What are the recommendations for testosterone replacement therapy in older men with androgen deficiency?
The most recent guidelines from the Endocrine Society published in 2018 recommend against routinely prescribing testosterone to all men age ≥65 years with low serum testosterone concentrations. The Endocrine Society recommends screening for and diagnosing androgen deficiency in older men only when they have consistent signs and symptoms of low androgen levels. They recommend the use of a high-quality assay to measure morning fasted serum total testosterone concentrations and confirming a low result with a repeat morning fasted total testosterone level and/or free or bioavailable testosterone level if SHBG is altered or if total testosterone is borderline. Even if low testosterone levels are confirmed, only men with clinically significant and symptomatic androgen deficiency and no contraindications (i.e., planning fertility, presence of an obstructing urinary tract or prostate condition, elevated hematocrit or thrombophilia, untreated obstructive sleep apnea, or neuro- or cardiovascular event within the preceding 6 months) should be considered for treatment. Men with low testosterone levels should always be evaluated for the cause of androgen deficiency. If therapy is initiated, the clinician should ensure that the patient understands the uncertainty of the risks and benefits of testosterone therapy. The choice of supplementation should be at the discretion of both the clinician and the patient. Although the Endocrine Society advises a target total testosterone level in the mid-normal range when prescribing testosterone therapy, many clinicians aim for total testosterone levels in the low-normal range to avoid potential cardiovascular or respiratory side effects despite lack of evidence supporting this practice. Monitoring patients during the first year of therapy should include evaluations for hematocrit and prostate cancer risk.
At this time, testosterone replacement should continue to be reserved for the minority of older men who have frankly low serum testosterone levels and clear clinical signs and symptoms of hypogonadism, who do not have an existing clear contraindication for androgen therapy.