History and examination in male androgen deficiency
Androgen deficiency should not be diagnosed unless symptoms and signs are found on history and examination. Many symptoms of androgen deficiency are nonspecific.
Symptoms and signs most likely to indicate androgen deficiency include reduced libido, decreased spontaneous erections, hot flushes, reduced facial hair growth, breast discomfort or gynaecomastia, loss of axillary and pubic hair, small testes (especially volume under 5 mL, assessed using an orchidometer) and low bone mass (particularly low Z-scores). Very small testes are a feature of Klinefelter syndrome1, which is often missed unless a testicular examination is performed.
Less specific symptoms and signs of androgen deficiency include decreased energy, motivation, concentration, memory or work performance; low mood; disturbed sleep or increased sleepiness; reduced muscle bulk and strength; increased body fat or body mass index; and mild anaemia. Many of these features may be seen with different diagnoses associated with low serum testosterone, such as:
- functionally low serum testosterone concentration
- acute illness.
Rather than typical signs of androgen deficiency (although testicular shrinkage is a feature), use of exogenous androgenic steroids may cause truncal acne and marked muscular development. Ask directly about the use of exogenous synthetic androgens (including unregulated supplements, which may contain unrecognised ingredients).