Clinicians should monitor men receiving testosterone replacement therapy for symptom improvement, potential adverse effects, and adherence. Evidence is conflicting regarding its effect on cardiovascular events and mortality. After 1 year, prostate monitoring should conform to standard guidelines for prostate cancer screening based on the race and age of the patient.
A retrospective review of 399 men (mean age 37 years) with a mean total testosterone of 308 ng/dL found that 35% of patients had BMD at osteopenic levels and 3% had osteoporosis. Specifically, the odds ratio for developing ED in men with total testosterone 6 used a single question to define ED and also showed an increase in ED risk as total testosterone levels decreased. In a small study of young men with acute respiratory infections, mean total testosterone levels declined by 10%, with some cohorts experiencing reductions of up to 30%.25 Where possible, clinicians should use LCMS to measure total testosterone levels to maximize accuracy and limit CV between tests in men undergoing testing, particularly in men with very low total testosterone levels. It was decided that a cut-off value was critical to define testosterone deficiency and that this cut-off be based on at least two total testosterone levels drawn in an early morning fashion at the same laboratory using the same assay. Given the growing concern and need for proper testosterone therapy, the AUA identified a need to produce an evidence-based document that informs clinicians on the proper evaluation and management of testosterone deficient patients. Patients with testosterone deficiency and a history of prostate cancer should be informed that there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy.
The Panel explicitly uses the term testosterone therapy rather than testosterone replacement therapy or testosterone supplementation to be in keeping with the beliefs of the current thought leaders in the field. Thus, a patient is considered testosterone deficient and a candidate for testosterone therapy only when he meets both criteria. Ultimately, the AUA and the Testosterone Panel were committed to creating a Guideline that ensures that men in need of testosterone therapy are treated effectively and safely. Clinicians should discuss the risk of transference with patients using testosterone gels/creams. Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive. All men with testosterone deficiency should be counseled regarding lifestyle modifications as a treatment strategy. Men with testosterone deficiency who are interested in fertility should have a reproductive health evaluation performed prior to treatment.
The few studies of testosterone therapy for depressed mood had mixed results.28–31 Testosterone therapy does not improve cognitive function in men with or without preexisting cognitive impairment.32–34 There is also mixed evidence for prescribing testosterone to improve vitality, general quality of life, and male "symptoms of aging," with some studies demonstrating improvement with therapy,35,36 and other studies finding no change.10,37 As part of the Choosing Wisely campaign, the American Urological Association says physicians should not prescribe testosterone therapy for men with erectile dysfunction and normal testosterone levels.20 In men with borderline total testosterone levels, measurement of free testosterone and sex hormone–binding globulin levels should be considered, especially in the presence of conditions that affect sex hormone–binding globulin levels (most commonly, aging, obesity, and diabetes). Male hypogonadism should be diagnosed only if there are signs or symptoms of hypogonadism and total serum testosterone levels are low on at least two occasions. Other possible risks include rising prostate-specific antigen levels, worsening lower urinary tract symptoms, polycythemia, and increased risk of venous thromboembolism.
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. The AUA and the Testosterone Panel were committed to creating a Guideline that ensures that men in need of testosterone therapy are treated effectively and safely. The Evaluation and Management of Testosterone Deficiency AUA Guideline provides guidance to the practicing clinician on how to diagnose, treat and monitor the adult male with testosterone deficiency. Results from the first adequately powered randomized controlled trial evaluating the risk of MACE in hypogonadal men (TRAVERSE) are expected in late 2022, and it is hoped that they will inform clinical practice.53 DTT may also be high in some conditions in which SHBG levels are high, such as HIV or use of some anticonvulsants. Conditions that alter SHBG levels include obesity, diabetes mellitus, use of glucocorticoids, some progestins and androgenic steroids, nephrotic syndrome, acromegaly, aging, HIV, cirrhosis and hepatitis, hypo- or hyperthyroidism, use of some anticonvulsants, estrogen use, and polymorphisms in the SHBG gene.
These are low-cost drugs and offer good tolerance and satisfactory clinical response, although they are not able to simulate the circadian rhythm and induce a supraphysiologic testosterone plasmatic level on the 1st days after administration (Table 1).210 It is recommended that transgender men under androgen therapy be monitored every 3 months during the 1st year of treatment and then, every 6 to 12 months. The use of testosterone therapy in women is summarized in Table 6.64,65 A comprehensive meta-analysis of post-menopausal women found improvement in sexual function with testosterone therapy. Most experts agree that the goal serum testosterone level should be in the midnormal range (i.e., 400 to 700 ng per dL 13.9 to 24.3 nmol per L); values outside of this range require a dose adjustment.9 Most importantly, ongoing evaluation of treatment effectiveness is required.
An overview of the assays available to aid in the diagnosis of testosterone deficiency is available in Table 4 (See button below). Given these inconsistences, prevalence of low testosterone has varied dramatically among studies, with statistics reporting %.5-8 A summary of findings from four large-scale contemporary prevalence studies can be found in Table 3 (See button below). Across the prevalence literature, the cut-off values used to define low testosterone vary widely, heterogeneity exists in the populations studied, the forms of testosterone used to measure testosterone (total and/or free) are not consistent, and the assays utilized to measure testosterone differ. The prevalence of testosterone deficiency in the American male population is difficult to quantify. Finally, testosterone pellets are also available in branded form, with no generic agents currently available.
Testosterone deficiency is prevalent in men presenting for an infertility evaluation.159  The testes contain germ cells that produce spermatozoa and Leydig cells that produce testosterone; any pathology of the testes can result in infertility and testosterone deficiency, conditions that frequently co-exist. As such, all patients who have a history of unexplained anemia should have their testosterone tested. Gynecomastia is a benign enlargement of the male breast tissue that can occur at times of male androgen/estrogen change (alteration in testosterone/estradiol E2 ratio), infancy, adolescence, or old age, and may be a sign of low serum testosterone. To minimize these effects, two morning draws for testosterone are recommended before any clinical intervention.
The androgenization may be offered to transgender men who are 18 years old or older and who have characteristics of gender dysphoria/gender incongruence, which must be attested by a mental health professional, and who also are completely capable of deciding to receive or not an individualized treatment, based on cost/benefit ratio, on social and economic issues and on individual specific necessities.5 The use of androgens for virilization is usually well tolerated and improves the quality of life and reduces the self-acceptance conflicts. According to the offered protocol, in order to be submitted to a surgical procedure for sexual reassignment, an individual must be at least 21 years old, and have no less than 1 year of hormonal therapy and a 2-year follow-up with a mental health professional. According to the World Professional Association for Transgender Health (WPATH)5 and the MS in Brazil (regulatory ordinance n° 2.803, 2013 November 19th Art. 13),4 it is recommended that the gender affirmation process is performed by a team composed of a social assistance provider, mental health professionals (psychiatrist and psychologist), an endocrinologist, a gynecologist and a plastic surgeon, while the diagnosis and treatment are being determined.45 This determination established guidelines to regulate clinical and surgical procedures that could be used to adapt the genital status to match gender identification in transgender individuals. The recognition and acceptance of transgender women (individuals 46 XY, with male phenotype and female identity) and transgender men (individuals 46 XX, with female phenotype and male identity) have increased in the last decade, both among health providers and among the general population.2

Gender: Female

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