Is treatment indicated for asymptomatic hypogonadism (low testosterone) in a 45-year-old male?

From the Guidelines

Treatment is not recommended for low testosterone in an asymptomatic 45-year-old male. According to the American College of Physicians guideline 1, testosterone treatment is suggested only for men with age-related low testosterone and sexual dysfunction who want to improve sexual function. For asymptomatic men, the potential benefits of treatment do not outweigh the potential harms, including serious adverse events and major adverse cardiovascular events.

Key points to consider in this scenario include:

• The natural decline of testosterone levels with age, with an average rate of 1.6% per year 1
• The lack of a well-defined threshold for testosterone levels below which symptoms of androgen deficiency and adverse health outcomes occur 1
• The importance of discussing potential benefits, harms, costs, and patient preferences before initiating treatment 1
• The need for regular reevaluation of symptoms and discontinuation of treatment if no improvement is seen 1

In the absence of symptoms such as decreased libido, erectile dysfunction, fatigue, depression, reduced muscle mass, or increased body fat, observation rather than testosterone replacement therapy is typically recommended. If symptoms develop, treatment options can be considered, and regular monitoring of testosterone levels, complete blood count, and prostate-specific antigen would be required if treatment were initiated.

From the Research

Treatment for Low Testosterone in Asymptomatic Males

• The need for treatment in asymptomatic males with low testosterone levels is a topic of discussion among medical professionals, as evidenced by studies such as 2 and 3.
• According to 2, many men with low testosterone levels have no symptoms, and many men with symptoms who receive treatment and reach goal testosterone levels have no improvement in their symptoms.
• The study 3 suggests that the benefits of androgen therapy outweigh the risks in men with classic hypogonadism, but for men with mild hypogonadism or andropause, the balance between benefits and risks is not always clear.

Considerations for Treatment

• The decision to treat low testosterone in asymptomatic males should be based on individual patient factors, including the presence of symptoms and the potential risks and benefits of treatment, as discussed in 3 and 4.
• The study 4 found that testosterone therapy induces modest, yet statistically significant, improvements in sexual function without increasing short-term to medium-term cardiovascular or prostate cancer risks in men with functional hypogonadism.
• However, the same study notes that there is insufficient evidence to determine the safety and effectiveness of testosterone use for the prevention of fractures or type 2 diabetes.

Age-Related Considerations

• The prevalence of hypogonadism increases with age, with an estimated 39% of men aged 45 years or older presenting to primary care offices in the United States having low testosterone levels, as reported in 2.
• The study 3 recommends measurement of hematocrit for detection of polycythemia and a digital rectal examination with a serum prostate-specific antigen level measurement for prostate cancer screening during the first few months of androgen therapy in men aged >50 years.