What to advise a 35-year-old male with elevated testosterone levels, normal free testosterone (>50), normal hemoglobin (Hemoglobin) and hematocrit (Hematocrit)?

From the Guidelines

I would strongly advise this 35-year-old male with significantly elevated testosterone levels (2975.4 ng/dL) and Free T >50 pg/mL to immediately discontinue any exogenous testosterone or anabolic steroid use, as these levels are well above the normal range (typically 300-1000 ng/dL for total testosterone), strongly suggesting external supplementation 1. Despite normal hemoglobin and hematocrit levels currently, these extremely high testosterone values pose serious health risks including cardiovascular complications, liver damage, and potential psychiatric effects.

Key Considerations

• The patient's testosterone levels are significantly elevated, indicating potential exogenous supplementation.
• Normal hemoglobin and hematocrit levels do not negate the risks associated with high testosterone levels.
• Cardiovascular complications, liver damage, and psychiatric effects are potential risks associated with elevated testosterone levels.

Recommendations

• Immediate discontinuation of exogenous testosterone or anabolic steroid use is necessary to mitigate potential health risks.
• The patient should seek medical care promptly for proper evaluation, including comprehensive blood work to assess liver function, lipid profile, and cardiac markers.
• If the patient is using prescribed testosterone, his dosage needs immediate adjustment under medical supervision.
• If using non-prescribed substances, a gradual tapering approach rather than abrupt cessation may be necessary to avoid withdrawal symptoms, guided by a healthcare provider.
• Post-cessation, the patient may require temporary hormone replacement therapy to restore natural testosterone production, which can be suppressed by exogenous use, as suggested by guidelines on testosterone deficiency management 1.

Monitoring and Follow-up

• Regular monitoring of testosterone levels, hematocrit, and hemoglobin is crucial, as recommended in guidelines for testosterone-replacement therapy 1.
• The patient should be aware of the potential risks of exogenous testosterone use, including polycythemia, and the importance of regular monitoring to prevent adverse effects.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Testosterone Levels and Evaluation

• The patient's testosterone level is 2975.4, which is above the normal range, and Free T is >50 2.
• According to the study by 2, the mean lower reference value of total testosterone is 231 ± 46 ng/dl, and the mean upper limit is 850 ± 141 ng/dl.
• The patient's hemoglobin and hematocrit levels are within normal limits (WNL), which is important to consider when evaluating testosterone levels and potential treatment options 3.

Potential Causes and Evaluation

• The study by 4 suggests that pituitary imaging by MRI is not warranted in all patients with hypogonadotropic hypogonadism, as the yield of identifiable abnormalities is quite low.
• However, the study by 5 found that MRI of the pituitary can be useful in evaluating hypogonadal men, particularly those with high levels of prolactin or low levels of total testosterone.
• The patient's symptoms and medical history should be taken into account when determining the need for further evaluation, such as pituitary imaging 3.

Treatment Considerations

• The Endocrine Society clinical practice guideline recommends making a diagnosis of hypogonadism only in men with symptoms and signs consistent with testosterone deficiency and unequivocally and consistently low serum T concentrations 3.
• The guideline also recommends measuring fasting morning total T concentrations using an accurate and reliable assay as the initial diagnostic test, and confirming the diagnosis by repeating the measurement of morning fasting total T concentrations 3.
• Treatment with testosterone therapy may be considered for men with symptomatic testosterone deficiency, but potential benefits and risks should be discussed with the patient, and monitoring of therapy should be implemented 3.