![]() Because hypothalamic and pituitary hormones are prone to variation, testosterone fluctuates over hours, days, and weeks. Testosterone level should be repeated at least twice (or 3 times in the case of equivocal results) over weeks or months, to confirm a consistently low value in the absence of any other external cause. Confirm unequivocally low testosterone levels on at least 2 -3 occasions before making a diagnosis.Also, food intake can suppress testosterone levels, so fasting is recommended. Measuring testosterone at any other time of day is not a valid indicator of endogenous testosterone production. ![]() The morning, fasting testosterone level (8 am) has been validated for assessment of hypogonadism. Testosterone exhibits diurnal variation, peaking in the morning (between 8-10 am) with a nadir in the evening (about 8 pm). If the TT is repeatedly equivocal (“borderline”),the measurement of calculated fT or bT may be helpful to clarify the diagnosis. If TT is unequivocally normal or low, no further testing is needed. Consequently, TT is recommended as the first choice for evaluating male hypogonadism. While calculated bioavailable (bT) or free testosterone (fT) measurements theoretically reflect physiological levels, standard methods for measuring these values have not been well established. Sensitivity and specificity vary depending on the reference range. ![]() Total testosterone (TT) is the most direct measure of testosterone in men. A testosterone level should not be ordered until and unless other diagnoses have been thoroughly explored. For men who express non-specific symptoms, but not sexual symptoms, investigations should focus on other potential diagnoses. Non-specific symptoms, such as fatigue, low mood, weight gain, or generalized weakness have many potential causes. Evidence suggests that sexual symptoms, such as reduced libido, decreased sexual thoughts, and fewer morning erections are more specifically associated with male hypogonadism. The clinical diagnosis of hypogonadism is made in men who have low total testosterone levels combined with symptoms and/or signs suggesting hypogonadism. Do not order a testosterone level in men who express only non-specific symptoms.When assessing for male hypogonadism, consider the following: ( see Figure 1) For these reasons, it is particularly important to have a rational approach to testing and diagnosis of hypogonadism in men. Also, once men start treatment, they may find it difficult to stop because of prolonged hypogonadism during recovery of the hypothalamic-pituitary-testicular axis. Testosterone therapy suppresses endogenous hormone production and reduces fertility. While men with unequivocally low testosterone levels usually benefit from hormone replacement, the risk/benefit ratio for men with equivocal (“borderline”) levels is not clear, especially in men who desire fertility. The reasons for this increase appear to be due to the frequency of testing and marketing of testosterone replacement for middle-aged and older men. The therapeutic use of testosterone has increased dramatically in the last two decades. Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements. Recommendations in this article are consistent with current practice patterns. ![]() No conflict of interest involving testosterone testing or products. Paty has received speaking fees and/or sat on advisory boards for Abbott, Astrazeneca, BI/Lilly Alliance and Novo Nordisk related to diabetes monitoring and treatment. Paty, MD ( biography and disclosures) Disclosures: Dr.
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