Evaluation and Management of Testosterone Deficiency

Publication Date: July 1, 2018
Last Updated: March 14, 2022

Guideline Statements

Diagnosis of Testosterone Deficiency

1. Clinicians should use a total testosterone level below 300 ng/dL as a reasonable cut-off in support of the diagnosis of low testosterone. (Moderate, B)
2. The diagnosis of low testosterone should be made only after two total testosterone measurements are taken on separate occasions with both conducted in an early morning fashion. (Strong, A)
3. The clinical diagnosis of testosterone deficiency is only made when patients have low total testosterone levels combined with symptoms and/or signs. (Moderate, B)
4. Clinicians should consider measuring total testosterone in patients with a history of unexplained anemia, bone density loss, diabetes, exposure to chemotherapy, exposure to testicular radiation, HIV/AIDS, chronic narcotic use, male infertility, pituitary dysfunction, and chronic corticosteroid use even in the absence of symptoms or signs associated with testosterone deficiency. (Moderate, B)
5. The use of validated questionnaires is not currently recommended to either define which patients are candidates for testosterone therapy or to monitor symptom response in patients on testosterone therapy. (Conditional, C)

Adjunctive Testing

6. In patients with low testosterone, clinicians should measure serum luteinizing hormone levels. (Strong, A)
7. Serum prolactin levels should be measured in patients with low testosterone levels combined with low or low/normal luteinizing hormone levels. (Strong, A)
8. Patients with persistently high prolactin levels of unknown etiology should undergo evaluation for endocrine disorders. (Strong, A)
9. Serum estradiol should be measured in testosterone deficient patients who present with breast symptoms or gynecomastia prior to the commencement of testosterone therapy. (Expert Opinion, )
10. Men with testosterone deficiency who are interested in fertility should have a reproductive health evaluation performed prior to treatment. (Moderate, B)
11. Prior to offering testosterone therapy, clinicians should measure hemoglobin and hematocrit and inform patients regarding the increased risk of polycythemia. (Strong, A)
12. PSA should be measured in men over 40 years of age prior to commencement of testosterone therapy to exclude a prostate cancer diagnosis. (Clinical Principle, )

Counseling Regarding Treatment of Testosterone Deficiency

13. Clinicians should inform testosterone deficient patients that low testosterone is a risk factor for cardiovascular disease. (Strong, B)
14. Patients should be informed that testosterone therapy may result in improvements in erectile function, low sex drive, anemia, bone mineral density, lean body mass, and/or depressive symptoms. (Moderate, B)
15. Patients should be informed that the evidence is inconclusive whether testosterone therapy improves cognitive function, measures of diabetes, energy, fatigue, lipid profiles, and quality of life measures. (Moderate, B)
16. The long-term impact of exogenous testosterone on spermatogenesis should be discussed with patients who are interested in future fertility. (Strong, A)
17. Clinicians should inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer. (Strong, B)
18. Patients with testosterone deficiency and a history of prostate cancer should be informed that there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy. (Expert Opinion, )
19. Patients should be informed that there is no definitive evidence linking testosterone therapy to a higher incidence of venothrombolic events. (Moderate, C)
20. Prior to initiating treatment, clinicians should counsel patients that, at this time, it cannot be stated definitively whether testosterone therapy increases or decreases the risk of cardiovascular events (e.g., myocardial infarction, stroke, cardiovascular-related death, all-cause mortality). (Moderate, B)
21. All men with testosterone deficiency should be counseled regarding lifestyle modifications as a treatment strategy. (Conditional, B)

Treatment of Testosterone Deficiency

22. Clinicians should adjust testosterone therapy dosing to achieve a total testosterone level in the middle tertile of the normal reference range. (Conditional, C)
23. Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive. (Strong, A)
24. Testosterone therapy should not be commenced for a period of three to six months in patients with a history of a cardiovascular events. (Expert Opinion, )
25. Clinicians should not prescribe alkylated oral testosterone. (Moderate, B)
26. Clinicians should discuss the risk of transference with patients using testosterone gels/creams. (Strong, A)
27. Clinicians may use aromatase inhibitors, human chorionic gonadotropin, selective estrogen receptor modulators, or a combination thereof in men with testosterone deficiency desiring to maintain fertility. (Conditional, C)
28. Commercially manufactured testosterone products should be prescribed rather than compounded testosterone, when possible. (Conditional, C)

Follow-up of Men on Testosterone Therapy

29. Clinicians should measure an initial follow-up total testosterone level after an appropriate interval to ensure that target testosterone levels have been achieved. (Expert Opinion, )
30. Testosterone levels should be measured every 6-12 months while on testosterone therapy. (Expert Opinion, )
31. Clinicians should discuss the cessation of testosterone therapy three to six months after commencement of treatment in patients who experience normalization of total testosterone levels but fail to achieve symptom or sign improvement. (Clinical Principle, )

Recommendation Grading




Evaluation and Management of Testosterone Deficiency

Authoring Organization

Publication Month/Year

July 1, 2018

Last Updated Month/Year

June 7, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

Provides guidance to the practicing clinician on how to diagnose, treat and monitor the adult male with testosterone deficiency

Inclusion Criteria

Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D013739 - Testosterone


hormone therapy, Testosterone Deficiency

Supplemental Methodology Resources

Methodology Supplement


Number of Source Documents
Literature Search Start Date
January 1, 1980
Literature Search End Date
February 6, 2017