Guideline sources The following summarized guidelines for the evaluation and management of testosterone deficiency are prepared by our editorial team based on guidelines from the American Urological Association (AUA/SMSNA 2022), the Endocrine Society (ES 2020), and the British Society for Sexual Medicine (BSSM 2017). 1 2 3 Guidelines 1. Screening and diagnosis Indications for screening: Obtain screening for testosterone deficiency in all patients with: consistent and multiple signs of testosterone deficiency B erectile dysfunction, loss of spontaneous erections, or low sexual desire A T2DM, BMI > 30 kg/m or waist circumference > 102 cm B long-term opiate, antipsychotic, or anticonvulsant use. B Diagnosis: restrict the diagnosis of testosterone deficiency to patients with persistent symptoms suggesting testosterone deficiency and confirmed low testosterone. B https://web.pathway.md/diseases/recvwdoQQGqRRrluH 1/3 6/24/23, 4:05 PM Testosterone deficiency Pathway 2. Diagnostic investigations Testosterone levels: Obtain fasting testosterone levels in the morning before 11 am, recognizing that, in normal life, non-fasting levels could be 30%. B Obtain repeated total testosterone testing on 2 occasions by a reliable method, and in addition, obtain free testosterone in patients with levels close to lower normal range (8-12 nmol/L) or with suspected or known abnormal SHBG levels. A Lutenizing hormone levels: obtain serum LH to differentiate primary from secondary testosterone deficiency. B 3. Medical management General principles: base decisions on therapy on published action levels rather than laboratory reference ranges. B Show 3 more Testosterone replacement therapy: Consider initiating testosterone therapy as symptomatically indicated and not as an approach to improve dyslipidemia or CVD risk in patients with low testosterone levels. C Initiate testosterone therapy in symptomatic patients with testosterone deficiency syndrome for treated localized low-risk prostate cancer (Gleason score < 8, stages 1-2, preoperative PSA level < 10 ng/mL, and not starting before 1 year of follow-up) and without evidence of active disease (based on measurable PSA level, DRE result, and evidence of metastatic disease). B Show 2 more 4. Nonpharmacologic interventions Lifestyle and dietary modifications: Recognize that lifestyle and dietary advice alone is unlikely to produce meaningful clinical improvement within a relevant clinical period in severely symptomatic patients with total testosterone levels < 8 nmol/L. B Advise weight-loss and lifestyle changes as standard management in patients with adult-onset testosterone deficiency, when testosterone replacement therapy is prescribed. B 5. Specific circumstances Patients with delayed ejaculation: consider offering treatment to normalize serum testosterone levels in patients with testosterone deficiency and delayed ejaculation. E 6. Patient education https://web.pathway.md/diseases/recvwdoQQGqRRrluH 2/3 6/24/23, 4:05 PM Testosterone deficiency Pathway General counseling: Inform the patient about expected benefits and side effects of therapy and facilitate a joint decision by an informed patient and physician. B Discuss the adverse effect of testosterone therapy and its future reversibility on future fertility for each patient and his partner and offer alternative treatment as necessary. B 7. Follow-up and surveillance Follow-up: assess response to therapy at 3, 6, and 12 months and every 12 months thereafter. B Show 4 more References 1. Alan W Shindel, Stanley E Althof, Serge Carrier et al. Disorders of Ejaculation: An AUA/SMSNA Guideline. J Urol. 2022 Mar;207 3 504 512. Open 2. Hackett G, Kirby M, Edwards D et al. British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice. J Sex Med. 2017 Dec;14 12 1504 1523. Open 3. Connie B Newman, Michael J Blaha, Jeffrey B Boord et al. Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2020 Dec 1;105 12):dgaa674. Open 4. Wierman ME, Arlt W, Basson R et al. Androgen therapy in women: a reappraisal: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2014 Oct;99 10 3489 510. Open 5. A Michael Lincoff, Shalender Bhasin, Panagiotis Flevaris et al. Cardiovascular Safety of Testosterone- Replacement Therapy. N Engl J Med. 2023 Jun 16. Open https://web.pathway.md/diseases/recvwdoQQGqRRrluH 3/3