| name | icsm-indications-for-testosterone-assessment |
| description | Recommends evaluating testosterone in men presenting with sexual symptoms (low libido, erectile dysfunction, decreased morning erections), metabolic conditions (obesity, type 2 diabetes, metabolic syndrome), HIV infection, opioid or glucocorticoid use, bone density loss, or male infertility. Triggers when a clinician encounters a patient with any of these indications and considers whether to check testosterone levels. |
Assess clinical indications for testosterone measurement
STEP 1 — Gather Information
Collect history of sexual symptoms (libido, erectile dysfunction, morning erections), metabolic disease (BMI, HbA1c, waist circumference), HIV status, opioid/glucocorticoid use, bone health (prior fracture, osteoporosis), reproductive history (time trying to conceive, semen analysis), medication list, and perform physical exam focusing on testes size, body hair, gynecomastia.
STEP 2 — Rule In / Rule Out
Is there at least one indication from sexual symptoms, metabolic conditions, HIV, opioid/glucocorticoid use, bone density loss, or male infertility? If YES, proceed to testosterone measurement; if NO, routine testosterone screening is not recommended.
STEP 3 — Classify or Stratify
If the patient has clear dysmetabolic conditions (obesity, type 2 diabetes, metabolic syndrome), plan to measure SHBG and calculate free testosterone in addition to total testosterone; otherwise, total testosterone alone is sufficient for initial assessment.
STEP 4 — Decide
Order a morning (07:00–11:00) fasting total testosterone; if dysmetabolic conditions present, also order SHBG; if total testosterone <12 nmol/L on two separate occasions, consider testosterone therapy after excluding other causes; if normal, investigate alternative etiologies for symptoms.
Clinical Guardrails / Mimics / Pitfalls
Do not order testosterone in asymptomatic men or during acute illness; avoid relying on a single low result; do not initiate testosterone therapy solely for osteoporosis, depression, or cardiovascular risk reduction; remember that opioids and glucocorticoids can suppress testosterone independent of hypogonadism; ensure proper timing and fasting state for accurate measurement.
Concrete Clinical Example
A 58‑year‑old man with type 2 diabetes reports decreased libido and morning erections; history reveals no opioid use, normal bone density, and he is trying to conceive for 1 year; step 1 collects metabolic and sexual symptoms; step 2 indicates testing is warranted; step 3 adds SHBG due to diabetes; step 4 shows morning total testosterone 9 nmol/L (low) on two repeats, SHBG normal, leading to discussion of testosterone replacement therapy.
Source: Male hypogonadism: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024), Mohit Khera et al., 2025, https://doi.org/10.1093/sxmrev/qeaf036
