Testosterone Deficiency? How To Decide

I’m going to review some of The Curbsiders podcasts and posts and review my past posts and other resources on the subject as I review each Curbsiders podcast.

First up is #1: Miracle Cure of Libido Band Aid? Dealing with Male Hypogonadism and Low Testosterone [Link is to the podcast and show notes]FEBRUARY 17, 2016.

Here are some excerpts from the excellent show notes:


  1. Order AM total testosterone x1. If less than 300 then repeat total T with prolactin, FSH, LH, SHBG and bioavailable testosterone. Consider a brain MRI in young men.
  2. Treat modifiable risk factors: opiate abuse, heavy alcohol use, sleep apnea, obesity
  3. Recommend a trial of topical therapy at 40 mg daily. Goal total T is 400-700.  Monitor PSA and CBC yearly.


Step 1) Check total testosterone (total T) between 7am and 10am. Testosterone is 60% bound to sex hormone binding globulin (SHBG), 39% albumin bound and 1% free testosterone.

Step 2) If total T is less than 300, then repeat total T but add FSH, LH, prolactin, SHBG and bioavailable testosterone.

Step 3) Consider MRI if prolactin high or if low testosterone in a young male

Note: Obese males have low sex hormone binding globulin. This creates an artifact of low Total T (since 60% is bound to SHBG). Therefore, do not treat these patients unless they have low bioavailable testosterone.


Trial of topical therapy recommended. Apply in AM to mimic physiologic levels. Start at 40 mg. Consider repeat level in 2-4 weeks. Goal is Total T 400 to 700 and monitor for improved mood, energy and libido. If no improvement then stop therapy.

Next jump to my post Evaluation And Management Of Male Hypogonadism – The New 2018 Guidelines Posted on March 19, 2018. In the post, I excerpt portions of the new guidelines which really are pretty much the same as the Curbsiders recommendations.

This current post and the past post above contains the information you’ll need to decide whether or not to initiate a workup for testosterone deficiency.

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