In a 34‑year‑old man with reduced libido and normal total testosterone (~557 ng/dL) and free testosterone (~7.3 pg/mL), what is the appropriate management recommendation?

Management of Reduced Libido with Normal Testosterone Levels

Do not initiate testosterone therapy in this patient, as his total testosterone of 557 ng/dL is well above the diagnostic threshold for hypogonadism and testosterone replacement is not indicated for men with normal testosterone levels, regardless of symptoms. 1, 2

Why Testosterone Therapy Is Not Appropriate

Your patient's testosterone levels are clearly normal:

• Total testosterone of 557 ng/dL is well within the healthy adult male range (264–916 ng/dL, mean 500–600 ng/dL) 2
• This value is nearly double the diagnostic threshold for hypogonadism (<300 ng/dL on two separate morning measurements) 1, 2
• The 2025 European Association of Urology guidelines explicitly recommend against testosterone therapy in eugonadal men, even for symptoms like reduced libido, weight loss, or vitality concerns 1, 2

Critical point: Approximately 25–30% of men receiving testosterone therapy do not actually meet diagnostic criteria for hypogonadism—this represents inappropriate prescribing that exposes patients to risks without evidence of benefit 2

The Free Testosterone Result Requires Clarification

The reported free testosterone of 7.3 pg/mL appears inconsistent with the total testosterone level and warrants investigation:

• With a total testosterone of 557 ng/dL, the expected free testosterone should be elevated or high-normal, not low 2
• Direct immunoassay methods for free testosterone are notoriously unreliable and should not guide clinical decisions 1, 3
• Repeat free testosterone measurement using equilibrium dialysis (the gold standard) or calculate the free androgen index (total testosterone ÷ SHBG × 100) 1, 2, 3
• Also measure sex hormone-binding globulin (SHBG) to assess whether binding protein abnormalities explain the discrepancy 1, 2, 3

Recommended Diagnostic Approach

Step 1: Confirm the Laboratory Values

• Repeat morning total testosterone (8–10 AM, fasting) on a second occasion to confirm the initial value 1, 2, 3
• Obtain free testosterone by equilibrium dialysis (not direct immunoassay) 1, 2, 3
• Measure SHBG to calculate the free androgen index if equilibrium dialysis is unavailable 1, 2
• An FAI <30 would indicate true hypogonadism despite borderline-normal total testosterone, but with total testosterone of 557 ng/dL this is highly unlikely 2

Step 2: Evaluate Alternative Causes of Reduced Libido

Reduced libido in a eugonadal man requires investigation of non-hormonal etiologies 1, 2:

• Psychological factors: depression, anxiety, relationship stress, performance anxiety 1
• Medications: antidepressants (SSRIs, tricyclics), antihypertensives (β-blockers, diuretics), tranquilizers 1
• Metabolic conditions: uncontrolled diabetes (check HbA1c, fasting glucose), metabolic syndrome, thyroid dysfunction (check TSH) 1, 2
• Sleep disorders: obstructive sleep apnea, chronic sleep deprivation 2
• Chronic systemic illness: inflammatory conditions, chronic pain, cardiovascular disease 2
• Lifestyle factors: obesity, sedentary behavior, excessive alcohol use, smoking 1, 2

Step 3: Consider Erectile Dysfunction Evaluation

• Reduced libido often coexists with erectile dysfunction 1, 4, 5
• If erectile dysfunction is present, phosphodiesterase-5 inhibitors (sildenafil, tadalafil) are first-line therapy and can be used effectively in men with normal testosterone 1
• Sexual counseling and partner involvement are important components of treatment 1

What the Evidence Shows About Testosterone Therapy in Eugonadal Men

• Testosterone therapy produces little to no benefit for libido, energy, physical function, or mood in men with normal testosterone levels 1, 2
• Even in men with confirmed hypogonadism (testosterone <300 ng/dL), the improvement in sexual function is modest (standardized mean difference 0.35), with minimal effects on energy, vitality, or cognition 1, 2
• Testosterone therapy in eugonadal men carries real risks without proven benefit: erythrocytosis (up to 44% with injectable testosterone), cardiovascular concerns, suppression of fertility, and potential prostate effects 1, 2

Lifestyle Modifications That May Help

• Weight loss (if BMI >25): a 5–10% reduction can improve sexual function and testosterone levels in overweight men 1, 2
• Regular exercise: minimum 150 minutes/week of moderate-intensity aerobic activity plus resistance training 2–3 times weekly 1, 2
• Optimize sleep: address sleep apnea if present, aim for 7–9 hours nightly 2
• Stress reduction: cognitive behavioral therapy, mindfulness, or couples counseling 1
• Medication review: discontinue or substitute libido-suppressing drugs when feasible 1

Critical Pitfalls to Avoid

• Never diagnose hypogonadism on symptoms alone without biochemical confirmation of low testosterone on two separate morning measurements 1, 2
• Never prescribe testosterone to men with normal testosterone levels, even if symptomatic—this violates evidence-based guidelines and exposes patients to unnecessary risks 1, 2
• Never rely on direct immunoassay free testosterone results when they conflict with total testosterone; always confirm with equilibrium dialysis or calculated values 1, 2, 3
• Never skip the evaluation for reversible causes of sexual dysfunction—depression, medications, and relationship factors are far more common than true hypogonadism in men with normal testosterone 1, 2

Summary Algorithm

1. Repeat morning total testosterone and obtain free testosterone by equilibrium dialysis plus SHBG 2, 3
2. If total testosterone remains >350 ng/dL on repeat testing, testosterone therapy is not indicated 2
3. Screen for depression (PHQ-9), review medications, check HbA1c, TSH, and lipid panel 1, 2
4. Assess for erectile dysfunction; if present, offer PDE5 inhibitors 1
5. Recommend lifestyle modifications: weight loss, exercise, sleep optimization, stress management 1, 2
6. Consider referral to sexual medicine specialist or mental health professional if symptoms persist despite addressing reversible factors 1