What screening tests should you use to evaluate a man with low testosterone?

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What screening tests should you use to evaluate a man with low testosterone?

J Fam Pract. 2008 November;57(11):756-758

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References

1. Darby E, Anawalt BD. Male hypogonadism: an update on diagnosis and treatment. Treat Endocrinol. 2005;4:293-309.

2. Badar F, Mirmira V, Hemady N. Hypogonadism in men: underdiagnosed and undertreated. Resid Staff Physician. 2006;52(6):6-12.

3. American Association of Clinical Endocrinologists American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hypogonadism in adult male patients—2002 update. Endocr Prac. 2002;8:440-456.

4. Smyth CM, Bremner WJ. Klinefelter syndrome. Arch Intern Med. 1998;158:1309-1314.

5. Spratt DI, O’Dea LS, Schoenfeld D, et al. Neuroendocrine-gonadal axis in men: frequent sampling of LH, FSH, and testosterone. Am J Physiol. 1988;254(5 Part 1):E658-E666.

6. Seftel AD. Male hypogonadism. Part I: epidemiology of hypogonadism. Int J Impot Res. 2006;18:115-120.

7. Sadovsky R, Dhindsa S, Margo K. Testosterone deficiency: which patients should you screen and treat? J Fam Pract. 2007;56(5 suppl):S1-S24.

8. Bhasin S, Jameson DL. Disorders of the testes and male reproductive system. Ch 340. In: Fauci AS, Braunwald E, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.

9. US Census Bureau. US Interim projections by age, sex, race, and Hispanic origin: 2000-2050. Created March 18, 2004. Available at: www.census.gov/ipc/www/usinterimproj/. Accessed March 14, 2006.

10. Schrier SL, Bacon BR. Clinical manifestations of hereditary hemochromatosis. Up to Date [online database]. Version 15.1. Waltham, Mass: UpToDate; 2008.

11. Harman SM, Metter EJ, Tobin JD, et al. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metab. 2001;86:724-731.

12. Kaufman JM, Johnell O, Abadie E, et al. Background for studies on the treatment of male osteoporosis: state of the art. Ann Rheum Dis. 2000;59:765-772.

13. Abbasi AA, Rudman D, Wilson CR, et al. Observations on nursing home residents with a history of hip fracture. Am J Med Sci. 1995;310:229-234.

14. Pietrangelo A. Hereditary hemochromatosis—a new look at an old disease. N Engl J Med. 2004;350:2383-2397.

Is the patient pre- or postpubertal?

Assessment of low testosterone should distinguish between pre- and postpubertal males. In prepubertal males, chromosomal analysis is indicated because hypothalamic-pituitary-gonadal axis defects are common—especially Klinefelter syndrome (1 in 500 males).^6,8

Men with very low testosterone levels (<150 ng/dL) or signs and symptoms suggesting pituitary pathology warrant pituitary imaging and measurement of thyroxine, cortisol, and prolactin levels.⁶ Both pre- and postpubertal males with low testosterone should have FSH, LH, and prolactin levels tested to differentiate primary from secondary hypogonadism.^6,9

Be alert for hemochromatosis and low bone density

FAST TRACK

Prepubertal males with low testosterone and elevated FSH and LH should undergo chromosomal studies to assess for Klinefelter syndrome

Order biopsy or ultrasound examination of testicular masses and iron studies if hemochromatosis is suspected. Hemochromatosis is the most common single gene disorder of Caucasian Americans (1 in 250-300 are homozygous; 1 in 10 are heterozygous) and is associated with hypogonadotrophic hypogonadism.^5,10 In a series of 3 studies, 30% (26 of 89) of men with hemochromatosis had hypogonadism.¹¹ The prevalence of hemochromatosis in males with hypogonadism hasn’t been reported.

Because chronic hypogonadism leads to low bone density and increased risk of fracture, baseline bone densitometry may be prudent.¹² A chart review study of nursing home residents found that 66% of men with hip fractures and 20% of men with vertebral fractures had low testosterone.¹³ Notably, 50% of men in their 80s have testosterone levels in the hypogonadal range (<300 ng/dL), compared with 12% of men <50 years.^1,14

Recommendations

Scant guidance is available concerning what screening tests to order for a male with low testosterone. The United States Preventive Services Task Force and Canadian Task Force on Preventive Health Care make no recommendations; the Cochrane collaboration has no reviews on the topic. The American Association of Clinical Endocrinologists’ (AACE) guidelines are based on expert opinion.³

FAST TRACK

Consider checking for osteoporosis in men with chronic hypogonadism

The AACE consensus guideline used peer review for validation and didn’t specify the method used to assess the quality and strength of the evidence used to write the statement. The AACE guideline recommends a history and physical exam, obtaining repeat morning testosterone levels, prolactin, FSH, LH, bone densitometry, and a semen analysis if fertility is an issue.

In acquired hypogonadism, pituitary imaging is recommended along with thyroid, adrenal, and growth hormone axis testing. Prepubertal males should undergo chromosome analysis, and men with a suspected mass should have a testicular ultrasound examination.

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What screening tests should you use to evaluate a man with low testosterone?

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