Last updated December 18, 2021

Testosterone Therapy in Men With Hypogonadism

Recommendations

Diagnosis of hypogonadism in men

Diagnosis of men with suspected hypogonadism

We recommend diagnosing hypogonadism in men with symptoms and signs of testosterone deficiency and unequivocally and consistently low serum total testosterone and/or free testosterone concentrations (when indicated). (1-M)
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Screening and case detection for hypogonadism

 We recommend against routine screening of men in the general population for hypogonadism. (1-L)
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Distinguishing between primary or secondary hypogonadism

In men who have hypogonadism, we recommend distinguishing between primary (testicular) and secondary (pituitary–hypothalamic) hypogonadism by measuring serum luteinizing hormone and follicle-stimulating hormone concentrations. (1-M)
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Evaluation for determining the etiology of hypogonadism

In men with hypogonadism, we suggest further evaluation to identify the etiology of hypothalamic, pituitary, and/or testicular dysfunction. (2-L)
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Treatment of hypogonadism with testosterone

We recommend testosterone therapy in hypogonadal men to induce and maintain secondary sex characteristics and correct symptoms of testosterone deficiency. (1-M)
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We recommend against testosterone therapy in men planning fertility in the near term or in men with breast or prostate cancer, a palpable prostate nodule or induration, a prostate-specific antigen level > 4 ng/mL, a prostate-specific antigen level > 3 ng/mL combined with a high risk of prostate cancer (without further urological evaluation), elevated hematocrit, untreated severe obstructive sleep apnea, severe lower urinary tract symptoms, uncontrolled heart failure, myocardial infarction or stroke within the last 6 months, or thrombophilia. (1-M)
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In hypogonadal men 55 to 69 years old, who are being considered for testosterone therapy and have a life expectancy > 10 years, we suggest discussing the potential benefits and risks of evaluating prostate cancer risk and prostate monitoring and engaging the patient in shared decision making regarding prostate cancer monitoring. For patients who choose monitoring, clinicians should assess prostate cancer risk before starting testosterone treatment and 3 to 12 months after starting testosterone. (2-VL)
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In hypogonadal men being considered for testosterone therapy who are 40 to 69 years old and at increased risk of prostate cancer (e.g., African Americans and men with a first-degree relative with diagnosed prostate cancer), we suggest discussing prostate cancer risk with the patient and offering monitoring options. (2-VL)
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Older men with age-related decline in testosterone concentration

We suggest against routinely prescribing testosterone therapy to all men 65 years or older with low testosterone concentrations. (1-L)
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In men >65 years who have symptoms or conditions suggestive of testosterone deficiency (such as low libido or unexplained anemia) and consistently and unequivocally low morning testosterone concentrations, we suggest that clinicians offer testosterone therapy on an individualized basis after explicit discussion of the potential risks and benefits. (2-L)
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HIV-infected men with weight loss

We suggest that clinicians consider short-term testosterone therapy in HIV-infected men with low testosterone concentrations and weight loss (when other causes of weight loss have been excluded) to induce and maintain body weight and lean mass gain. (2-L)
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Men with type 2 diabetes mellitus

 In men with type 2 diabetes mellitus who have low testosterone concentrations, we recommend against testosterone therapy as a means of improving glycemic control. (1-L)
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Monitoring of testosterone replacement therapy

In hypogonadal men who have started testosterone therapy, we recommend evaluating the patient after treatment initiation to assess whether the patient has responded to treatment, is suffering any adverse effects, and is complying with the treatment regimen. (UGPS)
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We recommend a urological consultation for hypogonadal men receiving testosterone treatment if during the first 12 months of testosterone treatment there is a confirmed increase in prostate-specific antigen concentration > 1.4 ng/mL above baseline, a confirmed prostate-specific antigen > 4.0 ng/mL, or a prostatic abnormality detected on digital rectal examination. After 1 year, prostate monitoring should conform to standard guidelines for prostate cancer screening based on the race and age of the patient. (2-L)
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Recommendation Grading

Overview

Title

Testosterone Therapy in Men With Hypogonadism

Authoring Organization

Publication Month/Year

March 17, 2018

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Adult, Older adult

Health Care Settings

Ambulatory

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D013739 - Testosterone, D007006 - Hypogonadism, D000728 - Androgens

Keywords

male hypogonadism, testosterone, low testosterone, Androgen Deficiency Syndromes

Source Citation

Shalender Bhasin, Juan P Brito, Glenn R Cunningham, Frances J Hayes, Howard N Hodis, Alvin M Matsumoto, Peter J Snyder, Ronald S Swerdloff, Frederick C Wu, Maria A Yialamas, Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 103, Issue 5, May 2018, Pages 1715–1744, https://doi.org/10.1210/jc.2018-00229