Male hypogonadism Diagnosis and management Indications for screening ES Q Does the man have symptoms and signs of testosterone deficiency? No Do not obtain routine screening for male hypogonadism in the general population. D Yes Testosterone levels ES Q Does the patient have symptoms or signs of an intercurrent illness? Q Is the patient receiving medications that can suppress testosterone concentration? Yes to any Avoid testing for hypogonadism in patients with an acute intercurrent illness, or in patients using medications that suppress testosterone concentrations. D No to all Obtain measurement of fasting total testosterone concentrations on two separate mornings in patients with suspected hypogonadism. B Testosterone levels ES Q Does the patient have a condition that alters sex-hormone binding globulin levels? Q Does the patient have a borderline initial testosterone concentration? Yes to any Determine free testosterone concentrations either directly from equilibrium dialysis assays or by calculations using total testosterone, sex hormone-binding globulin, and albumin concentrations in patients with conditions altering sex hormone-binding globulin (obesity, diabetes mellitus, corticosteroids, nephrotic syndrome, hypothyroidism, acromegaly, SHBG gene polymorphisms, older age, human immunodeficiency virus, cirrhosis, hepatitis, hyperthyroidism, certain anticonvulsants, estrogens) or with initial total testosterone concentrations at or near the lower limit of the normal range (200-400 ng/dL). Do not use direct analog-based free testosterone immunoassays. B Measure total testosterone concentrations on two separate mornings in the fasting state since testosterone concentrations exhibit significant diurnal and day-to-day variations and may be suppressed by food intake or glucose. B Do not obtain testosterone testing in patients with or recovering from an acute illness or using medications (such as opioids) suppressing testosterone concentrations. D No to all Diagnostic criteria ES Q Does the man have unequivocally and consistently low serum total testosterone and/or free testosterone concentrations? No Consider alternative diagnoses. Yes Diagnose hypogonadism in patients with symptoms and signs of testosterone deficiency and unequivocally and consistently low serum total testosterone and/or free testosterone concentrations (when indicated). B Consider obtaining further evaluation in patients with hypogonadism to identify the etiology of hypothalamic, pituitary, and/or testicular dysfunction. C LH/FSH levels Measure serum LH and FSH concentrations in patients with hypogonadism to distinguish between primary (testicular) and secondary (pituitary/hypothalamic) hypogonadism. B Contraindications for testosterone therapy Do not initiate testosterone replacement therapy in patients planning fertility in the near future. D Do not initiate testosterone replacement therapy in patients with any of the following: severe LUTS palpable prostate nodule or induration PSA level > 4 ng/mL or PSA level > 3 ng/mL combined with a high risk of prostate cancer (without further urological evaluation) breast or prostate cancer elevated hematocrit thrombophilia myocardial infarction or stroke within the last 6 months uncontrolled HF untreated severe obstructive sleep apnea. D Avoid initiating testosterone replacement therapy in 65 years old patients with low testosterone concentrations. D Indications for testosterone therapy Initiate testosterone replacement therapy to induce and maintain secondary sex characteristics and correct symptoms of testosterone deficiency in patients with hypogonadism. B Consider initiating testosterone replacement therapy on an individualized basis in > 65 years old patients with symptoms or conditions suggestive of testosterone deficiency (such as low libido or unexplained anemia) and consistently and unequivocally low morning testosterone concentrations. C Consider discussing prostate cancer risk with the patient and offering monitoring options in 40-69 years old patients at increased risk of prostate cancer (such as African Americans, a first-degree relative with diagnosed prostate cancer) with hypogonadism being considered for testosterone therapy. C Consider initiating testosterone replacement therapy in 55-69 years old patients with hypogonadism with a life expectancy > 10 years only after discussing the potential benefits and risks of evaluating prostate cancer risk and prostate monitoring and engaging the patient in shared decision-making regarding prostate cancer monitoring. Assess prostate cancer risk before and 3-12 months after initiating testosterone therapy in patients choosing monitoring. C Do not initiate testosterone replacement therapy to improve glycemic control in patients with T2DM mellitus and low testosterone concentrations. D Consider initiating short-term testosterone replacement therapy to induce and maintain body weight and lean mass gain in patients with human immunodeficiency virus infection with low testosterone concentrations and weight loss, if other causes of weight loss have been excluded. C Serial clinical and laboratory assessment Assess response to treatment, adverse effects, and treatment adherence in patients on testosterone therapy. B Indications for specialist referral Q Does the patient have a confirmed increase in PSA concentration > 1.4 ng/mL above baseline during the first 12 months of testosterone treatment? Q Does the patient have a confirmed PSA > 4.0 ng/mL during the first 12 months of testosterone treatment? Q Does the patient have a prostatic abnormality detected on DRE during the first 12 months of testosterone treatment? No to all Continue management as clinically appropriate. Yes to any Refer patients with hypogonadism to a urologist in case of a confirmed increase in PSA concentration > 1.4 ng/mL above baseline or confirmed PSA > 4.0 ng/mL, or a prostatic abnormality detected on DRE during the first 12 months of testosterone therapy. B