Ep 84 – Testosterone deficiency

Testosterone deficiency (TD) is an increasingly common problem with significant health implications, but the diagnosis and management of this condition may present problems in primary care. Low levels of testosterone in men are associated with increased risk of incident type 2 diabetes mellitus, worse outcomes in chronic kidney disease and COVID-19 infection (with increased all-cause mortality), along with significant implications in the areas of mental health and relationships. In this podcast, Dr Roger Henderson provides a reminder of how to diagnose TD — including from the patient’s history as well as clinical findings — and current guidelines on its management.

Key references

1. NICE. Testosterone. Accessed 21 November 2023. 
2. BMJ Best Practice. Hypogonadism in men. 21 October 2023. 
3. NHS. The 'male menopause'. 13 October 2022
4. British Society for Sexual Medicine. A practical guide on the assessment and management of testosterone deficiency in adult men. December 2017.

Key take home points

• Testosterone is the most important androgen in men.
• When testosterone levels fall, patients can experience significant adverse physical and psychological effects.
• TD is defined as a clinical and biochemical syndrome, characterised by a deficiency in serum testosterone plus relevant signs and symptoms.
• The diagnosis of symptomatic TD requires the presence of characteristic signs and symptoms plus reduced serum concentrations of total testosterone or free testosterone.
• Screening for testosterone should be performed in men with erectile dysfunction, type 2 diabetes, a BMI greater than 30, or if taking long-term opiates, anticonvulsants or antipsychotics.
• Measure serum testosterone between 7 am and 11 am on at least two occasions, preferably four weeks apart.
• Testosterone therapy is appropriate for treating erectile dysfunction, particularly at total testosterone levels below 8 nmol/L.
• Patients with low testosterone levels should always be accurately counselled about the benefits and risks of testosterone therapy.
• There is no evidence that testosterone therapy is associated with increased risk of prostate cancer or cardiovascular risk.
• The main contraindications to testosterone therapy are prostate cancer, male breast cancer, a haematocrit greater than 54%, severe chronic heart failure and a desire to have children in the future.