From the Guidelines
For a 27-year-old male with low testosterone (6.8 nmol/L), I strongly recommend confirming the diagnosis with two total testosterone measurements taken on separate occasions in an early morning fashion, as a single measurement may not be reliable 1. To convert the given testosterone level to ng/dL, we use the conversion factor 1 nmol/L = 28.84 ng/dL, which gives us approximately 196.7 ng/dL. According to the American Urological Association (AUA) guideline, a total testosterone level below 300 ng/dL is considered a reasonable cut-off for the diagnosis of low testosterone 1. Given the patient's age and low testosterone level, it is essential to investigate the underlying cause of the deficiency.
- The diagnosis of testosterone deficiency requires both a low testosterone measurement and the presence of select symptoms and/or signs, such as reduced energy, reduced endurance, diminished work and/or physical performance, fatigue, visual field changes, anosmia, depression, reduced motivation, poor concentration, impaired memory, irritability, infertility, reduced sex drive, and changes in erectile function 1.
- A targeted physical exam should be conducted to examine patients for signs associated with low testosterone, including evaluation of general body habitus, virilization status, body mass index or waist circumference, gynecomastia, testicular evaluation, varicocele presence, and prostate size and morphology 1. Before starting any treatment, a comprehensive evaluation, including medical history, physical examination, and laboratory tests, such as luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and estradiol, should be performed to determine the underlying cause of the low testosterone level 1. Lifestyle modifications, such as regular exercise, adequate sleep, stress management, and maintaining a healthy weight, can naturally support testosterone levels. If testosterone replacement therapy (TRT) is deemed necessary, regular monitoring of testosterone levels, hematocrit, prostate-specific antigen (PSA), and liver function is essential during treatment to ensure safety and efficacy.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Low Testosterone Levels
- A testosterone level of 6.8 nmol/L is considered low, as the normal range is typically above 8 nmol/L 2.
- Hypogonadism is a clinical syndrome complex that comprises symptoms with or without signs, as well as biochemical evidence of testosterone deficiency 2.
Diagnosis and Treatment
- The diagnosis of hypogonadism includes both clinical history and examination, as well as biochemical assessment of serum testosterone levels 2.
- Human chorionic gonadotropin (hCG) monotherapy has been shown to improve hypogonadal symptoms in men with low testosterone levels, without changing hematocrit, prostate-specific antigen, and hemoglobin A1c 3.
- hCG therapy may be a viable option for managing secondary hypogonadism and male infertility, as it triggers testosterone and sperm production without the side effects on fertility seen in testosterone replacement therapy 4.
Fertility Preservation
- Testosterone replacement therapy can impair spermatogenesis, leading to azoospermia in 40% of patients 5.
- Concomitant intramuscular hCG has been shown to preserve spermatogenesis in men undergoing testosterone replacement therapy, and may support continued fertility in these patients 5.
Considerations for Treatment
- The actual prevalence of hypogonadism has been estimated to be 39% in men aged 45 years or older presenting to primary care offices in the United States 6.
- 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 6.
- A trial period of testosterone treatment may be required to determine the effectiveness of treatment in individual patients 2.