What can be done for a 47-year-old patient with hypogonadism (low testosterone levels)?

From the Guidelines

For a 47-year-old patient with a testosterone level of 162 ng/dL, discussing whether to initiate testosterone treatment to improve sexual function is recommended, as this level falls below the normal range and may indicate hypogonadism, according to the American College of Physicians guideline 1. The patient's symptoms and preferences should be taken into account when making this decision, as the evidence for testosterone treatment is low-certainty and conditional 1. Some key points to consider include:

• The potential benefits of testosterone treatment, such as improved sexual function and overall well-being 1
• The potential harms, including serious adverse events and major adverse cardiovascular events 1
• The costs of treatment and the patient's preferences 1
• The need for regular monitoring and reevaluation of symptoms within 12 months and periodically thereafter 1 It is also important to note that testosterone treatment should not be initiated to improve energy, vitality, physical function, or cognition, as the evidence does not support this use 1. In terms of treatment options, intramuscular formulations may be considered over transdermal formulations due to lower costs and similar clinical effectiveness and harms 1. Overall, the decision to initiate testosterone treatment should be made on a case-by-case basis, taking into account the individual patient's needs and preferences, and with careful consideration of the potential benefits and harms. Additionally, more recent guidelines from 2023 suggest that in men with diabetes who have symptoms or signs of hypogonadism, such as decreased sexual desire or activity, or erectile dysfunction, screening with a morning serum testosterone level should be considered 1. However, the most recent and highest quality study on this topic is from the American College of Physicians guideline in 2020 1, which should be prioritized when making treatment decisions.

From the FDA Drug Label

INDICATIONS AND USAGE Males Testosterone Enanthate Injection, USP is indicated for replacement therapy in conditions associated with a deficiency or absence of endogenous testosterone. The patient's testosterone level of 162 ng/dL indicates a deficiency in endogenous testosterone.

• Replacement therapy with Testosterone Enanthate Injection, USP may be considered for this patient, as it is indicated for conditions associated with a deficiency or absence of endogenous testosterone 2.
• However, safety and efficacy of Testosterone Enanthate Injection, USP in men with age-related hypogonadism have not been established, and the patient's age and condition should be carefully evaluated before initiating treatment.

From the Research

Treatment Options for Low Testosterone

For a 47-year-old patient with a testosterone level of 162 ng/dL, several treatment options are available:

• Testosterone replacement therapy (TRT) can be used to improve symptoms and signs of testosterone deficiency, including decreased libido, erectile dysfunction, and loss of muscle and bone mass 3.
• TRT has been used for over 70 years and comes in various preparations and formulations, including buccal, nasal, subdermal, transdermal, and intramuscular (IM) routes of delivery 3.
• A study comparing intramuscular testosterone cypionate (IM-TC) and subcutaneous testosterone enanthate (SCTE-AI) found that both treatments increased total testosterone levels, but SCTE-AI was associated with lower levels of estradiol and hematocrit 4.

Considerations for Older Men

When considering testosterone therapy for older men, it is essential to weigh the benefits and risks:

• Testosterone treatment can improve sexual function, anemia, and bone mineral density in older men, and may also prevent or revert type 2 diabetes mellitus in men at high risk 5.
• However, testosterone treatment may also have potential risks, such as an increase in hematocrit and prostate-specific antigen (PSA) levels, although a study found that SCTE-AI was not associated with significant post-therapy elevation of PSA 4.
• A retrospective analysis of long-term testosterone replacement in older hypogonadal males found that testosterone replacement therapy was well-tolerated by over 84% of subjects, but frequent follow-up blood tests and examinations are necessary to monitor potential complications 6.

Individualized Treatment

It is crucial to individualize treatment for each patient:

• A narrative review emphasizes the need to formulate a proper diagnosis and guide toward an individualized treatment plan, taking into account the patient's unique characteristics and medical history 7.
• The treatment of male hypogonadism should be based on a thorough evaluation of the patient's symptoms, medical history, and laboratory results, and should be monitored regularly to maximize benefits and minimize risks 3, 7.