Precautions for Patients with Low Testosterone Levels

Diagnostic Confirmation

The American Urological Association recommends confirming the diagnosis with two separate morning total testosterone measurements below 300 ng/dL before initiating treatment 1, 2
The Endocrine Society suggests ensuring symptoms of testosterone deficiency are present in addition to low laboratory values, such as reduced energy, reduced endurance, diminished performance, fatigue, depression, poor concentration, infertility, reduced sex drive, and erectile dysfunction 1, 2
Measure serum luteinizing hormone (LH) levels to establish the etiology of testosterone deficiency, and measure serum prolactin in patients with low testosterone and low/normal LH levels to screen for hyperprolactinemia 3
Consider pituitary MRI for patients with total testosterone <150 ng/dL and low/normal LH regardless of prolactin levels, and measure serum estradiol in patients presenting with breast symptoms or gynecomastia prior to starting therapy 3

Assess all patients for cardiovascular disease risk factors, and measure hemoglobin/hematocrit at baseline to monitor for polycythemia 3, 4
Perform digital rectal examination and measure PSA before initiating treatment, and conduct a reproductive health evaluation in men interested in fertility before treatment 3, 4
Evaluate for sleep apnea by history taking 4

Schedule first follow-up visit at 1-2 months to assess efficacy and consider dose adjustments, and monitor at 3-6 month intervals for the first year and yearly thereafter 4
At each visit, assess symptomatic response to treatment, voiding symptoms, sleep apnea symptoms, digital rectal examination, serum testosterone levels, PSA levels, and hematocrit or hemoglobin 4

Polycythemia (elevated hematocrit) may require temporary discontinuation, dose reduction, or phlebotomy, and testicular size and consistency diminishment may occur 4
Skin reactions are more common with patches (66%) than with gels (5%), and local injection site reactions with intramuscular formulations may occur 4

Use testosterone cautiously in men with congestive heart failure or renal insufficiency due to potential fluid retention, and be aware that testosterone therapy will greatly compromise fertility due to gonadotropin down-regulation 4
Avoid treating based on symptoms alone without laboratory confirmation, and target testosterone levels in the mid to upper-normal range for optimal response, but avoid supraphysiologic levels 4, 5