How should I treat a 55-year-old man with a total testosterone of 245 ng/dL?

Treatment Approach for a 55-Year-Old Man with Testosterone 245 ng/dL

You should initiate testosterone replacement therapy only if this patient has specific sexual symptoms—diminished libido or erectile dysfunction—confirmed on two separate morning measurements below 300 ng/dL, and after ruling out contraindications and reversible causes. 1

Step 1: Confirm the Diagnosis

Before any treatment decision, you must confirm biochemical hypogonadism with proper testing:

• Repeat morning total testosterone (8–10 AM) on a second occasion to verify persistent low levels, as single measurements are unreliable due to diurnal variation and assay differences 1, 2
• Both measurements must be below 300 ng/dL to establish hypogonadism 1, 3
• Measure LH and FSH after confirming low testosterone to distinguish primary (elevated LH/FSH) from secondary (low/normal LH/FSH) hypogonadism—this distinction is critical for treatment selection and fertility counseling 1, 2
• Obtain free testosterone by equilibrium dialysis if the patient is obese or has borderline values, as low SHBG can artificially lower total testosterone while free testosterone remains normal 1, 2

A testosterone level of 245 ng/dL falls clearly below the 300 ng/dL threshold, but you still need confirmation and symptom assessment before proceeding 1, 3.

Step 2: Assess for Qualifying Symptoms

Testosterone therapy is justified only for diminished libido and erectile dysfunction—these are the only symptoms with proven benefit from replacement 1. The evidence is clear:

• Small but significant improvements occur in sexual function (standardized mean difference 0.35) 1
• Little to no effect on energy, vitality, physical functioning, depressive symptoms, or cognition even with confirmed hypogonadism 1
• Fatigue, low energy, mood changes, and "brain fog" should not trigger therapy, as improvement in these domains is negligible (effect size 0.17 for energy) 1

If your patient's primary complaints are non-sexual (fatigue, low energy, poor concentration), do not initiate testosterone therapy—the evidence shows no meaningful benefit for these symptoms 1.

Step 3: Rule Out Contraindications

Before starting therapy, verify the patient does not have:

• Active desire for fertility preservation—testosterone causes prolonged azoospermia; use gonadotropin therapy (hCG + FSH) instead if fertility is desired 1, 2
• Prostate cancer or PSA >4.0 ng/mL (>3.0 ng/mL in high-risk men) without urologic clearance 1, 2
• Breast cancer 1, 2
• Hematocrit >54% 1, 2
• Severe untreated obstructive sleep apnea 1, 2
• Recent cardiovascular event within 3–6 months 1

Step 4: Evaluate for Reversible Causes (Especially in Secondary Hypogonadism)

If LH/FSH are low or low-normal (secondary hypogonadism), investigate treatable causes before committing to lifelong testosterone:

• Obesity-associated hypogonadism—attempt weight loss (500–750 kcal/day deficit) and exercise (≥150 min/week moderate aerobic + resistance training 2–3×/week) first, as 5–10% weight loss can significantly raise endogenous testosterone 1
• Measure prolactin—if >1.5× upper limit of normal, order pituitary MRI to exclude prolactinoma 1, 2
• Check fasting glucose/HbA1c to exclude diabetes 1
• Screen for chronic systemic illness, hemochromatosis (iron studies), thyroid dysfunction (TSH) 1

For a 55-year-old man with testosterone 245 ng/dL, if he is obese with secondary hypogonadism, lifestyle modification should be attempted first before pharmacologic therapy 1.

Step 5: Choose the Appropriate Formulation

If the patient meets criteria (confirmed low testosterone on two occasions, sexual symptoms, no contraindications), select a testosterone formulation:

First-Line: Transdermal Testosterone Gel

• Transdermal testosterone gel 1.62% at 40.5 mg daily is preferred due to stable day-to-day levels and lower erythrocytosis risk (15.4% vs. 43.8% with injectables) 1, 3
• Target mid-normal testosterone levels (450–600 ng/dL) 1, 3
• More expensive (≈$2,135/year) but better tolerated 1

Alternative: Intramuscular Injections

• Testosterone cypionate or enanthate 100–200 mg every 2 weeks (or 50–100 mg weekly for more stable levels) 1, 3
• More economical (≈$156/year) 1
• Higher erythrocytosis risk (43.8%) due to supraphysiologic peaks 2–5 days post-injection 1
• Measure testosterone levels midway between injections (days 5–7 for weekly, days 7–10 for bi-weekly) targeting 500–600 ng/dL 1, 3

For a 55-year-old man, start with transdermal gel to minimize erythrocytosis risk, especially if he has cardiovascular risk factors 1.

Step 6: Baseline Testing Before Initiation

Obtain these labs before starting therapy:

• Hematocrit/hemoglobin (contraindication if >54%) 1, 2
• PSA (if >40 years old; >4.0 ng/mL requires urologic evaluation) 1, 2
• Digital rectal exam 1, 2
• Lipid profile 1

Step 7: Monitoring Protocol

Initial Follow-Up (2–3 Months)

• Measure total testosterone (midway between injections for injectables, anytime for gel) 1, 3
• Repeat hematocrit—withhold therapy if >54% and consider phlebotomy in high-risk cases 1, 2
• Repeat PSA 1, 2
• Assess clinical response, particularly sexual function 1

Ongoing Monitoring (Every 3–6 Months First Year, Then Annually)

• Testosterone levels 1, 3
• Hematocrit 1, 2
• PSA—refer to urology if rise >1.0 ng/mL in first 6 months or >0.4 ng/mL/year thereafter 1, 2
• Digital rectal exam 1, 2
• Lipid profile 1

Discontinuation Criteria

• If no improvement in sexual function at 12 months, discontinue therapy to avoid unnecessary long-term exposure without benefit 1

Critical Pitfalls to Avoid

• Do not diagnose hypogonadism on a single measurement—two morning values are required 1, 2
• Do not start therapy for non-sexual symptoms (fatigue, low energy, mood)—the evidence shows no benefit 1
• Do not omit LH/FSH testing—the primary vs. secondary distinction directs fertility counseling and treatment choice 1, 2
• Do not initiate therapy without confirming the patient does not desire fertility—testosterone causes azoospermia 1, 2
• Do not ignore obesity as a reversible cause—attempt lifestyle modification first in secondary hypogonadism 1
• Do not continue therapy if hematocrit exceeds 54%—this is an absolute indication to withhold treatment 1, 2

Expected Outcomes: Set Realistic Expectations

Counsel your patient that testosterone therapy will provide:

• Small but significant improvement in sexual function and libido (effect size 0.35) 1
• No meaningful improvement in energy, physical strength, mood, or cognition 1
• Modest quality-of-life gains confined to sexual domains 1

For a 55-year-old man with testosterone 245 ng/dL, the decision hinges entirely on whether he has diminished libido or erectile dysfunction. If his primary complaints are fatigue or low energy, testosterone therapy is not indicated regardless of the low level 1.