocrit 1, 2