Evaluation And Management Of Male Hypogonadism – The New 2018 Guidelines

The following are excerpts from Resource (1) which is a summary of Resource (2) below:

• Hypogonadism can be established in men who have signs and
symptomsof testosterone deficiency and have unequivocally low
total testosterone on 2 measurements. Free testosterone
should be measured when sex hormone–binding globulin
(SHBG) levels may be abnormal, such as in obesity, diabetes,
nephrotic syndrome, hypothyroidism, acromegaly, and in
patients taking steroids or progestins (decreased SHBG
levels); or in older age, HIV disease, cirrhosis and hepatitis,
hyperthyroidism, and in patients taking certain anticonvulsants
or those taking estrogen (increased SHBG levels).                           • When hypogonadism is present, measure luteinizing hormone
(LH) and follicle-stimulating hormone (FSH) to distinguish
between primary hypogonadism (low testosterone, high LH
and FSH) and secondary hypogonadism (low testosterone,
normal or reduced LH and FSH) (strong recommendation,
moderate-quality evidence).

• Testosterone therapy is recommended for men diagnosed
with hypogonadism to maintain secondary sex characteristics
and to correct symptoms of testosterone deficiency (strong
recommendation, moderate-quality evidence).
• Testosterone therapy is not recommended for men planning
fertility in the near term, with breast or prostate cancer, with
a palpable prostate nodule or induration, a prostate-specific
antigen (PSA) level>4.0 ng/mL (or>3.0 ng/mLwith a high risk of prostate cancer), elevated hematocrit (>48% or >50% for men
living at high altitude), untreated obstructive sleep apnea,
severe lower urinary tract symptoms, uncontrolled heart failure,myocardial infarction or stroke within the last 6 months, or thrombophilia (strong recommendation, low-quality evidence).
• For men >65 years who meet the diagnostic criteria for
hypogonadism, testosterone therapy can be offered after
individualized discussion of the risks and benefits
(conditional recommendation, low-quality evidence).

• Patients should be evaluated for therapeutic effect, serum
testosterone levels, hematocrit, and PSA levels several times
during the first year of therapy and annually thereafter.

• Patients should be evaluated for therapeutic effect, serum
testosterone levels, hematocrit, and PSA levels several times
during the first year of therapy and annually thereafter.

Benefits and Harms
The guideline’s structured, evidence-based approach could improve care quality and outcomes for men with hypogonadism by standardizing the diagnostic evaluation (a fasting morning total serum testosterone using an accurate and reliable assay, confirmed at least once), limiting treatment only to patients meeting the diagnostic criteria for hypogonadism, recommending evaluation for secondary causes of hypogonadism, and avoiding prescribing testosterone
to patients who do not have symptomatic hypogonadism,
or to those at risk of complications. The current guideline cites a recent double-blind, placebo-controlled trial of 790 symptomatic men older than 65 years who had 2 serum testosterone levels lower than 275 ng/dL that found modest benefit in sexual function and mood, some improvement in walking distance, but no benefit in vitality.5 Testosterone increased bone mineral density,6 and among men with unexplained anemia, raised hemoglobin levels.7 However, testosterone treatment also increased coronary plaque volume,8 and in a separate study, it was associated with a short-term increased risk for venous thromboembolism.9 Additional information about potential
adverse cardiovascular and prostate outcomes is needed given
evidence of both benefit and harm. The guideline does not emphasize comorbid conditions associated with low testosterone levels (eg, inactivity and obesity) and does not address potential benefits associated with lifestyle interventions, which may have important health benefits among men with symptoms of hypogonadism but whose testosterone levels are normal or inconsistently low.

The new guideline largely agrees with the 2010 Endocrine Society clinical practice guideline. Importantly, neither guideline suggests specific testosterone levels at which treatment is likely to be beneficial. In contrast, the International Society for Sexual Medicine suggests that men with total testosterone of 346 ng/mL or higher are unlikely to have testosterone deficiency and benefit from treatment, while the diagnosis and therapeutic benefit are more likely at levels lower than 231 ng/dL. Regular monitoring for therapeutic response and adverse effects, combined with discontinuing therapy in patients who do not experience clear improvement in symptoms,
should increase the likelihood of benefit while limiting expense
and potential harm.

For detailed recommendations on testosterone therapy in male hypogonadism, see the complete Endocrine Society guideline below, Resource (2).

And for many helpful resources on diagnosis and treatment, see Resource (3)


(1) Evaluation and Treatment of Male Hypogonadism JAMA Clinical Guidelines Synopsis March 17, 2018. This is a summary of Resource (2).

(2) Testosterone Therapy in Men With Hypogonadism: An Endocrine Society* Clinical Practice Guideline [PDF] 2018 The Endocrine Society

(3) International Society for Sexual Medicine This site has many useful resources that are available to both members and non-members:

Sexual health information for healthcare providers, both ISSM members and non-members…
  1. Research Summaries
  2. Clinical Guidelines
  3. Events
  4. Grants and Prizes
  5. Reviews and Reports
Read More


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