Considerations for the diagnosis and treatment of testosterone deficiency in elderly men

Increased longevity and population aging will increase the number of men with relative testosterone deficiency, as systemic levels of testosterone decrease by about 1% each year. Androgen deficiency should only be diagnosed in men with definite signs and symptoms, accompanied by low total testosterone levels measured in the morning by a reliable assay. Although clinical trials data are limited, current practice guidelines recommend testosterone replacement therapy for symptomatic men with low testosterone levels to improve bone mineral density, muscle mass and strength, sexual function, and quality of life. Testosterone replacement is not recommended for all older men with low testosterone levels, and should be avoided in patients with prostate or breast cancer, hyperviscosity, erythrocytosis, untreated obstructive sleep apnea, or severe heart failure. The goal of all available testosterone treatment modalities (intramuscular injections, nongenital patch or gel, bioadhesive buccal and oral testosterone, and pellets) is to achieve serum testosterone levels in the mid-normal range during treatment. Cost varies widely among these preparations and may limit their use. Patients receiving testosterone replacement therapy should be re-evaluated 3 months after testosterone initiation and at least annually thereafter.