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Optimizing testosterone therapy in hypogonadism

After clinicians identify hypogonadism and initiate treatment, it is important to counsel patients, along with the monitoring for safety and efficacy discussed previously. Appropriate counseling and education—explaining that testosterone therapy should not be solely equated with sexual function, setting realistic expectations, and discussing the risks, benefits, and perceived fears of therapy—will all help to increase adherence and improve patient outcomes.

To optimize the treatment of hypogonadal men who are obese, “…combine androgen with a lifestyle alteration process rather than just treating it as a strictly hormonal situation

Robert S. Tan, MD

Expert snapshot To improve patient adherence:

  • Involve the patient in treatment selection

  • Individualize the treatment plan

  • Set specific and realistic goals

  • Provide patient education

  • Listen to the patient: be aware of his priorities, goals, time constraints, and expectations

  • Conduct regular follow-up and monitoring; include a follow-up phone call from office

Team approach

Although in many cases, primary care physicians can successfully treat men with hypogonadism, there are some instances when a team approach would be more appropriate. Primary care physicians should consider referring to an endocrinologist a patient who exhibits signs or symptoms of a pituitary tumor, including visual field abnormalities, headaches, hyperprolactinemia, or hypopituitarism or who has a testosterone level <150 ng/dL with normal LH and FSH levels (Table 9). A patient should be referred to a urologist if he has a PSA level >4.0 ng/mL, a yearly increase in his PSA level of >0.75 to 1.0 ng/mL, a prostatic abnormality detected by DRE, or an American Urological Association score or International Prostate Symptom Score >19.1,22 Other specialists that may become involved in the treatment of patients with low testosterone levels are cardiologists and sleep specialists.


We need to literally legitimize the primary care clinician who just screens and then refers if there are any questions or any abnormality

Richard Sadovsky, MD

Key messages

  • Treatment goals should be based on resolution of symptoms and signs of low testosterone

  • A variety of delivery systems and formulations of testosterone are available, each with its own advantages and disadvantages

  • An ideal formulation of testosterone would safely and effectively reestablish physiologic levels of testosterone while being convenient to administer and cost-effective

  • Without documented, verifiable evidence of the risks of testosterone therapy, it is important to screen patients before initiating testosterone therapy and to monitor the prostate during therapy

  • Counseling and education, along with realistic goals and continuous follow-up, are essential to optimizing testosterone therapy

  • An interdisciplinary team approach may be needed to treat a patient with hypogonadism, and primary care clinicians should feel comfortable referring patients to specialists when appropriate


Hypogonadism is underrecognized, underdiagnosed, and undertreated for many reasons. Being aware of these reasons and having a deeper understanding of the condition will help primary care clinicians recognize and treat this disorder.

Diagnosing hypogonadism is complicated by myriad issues, including overlaying symptomatology, lack of concrete testosterone thresholds, and wide variability in assays and laboratory measurements.

Table 9. Reasons for a Patient to Be Referred to a Specialist

Considerations for Referral to Endocrinologist

Signs and symptoms of pituitary tumor

  • Visual field abnormalities

  • Headaches

Considerations for Referral to

Urologist PSA >4.0 ng/mL

Increase in serum or plasma PSA concentration >0.75 to 1.0 ng/mL in any 12-mo treatment period

  • Hyperprolactinemia or hypopituitarism

  • Testosterone <150 ng/dL with normal LH and FSH levels22

  • Other pituitary abnormaliti

  • Further consideration for

unclear etiology


Prostatic abnormality detected by DRE

AUA or IPSS symptom score >19

AUA, American Urological Association; DRE, digital rectal examination; FSH, follicle-stimulating hormone; IPSS, International Prostate Symptom Scale; LH, luteinizing hormone; PSA, prostate-specific antigen.

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