Diagnosis and Treatment of Female Hypogonadism

Diagnostic Considerations

Free testosterone is a better index of gonadal status than total testosterone and should be measured when possible, according to the Endocrine Society 1
Morning serum total testosterone measurement is essential for diagnosis, as stated by the Infectious Diseases Society of America 2
Measurements should be repeated to confirm low levels due to variability in assays, as recommended by the Infectious Diseases Society of America 2
The free testosterone index, calculated as the ratio of SHBG to total testosterone, can affect interpretation and should be considered, according to the Endocrine Society 1

HIV infection is a potential cause of female testosterone deficiency, as noted by the Infectious Diseases Society of America 2
For premenopausal women with hypogonadism, estrogen replacement with progesterone should be offered, as suggested by the Endocrine Society 1
Transdermal hormone replacement therapy (HRT) can be given to premenopausal or postmenopausal women, as recommended by the Endocrine Society 1

Patients on hormone replacement therapy should be monitored regularly for efficacy and side effects, according to the Endocrine Society 1
Bone density should be measured at baseline and periodically during treatment if osteoporosis is a concern, as recommended by the Endocrine Society 1
Treatment should be given for a minimum of five years with bone density repeated after two years and at the end of treatment if osteoporosis is present, according to the Endocrine Society 1

Ensure adequate nutrition as low body mass index is an independent risk factor for complications, as noted by the Endocrine Society 1
Consider calcium (1 g/day) and vitamin D3 (800 U/day) supplementation, particularly if there are concerns about bone health, as recommended by the Endocrine Society 1
Regular weight-bearing exercise should be encouraged, according to the Endocrine Society 1
Smoking cessation should be advised, as recommended by the Endocrine Society 1

Failing to distinguish between primary and secondary hypogonadism, which require different management approaches, is a pitfall to avoid, as noted by the Infectious Diseases Society of America 2
Treating based on symptoms alone without laboratory confirmation of low testosterone levels is not recommended, according to the Infectious Diseases Society of America 2
Not considering other causes of similar symptoms before attributing them to testosterone deficiency is a mistake to avoid, as recommended by the Infectious Diseases Society of America 2
Consider checking serum prolactin levels in patients with low testosterone combined with low or low/normal LH levels, as suggested by the American Urological Association 3

The American Urological Association suggests that total testosterone is low at 5.5 nmol/L (reference range: 8.4-28.8 nmol/L) 4
The Endocrine Society indicates that free testosterone is normal at 122 pmol/L (reference range: 115-577 pmol/L) 4
Bioavailable testosterone is normal at 2.9 nmol/L (reference range: 2.7-13.5 nmol/L), as reported by the American Urological Association 4
Sex Hormone Binding Globulin (SHBG) is normal at 24.3 nmol/L (reference range: 19.0-76.0 nmol/L), according to the American Urological Association 4

A clinical diagnosis of testosterone deficiency requires both low testosterone levels AND symptoms/signs of hypogonadism, as stated by the American Urological Association and the Endocrine Society 4, 5, 6

The American Urological Association recommends that no immediate testosterone replacement therapy is needed since free and bioavailable testosterone levels are normal 4
Repeat morning total testosterone measurements on a separate occasion to confirm the low level, as recommended by the American Urological Association and the Endocrine Society 4, 5
Assess for symptoms of hypogonadism such as reduced energy, reduced endurance, fatigue, depression, poor concentration, infertility, reduced sex drive, and erectile dysfunction, as suggested by the American Urological Association and the Endocrine Society 4, 5, 6
Measure luteinizing hormone (LH) levels to help establish the etiology of testosterone deficiency if symptoms are present, as recommended by the American Urological Association and the Infectious Diseases Society of America 4, 7