screening and assessment for testosterone defiency (TD)

Last edited 05/2022 and last reviewed 06/2023

Screening for TD

Screen for TD in:

• adult men with consistent and multiple TD signs and symptoms
• all men with loss of spontaneous erections, ED, or low sexual desire
• all men with type 2 diabetes mellitus
• all men with BMI >=30 kg/m2 or waist circumference > 102 cm
• all men with on long-term opiate, anticonvulsant or antipsychotic medication

Diagnosing TD

A diagnosis of symptomatic TD is based on characteristic signs and symptoms PLUS reduced serum levels of total testosterone or free testosterone.1

The more signs and symptoms are present, the greater the likelihood of genuine TD.1,2

However, it is important to remember that many TD signs and symptoms are non-specific, multifactorial in origin and associated with various lifestyle and psychological factors, as well as with normal aging, so they may also be found in men with normal testosterone levels.3

TD signs and symptoms

The following signs and symptoms are suggestive of TD:2-6

Psychological

• changes in mood (e.g. irritability, anger, sadness, depression)
• decreased well-being/poor self-rated health
• impaired cognitive function (e.g. difficulty concentrating, decreased verbal memory and/or spatial performance)

Physical

• decreased body hair
• reduced muscle mass and strength
• gynaecomastia
• poor sleep
• hot flushes/sweats
• fatigue
• osteoporosis/height loss/low trauma fractures

Cardiometabolic

• increased BMI
• visceral obesity
• metabolic syndrome
• insulin resistance
• type 2 diabetes mellitus

Sexual

• delayed puberty
• small testes
• infertility
• decreased sexual desire/activity
• reduced frequency of sexual thoughts
• absent or fewer morning/night-time erections
• erectile dysfunction
• delayed ejaculation
• decreased volume of ejaculate

The 3 most common TD symptoms are ED, loss of early morning erections and low sexual desire. Men commonly present with sexual dysfunction and a desire for treatment.

History taking

When considering a diagnosis of symptomatic TD:

• Identify signs and symptoms suggestive of TD
• Enquire about current and previous, prescription, over-the-counter and recreational, drug use3
• Confirm alcohol intake3
• Assess and exclude systemic illness, acute disease, malabsorption and malnutrition1
• Consider the use of validated questionnaires to provide a quantitative assessment of baseline symptoms and evaluate the clinical response to treatment

Questionnaires

Exampleds of validated questionnaires include the Androgen Deficiency in the Ageing Male (ADAM) questionnaire (included in the Sexual Advice Association SMART SAA app, available at:

• http://sexualadviceassociation.co.uk/), and the Ageing Males' Symptoms (AMS) Scale (available at: http://www.issam.ch/AMS_English.pdf).

Information on interpreting the scores can be found at: https://zeg-berlin.de/wp-content/uploads/2017/01/norm.pdf

Physical examination

When considering a diagnosis of symptomatic TD:

• Measure the patient's height, weight, BMI and waist circumference1
• Assess the amount of body hair (including facial and pubic)1
• Examine the patient for any breast enlargement, and abnormalities of the penis, testicles1,3 and scrotum1
• Check the prostate via digital rectal examination3

References

• 1. Lunenfeld B, Mskhalaya G, Zitzmann M, et al. Recommendations on the diagnosis, treatment and monitoring of hypogonadism in men. Aging Male 2015;18:5-15.
• 2. Zitzmann M, Faber E, Nieschlag E. Association of specific symptoms and metabolic risk with serum testosterone in order men. J Clin Endocrinol Metab 2006;91:4335-4343.
• 3. Dohle GH, Arver S, Bettochi C et al. Guidelines on Male Hypogonadism. European Association of Urology 2017. Available at: http://uroweb.org/guideline/male-hypogonadism/ (Accessed May 2018).
• 4. Khera M, Adaikan G, Buvat J, et al. Diagnosis and Treatment of Testosterone Deficiency: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2016;13:1787-1804.
• 5. Hackett G, Kirby M, Edwards D, et al. UK policy statements on testosterone deficiency. Int J Clin Pract 2017;71.
• 6. Dean JD, McMahon CG, Guay AT, et al. The International Society for Sexual Medicine's process of care for the assessment and management of testosterone deficiency in adult men. J Sex Med 2015;12:1660-1686.