An estimated 6% of middle-aged and older men have symptomatic androgen deficiency, and many are treated in primary care. Evaluation and management may be complex, according Glenn R. Cunningham, MD, professor of medicine and of molecular and cellular biology at Baylor College of Medicine in Houston. “It is likely to require effort for primary-care practitioners to be informed about these issues,” Dr. Cunningham says.

The Endocrine Society’s recently revised clinical practice guideline offers detailed recommendations on testing and treatment. The key idea, explains Dr. Cunningham, an author of the guideline, is that “diagnosis requires both symptoms and low testosterone levels, not just one or the other.”

Testing and diagnosis

Symptoms of androgen deficiency are generally the basis for testing. The Endocrine Society’s guideline does not advocate general screening but recommends serum assay for those with the following clinical manifestations strongly associated with androgen deficiency:

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  • Incomplete or delayed sexual development
  • Altered sexual function, notably reduced libido, sexual activity, and spontaneous erections
  • Physical signs that may include breast discomfort or gynecomastia, loss of body hair and reduced shaving, very small or shrinking testes
  • Low or zero sperm count; inability to father children
  • Signs of bone loss: height loss, low trauma fracture, low bone mineral density (BMD)
  • Hot flushes or sweats

Consider also testing men with less specific symptoms that suggest low testosterone: decreased energy or motivation; depressive symptoms, including low mood, diminished motivation or self-confidence, poor concentration and memory, and disturbed sleep; mild anemia; reduced muscle bulk and increased body fat; and diminished physical performance.

Testing may be indicated for men with medical conditions associated with increased risk of androgen deficiency. These conditions include HIV-associated illness, end-stage renal disease, chronic obstructive pulmonary disease, infertility, osteoporosis, and type 2 diabetes. Patients under treatment with medications that reduce testosterone production (i.e., glucocorticosteroids or opioids) should be considered candidates for testing as well.

More generally, obese patients and those with inflammatory disorders are at heightened risk for testosterone deficiency and might be questioned more actively about indicative symptoms.

Testing procedure. Testosterone level should be determined by reliable assay of a morning blood sample and re­peated for confirmation. Timing is important, Dr. Cunningham advises. “Testosterone is subject to diurnal variation, and norms are based on early-morning levels.”