Low testosterone levels are associated with increased risk of cardiovascular disease and increased mortality in ageing men. Men with pathologically based hypogonadism should be considered for testosterone supplementation. For older men suspected of being androgen deficient in the absence of pituitary or testicular disease, controversy exists because symptoms can be nonspecific, the definition of low testosterone levels is under debate and the risks of extended treatment are uncertain.
- Men who have an identifiable lesion of the hypothalamo-pituitary-gonadal axis or a primary testicular disorder may exhibit pathologically based hypogonadism. These men should be considered for testosterone supplementation.
- Symptoms and signs of androgen deficiency include reduced libido, decreased spontaneous erections, loss of body hair and reduced need for shaving, gynaecomastia, and increased risk of osteoporosis or fracture.
- Biochemical evaluation should include measurement of circulating testosterone and luteinising hormone levels.
- Low testosterone levels are associated with increased risk of cardiovascular disease and increased mortality in ageing men. In this context, it remains unclear whether a reduced testosterone level is a causal factor or a biomarker for ill health.
- Adequately powered randomised clinical trials investigating testosterone therapy in older men with hard clinical endpoints are needed.
- Consensus clinical guidelines currently recommend making a diagnosis of androgen deficiency only in symptomatic men with unequivocally low testosterone levels, with a careful discussion of the risks versus benefits of any intervention.