Testosterone Treatment in Adult Men with Age-Related Low Testosterone
Summary
Testosterone levels in men begin to drop in their mid-30s, with over 50% of men having low levels of testosterone by the age of 80. This age-related low testosterone is sometimes accompanied by symptoms of androgen deficiency such as decreased libido and sexual dysfunction. There is no universally accepted level of testosterone below which it is considered pathologic, and instead providers must use their best judgement combining signs and symptoms with low laboratory levels of testosterone to diagnosis clinically significant low testosterone. While primary and secondary hypogonadism is always treated, there is still controversy regarding the treatment for low testosterone due to age. The American College of Physicians has published a guideline for the use of testosterone in men with age-related low testosterone.
Clinical Signs and Symptoms
- The signs and symptoms of androgen deficiency can be difficult to isolate in the setting of older male patients with multiple co-morbidities
- The clinician should consider whether symptoms are not more likely due to a comorbidity or medication side effect
- Symptoms include:
- Reduced libido | Erectile dysfunction | Depressed mood | Fatigue
- Signs include:
- Reduced muscle mass | Reduced strength | Increased adiposity | Osteoporosis/low bone mass | Cardiovascular disease | Decreased volume of ejaculate | Loss of body and facial hair | Anemia
Diagnosis
- Low Testosterone Syndrome
- Defined as at least 3 sexual dysfunction symptoms with a total testosterone level < 11.1 nmol/L (< 320 ng/dL)
- Endocrine Society recommends measuring total testosterone concentrations on two separate mornings between 7-10 AM when the patient is fasting
- Testosterone levels can vary depending on: Time of day | Glucose intake | sex
hormone binding globulin levels | Recent illness | Medications - Clinicians should not test levels following recent illness or if patient is on a short course of medication that can alter SHBG levels (e.g., opiates, glucocorticoids)
- In men whose total testosterone is near the lower limit of normal or who have a chronic condition or medication that cannot be halted that alters SHBG, obtain a free testosterone concentration using either equilibrium dialysis or estimating it using an accurate formula
- Testosterone levels can vary depending on: Time of day | Glucose intake | sex
Treatment
- Treatment with testosterone can be offered to men with sexual dysfunction due to age-related low testosterone who wish to improve sexual dysfunction
- Patients should be counseled on possible risks and side effects of taking testosterone
- Evidence shows small improvements in sexual dysfunction symptoms with testosterone replacement therapy
- This improvement was found regardless of starting testosterone level (as long as level was low)
- There is no improvement in other symptoms including: Strength | Stamina| Mood| Energy | Cognition
- ACP suggests using intramuscular formulation of testosterone instead of transdermal due to similar efficacy and greatly decreased price ($156.32 vs. $2135.32 per year)
Risks and Adverse Effects
- For patients on testosterone therapy, clinicians should reevaluate symptoms within 12 months and then again on subsequent follow ups
- Testosterone should be discontinued if there is no improvement in sexual dysfunction
- Studies of harms from long term testosterone use are inconclusive but there is concern for increased risk of: Heart attacks | Strokes | Prostate cancer | Polycythemia
- Monitoring PSA and CBC while on testosterone is recommended
- Increases in either level should prompt discussion of drug discontinuation
Key Points
- Low testosterone is very common in older men due to physiologic decreases with increasing age
- Not all men with low testosterone will develop symptoms of androgen deficiency, and should not be offered treatment in the absence of symptoms
- Testosterone therapy can be offered to patients with low T who wish to improve sexual dysfunction, as long as patient is willing to accept possible risks of therapy
- If giving testosterone, intramuscular formulations are preferred to transdermal
Primary Sources – Learn More
Choosing Wisely: American Urological Association on Testosterone Therapy for Erectile Dysfunction
Testosterone Therapy in Men With Hypogonadism: An Endocrine Society* Clinical Practice Guideline

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