Treatment Options for Symptomatic Low Testosterone

Diagnosis and Treatment

The European Association of Urology recommends testosterone replacement therapy (TRT) as the first-line treatment for men with symptomatic low testosterone, with formulation choice based on patient preference, cost considerations, and clinical factors 1
Diagnosis requires both low testosterone levels (<300 ng/dL) on at least two separate morning measurements AND presence of symptoms/signs, as recommended by The Journal of Urology 3
Symptoms may include reduced energy, diminished work performance, fatigue, depression, reduced motivation, poor concentration, infertility, reduced sex drive, and erectile dysfunction, according to The Journal of Urology 3
The American Urological Association suggests measuring luteinizing hormone (LH) levels to determine if hypogonadism is primary or secondary 3
The Endocrine Society recommends considering measuring prolactin in patients with low testosterone and low/normal LH levels 4
The European Association of Urology suggests measuring estradiol in patients with breast symptoms or gynecomastia before starting TRT 4

The European Association of Urology recommends intramuscular injections as a more economical option ($156.24 annually) compared to topical gels/creams ($2,135.32 annually) 5, 2
The American College of Physicians suggests that intramuscular injections may cause fluctuating testosterone levels 6
The European Association of Urology recommends expected benefits of TRT, including improved sexual function and erectile function, modest improvements in vitality, fatigue, and depressive symptoms, and increased muscle mass, strength, and bone mineral density 2

The European Association of Urology recommends absolute contraindications for TRT, including active or treated male breast cancer and men seeking fertility (standard TRT) 1
The American Heart Association suggests relative contraindications/precautions, including recent cardiovascular disease 5

The European Association of Urology recommends checking testosterone levels 2-3 months after starting treatment and re-evaluating symptoms within 12 months and periodically thereafter 6, 2
The American College of Physicians suggests monitoring for adverse effects, including erythrocytosis, which occurs in 3-18% with transdermal and up to 44% with injections 6

The European Association of Urology recommends selective estrogen receptor modulators (SERMs) for men with secondary hypogonadism, especially those wishing to preserve fertility 3
The American Society for Reproductive Medicine suggests gonadotropin therapy for secondary hypogonadism patients seeking fertility 1
The Academy of Nutrition and Dietetics recommends lifestyle modifications, including weight loss through low-calorie diets and physical activity, to improve testosterone levels in obese men 1