Approach to testosterone replacement therapy
Before considering testosterone replacement therapy, perform assessment as outlined in Approach to diagnosis in suspected male androgen deficiency to determine whether criteria for a diagnosis of male androgen deficiency are met.
If criteria are not met but functionally low serum testosterone concentration is suspected, consider whether correction of underlying causes is possible. Management should focus initially on lifestyle measures, particularly weight loss where relevant, and treating comorbidities. Australian management guidelines recommend against testosterone therapy for functionally low serum testosterone concentration. The T-Trials1 enrolled males with functionally low serum testosterone concentrations and at least one of the following problems: decreased libido, difficulty walking, or low vitality. Testosterone treatment modestly improved sexual function in those with low libido, walking distance in men with difficulty walking, haemoglobin concentration, and lumbar spine bone mineral density, but questions remain about cardiovascular safety, and long-term clinical outcomes.
Consider referral to an endocrinologist for management of functionally low serum testosterone concentration.
If criteria for diagnosing androgen deficiency are met, investigate causes as outlined in Approach to diagnosis in suspected male androgen deficiency, if feasible, or refer for investigation and management.
Testosterone replacement aims to relieve the symptoms and signs of androgen deficiency. It is not indicated for treatment of low libido or erectile dysfunction in males who are not androgen deficient. The Pharmaceutical Benefits Scheme criteria for prescribing of testosterone for androgen deficiency are stringent; specialist referral is required. Testosterone replacement suppresses spermatogenesis, so referral to a fertility specialist may be required before starting replacement.
Androgen deficiency may recover if a reversible cause is treated (eg hyperprolactinaemia is corrected with a dopamine agonist). Androgen deficiency caused by an irreversible disorder requires lifelong testosterone replacement therapy.
Testosterone therapy is contraindicated in males with current prostate or breast cancer, those desiring fertility, and elite athletes (because it is a prohibited substance). For males who have had curative treatment for breast or prostate cancer, specialist assessment of harms and benefits of testosterone therapy is required.
Monitoring of testosterone replacement therapy is advised to assess efficacy and detect adverse effects.