Low testosterone levels without symptoms can be a normal part of ageing. Testing is indicated where a low level would have important consequences for patient management. Restrict screening to symptomatic patients, or those with medical conditions associated with insulin resistance (obesity, type 2 diabetes, and metabolic syndrome and testosterone deficiency (TD) signs and/or symptoms). TD screening should be considered for men with HIV-associated weight loss, osteoporosis (or height loss, or low trauma fracture), patients using long-term opioids, high alcohol intake or glucocorticoids.
Signs and symptoms
Reduced sexual response is common and prominent. Low sexual desire and decreased nocturnal and morning erections are clearly associated with TD, whereas the association with impaired sex-induced erections is less evident. Other common symptoms include inability to perform vigorous activity, muscle weakness, fatigue, depression and increased body fat. Hot flushes and alterations in cognition and memory are less common.
Men with suspected TD should be examined to identify physical signs. Examination may be normal. The most prevalent signs of TD are increased visceral obesity and smaller prostate volume. Decreased muscle mass is less prevalent and difficult to confirm. Not all manifestations need to be evident simultaneously and interindividual variability exists. An erection symptom score sheet can be helpful.
Investigating patients with suspected TD starts with a morning (before 8am) total testosterone (TT) test. If low (TT below the laboratory reference range) repeat it with serum LH, FSH, SHBG and calculated free testosterone. At this point the biochemist/pathologist at the lab will indicate if testing Prolactin is appropriate. Repeat TT, as two test results are required for PBS prescribing.
Treatment starts with lifestyle interventions. Weight loss, diet, exercise, cessation of smoking, and reduction of alcohol intake can be effective at improving testosterone levels, as well as having positive effects on lipids, sugars, cardiovascular risk and mental health.
Symptomatic men with TT lower than 6nmol/L can be treated with testosterone therapy (TTh) under the PBS guidelines. The patient must be treated by a urologist, endocrinologist or a fellow of the Australian Chapter of Sexual Medicine or in consultation with one of these specialists (see PBS guidelines for more details).
A trial of TTh in symptomatic men with levels higher than 6nmol/L can be considered based on clinical presentation (if no contraindications), via a private prescription. However, it is important to note that once patients commence testosterone therapy, they are rarely able to cease so careful consideration is required.
- Testosterone deficiency affects many older men
- Screening is appropriate in certain patient groups
- Treatment includes lifestyle and testosterone therapy
References available on request.
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Author competing interests: nil relevant disclosures.
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