Prostate Restored
Prostate Restored
Photo: Tatiana Syrikova
Testosterone exhibits diurnal variation, peaking in the morning (between 8-10 am) with a nadir in the evening (about 8 pm).
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Read More »Breay W. Paty, MD (biography and disclosures) Disclosures: Dr. Paty has received speaking fees and/or sat on advisory boards for Abbott, Astrazeneca, BI/Lilly Alliance and Novo Nordisk related to diabetes monitoring and treatment. No conflict of interest involving testosterone testing or products. Recommendations in this article are consistent with current practice patterns. Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements.
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Read More »Testosterone level should be repeated at least twice (or 3 times in the case of equivocal results) over weeks or months, to confirm a consistently low value in the absence of any other external cause. Because hypothalamic and pituitary hormones are prone to variation, testosterone fluctuates over hours, days, and weeks. For this reason, it is important to repeat the testosterone test on several occasions, especially if there is an external factor that may be suppressing hypothalamic or pituitary function. For men under the age of 50, repeated TT levels below 8.0 nmol/L (or below 7.0 nmol/L for men over the age of 50) on 2-3 occasions are considered unequivocally low. Total testosterone levels between 8.0-11.0 nmol/L (7.0-11.0 nmol/L for men over age 50) are considered equivocal and the test should be repeated and external causes should be examined (see 5 below). Total testosterone values above 11.0 nmol/L are considered normal and do not require further testing. Total Testosterone (TT) levels measured at 8 AM, fasting (repeated) Hypogonadism Equivocal Normal < 8.0 mmol/L (men < 50 years) < 7.0 mmol/L (men > 50 years) 8.0-11.0 mmol/L (men < 50 years) 7.0-11.0 mmol/L (men > 50 years) > 11.0 mmol/L If hypogonadism is diagnosed, determine if it is primary (testes) or secondary (brain) If an unequivocally low testosterone is identified, luteinizing hormone (LH) and follicular stimulating hormone (FSH) should be ordered (along with a repeat morning testosterone). An elevated LH or FSH suggests a primary (testicular) cause, while a low or inappropriately “normal” LH and FSH suggests that the problem may be hypothalamic or pituitary (brain) in origin. This will help guide further investigation and treatment. In cases of secondary hypogonadism, look for a treatable cause. In cases of secondary (brain) hypogonadism, prolactin should be ordered to rule out hyperprolactinemia and ferritin to rule out hemochromatosis. If these tests are normal, then other factors should considered. Hypothalamic/ pituitary hormones can be influenced by a variety of external factors (so-called “functional” hypogonadism), including obesity, stress, depression, systemic illness, extreme exercise or diet, medication, alcohol, marijuana and other causes. These factors may often be transient and treatable. If any external factors are identified, they should be addressed before considering testosterone therapy. In cases of primary hypogonadism (low testosterone, elevated LH/FSH), including congenital conditions, such as Klinefelter syndrome, or acquired conditions, such as mumps or testicular trauma, testosterone treatment is often the best option. In cases where the cause uncertain, consider a referral to an endocrinologist or other specialist familiar with the evaluation and treatment of male hypogonadism.
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Read More »If a man with hypogonadism desires fertility (either immediately or in the future), testosterone therapy is not generally recommended (except for unequivocal primary hypogonadism), since it tends to suppress fertility. For men with secondary (hypothalamic/pituitary) hypogonadism, in whom no cause is identified and who desire fertility, a semen analysis should be obtained and if it is low, consider referring the patient to a fertility clinic. This is not a complete review of the investigation of male hypogonadism, but addresses some of the common issues that arise in the primary care setting. Having a sound approach to testosterone testing is critical to good clinical decision making, especially for men with equivocal testosterone levels and other factors which may be causing their symptoms. Understanding what symptoms to look for and how to undertake investigation will allow for appropriate choices for therapy and help to avoid unnecessary or inappropriate use of testosterone.
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