Table of contents

Male hypogonadism

What's new

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


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 European Association of Urology (EAU 2023), 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 (ES 2020,2018), the European Academy of Andrology (EAA ...
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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 EAU 2023 guidelines, obtain measurement of total testosterone in the morning (7 and 11 AM) and in the fasting state with a reliable laboratory assay for the evaluation of late-onset hypogonadism.
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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 2023 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 2023 guidelines, advise lifestyle improvements and weight reduction in patients with late-onset hypogonadism.

Specific circumstances

Patients with hypogonadotropic hypogonadism: as per EAU 2023 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 EAU 2023 guidelines:
Inform patients fully about the expected benefits and adverse effects of any treatment option. Select the testosterone preparation in a joint decision process, only with fully informed patients.
Provide full counseling in patients with symptomatic hypogonadism previously surgically treated for localized prostate cancer (currently not showing evidence of active disease) and considering testosterone therapy, emphasizing the benefits and lack of sufficient safety data on long-term follow-up.

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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  • Serial clinical and laboratory assessment