Male hypogonadism

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway

Male hypogonadism is a clinical syndrome which comprises BOTH symptoms AND biochemical evidence of testosterone deficiency.

Avoid testing testosterone in men with no or only vague symptoms.

Defer testing in men with acute reversible illness - testosterone levels often drop transiently

Typical symptoms include

  • reduced libido,
  • erectile dysfunction, and
  • loss of spontaneous or early-morning erections.

Some men instead present with a low-impact (osteoporotic) fracture or an unexplained normocytic anaemia.

Testosterone <7 nmol/L more often reflects a secondary (gonadal or pituitary) cause; 7–11 nmol/L more often reflects non-gonadal illness or late-onset hypogonadism associated with increasing age and obesity.

Assessment

Initial test — total testosterone. Brown tube, must be taken 0800–0900h; reference range 10–30 nmol/L. 

>11 nmol/L — androgen deficiency unlikely. Referral not indicated; consider another cause for the symptoms.

7–11 nmol/L — equivocal

<7 nmol/L — androgen deficiency likely

For a result < 12 nmol/L with no co-existing illness -

  • Confirm the diagnosis. A single low reading is not diagnostic.

Recheck after 4 weeks:

  • Bioavailable + free testosterone — fasted, 0800–0900h

along with:

  • LH/FSH,
  • prolactin,
  • TSH and
  • ferritin.

Primary care management

Confirmed low testosterone:

  • Review medication for drugs that cause androgen deficiency (see below).
  • Address lifestyle and weight. In milder deficiency, a 5–10% weight loss may improve testosterone concentrations.

Drugs that cause androgen deficiency

  • Opiates, including methadone (and illicit opiates)
  • Glucocorticoids — particularly high-dose oral or parenteral
  • Anabolic or gonadal steroids
  • Alkylating / antineoplastic (chemotherapy) agents — current or recent
  • Drugs causing hyperprolactinaemia — antipsychotics, anti-emetics, some antidepressants
  • Alcohol excess and drugs of abuse (e.g. cannabis, amphetamines)
  • Anticonvulsants — carbamazepine and phenobarbitone
  • Others — e.g. ketoconazole, spironolactone

Chemotherapy, opiate and anabolic-steroid effects can be profound and may persist long after the drug is stopped.

In mild testosterone deficiency with likely drug or lifestyle cause, address underlying cause and repeat levels in 6 months

Who to refer

Refer to endocrinology

  • Confirmed testosterone <7 nmol/L — once illness and drug effects are excluded.
  • Confirmed 7–11 nmol/L — only where the patient is clearly symptomatic, not improving, and illness/drug effects are excluded.

Endocrinology will accept referrals for confirmed testosterone deficiency and will discuss treatment. In borderline cases a 3–6 month therapeutic trial may be considered after counselling on the potential benefits and risks.

Who not to refer

  • Testosterone >11 nmol/L — androgen deficiency unlikely.
  • An unconfirmed single low reading — repeat and complete the panel first.
  • Any low result taken during acute illness or with vague symptoms — repeat when the patient is well.
  • Confirmed 7–11 nmol/L who are asymptomatic or improving — repeat in 6 months if symptoms persist.

Treatment and monitoring

Treatment is initiated and titrated by endocrinology, which monitors for the first year and, if stable, discharges to primary care for ongoing annual monitoring. 

Absolute contraindications to testosterone treatment

  • Desire for fertility — fertility services guide treatment instead
  • Current prostate carcinoma
  • Breast carcinoma
  • Haematocrit >0.50
  • Unevaluated elevated PSA or prostate lump on digital rectal examination
  • NYHA grade 3 or 4 heart failure
  • Liver tumour
  • Hypercalcaemia
  • Nephrotic syndrome

Monitoring

  • Check FBC, PSA, lipids and LFTs before starting.
  • PSA at baseline then annually; bone density at baseline then every 4 years.
  • Repeat monitoring at 3, 6 and 12 months, then annually.
  • Monitor the haematocrit to avoid polycythaemia.
  • In milder deficiency from non-gonadal illness, consider stopping at 3–6 months if there is no clinical improvement.

Counselling points: long-term cardiovascular safety is unknown; testosterone does not cause prostate cancer but may promote growth of an existing tumour; BPH symptoms may be unmasked; some studies report increased risk of venous thromboembolism, atrial fibrillation and fractures; and erectile dysfunction may not improve. Routine prostate cancer screening during treatment is not recommended, though a baseline PSA monitored annually is usual practice.

Preparations — base the choice of gel or injection on patient preference and availability; gels are often used first to assess response and tolerability.

Gels

Tostran 2% gel — one metered application contains 10 mg testosterone.

  • Apply in the morning to clean, dry, intact skin of the abdomen or both inner thighs; rub in with a finger until dry before dressing. Wash hands with soap and water afterwards and avoid washing the application site for at least 2 hours. Not to be applied to the genital area.
  • Start 4 applications (40 mg) once daily, adjusted according to response (note this is lower than the BNF starting dose of 60 mg). Usual maintenance 4 applications (40 mg) per day; maximum 8 applications (80 mg) per day.

Testogel 16.2 mg/g gel sachet — one 2.5 g sachet contains 40.5 mg testosterone.

  • Apply a thin layer to clean, dry, healthy skin over both upper arms and shoulders immediately after opening the sachet. Allow to dry for 3–5 minutes before dressing; wash hands afterwards and cover the site with clothing once dry. Avoid a shower or bath for at least 1 hour. Not to be applied to the genital area (high alcohol content may cause local irritation).
  • 1 sachet (40.5 mg) once daily, adjusted in steps of 20.25 mg according to response. Usual dose 1 sachet (40.5 mg) per day; maximum 2 sachets (81 mg) per day.

Testogel 16.2 mg/g gel pump — one actuation delivers 1.25 g of gel containing 20.25 mg testosterone.

  • Apply a thin layer to clean, dry, healthy skin over both upper arms and shoulders. Allow to dry for 3–5 minutes before dressing; wash hands afterwards and cover the site with clothing once dry. Avoid a shower or bath for at least 2 hours. Not to be applied to the genital area (high alcohol content may cause local irritation).
  • 2 actuations (40.5 mg) once daily, increased in steps of 20.25 mg according to response. Usual maintenance 2 actuations (40.5 mg) per day; maximum 4 actuations (81 mg) per day.

Gel notes

  • Apply daily in the morning per the manufacturer's instructions.
  • Check testosterone 2–6 hours after applying the gel, aiming for the middle of the reference range. A level >30 nmol/L requires a dose reduction (note possible skin contamination of the sample).
  • Wash hands after application and avoid skin-to-skin contact for 6 hours.
  • Can be discontinued quickly.

Injections

Testosterone undecanoate (Nebido) 1 g/4 mL (250 mg/mL) solution for injection

  • 1 g by deep IM (gluteal) injection over 2 minutes.
  • Give the first two injections 6 weeks apart to reach steady-state plasma levels quickly, then approximately every 12 weeks.
  • Aim for a trough level just below, or at the lower end of, the normal reference range before the third injection, then adjust the interval to every 10–14 weeks (occasionally a longer interval is needed).

Testosterone 250 mg injection (Sustanon)

  • Adjust the dose to the individual response; usually one injection of 1 mL every 3 weeks is adequate in adults (including the elderly).
  • Contains arachis oil — contraindicated in peanut or soya allergy.

References

Editorial Information

Last reviewed: 21/07/2026

Next review date: 21/07/2028

Author(s): Fiona Green.

Version: 1.0

Reviewer name(s): Fergus Donachie.