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Male hypogonadism

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Updated 2023 EAU and 2020 ACP guidelines for the diagnosis and management of male hypogonadism.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of male hypogonadism are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2017), the European Association of Urology (EAU 2024), the American Urological Association (AUA/SMSNA 2022), the Italian Society of Endocrinology (SIE/SIAMS 2022), the American College of Physicians (ACP 2020), the Endocrine Society ...
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Screening and diagnosis

Indications for screening, general population: as per EAA 2020 guidelines, do not obtain universal screening for hypogonadism in middle-aged or older males by structured interviews or questionnaires and/or random total testosterone measurements.
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  • Indications for screening (symptomatic patients)

  • Diagnostic criteria

Diagnostic investigations

Testosterone levels: as per AAFP 2024 guidelines, obtain measurement of fasting morning testosterone level in patients with symptoms of testosterone deficiency. Repeat the test to confirm the diagnosis if the level is < 300 ng/dL (10.41 nmol/L) and obtain additional workup to determine etiology.
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  • LH/FSH levels

  • Prolactin levels

  • Pituitary imaging

  • Evaluation before testosterone therapy

Medical management

Management of underlying causes, contributing medications: as per EAU 2024 guidelines, assess for concomitant diseases, drugs, and substances possibly interfering with testosterone production/action.
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  • Management of underlying causes (pituitary tumor)

  • Management of underlying causes (cryptorchidism)

  • Testosterone therapy (indications for initiation)

  • Testosterone therapy (indications for avoidance)

  • Testosterone therapy (contraindications)

  • Testosterone therapy (choice of preparation)

  • Testosterone therapy (goals of treatment)

  • PDE5 inhibitors

Nonpharmacologic interventions

Lifestyle modifications: as per EAU 2024 guidelines, advise lifestyle improvements and weight reduction in patients with late-onset hypogonadism.
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Specific circumstances

Patients with hypogonadotropic hypogonadism: as per EAU 2024 guidelines, initiate combined hCG and FSH (recombinant FSH, highly purified FSH) or pulsed GnRH via pump therapy to stimulate spermatogenesis in patients with hypogonadotropic hypogonadism (secondary hypogonadism), including congenital causes.
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  • Patients with delayed ejaculation

Patient education

General counseling
As per AAFP 2024 guidelines:
Counsel patients with heart disease or high cardiovascular risk that although evidence has been mixed, recent data shows testosterone replacement therapy does not appear to increase the risk of myocardial infarction, stroke, or cardiovascular death.
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Recognize that testosterone replacement therapy leads to modest improvements in sexual function and depressive symptoms.
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Follow-up and surveillance

Indications for specialist referral: as per ES 2018 guidelines, refer patients with hypogonadism to a urologist in case of a confirmed increase in PSA concentration > 1.4 ng/mL above baseline or confirmed PSA > 4.0 ng/mL, or a prostatic abnormality detected on DRE during the first 12 months of testosterone therapy.
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  • Clinical and laboratory follow-up