AUA: New Guidelines for Diagnosis, Management of Testosterone Deficiency

Clinicians should use a total testosterone level below 300ng/dL as a reasonable cut-off in support of the diagnosis of low testosterone.

The American Urological Association (AUA) has issued new clinical guidelines on the diagnosis and management of testosterone deficiency

An expert panel was assembled to conduct a systematic review to provide an evidence-based document for the appropriate assessment and management of patients with testosterone deficiency. The guideline outlines the definition of testosterone deficiency, noting that it is not solely characterized by low testosterone production, but rather a state of low production along with low testosterone symptoms (eg, lower sex drive, erectile dysfunction, loss of energy, reduced muscle mass, bone density, fatigue). Both criteria must be met in order to be considered testosterone deficient. 

Some of the key recommendations include:


  • Clinicians should use a total testosterone level <300ng/dL as a reasonable cut-off in support of the diagnosis of low testosterone.
  • The diagnosis of low testosterone should be made only after two total testosterone measurements are taken on separate occasions with both conducted in an early morning fashion.
  • Clinicians should consider measuring total testosterone in patients with a history of unexplained anemia, bone density loss, diabetes, exposure to chemotherapy, exposure to testicular radiation, HIV/AIDS, chronic narcotic use, male infertility, pituitary dysfunction, and chronic corticosteroid use even in the absence of symptoms or signs associated with testosterone deficiency.

 Adjunctive Testing

  • In patients with low testosterone, clinicians should measure serum luteinizing hormone levels.
  • Serum prolactin levels should be measured in patients with low testosterone levels combined with low or low/normal luteinizing hormone levels.
  • Patients with persistently high prolactin levels of unknown etiology should undergo evaluation for endocrine disorders.
  • Prior to offering testosterone therapy, clinicians should measure hemoglobin and hematocrit and inform patients regarding the increased risk of polycythemia.

Counseling Regarding Treatment of Testosterone Deficiency

  • Clinicians should inform testosterone deficient patients that low testosterone is a risk factor for cardiovascular disease.
  • The long-term impact of exogenous testosterone on spermatogenesis should be discussed with patients who are interested in future fertility.
  • Clinicians should inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer.

Treatment of Testosterone Deficiency

  • Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive.
  • Clinicians should discuss the risk of transference with patients using testosterone gels/creams.

Follow-Up of Men on Testosterone Therapy

  • Testosterone levels should be measured every 6-12 months while on testosterone therapy.
  • Clinicians should discuss the cessation of testosterone therapy three to six months after commencement of treatment in patients who experience normalization of total testosterone levels but fail to achieve symptom or sign improvement.

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The full guideline can be found here.

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