NEW 2018 AUA GUIDELINES
Download the official evaluation guidelines for low testosterone
Download the official treatment guidelines for low testosterone
Few topics in medicine are as controversial as the treatment of low testosterone. This hormone is such a powerful and important one that it has been the subject of abuse and underuse. If you want to start a fight at a medical convention just say the word "Testosterone" and watch what happens.
If you are at this page you probably have done quite a bit of reading already, so we'll start with the official 2018 AUA guidelines on the diagnosis and treatment of low testosterone.
Do You Have Low Testosterone?
A few important points:
1- work up work up work up
As you can see from the statements below, low testosterone is a legitimate medical condition which needs to be properly worked up. It's not enough to just measure it and prescribe it. The reason is that low testosterone is not a "condition" but rather a "symptom" which can have an underlying cause. It's like seeing smoke coming out of your house and instead of looking for the fire you turn on the fans to get rid of the smoke rather than find where the fire is and extinguish it with water. The solution to your low testosterone could be water rather than a fan!
2- No it's not "normal" even if it's prevalent
Another controversial point of view that some physicians will take is that "older men have lower testosterone on average therefore we do not need to fix it". Although it is true that as men age their testosterone can decline "Andropause", but this is not a reason to not treat it. It's like saying that older people have more joint problems than younger people therefore they should not seek treatment for that. As we age, we do have more medical conditions, and we are lucky to live in an age where there are solutions, so let's use them!
3- Treat the patient not the number
Yet another controversial practice that many "Men's Clinics" are taking is to measure Testosterone and give it regardless of symptoms. They are using statistical variations in lab results as a reason to provide unnecessary treatment. If you do not have the symptoms of low testosterone you should not accept to take Testosterone: the data is clear on this. The reason is that Testosterone is an important hormone in your body and having too much of it can mess up other things that get affected by it. The bottom line is "if it's not broke dont mess with it" because you might break something else.
Official 2018 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 Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade C)
6. In patients with low testosterone, clinicians should measure serum luteinizing hormone levels. (Strong Recommendation; Evidence Level: Grade A)
7. Serum prolactin levels should be measured in patients with low testosterone levels combined with low or low/normal luteinizing hormone levels. (Strong Recommendation; Evidence Level: Grade A)
8. Patients with persistently high prolactin levels of unknown etiology should undergo evaluation for endocrine disorders. (Strong Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade B)
11. Prior to offering testosterone therapy, clinicians should measure hemoglobin and hematocrit and inform patients regarding the increased risk of polycythemia. (Strong Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade B)
16. The long-term impact of exogenous testosterone on spermatogenesis should be discussed with patients who are interested in future fertility. (Strong Recommendation; Evidence Level: Grade A)
17. Clinicians should inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer. (Strong Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade B)
21. All men with testosterone deficiency should be counseled regarding lifestyle modifications as a treatment strategy. (Conditional Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade C)
23. Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive. (Strong Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade B)
26. Clinicians should discuss the risk of transference with patients using testosterone gels/creams. (Strong Recommendation; Evidence Level: Grade 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 Recommendation; Evidence Level: Grade C)
28. Commercially manufactured testosterone products should be prescribed rather than compounded testosterone, when possible. (Conditional Recommendation; Evidence Level: Grade 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)