Symptoms, physical examination, and blood tests
Signs and Symptoms of Testosterone Deficiency (hypogonadism)
|A. Signs and symptoms suggestive of testosterone deficiency (hypogonadism) in men||B. Other, less specific symptoms and signs associated with testosterone deficiency (hypogonadism)|
|Incomplete sexual development, eunuchoidism, aspermia||Decreased energy, motivation, initiative, aggressiveness, self-confidence|
|Reduced sexual desire (libido) and activity||Feeling sad or blue, depressed mood, dysthymia|
|Decreased spontaneous erections||Diminished physical or work performance|
|Reduced muscle bulk and strength||Poor concentration and memory|
|Hot flushes, night sweats||Increased body fat, body mass index|
|Loss of body (axillary and pubic) hair, reduced shaving||Insulin resistance|
|Breast discomfort, gynaecomastia||Sleep disturbance, increased sleepiness|
|Very small or shrinking testes||Mild anaemia|
|Inability to father children, low or zero sperm counts|
|Height loss, low trauma fracture, low bone mineral density (osteoporosis)|
The symptom most associated with testosterone deficiency (hypogonadism) is reduced libido, however other manifestations can also be associated with low testosterone, and a diagnosis of testosterone deficiency (hypogonadism) is made on the basis of low serum testosterone levels occurring in association with one or more of the symptoms and signs listed in the table.1,2
The symptoms of testosterone deficiency (hypogonadism) may vary from individual to individual. In late-onset testosterone deficiency (hypogonadism) many symptoms resemble those of aging and as a consequence this condition is often undiagnosed. Various diagnostic procedures are available to confirm testosterone deficiency (hypogonadism) in a patient who presents with symptoms or signs of testosterone deficiency (hypogonadism). These include:
- Medical history (personal and familial)
- A general physical examination including blood pressure, evaluation of secondary sexual characteristics, testicle examination, waist circumference measurement and distribution of fat
- Examination of the prostate, as it is important to eliminate prostate cancer should testosterone therapy be indicated.
- Laboratory tests including determination of testosterone values
- Baseline FBC and PSA should testosterone replacement therapy be commenced
Repeat measurement of morning total testosterone (when levels of serum testosterone can be expected to be higher because of the diurnal rhythm of testosterone) using a reliable assay is recommended by international professional societies in the field as the most widely accepted parameter to establish the presence of testosterone deficiency (hypogonadism) in combination with consistent symptoms and signs. In some men, determination of free or bioavailable testosterone may be appropriate.1,2 This may be done indirectly by way of measuring free T and SHBG levels.
Supplementary tests, for example a bone density test for suspected osteoporosis or tests to exclude other diseases that may explain the symptomatology, may be necessary. The physician’s experience and, in some cases, the observation of clear clinical benefits after the initiation of testosterone therapy may provide confirmation of a diagnosis of testosterone deficiency (hypogonadism).
The measurement of testosterone levels in the diagnosis of testosterone deficiency (hypogonadism) is summarised below
Values for normal testosterone ranges vary among laboratories depending on the commercial assay employed, and local values should be consulted when a diagnosis of testosterone deficiency (hypogonadism) is considered. There is no generally accepted lower limit of normal. However, a morning testosterone concentration in the blood of 12-35 nmol/L can be considered normal. Testosterone treatment might be recommended if this value is found to be below 12 nmol/L. There is general agreement that total testosterone levels above 12 nmol/L (346 ng/dL) or free testosterone levels above 250 pmol/L (72 pg/mL) do not require testosterone treatment.3 The European Association of Urology (EAU), International Society for the Study of the Aging Male (ISSAM), International Society of Andrology (ISA), European Academy of Andrology (EAA) and American Society of Andrology (ASA) suggest that serum total testosterone levels below 8 nmol/L (231 ng/dL) or free testosterone below 180 pmol/L (52 pg/mL) require testosterone replacement therapy. In addition, concentrations of the pituitary hormones can be measured. They provide information as to whether the testosterone deficiency (hypogonadism) is due to disorders of testicular function or of the hypothalamic-pituitary system.
Since symptoms of testosterone deficiency (hypogonadism) become manifest between 8 and 12 nmol/L (231–346 ng/dL), trials (3– >6 months) of treatment of at least 6 months can be considered in men with a clinical picture of testosterone deficiency (hypogonadism) and borderline testosterone levels when alternative causes of these symptoms have been excluded.1,2
What published guidelines are available on TD?
BSSM guidelines on adult testosterone deficiency, with statements for UK practice
A practical guide from the BSSM on the assessment and management of testosterone deficiency in adult men
- Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2006; 91(6): 1995-2010.
- Wang, C., E. Nieschlag, R. Swerdloff, et al. Investigation, treatment and monitoring of late-onset hypogonadism in males: ISA, ISSAM, EAU, EAA and ASA recommendations. Eur J Endocrinol 2008, 159(5): 507-514.
- Eur J Endocrinol. 2008 Nov;159(5):507-14. doi: 10.1530/EJE-08-0601. E. Nieschlag, R. Swerdloff, H. M. Behre, L. J. Gooren, J. M. Kaufman, J.-J. Legros, B. Lunenfeld, J. E. Morley, C. Schulman, C. Wang, W. Weidner, F. C. W. Wu Investigation, Treatment, and Monitoring of Late-Onset Hypogonadism in Males: ISA, ISSAM, and EAU Recommendation